1. GASLESS LAPAROSCOPIC SURGERY Metin BERBEROGLU M.D. Muhittin ALKIS M.D. Mustafa BAGCIOGLU M.D. Fatih GUNBATILI M.D. ANKARA NUMUNE HOSPITAL 6.th SURGICAL UNIT

2. Laparoscopic surgery which has gained wide acceptance in our country is currently being performed with only CO 2 insufflation technique. Laparoscopic surgery which has gained wide acceptance in our country is currently being performed with only CO 2 insufflation technique. GASLESS LAPAROSCOPY

3. Hypercarbia, increased systemic vascular resistance, CO 2 embolus, shoulder pain etc. are the known major problems associated with this insufflation technique. This has lead to the development of gasless laparoscopic surgery. Hypercarbia, increased systemic vascular resistance, CO 2 embolus, shoulder pain etc. are the known major problems associated with this insufflation technique. This has lead to the development of gasless laparoscopic surgery.

4. PROBLEMS DUE TO CO 2 PNEUMOPERITONEUM ORGAN INJURY ORIGINATED FROM ORGAN INJURY ORIGINATED FROM VERRES NEEDLE INSERTION VERRES NEEDLE INSERTION TROCAR PLACEMENT TROCAR PLACEMENT COMPLICATIONS ASSOCIATED WITH CO 2 INSUFFLATION COMPLICATIONS ASSOCIATED WITH CO 2 INSUFFLATION CARBONDIOXIDE EMBOLUS CARBONDIOXIDE EMBOLUS HYPERCARBIA, ACIDOSIS HYPERCARBIA, ACIDOSIS ELEVATED INTRAABDOMINAL PRESSURE ELEVATED INTRAABDOMINAL PRESSURE OESOPHAGOGASTRIC REFLUX OESOPHAGOGASTRIC REFLUX DEEP VENOUS THROMBOSIS DEEP VENOUS THROMBOSIS CARDIAC ARRYTHMIAS, BRADICARDIA CARDIAC ARRYTHMIAS, BRADICARDIA SHOULDER PAIN, SHOULDER PAIN, DEEP VAGAL STIMULI, SYSTEMIC HYPERTENSION DEEP VAGAL STIMULI, SYSTEMIC HYPERTENSION INSUFFLATION ERRORS INSUFFLATION ERRORS MEDIASTINAL EMPHYSEMA MEDIASTINAL EMPHYSEMA EXTRAPERITONEAL INSUFFLATION EXTRAPERITONEAL INSUFFLATION SUBCUTANEOUS EMPHYSEMA DUE TO GAS LEAKAGE SUBCUTANEOUS EMPHYSEMA DUE TO GAS LEAKAGE RAPID GAS LOSS DURING RAPID GAS LOSS DURING SUCTION OF THE FLUIDS SUCTION OF THE FLUIDS WITHDRAWN ANY OBJECT SUCH AS GALL BLADDER WITHDRAWN ANY OBJECT SUCH AS GALL BLADDER IMPOSSIBILITY TO USING CONVENTIONAL INSTRUMENTS IMPOSSIBILITY TO USING CONVENTIONAL INSTRUMENTS DIFFICULTIES TO PERFORM SOME OPERATIONS DIFFICULTIES TO PERFORM SOME OPERATIONS RISK OF CARDIAC AND PULMONARY FAILURE RISK OF CARDIAC AND PULMONARY FAILURE

5. CURRENT SYSTEMS OF GASLESS LAPAROSCOPY DEVICETYPEREQUIRES PNEUMOSTATUS Mouret SuspendurCircularYesEurope Mouret SuspendurCircularYesEurope LaparoliftPlanarNoFDA LaparoliftPlanarNoFDA Bookler AWELT-BarYesFDA Bookler AWELT-BarYesFDA CuschieriSlingYesEurope CuschieriSlingYesEurope MaherCoat HangerNoAustralia MaherCoat HangerNoAustralia KitanoU-Shaped RetractorYesJapan KitanoU-Shaped RetractorYesJapan NagaiTent-Shaped LiftNoJapan NagaiTent-Shaped LiftNoJapan HashimatoDouble wire LiftNoJapan HashimatoDouble wire LiftNoJapan

