Marketing Gasless Surgery


Gasless laparoscopic surgery is an innovation with great potential. Although the innovation of laparoscopic or minimally invasive surgery almost as significant as that of discovery of anesthesia or antisepsis for surgery it has poor market penetration. The reason for this are the high costs, the logistics associated with provision of bottled gases and experiences anesthesiologists in rural areas. Gasless laparoscopic surgeries mitigates the problems associated with traditional laparoscopic surgeries and hence has a great potential.


Lancet commission on global surgery estimates that 5,000 surgeries are needed per 100,000 populations every year. Roughly about a fourth of this could be treated laparoscopically which is about 1,200 surgeries per 100,000 per year [1]. However, the actual number of surgeries that are carried out could be even less than 300 per 100,000 per year [2, 3]

It is estimated that only 7.5 million to 15 million laparoscopic surgeries are carried out annually whereas if all eligible surgeries are carried out laparoscopically it should be about 125 million [3,4]. As one would expect most of these surgeries would be in the well-developed Western World and Japan [66%].


Would gasless surgeries be possible for all the eligible 125 million every year? It has limitations. It is difficult in obese patients, almost impossible if the abdominal wall thickness is more than 2 inches and difficult if over 1.5 inches. It is very good for pelvic surgeries and would be difficult for complex upper abdominal surgeries. However in rural areas since the bulk of surgical procedures are in the lower abdomen it has great potential.
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  1. No gases involved and no logistic problems and much less cost
  2. Possible under spinal anesthesia that is low cost and easily available
  3. Low cost equipment
  4. Easy learning curve
  5. Single incision surgeries are easy


    1. Those doing traditional laparoscopic surgeries
    2. The niche market of single incision surgeries
    3. Those doing open surgeries


The advantage with this market is that just the sale of equipment and few demonstrations should suffice for them start doing the surgeries. However this market will show the least interest. They are already in their comfort zone and changing to gasless surgeries might decrease their income although it would be better for the patients. They will compare the price of the equipment with that of insufflators and those in rural areas might use air instead of carbon dioxide if they do have difficulty in getting gases.


The niche market laparoscopic surgeons would appreciate gasless laparoscopy for the following reasons:

  1. Single incision laparoscopic surgeries are far more easier and much less expensive compared to traditional laparoscopic surgeries
  2. The physiological advantages i.e. the lack of physiological changes because carbon dioxide is not used would be appreciated in longer duration surgeries and centers that compete for quality

This again is not a great market or a high volume market.


This is the ideal market for gasless laparoscopic surgeries. The potential is even greater in low income and LMIC countries where the patients would also be appropriately thin. There are many advantages:

    1. Lower costs for patients
    2. Surgeries under spinal anesthesia
    3. Quick turnover means surgeries are possible with visiting teams

The problem however is that the surgeons need training and preferably at their own place. However this also might not be sufficient. This is because at the present state of affairs they need to buy everything that traditional laparoscopic surgery needs except the insufflators and in addition get the gasless surgery apparatus. Hence the total investment for gasless surgery remains the same or may be even marginally higher. Hence it might not be an attractive option for teams who are not traveling to rural areas to operate. There are not many teams that do travel to rural areas for surgeries and the surgeons in rural areas who can afford gasless surgery can also afford traditional laparoscopic surgeries and might not see a great advantage to shift to gasless surgeries.


If the gases less surgeries are to reach the potential market of underserved population the following are necessary:

    1. The cost of the equipment should be at least 50% less than the current cost of the low cost traditional laparoscopic surgery set
    2. Extensive training programs are necessary


There are several ways in which the costs of the equipment could be reduced. The following are some important ones where further research is necessary:

  1. The bulk of the cost of traditional laparoscopic surgery is for the camera and telescope. The current designs are necessary for prevention of gas leakage. With gasless surgeries since there is no problem with gas leak a much better and lower cost camera could be designed and there is no need for telescope if lighting is provided by other means.
  2. Lowering the cost of camera would help the surgeons to upgrade to vessel sealing electrocautery machine that would be more useful.
  3. Local Televisions could be used instead of monitors. This already happens with low cost traditional laparoscopic set
  4. Regular computers could be used for processing the inputs from the camera.
  5. Sturdy instruments could be designed as the design need not take into account the gas leak.


There is a very great potential market for gasless laparoscopic surgeries especially in rural areas if comprehensive low cost equipment could be designed. Use of regular visiting teams and task specific training and competency based credentialing would greatly increase the surgical cover in rural areas.

Gnanaraj-64 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 gasless laparoscopic surgeries. During the past year, he has been training surgeons in innovative gasless single incision laparoscopic surgeries.

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This entry was posted in Practice Management, Practice Management Featured 2, Surgery and tagged , , , , . Volume: .


  1. Sunil Gaikwad
    Posted Feb 2017 at 5:47 pm | Permalink

    Training opportunities where

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