Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
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Editor’s note: This excellent chapter describes the 
use of a proprietary device of the authors’ design, the 
RAIS (Retractor for Abdominal Insufflation-less 
Surgery.) While it is possible to perform “gasless” 
reduced-pressure 
laparoscopy 
using 
ordinary 
laparoscopic equipment such as the Nathanson 
retractor, these authors show a better way. They 
present a compelling description of a well-designed 
device that is intended to be used in settings such as 
ours. The corresponding author’s contact details are 
available at the end of this article for those who want 
further information. -RD 
 
Introduction:  
Laparoscopic 
surgery 
allows 
surgical 
procedures to be performed through tiny openings in 
the abdomen, through which special surgical 
instruments are introduced. The space necessary for 
performing the surgery is usually created using CO2 
gas. A laparoscopic camera is used for visualizing 
the operative field. Although there are many 
advantages to laparoscopic surgery, there are 
disadvantages too. Some of them are the high costs, 
the need for general anaesthesia and the management 
of physiological changes due to carbon dioxide 
insufflation. The complications are few, but definite. 
Moreover, adoption of conventional laparoscopic 
surgery in low resource settings is complex and takes 
a longer time to set up. 
In 
high-resource 
settings, 
gasless 
laparoscopic 
surgeries, 
also 
called 
isobaric 
laparoscopic surgeries, became popular in the 1990s, 
in an attempt to mitigate the problems associated 
with gas insufflation. However, the early equipment 
offered less than optimal exposure due to tenting, and 
the design was clunky. Hence most of the 
publications were from single centre experiences, 
although these indicated a potential usefulness of the 
modality. The Gas Insufflation-Less Laparoscopic 
Surgeries (GILLS) was adopted by rural surgeons in 
low-resource settings primarily because of the 
following advantages: 
1. GILLS is less expensive and can be 
performed using the readily available spinal 
anaesthesia in rural areas 
2. Overall costs are lower compared with open 
surgery 
or 
conventional 
laparoscopic 
procedures 
3. It is relatively easy to learn for a practicing 
rural surgeon with some exposure to 
laparoscopic surgery in the past 
4. No CO2 related physiological complications 
5. Can be used in patients with cardiac and 
respiratory conditions  
6. No loss of space when suction is applied 
7. Conventional open surgery instruments can 
be used 
8. Ports are not required. When needed, 
reusable ports without valves can be used 
9. Reduction of aerosolization  
10. Sustainable - overall reduction in carbon 
emission and surgical waste  
Randomized control trials and meta-analyses 
showed no significant difference between GILLS 
and conventional techniques. The outcomes for 
GILLS were better when compared to open 
abdominal surgeries. Moreover, single incision 
laparoscopic surgeries are more straightforward and 
less expensive with GILLS.  
GILLS creates space for surgery by lifting 
half of the abdominal wall with a specially designed 
ring inserted through the umbilical incision. The 
patient is positioned so that the intestines move away 
from the operating field due to gravity. For example, 
a steep lithotomy position is used for pelvic surgeries 
along with a shoulder brace that prevents the patient 
from sliding down.  
An umbilical incision is used to insert the ring 
and to pass the laparoscope and instruments. If 
necessary, additional ports can be placed at 
convenient places. A combination of laparoscopic 
and long conventional open surgery instruments can 
be used.  
Exposure to current devices (STAAN and 
RAIS devices) is the same as conventional 
laparoscopic surgeries for patients with BMI less 
than 28. Large open suctions, gauze pieces for 
retraction and mopping, and other open methods 
could be comfortably used during GILLS, without 
loss 
of 
exposure 
due 
to 
collapse 
of 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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pneumoperitoneum that occurs with conventional 
laparoscopic surgeries. 
 
We will be describing two different devices 
used based on the author’s experience. The first one 
is the STAAN (name of the manufacturer) device 
which has been used for the last 5 years. We will 
briefly describe this device, to introduce the concept.  
The second device is the latest version of the 
gasless lift device – RAIS (Retractor for Abdominal 
Insufflation-Less Surgery.) The steps of gasless 
laparoscopic surgery will be illustrated by Dr. Biju 
Islary in detail using this device.  
 
STAAN Device: 
 
This device has three main components: The 
part that attaches to the operating table, the vertical 
component that holds the ring in place, and the ring 
itself:  
 
The STAAN Device, with all three parts.  
 
 
Part that attaches to the Operating Table. There is a “V” 
shaped cut that allows the clamp to attach to any operating 
table, and the screws fix it tight. The vertical portion should 
start low so that once the lift is set up, it can be rotated.  
 
