Why Gasless Laparoscopic Surgeries?

What is wrong with laparoscopic surgeries? Aren’t they good?

Like the discovery of anesthesia, laparoscopic surgeries were one of the landmark innovations in making surgeries minimally invasive. However, there are few drawbacks. Namely:

  1. There is a very small but definite risk of complications that can be fatal.
  2. The carbon dioxide that is used causes several physiological changes that make anesthesia more complex and increase post-operative morbidity.
  3. Several factors, like the need for general anesthesia, and the cost of the equipment and disposables or hand instruments make laparoscopic surgeries expensive.
  4. It has a steep learning curve.

gasless lap surgery 1 - dr g

When and why were gasless laparoscopic surgeries started?

In the late eighties and early nineties, Professor Hashimoto introduced the concept of gasless laparoscopic surgery to overcome some of the drawbacks of carbon dioxide usage. The early pioneers like Dr. Daniel Kruschinski did several animal studies to prove the superiority of the gasless laparoscopic surgeries.

gasless lap surgery 2 - dr g

Why didn’t it become very popular then?

Despite the clear physiological advantages, it did not become very popular because it was technically difficult to perform, as the exposure during surgery was not as good as that of regular laparoscopic surgeries. The Abdo-Lift designed in Germany was the first equipment to offer good exposure and was commercially available. This equipment was also difficult to set up and use.

Why is it becoming more popular now, after two decades?

There are two reasons for this:

  1. The equipment became less expensive, and with the later modifications, it became easy to use and could be set up in a short time
  2. Single incision surgeries were much easier with gasless laparoscopic surgeries

gasless lap surgery 3 - dr g

So what are the advantages of gasless laparoscopic surgeries?

  1. It is safer, as it does not have the complications that are associated with use of carbon dioxide insufflation.
  2. It does not cause physiological changes, and hence no stress on anesthesiologists or a need for special monitors. This makes it safer for patients with medical problems.
  3. It is much less expensive, both in terms of equipment and disposables, and also the use of regional or spinal anesthesia.
  4. Post-operative recovery is faster, and complications like post-operative adhesions are less.
  5. It is easier for surgeons to learn, and the traditional well-refined hand instruments could be used.

What are the common surgeries that are possible with gasless laparoscopy?

  1. The greatest advantage is for pelvic surgeries like removal of the uterus, ovarian cysts, surgery for infertility, etc.
  2. Appendicectomy is another single incision surgery that is easy to do with this method.
  3. Other surgeries like hernioplasty, colposuspension, anterior resection, cholecystectomy, etc. are possible too.

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Are there any problems or difficulties?

It is difficult to perform in obese patients, as the abdominal wall is very thick, and lifting is difficult. Patients with previous surgeries and adhesions have problems with insertion of the lifting apparatus. Sometimes gas is used to release or remove these adhesions, and then work is done with the gasless laparoscopic method.

Summary

Regular laparoscopic surgeries have a small but definite risk of complications that could be fatal. They also cause physiological changes that are a challenge to the anesthesiologist and some post operative complications. Professor Hashimoto is considered the father of gasless laparoscopic surgeries, and several animal studies in Germany proved its superiority. However, the earlier devices invented in the nineties were difficult to use, and the surgical exposure was inadequate for comfortable surgery. Recent equipment has better exposure, and they are easy to use and quick to set up.

They make single incision surgeries much more comfortable and easy to learn, as well-refined traditional hand instruments are used. They are ideal for pelvic surgery in thin to moderately built patients. Single incision hysterectomies, ovarian cystectomies and infertility surgeries are much better than with regular laparoscopy. Appendicectomy is another simple single incision surgery that is easy with this technique. Hernioplasty, cholecystectomy, anterior resection, colopsuspension, etc., are few other surgeries that were carried out.

gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.

References (click to show/hide)

  1. Gnanaraj J. Treatment of Ovarian cysts for rural patients. mdCurrent-India, September 2015. (http://mdcurrent.in/patients/treatment-of-ovarian-cysts-for-rural-patients/ )
  2. Gnanaraj J. Treatment for excessive menstrual bleeding in rural areas: A look at the available options. mdCurrent-India, September 2015. (http://mdcurrent.in/patients/treatment-for-excessive-menstrual-bleeding-in-rural-areas-a-look-at-the-available-options/ )
  3. Gnanaraj J. Uterine Fibroids: Symptoms, causes and treatment. mdCurrent-India, August 2015. [http://mdcurrent.in/obstetrics-gynaecology/uterine-fibroids-symptoms-causes-and-treatment/ ]
  4. Gnanaraj J. What is new about Appendix surgeries? mdCurrent-India, August 2015. (http://mdcurrent.in/patients/what-is-new-about-appendix-surgeries/ )
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