■ Deaths that are not directly associated with laparoscopic surgery, but are caused by carbon dioxide pneumoperitoneum (gas embolism or splanchnic vessel thrombosis) have been reported (98-100).

■ Sternberg et al. stated that gasless or low-pressure laparoscopic surgery should be considered for patients with preoperative impairment of splanchnic blood flow and/or a hypercoagulable state (98). Gasless laparoscopic surgery is valuable as a less invasive technique for patients with serious cardiopulmonary dysfunction.

■ We have performed laparoscopic surgery in about 720 patients at our institution. Gasless minilaparotomy (three radical nephrectomies and one adrenalectomy) was necessary in four patients with serious cardiopulmonary dysfunction contraindicating.

■ Gasless laparoscopic surgery has the major merit of little influence on cardiopulmonary function, but has the demerit that it only provides a small working space, particularly when the access site is blocked by the intestines or not.

■ Gasless laparoscopic surgery is considered to be more appropriate for surgery at sites that are not severely obstructed by the intestines, such as cholecystectomy, partial hepatectomy, oophorectomy, and adrenalectomy.

■ Gasless laparoscopy-assisted minilaparotomy may be useful for technically demanding operations on malignant tumors. Surgeons who aim to be an expert at laparoscopic surgery should master various techniques and approaches, and then select the most appropriate method for each tumor and patient. Abdominal wall lifting may be an option for laparoscopic surgery.

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