 
Vertical component that supports the ring. There are two ball 
and socket joints that allow movement to any desired position 
and can be fixed quickly with two-click locks. 
 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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The spiral ring that goes inside the abdomen 
 
The ring is the part that goes inside the 
abdomen and lifts the anterior abdominal wall. The 
spiral shape of the ring allows it to lift the abdominal 
wall to a dome shape, similar to the way gases would 
raise the wall in conventional laparoscopic surgery. 
The failure to lift in this dome shape was the 
drawback of many earlier devices. The flatter lifting 
devices allowed for surgeries like cholecystectomies 
because the rib cage provided the lift on one side. 
However, for pelvic surgeries, the dome shape is 
essential.  
 
 
Operative setup of STAAN Device 
 
RAIS Device: 
The next generation RAIS device (Retractor 
for Abdominal Insufflation-less Surgery) lift can be 
used to provide minimally invasive surgery in low 
resource settings. The RAIS device was designed to 
provide a retraction system for GILLS which meets 
current medical device standards (e.g. a modular 
system which can be readily cleaned and is 
compatible with auto-clave steam sterilisation,) is 
robust to transport and can be readily maintained 
without specialist intervention. 
 
Retractor for Abdominal Insufflation-Less Surgery (RAIS) 
device 
 
Setup and placement of the RAIS device proceeds in 
the following steps:  
● Positioning of the patient, including retention 
devices 
● Abdominal entry by open technique 
● Insertion and positioning of the ring 
● Docking of the ring to the device 
● Surgical intervention 
● Removal of the device and closure of the wounds 
 
Steps: 
1. With conventional laparoscopy, the gases move 
the intestines away from the surgery site, 
whereas, with gasless laparoscopic surgery, it is 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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gravity that does the job. Hence positioning is 
crucial, and so is the shoulder brace that prevents 
slipping of the patient during surgery. 
 
In order to retract intestines and other viscera away from the 
operative site, the patient will need to be tilted into extreme 
positions. Make sure they are secured well to the bed, including 
shoulder brace, arms well secured, and stirrups.  
 
2. The opening in the abdomen is made and the 
technique is like the mini laparotomy described 
by Hasson. (See Principles of Laparoscopy Part 
1 for further instructions.) Once the patient is 
cleaned and draped the lift apparatus is placed in 
the required position. The Incision is made a 
centimetre above or below the umbilicus. The 
lower edges are held up with the towel clips and 
a No. 15 blade is used to cut from the middle of 
the umbilicus. ‘S’ shaped retractors are used to 
expose and cut the rectus transversely. An artery 
clamp is used to check if the peritoneal cavity is 
entered. 
 
Making the periumbilical skin incision 
 
 
Incision of the Linea alba to safely enter the peritoneal cavity 
 
3. While maintaining anterior retraction on the 
abdominal wall with a penetrating towel clip, the 
index finger is passed into the peritoneal cavity. 
Check for any omental adhesions or trapped 
intestine between the ring and abdominal wall. 
At this point, the appropriate size ring is selected. 
The diameter of the ring should be 2-3 cm 
smaller than the distance from the umbilicus to 
the edge of the desired quadrant. For example, for 
cholecystectomy, use the distance from the 
umbilicus to the tip of 10th costal cartilage in this 
calculation. 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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Finger sweep maneuver to check for adhesions, attached 
bowel, omentum, or any other organs. 
 
4. Insert the ring while retracting the abdominal 
wall anteriorly 
 
Ready to insert the ring. 
 
Insertion of the spiral ring while lifting the abdominal wall 
 
5. Rotate the ring within the abdominal cavity to the 
quadrant of planned surgery. 
 
Positioning the ring in the required quadrant of the abdomen, 
in this case the left upper quadrant.  
 
6. Dock the ring to the RAIS Device and adjust the 
height of the ring. 
 
Adjust the RAIS device to the required position to ease the 
docking of the ring 
 
 
Maintaining the lift and ready to dock the ring to the RAIS 
device. 
 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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Docking the ring to the device 
 
 
Rotate the rotating screw handle in a clockwise manner to lift 
the abdominal wall to a desired height  
 
7. Insert the laparoscope and check that the ring is 
properly positioned and does not entrap any 
adjacent organs.  
 
Initial laparoscopy to confirm the location of the position of the 
ring.  
 
