Gasless laparoscopy using a planar lifting technique.

In clinical use, the mechanical lifting technique has demonstrated the ability to displace the abdominal wall and create a useful cavity for visualization and surgical manipulation. By forming a planar ceiling, as opposed to the domed ceiling of conventional pneumoperitoneum, the abdominal organs are brought into closer proximity of the surgeon. Instrument length may be shortened, imparting greater surgical control. Without the necessity for gas sealing, entry portals are simplified. Conventional instruments (right angle clamps) may be introduced through the fan retractor insertion sites or by way of separate stab incisions. The planar lifting technique has the potential for simplifying laparoscopy and restoring instrument control to the operating surgeon.

Novel technique and instrumentation for laparoscopic application of hemostatic clips.

A novel device for applying hemostatic clips in laparoscopic surgery incorporates a distal hook into a multiple-firing titanium clip applier. The hook may be used for blunt dissection of tissue, and to displace and control ducts and vessels during clip application. A single instrument may be used to achieve hemostasis in areas that are difficult to reach, and past pointing problems encountered with straight on clip appliers are alleviated. Comparative testing of the holding force of the curved clips used with this device versus the straight clips used in conventional multiple-clip appliers demonstrated a higher mean pull-off force of 0.473 lbs versus 0.33 lbs. Clinical application of the device in laparoscopic procedures including cholecystectomy, vaginal hysterectomy, Nissen fundoplication, vagotomy, varicocelectomy, and lymphadenectomy show the utility of the hook clip applier.

Mechanical peritoneal retraction as a replacement for carbon dioxide pneumoperitoneum.

A fan retractor and a mechanical lifting arm were developed to achieve planar displacement of the anterior abdominal wall for gasless laparoscopic procedures. The technique permits the use of conventional open surgical instruments as well as laparoscopic tools through minilaparotomy incisions. It also potentially addresses the technical constraints imposed by pneumoperitoneum, and physiologic concerns regarding carbon dioxide insufflation. Gynecologic, general surgical, and trauma procedures were performed in 104 patients, with successful completion of 86.5%. Continued application is necessary to delineate the full range of benefits of laparoscopy without insufflation.