GASLESS LAPAROSCOPY AND CONVENTIONAL INSTRUMENTS - THE NEXT PHASE OF MINIMALLY INVASIVE SURGERY

Objective: To assess the capability of a retractor system that permits laparoscopic surgery without pneumoperitoneum and to determine if the system facilitates the use of conventional surgical instruments during minimally invasive surgery. Design: Prospective evaluation and data collection with review. Setting: University-affiliated county hospital. Patients: Twenty-nine male and 29 female subjects evaluated prospectively via 27 trauma-related and 31 elective procedures. Methods: Fifty-eight laparoscopic procedures were performed between July 1992 and February 1993 with a system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm using conventional surgical and laparoscopic instruments. Results: Gasless laparoscopy was used in the evaluation of 27 patients with abdominal trauma (11 gunshot wounds, 11 stab wounds, and five blunt injuries), The need for celiotomy was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphragmatic lacerations, and one gastric perforation were repaired with conventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n=26), diagnostic laparoscopy (n=3), and appendectomy (n=2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) and two superficial wound infections occurred in this group. The ability to use conventional surgical instruments was advantageous in several cases. Conclusions: Comparable exposure was achieved in this cohort of patients with gasless laparoscopy. The use of conventional surgical instruments provides an advantage with this technique. Further improvements in abdominal wall lift systems and modification of existing surgical instruments may expand the role of gasless laparoscopy.