Gasless laparoscopy and adhesion prevention

Hugo Verhoeven, MD: “Good afternoon, my name is Hugo Verhoeven from the Centre for Reproductive Medicine in Düsseldorf, Germany. I’m reporting from the 12th Annual Meeting of the ISGE in Cancun, Mexico. I am talking this afternoon with Dr. Daniel Kruschinski, who is a very good friend of mine, and who is the inventor of the gasless laparoscopy. So, Daniel, thank you for giving me the pleasure of talking to you. First of all, what does this mean “gasless laparoscopy”? What are you doing differently to traditional laparoscopy using CO₂?”

Daniel Kruschinski, MD: “In general, the normal laparoscopy is working such that we are insufflating the abdominal cavity to get space, to get working space. Laparoscopy with CO₂ has several problems, which we will come to; we are trying to exclude the insufflation of CO₂ by elevating the abdominal cavity. So we are introducing a kind of retractor and elevating the abdominal wall and getting the space like this. So we don’t have the problem of CO₂ first, and secondly we can use normal valve-less trocars without any kind of valves and we can change our instruments without leakage of gas. So we are excluding some problems, which are directly connected with insufflation of CO₂.”

Hugo Verhoeven, MD: “So the principle is to just lift up the abdominal wall and create an additional space in the abdominal cavity where you can use the same instruments that you have used for many, many years in open laparotomy. You are now working in the Frankfurt region and it is my understanding that now many, teams all over the world are using this technique. We want to go now to the field of endometriosis. We know that endometriosis is the cause of severe adhesion formation. Adhesions are always a problem, how do you insert your umbrella?”

Daniel Kruschinski, MD: “Especially in an adhesion formation or adhesion surgery or in the endometriosis surgery you need to be very precise. I will come first to the point of precision. If we use normal instruments, which have only one joint and are very short, we are more precise during the surgery. So this is one point why it is better to use gasless and normal instruments because you feel what you do. You have an instrument in your hand that allows you to feel what you are doing, what you are touching, when you are cutting something. This is very good in cases of endometriosis or adhesion surgery. 

Second point is that if you have adhesions already around the umbilicus we are going to the left upper quadrant into the Palmer's point and there are nearly never adhesions and then elevating the abdominal wall from there. And then we have the first look and see if there are adhesions around the umbilicus. If we have adhesions around the umbilicus of course, we just take them down and insert our retractor inter-umbilically and elevate the abdominal wall. 

So it’s not a problem if patients already have adhesions, it’s only a problem how the surgeon is coming into the abdomen – not to have any injury. And as we are working always under vision it means we never have a blind puncture, we never go in blindly with a Verress needle or with any other instruments or the trocar into the abdominal cavity, and we are avoiding blind puncture injuries. And this is most important.”

Hugo Verhoeven, MD: “You are not entering your umbrella subcostally?”

Daniel Kruschinski, MD: “There are several systems. The retractor is small, like 8cm in diameter, and the other retractor is 10cm and then again 12cm, so we can go in with a very small retractor here in the abdominal quadrant, elevate the abdominal wall and see if we have adhesions somewhere already. And if the patient had longitudinal incisions, by laparotomy or several adhesions by Pfannenstiel incision, she always has adhesions around the pelvis. Sometimes also in the umbilicus because this is the way to prevent any injuries to the organs going by the left upper quadrant – also with gas. The people with gas also go in in the same area. “

Hugo Verhoeven, MD: “Okay, as soon as the umbrella is in place, well, it is like normal laparoscopy. You are respecting the principles of microsurgery, cutting the adhesions around the ovaries, and taking out the endometrioma and so on. Are there any complications of the gasless technique?”

Daniel Kruschinski, MD: “No. We avoid complications by gas, which is hypoxemia, which is acidosis, global acidosis, global necrosis on the peritoneum cells; Roger [Molinas] was just speaking about this, I heard it. And I think we avoid all these problems. Special complications of gasless laparoscopy we don’t have because our system is so well developed, for about 12 years, that we have measurements of how the force is being applied to the abdominal wall by elevating the abdominal wall. So we never go above a kind of 1.5 kilogram, which is designed as the level, you shouldn’t go above to have a good exposure but not to damage any abdominal wall structure, like vessels, like nerves, like muscles. It is very important.”

