Isopneumic laparoscopy in general surgery and trauma: an update

The purpose of this study was to assess the capability of a retractor system that permits laparoscopic surgery without carbon dioxide pneumoperitoneum and to determine if the system facilitates the use of traditional surgical instruments during minimally invasive surgery. This study was performed at a university-affiliated county hospital (Alameda County Medical Center, Highland General Hospital campus) in Oakland, California. The study design was prospective evaluation with data collection. Eighty-eight isopneumic laparoscopic procedures were performed between July 1992 and October 1993. A planar abdominal wall distention system consisting of an intra-abdominal fan retractor and an electrically powered mechanical arm was used to provide exposure. Conventional surgical instruments as well as laparoscopic instruments were used in each case. Laparoscopy without pneumoperitoneum was used in the evaluation of 43 patients with abdominal trauma (gunshot wound, 18; stab wound, 19; blunt trauma, 6). The need for formal abdominal exploration was obviated in 35 of 43 (81%) cases. Repair of three enterotomies, four diaphragmatic lacerations, and one gastric perforation was performed with conventional instruments. Isopneumic laparoscopic techniques were also used for cholecystectomy (n = 36), diagnosis laparoscopy (n = 4), appendectomy (n = 3), sigmoidopexy (n = 1), and closure of a perforated duodenal ulcer (n = 1). Abdominal exposure approximating that obtained by pneumoperitoneum was obtained in 37 of 45 cases. One major (trocar tip enterotomy) and two minor complications (superficial wound infection) occurred in this group of patients. The ability to use traditional surgical instruments was advantageous in several cases. Laparoscopic surgical procedures can be performed without pneumoperitoneum in the majority of cases. The ability to use conventional surgical instruments is an advantage of this technique. Further improvements in abdominal wall distention systems and modifications of existing surgical instruments are required to further expand the role of isopneumic laparoscopy.