GASLESS LAPAROSCOPIC SURGERY

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GASLESS LAPAROSCOPIC SURGERY

• Metin BERBEROGLU M.D.
• Muhittin ALKIS M.D.
• Mustafa BAGCIOGLU M.D.
• Fatih GUNBATILI M.D.
• ANKARA NUMUNE HOSPITAL
• 6.th SURGICAL UNIT

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GASLESS LAPAROSCOPY

• Laparoscopic surgery which has gained wide
  acceptance in our country is currently being
  performed with only CO2 insufflation technique.

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GASLESS LAPAROSCOPY

• Hypercarbia, increased systemic vascular
  resistance, CO2 embolus, shoulder pain etc. are
  the known major problems associated with this
  insufflation technique. This has lead to the
  development of gasless laparoscopic surgery.

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PROBLEMS DUE TO CO2 PNEUMOPERITONEUM

• ORGAN INJURY ORIGINATED FROM
• VERRES NEEDLE INSERTION
• TROCAR PLACEMENT
• COMPLICATIONS ASSOCIATED WITH CO2 INSUFFLATION
• CARBONDIOXIDE EMBOLUS
• HYPERCARBIA, ACIDOSIS
• ELEVATED INTRAABDOMINAL PRESSURE
• OESOPHAGOGASTRIC REFLUX
• DEEP VENOUS THROMBOSIS
• CARDIAC ARRYTHMIAS, BRADICARDIA
• SHOULDER PAIN,
• DEEP VAGAL STIMULI, SYSTEMIC HYPERTENSION
• INSUFFLATION ERRORS
• MEDIASTINAL EMPHYSEMA
• EXTRAPERITONEAL INSUFFLATION
• SUBCUTANEOUS EMPHYSEMA DUE TO GAS LEAKAGE
• RAPID GAS LOSS DURING
• SUCTION OF THE FLUIDS
• WITHDRAWN ANY OBJECT SUCH AS GALL BLADDER

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CURRENT SYSTEMS OF GASLESS LAPAROSCOPY

• DEVICE TYPE REQUIRES PNEUMO STATUS
• Mouret Suspendur Circular Yes Europe
• Laparolift Planar No FDA
• Bookler AWEL T-Bar Yes FDA
• Cuschieri Sling Yes Europe
• Maher Coat Hanger No Australia
• Kitano U-Shaped Retractor Yes Japan
• Nagai Tent-Shaped Lift No Japan
• Hashimato Double wire Lift No Japan

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SOME OF THE CURRENT SYSTEMS FOR GASLESS
LAPAROSCOPY
CUSHIERIS TECHNIQUE
U-Shaped retractor
Laparolift System
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ADVANTAGES OF THE GASLESS TECHNIQUE INCLUDE

• Avoidance of hemodynamic and metabolic changes
  associated with CO2 pneumoperitoneum
• Decreased reliance on maintaining an airtight
  pneumoperitoneum for exposure
• Decrease in complications directly associated
  with pneumoperitoneum, such as gas embolism or
  tension pneumothorax
• Reduction in the number of expensive disposable
  instruments
• The ability to use conventional instruments
  during laparoscopic procedures

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GASLESS LAPAROSCOPY

• We started using this technique in selected cases
  and have performed seven operations since
  November 1993. Before the deadline for abstract
  forms for this congress, there were some cases
  already performed successfully. As our experience
  improved, many other cases were added into our
  series.

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STATUS IN OUR CLINIC BEFORE DEADLINE

• CASE OPERATION RESULT
  
  
• 1 CHOLECYSTECTOMY GASLESS FAILED, REQUIRED
  PNEUMOPERITONEUM
• 2 OVARIAN CYSTECTOMYTUBAL LIGATION SUCCESSFULLY
  COMPLETED
• 3 CHOLECYSTECTOMY GASLESS FAILED, REQUIRED
  PNEUMOPERITONEUM
• 4 DRAINAGE OF THE LIVER CYST SUCCESSFULLY
  COMPLETED
• 5 HERNIORRHAPHY GASLESS FAILED, REQUIRED
  PNEUMOPERITONEUM
• 6 CHOLECYSTECTOMY GASLESS FAILED, REQUIRED
  PNEUMOPERITONEUM
• 7 VARICOCELECTOMY SUCCESSFULLY COMPLETED

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GASLESS TECHNIQUE

• Gasless technique included insertion of a fan
  retractor LaparofanTM through a periumblical
  incision, separation of retractor blades and
  lifting the abdominal wall with an
  electromechanical lifting arm LaparoliftTM which
  is attached to the siderail of the operating
  table.

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GASLESS TECHNIQUE

• Once the working space was created, laparoscope
  was inserted through the umblical port. Some
  instruments can pass through the same place.
  There is no need to use trocar at umblical port.
• We advise to use flexible Gasless trocars for
  other ports. Flexible ones let us to use
  conventional instruments.
• The operations were then completed with
  conventional and/or laparoscopic surgical
  instruments.

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PRESENT CONDITION IN OUR CLINIC

• We already performed some procedures successfully
  other than listed before
• HYDATID DISEASE OF THE LIVER 3 CASES
• LEFT LOBE 1
• RIGHT LOBE 2
• LAPAROSCOPIC CHOLECYSTECTOMY 7 CASES
• OTHER PROCEDURES 7 CASES
• OVARIAN CYST 2
• ADHESIOLYSIS 3
• PLASTRONE APPENDICITIS 1
• VARICOCELECTOMY 1

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HINTS TO SUCCESS

• SURGEON MUST HAVE
• High tolerance for variability
• Enough ability to complete any laparoscopic
  maneuver
• PATIENT SELECTION
• At the beginning, select smaller and lighter
  patients
• Musculer males were difficult
• PROCEDURES
• Lower abdominal procedures are best
• Cholecystectomies and liver cyst operations
  fairly good
• Colectomies, hernial repair and etc can be
  performed
• ANESTHESIA
• Make sure the anesthesiologist is not using
  nitrous oxide
• There is no need to perform deep and frequent
  respiration

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GASLESS LAPAROSCOPY

• Gasless technique although avoids the problems
  associated with CO2 insufflation, has certain
  disadvantages at the moment but if the technical
  problems can be solved in the near future, it
  will be the next phase in minimally invasive
  surgery.