Introduction

Laparoscopic surgery compared to laparotomic one gives sure advantages such as scar reduction, morbidity reduction, pain and after-surgical course lowering and easy return to daily life and work; despite a global cost lowering. Moreover, despite of more technical difficulties, Laparoscopy gets better anatomical looking for the magnification that being very useful in surgical treatment of Fallopian tube, or next to nerves or vessels like in pelvic and lomboaortic Lymphoadenectomy.

However making and keeping abdominal insufflation in classic Laparoscopy may cause unfavourable effects. That's why new methods were studied for abdominal wall lifting.

This way several authors have conceived many lift systems getting to gas-less Laparoscopy, that has got general and technical advantages versus the classic Laparoscopy.

General advantages of Gas-less Laparoscopy General advantages are the CO2 exposure lack and no pressure increase in the abdominal cavity.

In fact CO2 insufflation has some unfavourable effects on cardiopulmonary, acid-base, endocrine and immunologic systems as well as on fetal-placental circulation. Moreover the increasing use of Laparoscopy in gynaecologycal oncology brings a question about the potential neoplastic spreading of pneumoperitoneum.

Cardiopulmonary system

Some changes of hemodynamic parameters were reported such as: reduction of venous getting back and cardiac output, increase of meanblood pressure and of the pulmonary impact of wedge, arrythmia. Venous getting back and cardiac output reduction are caused by rising abdominal pressure and compression of hollow inferior vein. The deceleration of the blood flow in that vein increases venous stasis in the legs with a bigger risk of tromboembolism.

The increase of systemic and pulmonary pressures is well known during surgical treatments being due to general anesthesia, but making abdominal insufflation, those parameters are effected also by the rising level of Noradrenalina and Endotelina from damaged peritoneum.

Moreover we have a rising pulmonary pressure during breath in and out proportional to abdominal pressure increase.

Acid-base system

We have some effects such as surface peritoneal acidosis, upper level of PCO2 in the pulmonary artery, rising level of CO2 in the last part of breath out.

All these effects are proportional to pressure in the abdominal cavity and operation lasting that could be increased by hard situations.

Endocrine and immunologic systems

Experimentally an increase of systemic Noradrenalina and Endotelina levels was detected probably coming from damaged peritoneal surface by abdominal insufflation.

Moreover it was seen a falling level of fagocyting macrophages and granulocytes. That effect is over about an hour after the Pneumoperitoneum has gone.

Although this reduction seems to be lower in Laparoscopy than in Laparotomy, it's possible that other unfavourable effects add themselves to it to determinate neoplastic spreading, when abdominal insufflation is performed in oncologic situations.

Pregnancy

Regard to pregnancy, in sheep experimental studies detected that CO2 Pneumoperitoneum exposure provokes fetal acidosis.

Moreover, intrauterine rising pressure proportional to increasing pressure in the abdominal cavity gives lower utero-placental flow and fetal ipossia.

Both effects can be avoided by Gas-less Laparoscopy that is to be considered the best way during pregnancy.CO2 abdominal insufflation and neoplastic spreading Laparoscopic techniques aren't considered the standard in Gynaecologyc oncology yet.

This is probably caused by the fear of breaking down malignant cistis or metastatic lymphonodes as well as the risk of neoplastic spreading or abdominal wall metastasys due to difficult pulling out of anatomical pieces.In fact, some studies report metastasis occurring in the trocar insert place in patients with Ovarian carcinoma (review in van Dam et. al, 16).However, recent studies give a question about an intrinsec power of abdominal insufflation on neoplastic spreading.

There are two possibilities: turbulence and mesotelial lesion.

Abdominal insufflation provokes turbulence that would give malignant cell esfoliation and peritoneal dissemination.

Moreover in the trocar insert place there are high gas flows both during Pneumoperitoneum, for normal waste, and at the evacuation time (so-called chimney effect) with a particular neoplastic cell concentration in those places that would explain the higher metastasis rate in the abdominal wall after Laparoscopy than Laparatomy. By the way, Bouvy e coll. study shows, in animal model a significant increase of intrabdominal neoplastic growth and port site metastasis in the group that underwent abdominal insufflation versus the gas-less laparascopic one.

If by a side turbulence provokes neoplastic falling and spreading, by the other mesotelial lesion would determinate following implant and proliferation. Istologically, Peritoneum is formed by a single mesothelial cell stratus laying on basal membrane over dense connective tissue.

Cell surface shows microvilli coated by glycoproteins and Glycosaminoglicani that gives Mesotelium negative electric power protecting from organ adhesion or malignant adhesion. Abdominal insufflation could cancel this electric protection because of acidosis due to the chemical reaction CO2 + H2O - H+ + HCO3 - increasing the risk of neoplastic adhesion on peritoneal surface.By the way, Volz e coll. study has confronted, in animal model, neoplastic spreading in CO2 Pneumoperitoneum versus Helium or Heated CO2 ones finding in classic CO2 abdominal insufflation the greatest neoplastic spreading.

