Surg Endosc (1995) 9:497-500
Surgical
Gasless laparoscopy in abdominal surgery
V. Paolucci, C. N. Gutt, B. Schaeff, A. Encke
Department of General Surgery, Johann-Wolfgang-Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt-am-Main, Germany
Received: 15 April 1994/Accepted: 14 October 1994
Abstract. Pneumoperitoneum, as a necessary precon-
dition of laparoscopic procedures, represents a restric-
tion of the surgeon's freedom of movement and can
lead to rare but typical complications. We describe our
first experiences with laparoscopic surgery without us-
ing pneumoperitoneum. Under direct vision and digital
control a fan-formed wall retractor, which is attached
to an electric lift arm, is introduced into the abdominal
cavity. After raising the abdominal wall, the scope is
introduced through the same access and the laparo-
scopic procedure can be started without the technical
and physiopathological problems which may occur us-
ing a pneumoperitoneum. In this gasless laparoscopic
procedure, simple valveless trocars and instruments
can be used. Furthermore, an unlimited suction can be
obtained without a loss of exposure. During anesthe-
sia, neither increased ventilation nor increased venti-
lation pressure is necessary, and the surgeon has in-
creased freedom of action. Not only special laparo-
scopic instruments, but the conventional instruments,
used in open surgery, can also be employed in gasless
laparoscopy. In this way we performed gasless lapa-
roscopic surgery on 54 patients: cholecystectomy (n =
37), abdominal exploration for NSAP (n = 5) or tumor
staging (n = 4), fenestration of liver cysts (n = 5), and
appendectomy (n = 3). We did observe three wound
infections as related complications. Six times, we had
to change the surgical procedure. Compared to the
traditional procedure with a CO2 pneumoperitoneum,
the results of the first gasless procedures demonstrate
potential advantages.
Key words: Minimal invasive surgery - - Pneumoperi-
toneum - - Gasless laparoscopic surgery
Safe placement of the pneumoperitoneum is the first
step in all traditional laparoscopic procedures. The
Correspondence to: V. Paolucci
Endoscopy
© Springer-VedagNew York Inc. 1995
pneumoperitoneum represents an unavoidable restric-
tion of surgeon's freedom of movement and can be
made responsible for rare but specific complications
and problems [13, 15, 16]. Among them, the most com-
mon is carbon dioxide retention, which responds well
to hyperventilation. Maintaining the pneumoperito-
neum may be a problem during long laparoscopic op-
erations. Specially designed instruments for laparo-
scopic surgery with a pneumoperitoneum are expen-
sive and delicate, and surgeons are at first not familiar
with their handling. In literature several possible alter-
natives to the pneumoperitoneum in laparoscopic sur-
gery have been discussed [1, 2, 4, 7, 8, 10, 11].
Chin and Moll have designed a planar lifting system
which mechanically retracts the abdominal wall and in
this way allows an overview of the organs of an ab-
dominal quadrant, thereby avoiding a pneumoperito-
neum (Laparolift, Origin Medsystem) [3, 14]. Since
July 1993 we have been testing the same instrument
set, and in the present report we describe our first
experiences using the new technique in laparoscopic
surgery.
Materials and methods
The main part of the instrument set consists of an electrically pow-
ered lift arm (Laparolift) which is fastened to the operating table
and covered with a sterile bag. Pressing a button causes the lift a r m
to rise. It is adjustable in its length and can be swung (Fig. 1).
The other part of the system is a spreading retraction device,
which will open and attach to the tip of the telescopic arm of the
lifter (Laparofan). The branches of the retractor, which are intro-
duced into the abdominal cavity, have a maximum length of 15 cm.
The positioning of the retractor depends on the anatomic situation
and varies with the area of needed exposure. For example, in order
to perform a laparoscopic cholecystectomy, the right upper abdom-
inal quadrant has to be exposed (Fig. 2).
