Gasless Laparoscopic Surgery-A Technique Requiring Multidisciplinary Collaboration to Improve Equitable Access to Surgery Worldwide

Abstract

We read your recent article about the KeyLoop surgical retractor with interest and applaud the authors for their comprehensive and innovative evaluation of the device. Despite the various advantages of laparoscopic surgery (eg lower pain, earlier return to activity (and work), fewer wound infections, and shorter hospital stays) its implementation in low and middle-income countries (LMICs) is challenging due to factors including limited consumables, scarcity of funding and the risk of power outages, especially in rural regions. 1,2 To address these numerous challenges requires innovative solutions. Frugal technology and modified surgical techniques, such as Gas Insufflation-Less Laparoscopic Surgery (GILLS), provide the opportunity to ameliorate this trend and provide more equitable access to laparoscopic surgery in low-resource settings.The authors report that the methods, safety profile, and surgical outcomes of using gasless devices are not well described. However, a recently published systematic review included 3620 patients across 63 studies and concluded that GILLS has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings. 3 Gasless laparoscopic surgeries using abdominal wall lifting devices (or retractors) started in 1990, but declined in popularity due to perceived suboptimal surgical exposure, despite a reduction in adverse cardiovascular and respiratory effects. However, in the recent decade this trend has begun to change with the introduction of improved retraction devices for GILLS. The Staan Laparoscopy Positioner has been in use since 2013 in remote and rural areas of India and is mentioned in the WHO compendium of innovative health technologies (2016-17) for low-resource settings. 4 To date, the Staan device has been used in many gasless laparoscopic surgeries. A more recent device, the Retractor for Abdominal Insufflation-less Surgery (RAIS), aims to provide a modern and portable system for GILLS, compatible with modern sterilisation methods, and is now in the early stages of clinical use. 5