The diagnosis of acute abdomen in the emergency setting, still remains a challenging problem. In these cases timely diagnosis and management is of great importance, while the anesthetic risk is high. The combination of the risk of an open laparotomy and the relative high likelihood of negative findings when performed, creates the need for a better approach. The alternative actually exists since when Eruheim made the first gasless laparoscopy.
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Metrics details. The purpose of this study was to compare the clinical outcomes and cost effectiveness of the gasless laparoscopic appendectomy GLA and conventional laparoscopic appendectomy LA. The two groups were comparable in age, gender, body mass index, symptom duration, ASA score, and white blood cell count. The mean surgical duration was Postoperative complications did not significantly differ between the two groups.
The length of the total hospital stay was 4. GLA and conventional LA are comparable in terms of operative duration, complications, and total hospital stay. The obvious advantage of GLA is the significantly reduced hospital cost.
The demand for postoperative analgesics may also decrease following GLA. In conclusion, GLA is a safe and feasible procedure in selected patients. Since its initial description by Semm in [ 1 ], laparoscopic appendectomy LA has been shown to be superior to the open technique and has become the gold standard for the treatment of various types of appendicitis [ 2 ]. Secondly, LA results in a shorter hospital stay, a quicker return to activity, reduced pain, fewer wound complications, and better cosmesis.
Finally, LA is the best choice for obese patients and those with complicated appendicitis, due to improved visualization of the appendix.
Despite these advantages, when used in LA, pneumoperitoneum affects cardiopulmonary function [ 4 — 6 ] and is a possible cause of complications, some of which may be severe [ 7 — 9 ]. General anesthesia, which is required to establish CO 2 insufflation, increases hospital costs and may lead to patient refusal [ 10 ].
Therefore, pneumoperitoneum and general anesthesia limit the application of LA, particularly in elderly patients. To overcome these drawbacks, gasless laparoscopic appendectomy GLA was developed in [ 11 ].
GLA was performed without pneumoperitoneum or general anesthesia using various devices to mechanically elevate the anterior abdominal wall with epidural anesthesia. Although a number of potential advantages have been associated with GLA [ 12 ], no randomized controlled trial comparing GLA and conventional LA has been reported. The safety and feasibility of this procedure have not been evaluated.
Therefore, the purpose of this study was to compare the clinical outcomes and cost effectiveness of the two techniques. This study included patients with a clinical diagnosis of acute appendicitis in Shanghai Tongji hospital between Aug and Feb The initial diagnosis was made based on patient history and a physical examination. CT scan was performed in every patient to confirm the diagnosis of acute appendicitis. The patients were randomly allocated into two groups, GLA and LA, using a randomized central computer-generated sequence before they were sent to the operating theatre.
All of the patients were fully informed about the characteristics of this procedure and its advantages over open or conventional LA. Written consent was obtained from all participants or their family members before surgery. Two consultant surgeons performed the operations and had sufficient capabilities to perform the two procedures LA and GLA.
The patients in the two groups were managed by the same principles. Antibiotics were continued for a few days only in patients who suffered a perforation. Oral fluids were generally allowed on the day following surgery when bowel sounds returned; however, in some cases, perforation caused ileus and postponed this schedule.
When tolerated, a soft diet was introduced. Patient-controlled analgesia PCA with intravenous fentanyl was administered as required. The drain, if present, was removed when the aspirate was minimal or nonpurulent, usually in 1 to 2 days. The patients were followed up as outpatients for 7 to 10 days and 1 month postoperatively either at the outpatient clinic or by telephone interview. All of the operative details were recorded. The operative time minutes for both procedures was counted from the skin incision to the last skin stitch applied.
The parameters evaluated were the duration of the total hospital stay, the hospital cost, the needs for analgesia postoperatively, and the day morbidity. The patients were advised to void their bladders preoperatively. If unable to do so, a urinary catheter was inserted. After anesthesia plane satisfaction, the site was prepared with povidone and draped in a sterile manner.
Entry into the peritoneal cavity was made by the open method through a 1-cm infraumbilical incision. A mm cannula was then inserted. A sterilized stainless steel scaffold consisting of a lifting arm Mizuho Medical Inc. A sterilized needle Kirschner wire was then inserted through the subcutaneous tissue. The abdominal wall was lifted with the needle and fixed to the scaffold using a chain.
The lifting blades were attached to the winching retractor, which in turn, was connected to the extension rod Mizuho Medical Inc. The lifting system was secured to the side rail of the operative table through the iron side bar.
A general laparoscopic examination of the entire abdomen was performed, including an assessment of the degree of peritonitis from the spread of purulent peritoneal fluid. This port placement allows the surgeon to operate in a comfortable position with both arms close to their body. After identification of the appendix, the mesoappendix was coagulated with bipolar diathermy and cut. The base of the appendix was crushed and clipped with a Hem-o-lock clip or ligated using Vicryl 1.
The appendiceal specimen was retrieved through the mm left lateral port using an endo-bag. The mm laparoscope was reinserted, and the pus was completely removed using suction. If a perforation was present, a suction drain was placed in the pelvis through the lower port.