6. CUSHIERI’S TECHNIQUE U-Shaped retractor Laparolift System SOME OF THE CURRENT SYSTEMS FOR GASLESS LAPAROSCOPY

7. ADVANTAGES OF THE GASLESS TECHNIQUE INCLUDE: Avoidance of hemodynamic and metabolic changes associated with CO 2 pneumoperitoneum Avoidance of hemodynamic and metabolic changes associated with CO 2 pneumoperitoneum Decreased reliance on maintaining an airtight pneumoperitoneum for exposure Decreased reliance on maintaining an airtight pneumoperitoneum for exposure Decrease in complications directly associated with pneumoperitoneum, such as gas embolism or tension pneumothorax Decrease in complications directly associated with pneumoperitoneum, such as gas embolism or tension pneumothorax Reduction in the number of expensive disposable instruments Reduction in the number of expensive disposable instruments The ability to use conventional instruments during laparoscopic procedures The ability to use conventional instruments during laparoscopic procedures

8. GASLESS LAPAROSCOPY We started using this technique in selected cases and have performed seven operations since November 1993. Before the deadline for abstract forms for this congress, there were some cases already performed successfully. As our experience improved, many other cases were added into our series. We started using this technique in selected cases and have performed seven operations since November 1993. Before the deadline for abstract forms for this congress, there were some cases already performed successfully. As our experience improved, many other cases were added into our series.

9. STATUS IN OUR CLINIC BEFORE DEADLINE CASE OPERATION RESULT 1CHOLECYSTECTOMYGASLESS FAILED, REQUIRED PNEUMOPERITONEUM 2 OVARIAN CYSTECTOMY+TUBAL LIGATION SUCCESSFULLY COMPLETED 3CHOLECYSTECTOMYGASLESS FAILED, REQUIRED PNEUMOPERITONEUM 4 DRAINAGE OF THE LIVER CYST SUCCESSFULLY COMPLETED 5HERNIORRHAPHYGASLESS FAILED, REQUIRED PNEUMOPERITONEUM 6CHOLECYSTECTOMYGASLESS FAILED, REQUIRED PNEUMOPERITONEUM 7VARICOCELECTOMYSUCCESSFULLY COMPLETED

10. GASLESS TECHNIQUE Gasless technique included insertion of a fan retractor Laparofan TM through a periumblical incision, separation of retractor blades and lifting the abdominal wall with an electromechanical lifting arm Laparolift TM which is attached to the siderail of the operating table. Gasless technique included insertion of a fan retractor Laparofan TM through a periumblical incision, separation of retractor blades and lifting the abdominal wall with an electromechanical lifting arm Laparolift TM which is attached to the siderail of the operating table.

11. GASLESS TECHNIQUE Once the working space was created, laparoscope was inserted through the umblical port. Some instruments can pass through the same place. There is no need to use trocar at umblical port. Once the working space was created, laparoscope was inserted through the umblical port. Some instruments can pass through the same place. There is no need to use trocar at umblical port. We advise to use flexible Gasless trocars for other ports. Flexible ones let us to use conventional instruments. We advise to use flexible Gasless trocars for other ports. Flexible ones let us to use conventional instruments. The operations were then completed with conventional and/or laparoscopic surgical instruments. The operations were then completed with conventional and/or laparoscopic surgical instruments.

12. PRESENT CONDITION IN OUR CLINIC We already performed some procedures successfully other than listed before: HYDATID DISEASE OF THE LIVER 3 CASES LEFT LOBE 1 RIGHT LOBE 2 LAPAROSCOPIC CHOLECYSTECTOMY 7 CASES OTHER PROCEDURES 7 CASES OVARIAN CYST 2 ADHESIOLYSIS 3 PLASTRONE APPENDICITIS 1 VARICOCELECTOMY 1

13. HINTS TO SUCCESS SURGEON MUST HAVE: SURGEON MUST HAVE: High tolerance for variability High tolerance for variability Enough ability to complete any laparoscopic maneuver Enough ability to complete any laparoscopic maneuver PATIENT SELECTION PATIENT SELECTION At the beginning, select smaller and lighter patients At the beginning, select smaller and lighter patients Musculer males were difficult Musculer males were difficult PROCEDURES PROCEDURES Lower abdominal procedures are best Lower abdominal procedures are best Cholecystectomies and liver cyst operations fairly good Cholecystectomies and liver cyst operations fairly good Colectomies, hernial repair and etc can be performed Colectomies, hernial repair and etc can be performed ANESTHESIA ANESTHESIA Make sure the anesthesiologist is not using nitrous oxide Make sure the anesthesiologist is not using nitrous oxide There is no need to perform deep and frequent respiration There is no need to perform deep and frequent respiration

14. GASLESS LAPAROSCOPY Gasless technique although avoids the problems associated with CO 2 insufflation, has certain disadvantages at the moment but if the technical problems can be solved in the near future, it will be the next phase in minimally invasive surgery. Gasless technique although avoids the problems associated with CO 2 insufflation, has certain disadvantages at the moment but if the technical problems can be solved in the near future, it will be the next phase in minimally invasive surgery.