To avoid the disadvantages of COz insufflation, devices are available for lifting the anterior abdominal wall to facilitate gasless laparoscopy. Some devices provide tenting of the anterior abdominal wall by traction of the skin and subcutaneous tissues (U shaped retractor or subcutaneous wires), whereas others lift up the entire abdominal wall via an intraperitoneal retractor (wires, or L, T, or fan shaped retractor) (Fig. 14). Despite these inventions the technique of gasless laparoscopy has not yet achieved wide popularity. Potential advantages are:
• Avoids physiological alterations associated with C02 pneumoperitoneum;
• Minimizes the risk of gas embolization;
• Avoids the need and maintenance of a gas-tight operating environment;
• May allow the use of conventional instruments;
• Is a safe alternative method of laparoscopy in high risk patients. Disadvantages are:
• The overall exposure is usually inferior to that obtained with pneumoperitoneum.
• There is greater postoperative pain than with tension pneumoperitoneum.
Because the physiological effects of pneumoperitoneum appear to be most marked after initial abdominal insufflation and during high pressure insufflation (> i4mmHg), the use of a hybrid system of low pressure pneumoperitoneum (< 8mmHg) combined with an abdominal wall retracting technique may provide the best of both worlds.
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