The procedure starts with a 2.0-cm-long incision, which should
be periumbilical for cholecystectomy, appendectomy, and diagnos-
tic examination of the abdominal cavity. The parietal peritoneum
has to be checked by palpating for the occurrence of eventual ad-
hesions. Under direct vision and digital control for the special re-
tractor is introduced into the abdominal cavity (Fig. 3). The
branches of the retractor can be opened and fixed by an attached
lever.
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Fig. 1. The electrically powered arm is secured on the side of the operating-room table at about the level of the shoulder (for upper abdominal
procedures) and lifts the anterior abdominal wall.
Fig. 2. The position of the fan retractor is shown on the abdominal surface before the skin incision.

Fig. 3. The fan-shaped abdominal-wall retractor is introduced

under direct digital guidance.
Fig. 4. A flexible 12-ram port, which allows the introduction of
long conventional surgical instruments.
Fig. 5. A ring forcep laterally retracts the infundibulum of the
gallbladder and the conventional surgical scissors inside the
serosa.

Table 1. Characteristics of patients who underwent gasless laparo-
scopic procedures (n = 54)
Age (mean _+ SD, years) 56 _+ 16
Sex (M/F) 13/41
Weight (mean _+ SD, kg) 68 _+ 16
Adhesions/prior surgery 6 Wound infections
Elective cholecystectomy 37
Acute Cholecystitis 6 a
Exploration for NSAP 5
or Tumorstaging 4 Results
Elective liver cyst fenestration 5
Appendectomy 3 I n 31 c a s e s , l a p a r o s c o p i c c h o l e c y s t e c t o m y w a s p e r -
Table 2. Results of gasless laparoscopic cholecystectomy (n = 37)
Conversion to pneumoperitoneum 3 three male patients with an abdominal wall too strong
Conversion to open technique 3
Operating time (mean +- SD, min) (n = 31) 95 -+ 22
Hospital stay (mean ± SD, days) (n = 31) 3_+1
Wound infections 2 d e r to r e c e i v e a g o o d e x p o s u r e to t h e r i g h t u p p e r a b -
Afterward the retractor will be attached to the sterile covered lift
arm. When the button is pressed, the lift arm raises directly with the
retractor and the abdominal wall. The dilation of the abdominal wall
is limited by a spring mechanism and is visualized to the surgeon by
a scale. The maximum strength which is applied to the abdominal
wall is 30 lb (more than 14 kg). The gasless retraction technique
without pneumoperitoneum creates a sufficient dilation of the ab-
dominal cavity and exposure to the organs of the quadrant of inter-
est.
A simple valveless trocar is introduced next to the retractor
through the same access and is used to insert the laparoscope into
the peritioneal space.
While inspecting the abdominal cavity, the position of the retrac-
tor branches has to be controlled. Neither omentum nor intestinal
loops must be caught. In order to gain a good exposure inclusion of
the ligamentum hepatis teres can be helpful for operations in the
upper abdomen.
There is no essential difference in positioning the instrument
trocars compared to the common laparoscopic technique. Simple
rubber ports can be used, because sealings are not necessary in the
absence of pneumoperitoneum. An additional instrument can be
placed next to the scope and to the fan retractor via the 2-cm peri-
umbilical incision. Apart from special laparoscopic instruments,
conventional instruments for open surgery can be used as well. In
this way, the operating surgeon is offered a variety of new possibil-
ities in performing laparoscopic techniques (Figs. 4 and 5).
At the end of the procedure, the abdominal wall is relaxed by
lowering the lift arm and the closed retractor is removed. The 2-cm-
long incision requires a closure of each layer.
