Why gasless laparoscopy?


Gasless Lift – Laparoscopy: New technique of laparoscopy without carbon dioxide gas

Today, the surgical procedure known as keyhole surgery or minimally invasive surgery permits operations to be performed which formerly would have necessitated the use of the scalpel. Keeping the surgical wound as small as possible was for a long time the aim of physicians and surgeons. Therefore, surgical techniques were continually refined in order to gain access, with the minimum of adverse effects, to the site of disease. 

In gynecology, endoscopic investigations of the abdominal sex organs, such as the womb, fallopian tubes and ovaries, have a long tradition. Operations with the endoscope were also a routine procedure here. In the 70s laparoscopy was performed mainly for diagnosis or for tubal ligation. Thanks to the pioneer Professor Kurt Semm, from Kiel, more and more indications were established in Germany and worldwide. Today, laparoscopic procedures to treat benign manifestations in the ovaries and fallopian tubes (extrauterine pregnancy, ovarian cysts) as well as in the womb (myomas) are standard procedures carried out as a routine measure in endoscopic centers. The advantages of endoscopic operations for malignant cases cannot yet be definitively elucidated, which is why such operations are being conducted on an experimental basis in very few hospitals. 

Advantages of endoscopy 

Large surgical wounds are avoided on using endoscopy. Therefore, there is markedly less wound pain after surgery. The patient recovers and becomes mobile more quickly, hence the hospital stay is considerably shortened and indeed procedures can even be carried out in many cases on an outpatient basis. The cosmetic result is considerably better since only small scars remain. Wound healing disorders are seen less often after endoscopic operations than after open abdominal surgery, and there are fewer problems due to adhesions and scars. 

Risks and disadvantages of endoscopic operations 

But like all operations, endoscopic procedures also pose certain risks such as, for example, hemorrhage, organ injury or infection. Moreover, it can come to light in the course an endoscopic procedure that conventional surgery is warranted. Endoscopic procedures necessitate insufflation of the abdominal cavity with carbon dioxide in order to obtain a sufficient view of the surgical field and grant the surgeon enough space to work. This causes considerable build-up of pressure in the abdominal cavity and reduces the body temperature due to the cold gas, which in turn causes pain that in some cases can persist for several days, radiating to the shoulder and neck regions; these manifestations can prolong and complicate the recovery period. Moreover, the gas is held responsible for further side effects whose implications have not yet been adequately clarified. For example, there are increasingly more reports in the literature about incidences relating to carbon dioxide, which is converted in the body to carbonic acid. Long operations with carbon dioxide may lead, above all in older and less healthy patients, to a decrease in the pumping action of the heart or to overloading the organism with carbonic acid, and this in turn can cause acidosis of all organ systems. Insufflated gas can in very rare cases lead to gas accumulation in the vascular systems of the lungs (gas embolism), heart (decrease in coronary blood supply) and of the kidneys (poorer perfusion) or to the accumulation of carbon dioxide in the subcutaneous tissue of the skin (emphysema). While such side effects of carbon dioxide are extremely rare, they can prove fatal (kidney failure, heart attack, pulmonary embolism). 

Typical complications of an endoscopic procedure can occur while inserting the Verres needle – for gas insufflation – or the secondary trocars. This "insufflation needle" is pierced "blindly", i.e. without visual control, into the abdominal cavity. After the abdominal cavity has been filled with gas, the first trocar for the optic is inserted (also without visual control). Both can in rare cases cause injury to vessels or organs (for example the bladder, intestines, stomach and others), and this in turn can trigger emergency situations (e.g. bleeding) warranting immediate action. An undetected bowel injury following coagulation often results some time later in acute ileus and massive infection. 

Endoscopic operations are clearly more difficult and are therefore performed only by a few centers. By working with overly long, specially modified instruments, the surgeon loses tactile perceptions. The instruments are unfamiliar; they have the most diverse gripping systems and small graspers. All this detracts from precision during surgery. Only very few surgeons develop the ability to operate in the abdominal cavity with only indirect visual contact, i.e. looking at the monitor. Therefore, the learning curve associated with endoscopic surgical techniques is very long. The complication rate for endoscopic procedures is also higher than in open surgery, especially in the case of surgeons who are not yet optimally trained. This is also one of the reasons why, following the initial euphoria, stagnation can be noted in the spread of endoscopy. 

In order to avoid gas loss via the instruments, special trocars with valves were developed. The instruments themselves consist of multiple tubular and shaft systems which mimic the rotary and angled movements of the hand. To avoid gas loss while changing the instruments (for example between scissors and graspers), multi-functional instruments were developed. Industry has to make massive investments to manufacture these instruments, which is why the costs incurred for such instruments are much higher than in the case of conventional instruments. Endoscopic instruments are more laborious when it comes to maintenance and processing. Due to the myriad tubular systems, special washer-disinfectors must be purchased to clean these instruments and eliminate contaminants based on body secretions and blood which could cause infection. 

For the past 75 years (since the introduction of laparoscopy with carbon dioxide) industry has been trying in close cooperation with endoscopic surgeons to overcome the problems emanating from endoscopic procedures using gas. In the meantime, a very important market segment has therefore developed which, by continually developing newer instruments and equipment, makes endoscopic procedures using gas safer but also more expensive. The costs are spiraling due to, among other things, the use of special thread and suture materials, widespread use of disposables, such as titanium clip systems, suturing devices and angled instruments; all this calls into question the benefits of endoscopic procedures. 

Professor Axel Perneczky, neurosurgeon from Mainz, made the following statement regarding endoscopic surgery: "Keyhole surgery can be likened to a situation where we try to sew on a button on the bed linen in the bedroom with a tweezers through the keyhole of the front door; moreover, the rooms are full of furniture, around which we have to maneuver the tweezers…" 

Quotation by Dr. Daniel Kruschinski on the development and introduction of gasless laparoscopy: "Keyhole surgery can also be likened to a situation where we use a ladder to try to come in through a closed window of a bedroom on the first floor, although the front door is wide open…"