Video: GLLS Equipment

This is a teaching video about the Gas Less Laparoscopic Surgeries and how to set up the equipment and start the surgeries.

There are few discoveries that dramatically changed the surgical care. Prior to the days of anesthesia speed was very important. Most of the surgeries had to finish within minutes.

When the use of anesthesia started everyone used anesthesia for surgery. Sepsis was then a major problem and the anti–septic practice was then universally practiced.

The discovery of laparoscopic surgery should have had such dramatic impact but the penetration of laparoscopic surgery is poor with less than 10% practicing it all over the World. The high costs and need for trained anesthesiologists and gases limited its wide usage.
Although healthy patients tolerate the effects of carbon di oxide insufflation very well compromised patients can have life threatening complications due to insufflation like cardiac arrhythmias, myocardial infarction, cardiac failure and pulmonary insufficiency. In addition there is a small but definite risk of complications. Hence the Gas Less Laparoscopic surgeries were developed.

There are several advantages to the Gas less surgeries as this long list show:

1. 1. NO PHYSIOLOGICAL CHANGES DUE TO CARBON DIOXIDE, LIKE:
      1. CO2 absorption, intravasation and increased pCO2
      2. Hyperventilation
      3. Ametabolic acidosis
      4. Hypoxemia
      5. Hypothermia
      6. Hypercapnia / Hypercarbia (5.5%)
      7. Increased CVP and reduced cardiac output
      8. Increased vascular resistance
      9. Hyperventilation due to increased intra-abdominal pressure
      10. More stress response due to carbon dioxide
      11. Derangement of pulmonary function
      12. Adverse effect on urine output
   2. NO DISADVANTAGES DUE TO PNEUMOPERITONEUM, LIKE:
      1. Increased intra-abdominal pressure
      2. Lowering of temperature
      3. Shoulder pain
      4. Acidity
      5. Overdose of carbonic acid
   3. NO COMPLICATIONS RELATED TO PORT INSERTIONS, LIKE:
      1. Bowel and vessel injury
      2. Air embolism
      3. Pneumothorax (1.9%)
      4. Pneumomediastinum (2.1%)
      5. Pulmonary embolism
      6. Massive subcutaneous edema (2.3%)
   4. NO DISADVANTAGES DURING BLEEDING, LIKE:
      1. Poor vision due to pneumoperitoneal collapse during suction
      2. Movement of the vessel, due to changes in pressure
      3. Misting of the lens
   5. NO DISADVANTAGES IN THE POST-OPERATIVE PERIOD, LIKE:
      1. Increased adhesions and spreading of malignant cells
      2. Infection due to contamination of tubes with rust, viruses and bacteria
      3. Unfavorable effect on phagocytosis by carbon dioxide
   6. NO STEEP LEARNING CURVE
      1. Handling of laparoscopic instruments is different from open instruments
      2. Less tactile feedback
      3. The instruments are different and delicate
   7. NO DISADVANTAGES OF TRADITIONAL SINGLE INCISION LAPAROSCOPIC SURGERIES, LIKE:
      1. Handling of instruments in the opposite hands or unfamiliar hands (than one is used to, for regular laparoscopic surgery)
      2. The fragility of the instruments
      3. Need for previous SILS experience (previous LAP experience is not adequate for SILS)
   8. NO DISADVANTAGES OF HIGH COST, LIKE:
      1. Initial equipment
      2. Disposables

Why is not popular then?

The table shows that these devices were available from the early nineties. Despite the advantages they were not popular because they either had poor exposure, was difficult to fix and use and some of the mechanized version were very expensive. They were difficult to use and most of the publications were from single centers only.

There were some from India too. The video shows these devices.

We are now going to show you how to set up the instrument and start the surgery and the method of closing the wounds.

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.