Patients
Between July 1993 and February 1994 we performed gasless lapa-
roscopic procedures on 54 patients (41 women and 13 men). The
indication for laparoscopy was cholecystectomy (n = 37), abdomi-
nal exploration for nonspecific abdominal pain (NSAP) (n = 5) or
evaluation of tumor stage (n = 4), fenestration of liver cysts (n = 5),
and appendectomy (n = 3). Our decision, to use the gasless tech-
nique or the conventional technique with a pneumoperitoneum was
made by organizational and subjective considerations. We tended to
exclude patients markedly overweight and men with very strong
abdominal muscles. Table 1 summarizes the characteristics of the
patients who underwent gasless laparoscopic surgery. The first 12
cholecystectomies were exclusively performed with laparoscopic in-
struments. In the last procedures, we made use of conventional
instruments for open surgery (suction, gallbladder-grasper, right-
angle clamps, swabs, and scissors) in addition to the laparoscopic
set of instruments.
499
Table 3. Results of gasless laparoscopic surgery (n = 54)
Sufficient exposure for planned operation 48
Intraoperative conversion to other technique 6a
Shoulder pain 2
Abdominal wall tenderness secondary to distention 6
3
Cholecystectomies.
f o r m e d w i t h o u t t e c h n i c a l p r o b l e m s ( T a b l e 2). O u r a v -
e r a g e o p e r a t i n g t i m e w a s 95 rain, w h i c h is l o n g e r t h a n
the standard for a conventional laparoscopic cholecys-
t e c t o m y . I n six c a s e s t h e p r o c e d u r e w a s c h a n g e d . I n
f o r sufficient m e c h a n i c a l r e t r a c t i o n , w e h a d to c o n v e r t
to c o n v e n t i o n a l l a p a r o s c o p i c c h o l e c y s t e c t o m y in or-
domen. Removal of the retractor and instillation of a
carbon dioxide pneumoperitoneum provided a better
e x p o s u r e . T w i c e w e d e c i d e d to c h a n g e to o p e n s u r g e r y
because of an empyema of the gallbladder with a
h i g h l y i n f l a m e d w a l l i n c l u d i n g t h e bile d u c t a n d o n c e
b e c a u s e o f u n c l e a r a n a t o m i c r e l a t i o n s o f the g a l l b l a d -
d e r to t h e hilus o f t h e liver. T h e f a n r e t r a c t o r p r o v i d e d
a g o o d e x p o s u r e in all c a s e s o f d i a g n o s t i c l a p a r o s c o p y ,
liver cyst fenestration, and appendectomy. The me-
c h a n i c a l r e t r a c t i o n o f t h e a b d o m i n a l w a l l a l l o w s a suf-
ficient exposure of the abdominal organs. Compared
to a p n e u m o p e r i t o n e u m (12 m m H g CO2), t h e m e c h a n -
ical r e t r a c t i o n i n t e r f e r e s w i t h t h e o v e r v i e w , a n d it c a n
l e a d to a r e s t r i c t e d e x p o s u r e in u n f a v o r a b l e s i t u a t i o n s .
Sometimes, the antrum of the stomach and the trans-
verse colon impede the endoscopic view, because the
i n t r a a b d o m i n a l p r e s s u r e is m i s s i n g . I t c a n b e difficult
to o b t a i n l a t e r a l e x p o s u r e , e s p e c i a l l y in o b e s e p a t i e n t s .
T h e lift a r m as w e l l as t h e f a n r e t r a c t o r c a n i n t e r f e r e
w i t h t h e f r e e m o b i l i t y o f s u r g e o n ' s h a n d s d u r i n g dis-
section.
The use of long conventional surgical instruments,
e s p e c i a l l y ring f o r c e p s , for t h e r e t r a c t i o n o f t h e gall-
b l a d d e r , t o n s i l c l a m p s , s c i s s o r s , a n d l a p s p o n g e s in o u r
l a s t p a t i e n t s l e d to a n i m p r o v e d e x p o s u r e o f t h e o p e r -
ating field, a n d t h e r e f o r e to a s h o r t e r o p e r a t i n g t i m e .