 
Normal ring appearance in the peritoneal cavity 
 
8. Proceed with surgery. Note that single-incision 
surgery is much easier using this device than with 
conventional laparoscopic surgery. The telescope 
can be passed at the 12 o’clock position of the 
ring and other instruments inserted below it. If 
needed, a uterine manipulator could be used to 
move the uterus and achieve a clear view of the 
pelvic organs. 
 
Now that the RAIS system has been positioned and the 
abdominal wall lifted, the surgical procedure can proceed 
 
 
Safely tilt and position the patient as required 
 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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As there is no need to use a port or to prevent gas leak, several 
instruments can be inserted through the same incision site.  
 
9. Remove the instruments and close any incisions 
made. For any instrument site larger than 10mm, 
including the initial one, the fascia must be 
closed to prevent incisional hernia.  
 
Skin incisions following multi-port gasless laparoscopy 
 
Pitfalls 
● Gasless laparoscopy is limited to selective 
abdominal procedures (including those described 
below) and can be challenging in patients with 
high BMI and in those who have had previous 
abdominal wall surgery.  
● Less compliant abdominal wall: GILLS relies on 
retraction of the abdominal wall to create surgical 
working space. This might not be very effective 
where the abdominal wall is rigid and non-
compliant. Patients should be selected carefully, 
and the below points should be considered:  
o High BMI: This factor may limit the 
extent of abdominal wall retraction. 
Caution is advised for BMI >28, 
especially in the early part of the learning 
curve. 
o Abdominal wall thickness: wall thickness 
of more than 5cm has been found to 
increase difficulty levels and reduce 
surgeon satisfaction scores. 
o Abdominal wall scarring due to previous 
surgery or trauma also reduces the 
compliance of the abdomen, thus making 
surgery difficult. 
o A muscular abdominal wall increases the 
stiffness and thus reduces the working 
space, mainly if muscle relaxants are not 
used. It can be overcome by using general 
anaesthesia and muscle relaxants. 
● Multi-Compartment surgery: GILLS relies on 
external retraction; hence shifting to other 
abdominal quadrants may be cumbersome. This 
makes surgeries requiring work in more than one 
quadrant difficult with GILLS. However, newer 
devices like RAIS allow working in multiple 
quadrants without difficulty as the ring can easily 
be rotated without needing to shift the external 
lift. 
● Patient Positioning: GILLS effectively uses 
gravity to shift other abdominal viscera away 
from the working field. The patient is generally 
placed in steep positions like Trendelenburg, 
reverse Trendelenburg, and lateral positions. 
Proper support, bracing, and padding should be 
ensured to avoid any patient harm. 
● Electrosurgery: GILLS rings placed inside the 
abdominal cavity may cause passage of current 
to the abdominal wall. The ring design is such 
that the contact area to the abdominal wall is 
always high, thus making the chance of electrical 
injury negligible. However, caution is needed to 
avoid contact with the live electrode. Insulation 
of working instruments must be checked before 
use. All principles of safe electro-surgery must 
always be followed. 
● Injury to the abdominal wall: the GILLS ring 
may cause damage and stretch to the abdominal 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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wall muscle leading to hematomas, weakening, 
chronic pain etc. It is essential to carefully decide 
the extent of wall retraction suitable enough to 
ensure adequate working space while avoiding 
unnecessary stretch to the abdomen. 
● Size of ring: The GILLS ring size must be 
selected appropriately according to the patient's 
build. A too-small ring will be ineffective in 
creating a good dome-shaped space. A too-large 
ring will also be ineffective as the ribs and other 
structures might not allow the retraction. A 
simple rule may be followed: The diameter of the 
ring should 2-3 cm smaller than the distance from 
the umbilicus to the bony parts in the desired 
quadrant. For example, for cholecystectomy, 
take the distance from the umbilicus to the tip of 
10th costal cartilage. 
 
Specific Situations:  
Diagnostic Laparoscopy 
For the diagnostic laparoscopy, the initial 
inspection should be possible with the ring alone 
after making the umbilical incision. Then, it could be 
held in various quadrants by assistants and the 
operating table tilted to view the entire abdominal 
cavity.  
The indications for diagnostic laparoscopy 
could be broadly classified into 
1. Acute Abdominal conditions: appendicitis, 
diverticulitis, 
duodenal 
ulcer 
perforations, 
adhesions, Meckel’s diverticulitis, intestinal 
perforations, 
torsion 
of 
abdominal 
testis, 
cholecystitis, and abdominal abscess 
2. Gynaecological conditions: ectopic pregnancy, 
endometriosis, pelvic inflammatory diseases, 
tubo-ovarian lesions, fibroids, pelvic congestion 
syndrome and evaluation of infertility 
3. Chronic abdominal conditions: Some studies 
report a high percentage of positive findings in 
chronic abdominal pain 
4. Diagnostic purposes: Biopsies to differentiate 
malignancies when required for staging, or for 
diagnosis of tuberculosis.  
 
