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 durin g 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 prospect ively via 27 trauma-related and 31 elective procedures. Methods: Fifty -eight laparoscopic procedures were performed between July 1992 and Fe bruary 1993 with a system consisting of an intra-abdominal fan retract or and an electrically powered mechanical arm using conventional surgi cal and laparoscopic instruments. Results: Gasless laparoscopy was use d in the evaluation of 27 patients with abdominal trauma (11 gunshot w ounds, 11 stab wounds, and five blunt injuries), The need for celiotom y was obviated in 20 (74%) of 27 cases. Three enterotomies, two diaphr agmatic lacerations, and one gastric perforation were repaired with co nventional instruments. Gasless laparoscopic techniques were also used in cholecystectomy (n=26), diagnostic laparoscopy (n=3), and appendec tomy (n=2). Exposure similar to that obtained by pneumoperitoneum was obtained in 30 (97%) of 31 cases. One major (trocar tip enterotomy) an d 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 i nstruments provides an advantage with this technique. Further improvem ents in abdominal wall lift systems and modification of existing surgi cal instruments may expand the role of gasless laparoscopy.