Equipment And Technique

Gasless laparoscopy creates a working space in the abdominal cavity by lifting the abdominal wall instead of using carbon dioxide. To lift the abdominal wall, the following three methods are available; subcutaneous wire lifting in which a thin steel wire is passed subcutaneously to lift the abdominal wall; peritoneal planar lifting in which by a retractor is inserted into the abdominal cavity to lift the whole abdominal wall; and abdominal wall lifting in which the abdominal wall is lifted by a retractor inserted through a small skin incision (Fig. 1A-D).

Further, gasless laparoscopic surgery can be performed by the following techniques: a pure laparoscopic procedure in which several ports are placed after the abdominal wall is lifted and all surgical procedures are done under video monitoring; gasless laparoscopic minilaparotomy in which abdominal wall lifting is combined with a small skin incision to allow surgery under direct vision; hand-assisted surgery in which one hand of the surgeon is inserted through a small skin incision; and a combination of minilaparotomy and hand-assisted surgery.

Lifting devices for subcutaneous wire lifting that were developed by Nagai et al. and Hashimoto et al. are commercially available in Japanc (Fig. 2A and B). The abdominal wall is lifted with a subcutaneous steel wire to create a working space in the peritoneal cavity. Because the space created is relatively small, this method requires some skill when it is used in obese patients or for technically difficult operations.

cMizuho Medical Co., Ltd., http://www.pnet.mizuho.co.jp; Takasago Medical Industry Co., Ltd., http://www.takasagoika.co.jp.

FIGURE 2 ■ (A) Subcutaneous wire lifting methods was developed by Nagai et al. -

(2). (B) Subcutaneous wire lifting methods was developed by Hashimoto et al. (4).

FIGURE 2 ■ (A) Subcutaneous wire lifting methods was developed by Nagai et al. -

(2). (B) Subcutaneous wire lifting methods was developed by Hashimoto et al. (4).

FIGURE3 ■ Peritoneal planar lifting device: VarioLift.

However, technically easier operations such as cholecystectomy can be performed as a pure laparoscopic procedure without minilaparotomy.

A device for lifting the whole abdominal wall (Laparofan, Laparolift) was used in Western countries since around 1993, but is no longer being manufactured. The currently available device for peritoneal planar lifting is known as the VarioLift™d (Fig. 3).

Peritoneal planar lifting provides a slightly larger working space than the subcutaneous wire method because it raises the whole abdominal wall. However, a Japanese multicenter clinical study compared the peritoneal planar lifting with subcutaneous wire lifting and found that C-reactive protein was significantly increased in the peritoneal planar group postoperatively. This indicates that the peritoneal planar lifting may have a stronger effect on the peritoneum and abdominal wall muscles (45).

Yang et al. developed a mechanical retractor for video-assisted minilaparotomy live donor nephrectomye (Fig. 4). This device requires the insertion of several retractors into the retroperitoneum and a working space created by pulling on the retractors. This technique is generally used under direct vision in live donor nephrectomy. Suzuki et al. have performed hand-assisted, live donor nephrectomy by lifting the abdominal wall with retractors inserted into the retroperitoneumf to allow insertion of the

dAESCLAP Inc.; Center Valley, PA.

eThompson Surgical Instruments, Inc. Traverse City, MI.

fMinilaparotomy Retractor; Mizuho Medical Co., Ltd. http:/ /www.pnet.mizuho.co.jp.

Gasless surgery without carbon dioxide pneumoperitoneum is not associated with compression of the inferior vena cava and intestinal vessels, elevation of the diaphragm, and absorption of carbon dioxide gas into the blood. Therefore, the gasless laparoscopic surgery is superior with regard to the effects on hemodynamics and respiratory function.

Tumor growth may be attributable not to carbon dioxide gas, but to reduced blood flow in the peritoneum, liver, and renal cortex secondary to high-pressure pneumoperitoneum.

surgeon's hand (Fig. 5). The kidney and ureter are dissected with a hand-assisted technique under video monitoring, while the renal pedicle is managed under direct vision for safety.

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