That is probably because Helium abdominal insufflation doesn't provoke acidosis and in Heated CO2 one it is lower for gas rarefaction.These studies would show that the risk of neoplastic spreading depends on abdominal insufflation encouraging the use of Gas-less Laparoscopy.

Technical advantages of Gas-less

Laparoscopy Abdominal insufflation absence gives Laparoscopy large versatility making up for intestinal obstructing (reduce with more trendelemburg) and less exposure of lateral abdominal region (tent effect).First, without abdominal insufflation, it's possible to use laparoscopic umbilical way also for surgical tool introduction (laparoscopic or not). It sometimes allows little operations (Morgagni's Idatidys or little myomas removing, Endometriosis electric-cautery) with the introduction of one trocar only or no one (overall in diagnostic Laparoscopy) reducing invasivity. Moreover, in more complex operations, the umbilical way usefulness allows to avoid the third sovrapubic trocar and easier pulling out of anatomical pieces (ovarian cistis coats, whole little Myomas or broken big ones).

Another advantage we get in the case of severe Hemoperythoneum by tubarian pregnancy or bleeding luteal-body where classic Laparascopy (relatively not-indicated for Hemodynamic unfavourable effects) sometimes doesn't get easily Hemostasys.

On the other side, Gas-less Laparascopy has not negative hemodynamic effects and it allows (by umbilical way) both introduction of Laparoscope and the normal suction system that gets an easier blood cleaning.

We have noted also the chance to make Gas-less Laparoscopy in patients that couldn't undergo classic Laparoscopy because of latex allergy (there is Latex in the insufflation system).

We have had two cases of that kind treated with gas-less Laparoscopy. The absence of insufflation avoids scapolar pain due to frenic irritation getting better the patient being.Scapolar pain after gas-less Laparoscopy must lead to search for other causes such as frenic irritation by active bleeding (Kehr' sign).

Various kinds of Gas-less Laparoscopy

In Gas-less Laparoscopy we get abdominal relaxation by a mechanic lift of the abdominal wall.There are two systems allowing that:

1) by subcutaneous anchorage

2) Full-thickness.

Subcutaneous anchorage systems lift abdominal wall by the insertion of a big needle that flows in the subcutaneous tissue from pube to navel or by two strong bent needles that flow in the periumbilical zone (Laparotenser, Fig. 3). The free extremity of the needle/needles are hooked to a mechanical arm lifting the abdominal wall.

The main advantage of these devices consists of the independent application from adherences (peritoneal or periumbilical). But, it could be difficult to insert needles in slim patients while there is bigger tent effect.

The full thickness systems consists of devices that by umbilical way allow to hook the wall.They are: Laparofan and Air-lift (Picture 3). Laparofan is a single-use mechanical device whose arms open after the introduction into the abdominal cavity. Air-lift is a single-use rolled-up device; after insertion across the navel it must be insufflated till to get a bun.

Both Air-lift and Laparofan must be hooked to on electric lifting arm fixed to the surgical bed.

These devices could be difficult to insert in the case of unsuspected adherences; beside to a not homogeneus abdominal wall lifting for Laparofan because of its shape.

Our lift device for Gas-less Laparoscopy: Gas-lup.

In order to overcome those problems we have patented the "Gas-Lup" (by Gasbarro-Lupo), a new full-thickness device consisting simply of three indipendent valves with thin and long blade.

They can be inserted by a 15 mm umbilical hole at the 9, 12, 15 positions of the clock. The valve position can be changed because of adherences or we could use only two of them. An adaptor device allows to connect one another the valves to an horizontal arm for lifting and supporting. Such arm can glance into a vertical axis fixed to the surgical bed. In the valve arms there are two hook places, at different height, for fixing them to the adaptor: we usually employ the inferior hook place; the upper one is employed in fat women. Wall lift is made by operative pull up of the horizontal arm that must be Jammed in the chosen position. The whole system is reusable. Therefore it is very economic respect to Laparofan and Air-lift. Beside it is very easy to employ. Since two years our department has performed about 350 operations by Gas-lup. We have never needed abdominal insufflation. We have performed: laparo-assited isterectomy, ovarian cistis removing, myomectomy, pelvic lymphoadenectomy, extrauterine pregnancies, diagnostic laparoscopy.We show gynaecologists our method during T.I.G.E. courses (intensive training in gynaecologic endoscopy) performed at Chivasso's Hospital and Maria Vittoria's in Turin.

Managers of the courses are dr. N. Gasbarro and dr. T. Gargiulo. Courses are made monthly and you can take part to the surgical sessions (picture 8).

Conclusion

Gas-Less Laparoscopy has several advantages than the classic CO2 insufflation because it avoids abdominal pressure increase and CO2 exposure and it allows technical solutions that are impossible in the classical way.Particularly, Gas-Lup allows mechanic abdominal wall lift also in hard situations (periumbilical adherences) where other devices are hard to put, we underline that it's a reusable and very economic system.

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