T h e r e w a s no c a s e w h e r e s p e c i a l m a n a g e m e n t o f t h e
a n e s t h e s i a w a s n e c e s s a r y . I n o u r s e r i e s six p a t i e n t s
c o m p l a i n e d a b o u t p o s t o p e r a t i v e p a i n at t h e site o f ab-
d o m i n a l d i s t e n s i o n . E x c e s s i v e lifting, w h i c h m i g h t
c a u s e l a c e r a t i o n o f t h e a b d o m i n a l wall, c a n b e p r e -
vented because of the built-in barrier of the Laparofan.
We have observed three infections of the umbilical
wound.
T h e p o s t o p e r a t i v e c o u r s e w a s s i m i l a r to t h a t o f t h e
respective conventional laparoscopic procedures. The
average hospitalization time was 4 days. Two patients
c o m p l a i n e d a b o u t s h o u l d e r p a i n , w h i c h is t y p i c a l a f t e r
l a p a r o s c o p y w i t h a p n e u m o p e r i t o n e u m ( T a b l e 3).
Discussion
T h e p n e u m o p e r i t o n e u m , g e n e r a l l y u s e d f o r all l a p a r o -
s c o p i c p r o c e d u r e s , c a n l e a d to s p e c i f i c d i s a d v a n t a g e s
500
and result in complications. Among them are bowel
and vascular injuries by the Veress needle, air embo-
lism after direct intravascular CO2 insufflation, and
thromboembolism as a result of a decelerated blood
flow in the vena cava [12, 13]. An increased arterial
CO2 level during laparoscopic cholecystectomy is a
frequent condition, which usually can be compensated
for without any problems. This condition, in combina-
tion with an increased intraabdominal pressure and a
preexisting cardiopulmonary insufficiency, may lead
to a nontolerable cardiopulmonary risk. It is contrain-
dicated to subject these patients to a laparoscopic pro-
cedure using a pneumoperitoneum [9, 15, 16].
The production of laparoscopic instruments and
their trocars is technically complex and expensive.
One reason for this is that they need to be sealed to be
gastight. Furthermore, in the development of these in-
struments, ergonomic reasons often are not consid-
ered.
Some authors have tried to partly or completely
avoid the pneumoperitoneum during laparoscopic pro-
cedures [1, 2, 4-6, 8, 10]. Primarily, they used intricate
self-made retractor systems, which are complicated to
install. These experimental prototypes are not stan-
dardized instruments. In contrast to these prototypes,
the Origin planar lifting system is standardized and is
available on the market. This system has been clini-
cally tested at the University of California in Oakland
since July 1992. Their first results are encouraging
[141.
Our experiences with the Origin gasless retractor
system underline problems and advantages of this new
technique. The exposure of the region of interest is not
as satisfactory as the one reached by the conventional
gas insuttlation method. Yet without pneumoperito-
neum, the operating surgeon enjoys an increased free-
dom of action. Usually the main access for the re-
tractor and the laparoscope can be used for another
instrument. In this way it is generally possible to per-
form laparoscopic operations with fewer instrumental
ports as well as incisions. The extraction of operated
organs through 2-cm minilaparotomy is much easier
and safer. We think that this is a most promising ap-
proach especially for tumor and colon surgery and the
surgery of parenchymatous organs. For the surgeon,
to be able to make unlimited use of a regular suction
without any loss of exposure, is an appreciable advan-
tage.
A significant advantage of all gasless techniques for
abdominal surgery is the possibility to use those tra-
ditional surgical instruments for which no laparoscopic
equivalents exist. Ring forceps, right-angle clamps,
and bowel clamps give the surgeon more security.
Swabs and lap sponges allow wide retraction of bowel
loops.