Appendectomy 
For GILLS surgeries, the position of the 
patient is crucial. The intestines must fall away from 
the field of interest due to gravity. Hence for 
appendicectomy, the patient’s right side must be 
rotated up by 25-30 degrees and depending 
conditions inside the peritoneum, the head needs to 
go down by up to 15 degrees. Hence it is essential to 
use the shoulder support or shoulder brace to prevent 
the patient from slipping down, and to strap the 
patient sufficiently to avoid rolling off the table. If 
spinal anaesthesia is used, it is vital to ensure 
sufficient time for the aesthetic agent to fix.  
The GILLS apparatus is fixed using the two 
quick fix levers after placing it about 6 inches above 
the umbilicus and 2 inches towards the foot end. The 
apparatus is placed as mentioned earlier with the ring 
towards the right iliac fossa. The patient is placed in 
a head down and right side tilted up position.  
It is essential to pass the atraumatic grasper 
below the telescope (especially if it is an angled 
telescope) and go towards the caecum. Note: For 
novice laparoscopic surgeons and those not familiar 
with GILLS, two further 5mm incisions can be made 
in the left iliac fossa and suprapubic region to insert 
instruments. The learning curve is from open, to 
multiport, and then to single port surgeries. The 
taenia coli are traced to locate the base of the 
appendix. The base is near where the three taenia coli 
meet.  
The appendix is then held with either the 
atraumatic forceps, any special curved forceps that 
are available, or even a long Kelly clamp. The 
mesoappendix is then dissected using any available 
energy source. Sometimes just the dissection near the 
base should suffice.  
Several methods are available for tying the 
base of the appendix. One such method is the low-
cost loop made from polypropylene (Prolene ®) and 
the pusher used with a double-J ureteric stent. In 
addition, commercial loops can be used. Both intra – 
corporeal and extracorporeal knotting methods could 
also be used. 
The incision is closed after the appendix is 
removed. The rectus fascia sheath (linea alba) is 
usually closed with PDS sutures, and if subcutaneous 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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tissue is closed nicely, skin sutures would not be 
needed. Otherwise, skin sutures may be necessary.  
 
Cholecystectomy 
It is important to note that GIILS can be 
performed even in the presence of few relative 
contraindications 
to 
standard 
laparoscopic 
cholecystectomy like pulmonary or cardiac disease. 
This is because GILLS does not have gas-related 
complications. 
A surgeon needs to know and clearly 
understand the relevant anatomy in the hepato-cystic 
triangle. The dissection for cholecystectomy is 
mainly carried out in an area close to vital structures 
such as a portal vein, hepatic artery and common bile 
duct. Any misadventure here can lead the procedure 
into a significant bile duct or vascular injury. Also, it 
is essential to be mindful of various anatomical 
distortions due to pathological processes (i.e. acute. 
cholecystitis) or the anomalies of the hepatobiliary 
system. Important landmarks to be understood are  
● Hepatocytic triangle 
● Cystic plate 
● Segment IV of the Liver 
● Umbilical fissure 
● Rouviere’s sulcus 
 
Rouviere’s sulcus (White arrow) is a naturally occurring cleft 
in the right lobe of the liver that points the surgeon to the level 
of Calot’s triangle (Black arrow) and helps orient and avoid 
injury to the common bile duct (Red arrow.) Source: Stuart 
Lockhar, Gurpreet Singh-Ranger: Rouviere's sulcus—Aspects 
of incorporating this valuable sign for laparoscopic 
cholecystectomy. Asian Journal of Surgery 41(1)  2018 
 