Hugo Verhoeven, MD: “There is no subgroup of patients that you cannot treat with this technique?”

Daniel Kruschinski, MD: “Yes. This is a patient that is very small, like 150 centimetres and at the same time very corpulent, more than 110 kilograms. You will get into problems entering the abdominal cavity. But if you are experienced this is the same problem with gas. If you are experienced enough you will do it, over do it with experience and come also into the abdominal cavity. 

So there are no contra indications for gasless laparoscopy, even more we avoid problems by having no gas in the abdominal cavity and no pressure in the abdominal cavity, so we can work on patients who are risk patients, like cardiac insufficiency, like lack of lung obstruction, like pregnancy. We can perform this surgery also in pregnancy by local anaesthesia. We don’t need general anaesthesia. So on patients who are afraid of general anaesthesia, who cannot get general anaesthesia, we can perform laparoscopy with epidural or spinal anaesthesia and this is very, very important.”

Hugo Verhoeven, MD: “So my final question is: I saw many of your procedures and I was always very fascinated. So it is becoming more and more popular but in my impression not fast enough. I think everybody should consider performing this technique. Why are not all people so fascinated about this that they say “that’s what we’re going for”?”

Daniel Kruschinski, MD: “When you think about how [Kurt] Semm started and how long it took to get the concept of change in the surgery, and what I’m trying to do is change the concept of laparoscopy, because laparoscopy is already established. So everybody is working with gas and it’s established and he’s a king in his hospital because he knows how to do it. 

What I’m trying to do is to get everyone to be able to perform laparoscopy surgery because it will be easy with gasless, using ordinary instruments, old techniques, standard techniques. But I’m trying to change the concepts and there is already a market, there are already doctors who are performing laparoscopic surgery. They won’t change so quickly because they want to continue with their gas laparoscopic system, and changing the concept will take maybe another ten years. I’m working already 12 years for it but I’m patient and I’m doing surgery. 

The most important thing is that patients know where to go; so they read about the problems of gas and then know exactly what they will get if they already had laparoscopy with CO₂. They avoid pain, they avoid very ordinary pain like shoulder pain, which can last for even 10 days, and then patients know where to go – we are getting patients from all over the world. So I’m not very, very confused or concerned that other doctors are not doing it because it’s like my monopoly for now, and I’m getting patients for that. But if we do it enough the more we’ll think about it the more we’ll do it.”

Hugo Verhoeven, MD: “We will re-discuss this item 10 years from now. Daniel, thank you very much.”

Daniel Kruschinski, MD: “Thank you, Hugo.”

Feedback/Questions:

Question: 
What happens if the patient has so many adhesions, can you still use the abdolift? Have you ever encountered that? What do you offer if this arises? I have always been told by surgeons they started with laparoscope and ended with full laparotomy. 

I am anxious for your response. Thank you for taking time to respond. 

Mrs French 

Answer:
If there are adhesions around the umbilicus we are going to the left upper quadrant at the Palmer's point and there are nearly never adhesions. We than elevate the abdominal wall from there. And then we have the first look and see if there are adhesions around the umbilicus. If we have adhesions around the umbilicus of course, we just take them down and insert the retractor later on inter-umbilically and elevate the abdominal wall. So it is not a problem if patients already have adhesions, it is only a problem how the surgeon is coming into the abdomen not to have any injury. And as we are working always under vision, it means we never have a blind puncture, we never go in blindly with a Verress needle or with any other instruments or the trocar into the abdominal cavity, thus we are avoiding blind puncture injuries. And this is most important. We have mostly adhesion patients, coming from all over the world, for adhesion surgery where gasless laparoscopy plays a very important role as carbon dioxide is a cofactor in adhesion formation. 

Daniel Kruschinski, MD
For more information on Dr Kruschinki's work please see www.EndoGyn.com