Laparoscopic abdominal surgery without pneumo-
peritoneum, using a planar fan-shaped retractor, can
be performed under common clinical conditions. Our
experience demonstrates the practicability of this
technique. Compared to the traditional procedure with
a pneumoperitoneum, the results of our first proce-
dures appear to present potential advantages. The
main disadvantage, difficult exposure in obese and
muscolous patients, can probably be corrected by an
improved technology for example, with specially de-
signed fan retractors for each operative situation. In
the future, critical use will clarify whether the theoret-
ical advantages of gasless laparoscopic surgery can be
confirmed.
References
1. Araki K, Namikawa K, Yamamoto H, Mizutani J, Doiguchi M,
Arai M, Yamaguchi T, Uno K, Ido Y, Hayashi N, Ogawa M
(1993) Abdominal wall retraction during laparoscopic cholecys-
tectomy. World J Surg 17: 105-108.
2. Banting S, Shimi G, Vander Velpen G, Cushieri A (1993) Ab-
dominal wall lift: low pressure pneumoperitoneum laparoscopic
surgery. Surg Endosc 7: 57-59.
3. Chin A, Eaton J, Tsoi EKM (1994) Gasless laparoscopy using a
planar lifting technique. Surg. Gynecol Obstet (in press).
4. Gazayerli M (1991) The Gazayerli endoscopic retractor Model I.
Surg Laparosc Endosc 1: 98-100.
5. Hashimoto D, Nayeem SA, Kajiwara S, Hoshino T (1993) Lap-
aroscopic cholecystectomy: an approach without pneumoperi-
toneum. Surg Endosc 7: 54-56.
6. Hayakawa N, Nimura Y, Kamiya S (1991) Laparoscopic cho-
lecystectomy using retraction of the falciform ligament. Surg
Laparosc Endosc 1: 126.
7. Kitano S, Tomikawa M, Iso Y, Iwata S, Gondo K, Moriyama
M, Sugimachi K (1992) A safe and simple method to maintain a
clear field of vision during laparoscopic cholecystectomy. Surg
Endosc 6:197-198.
8. Kitano S, Iso Y, Tomikawa M, Moriyama M, Sugimachi K
(1993) A prospective randomized trial comparing pneumoperi-
toneum and U-shaped retractor elevation for laparoscopic cho-
lecystectomy. Surg Endosc 7:311-314.
9. Mark D, Murr W, Murr C (1993) Laparoscopic insuffiation of
the abdomen depresses cardiopulmonary function. Surg Endosc
7:12-16.
10. Nagai H, Inabo T, Kamiya S (1991) A new method of laparu-
scopic cholecystectomy: an abdominal wall lifting technique
without pneumoperitoneum. Surg Laparosc Endosc 1:26-28.
11. Nagai H, Kondo Y, Yasuda T, Kasahara K, Kanazawa (1992) A
new method of laparoscopic cholecystectomy and other abdom-
inal surgery: an abdominal wall-lift technique not utilizing peri-
toneal insufflation. Surg Endosc 6: 87.
12. Ponsky JL (1991) Complication of laparoscopic cholecystecto-
my. Am J Surg 161: 393-397.
13. Serum K (1993) Das pneumoperitoneum Fehler und Gefahren.
In: Brune IB, SchOnleben K (eds) Laparoendoskopische Chi-
rurgie. Hans MarseiUe Verlag, M0nchen, pp 21-42.
14. Smith RS, Fry WR, Tsoi EKM, Henderson VJ, Hirvela ER,
Koehler RH, Brains DM, Morabito DJ, Peskin GW (1993) Gas-
less laparoscopy and conventionalinstruments. The next phase
of minimally invasive surgery. Arch Surg 128: 1102-1107.
15. Wittgen CM, Andrus CH, Fitgerald SD, Baudendistel LJ,
Dahms TE, Kaminski DL (1991) Analysis of the hemodynamic
and ventilatory effects of laparoscopic cholecystectomy. Arch
Surg 126: 997-1001.
16. Wolfe BM, Gardiner BN, Leary BF, Frey CF (1991) Endo-
scopic cholecystectomy: an analysis of complications. Arch
Surg 126: 1192-1198.