A final verification for hemostasis and secure placement of the ligature or clip was made. They were intratracheally intubated and treated with general anesthesia. Entry into the peritoneal cavity was made by inserting a mm cannula through a 1-cm supraumbilical incision. The sites of puncture and the operation method were the same as those for the GLA group.
The data were analyzed using SPSS version A probability equal to or less than 0. The mean age of the patients was The main comorbidities were hypertension and diabetes.
One patient in the GLA group had hypothyroidism, and one patient in the LA group had resected bladder cancer. The histological results were comparable between the two groups. For these patients, the final diagnoses were bilateral ovarian cysts in the GLA group patient and sigmoid colon inflammation and a bowel mesenteric inflammatory mass in the LA group patients.
The patient with bilateral ovarian cysts in the GLA group was converted to conventional pneumoperitoneum and underwent anoophorocystectomy. An additional 2 cases in the GLA group were converted to conventional LA due to inadequate visualization caused by obesity or poor anesthesia.
One patient in the GLA group was converted to an open appendectomy because the appendiceal root was too thick and could not be treated laparoscopically. One patient in the GLA group suffered from vomiting during the operation and recovered after the common treatment, which did not cause further complications.
The two modalities did not have significantly different rates of postoperative complications. In addition, one case of paralytic ileus was caused by an abdominal abscess in the LA group. All of these complications were cured by conservative treatment. The present study showed that the operative duration, complications, and total hospital stay were comparable between GLA and conventional LA. However, GLA significantly reduced the hospital cost. The laparoscopic approach to appendectomy has gained wide acceptance over the last 30 years.
LA offers a lower risk of postoperative infection and a shorter period for full recovery [ 13 ]. Furthermore, LA is a preferred technique for suspected or complicated appendicitis [ 14 ].
However, pneumoperitoneum, which is required for LA, may cause a series of complications and prevent the use of LA for patients who are unable to tolerate them. For instance, significant metabolic and hemodynamic alterations are associated with the intra-peritoneal insufflation of carbon dioxide [ 15 ].
The arterial partial pressure of carbon dioxide and end-tidal carbon dioxide levels increase in a consistent manner. This phenomenon does not present significant difficulties in the majority of healthy patients, but it can seriously complicate the perioperative course of patients with obstructive pulmonary disease [ 16 ].
GLA, which was invented by Smith et al. Gasless laparoscopy employing an abdominal wall-lifting device has been shown to eliminate the adverse cardiopulmonary effects arising from abdominal insufflation [ 17 ]. Many retrospective studies reported in the last 20 years have focused on the technical improvement of GLA [ 18 ]. However, GLA is not considered an alternative for appendectomy because no RCTs have established its feasibility and safety. While gasless laparoscopy effectively prevents the complications associated with CO 2 pneumoperitoneum, inadequate visualization restrains its application in complicated surgeries.
A previous RCT showed that the gasless laparoscopic procedure was considerably more difficult to perform and required longer operative times [ 19 ]. Appendectomy, however, is a relative simple surgery that requires very little room, making it a good candidate for gasless laparoscopy. The present study showed that there was no significant increase in the operative time for GLA when compared to LA. The incidence of complications was also comparable between the two groups.
Wound infection and intraabdominal abscess, which occurred in both groups, are the most common complications for appendectomy and are not dependent on CO 2 insufflation [ 10 ]. In the GLA group, special complications that may be associated with decreased operative room in a gasless condition, such as thermal damage to the small bowel, were not observed. Evaluating the entire peritoneal cavity is a main advantage of LA, which is also preserved in GLA especially when appendix is not inflamed obviously.
All of these results indicate that the operative exposure provided by the lift system was adequate for most appendectomies. GLA was shown to be a safe and feasible procedure, which is consistent with previous reports [ 12 ]. One of the main advantages of gasless laparoscopy is the avoidance of general anesthesia in some surgeries.
Patients who are unable to tolerate general anesthesia and pneumoperitoneum may be candidates for GLA. The difference may not only be due to the change of anesthesia from general to epidural but also due to the trend toward a reduced hospital stay for the GLA group.
Frequently Asked Question About Gasless Laparoscopic Surgery
Metrics details. The purpose of this study was to compare the clinical outcomes and cost effectiveness of the gasless laparoscopic appendectomy GLA and conventional laparoscopic appendectomy LA. The two groups were comparable in age, gender, body mass index, symptom duration, ASA score, and white blood cell count. The mean surgical duration was
Gasless Laparoscopy in Abdominal Surgery
Gasless Laparoscopic Surgery is a laparoscopic procedure that does not require the use of gas carbon dioxide during the procedure. However, after realizing that there are many unfavorable effects using the conventional laparoscopic method, doctors found a way to get rid of the gas and still end up with a successful operation. With Gasless Laparoscopic Surgery procedure, gas loss will be prevented because there is no gas used. The removal of specimen and suction can also be performed with ease. The insufflation of the abdominal cavity with gas carbon dioxide poses a lot of health hazards to the patient especially in patient with previous cardiopulmonary diseases. We know for a fact that increased carbon dioxide content will cause acidosis to the vital organs of the body. In worse cases, accumulation of carbonic acid can lead to kidney failure or even heart attack.
The role of gasless laparoscopy in differential diagnosis of acute abdomen