Though lower abdominal GILLS can be 
performed 
under 
spinal 
anaesthesia, 
cholecystectomy 
needs 
general 
anaesthesia. 
However, in rural areas where facilities for General 
anaesthesia 
are 
not 
available, 
experienced 
anaesthesiologists help perform under high spinal 
anaesthesia. Studies have shown that regular 
laparoscopic cholecystectomies are possible and safe 
with low carbon dioxide pressures. GILLS 
cholecystectomies are regularly carried out in many 
rural hospitals.  
For standard position with the American 
approach, the patient is supine with arms out, and the 
surgeon 
stands 
on 
the 
patient’s 
left 
side. 
Alternatively, the patient can be placed in a split leg 
position (French approach) with the surgeon 
standing between the legs. The latter is preferred 
when a single incision approach is used. The position 
is the same as for classically described single-
incision cholecystectomy, but there is no help from 
the gas in keeping the operative field clear of 
contents. It is, therefore, helpful to elevate the head 
as high as possible to let gravity take away contents 
from the operative field. The ring is placed towards 
the right hypochondrium.  
GILLS cholecystectomy can be done by 
single incision, 3 ports (3/4 instrument) or even 4 
ports. The author uses 4 instruments through 3 
incisions.  
1. 1.5 cm Sub - umbilical incision, which 
accommodates the retraction ring, camera, and 
left-hand instrument 
2. 0.5 cm epigastric incision for right-hand 
instrument 
3. 0.5 cm in the right anterior axillary line at the 
level of the umbilicus for assistant retraction 
instrument. 
Another option is a single port approach, using a 
single 1.5-2 cm sub-umbilical incision is made, 
which provides entry to the telescope and two 
working instruments. 
 
Steps of laparoscopic cholecystectomy 
1. Abdominal cavity access through umbilicus 
2. Application of abdominal wall device and 
creating space. 
Gas Insufflation-less Laparoscopic Surgery 
Jesudian Gnanaraj, Anurag Mishra, Lovenish Bains, Biju Islary, Peter Culmer & Noel Aruparayil  
 
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3. Port placement and a quick look around the 
abdomen 
4. Initial dissection of the peritoneum. 
5. Dissection of the hepato-cystic triangle 
6. Dissection of gallbladder off bottom one-third of 
the cystic plate 
7. Confirmation of the Critical View of Safety 
8. Ligation and division of cystic duct and cystic 
artery 
9. Dissection of gallbladder off the remainder of the 
cystic plate 
10. Gallbladder extraction and port closure 
 
Pelvic Surgery 
Next, the patient is placed in a lithotomy 
position at the start and a uterine manipulator is 
inserted. Then, the patient is placed in a steep 
Trendelenburg (head downwards) position, so it is 
essential to have shoulder support to prevent the 
patient from slipping.  
If single incisions are used, it is essential to 
remember that the camera goes at the 12 o’clock 
position and the other instruments below it so that the 
instruments do not clash. 
A simple uterine manipulator is used for 
diagnostic laparoscopy procedures. The complex 
manipulators are necessary for totally laparoscopic 
hysterectomy, while the simple ones are sufficient 
for laparoscopic-assisted vaginal hysterectomy. If 
none of these is available, cervical (Hegar’s) dilators 
can be used. Rubin’s cannula is used to inject 
methylene blue. Leaving some solution in the pelvis 
to cool the ovaries is better than aspirating the fluid 
before closing. Vessel sealing instruments are handy 
for pelvic surgeries, and often the ovaries need to be 
preserved, so marsupialization is carried out. The 
posterior fornix can be used to retrieve large, 
resected lesions. 
The 
ureteroscope 
can 
be 
used 
for 
hydrosufflation and cannulation of the Fallopian 
tubes. The resectoscope could be used for treating 
uterine lesions like polyps, Asherman’s syndrome 
etc. The GILLS surgeries have the advantage that the 
larger open suction cannula can be used, and gauze 
pieces can be inserted without the problem of the 
collapse of pneumoperitoneum. As mentioned 
earlier, urology instruments help in many infertility 
investigations and treatments.  
 
An advantage of GILLS is that urologic instruments, such as a 
rigid ureteroscope (top) or operative cystoscope (bottom) can 
be used intra-abdominally.  
 
GILLS is a valuable technique for evaluating 
and treating infertility in women, as it is possible 
under spinal anaesthesia. It can be done with a single 
cosmetic incision and is relatively inexpensive. In 
addition, urology instruments offer an additional 
low-cost advantage. 
 
Hysterectomy 
Patients are advised to hydrate and eat lightly 
for 24 hours before the surgical procedure after 
optimizing their medical conditions. Prophylactic 
antibiotics are essential as some parts of the 
equipment, like the optics, are not sterile. The patient 
is placed in a lithotomy position with the free arm 
tucked in and shoulder braces to prevent slipping in 
the steep Trendelenburg position. Both the perineum 
and abdomen are prepared and draped.  
The double-bladed vaginal (Sims) speculum 
is used to visualize the cervix, which is held with a 
vulsellum forceps. Then, dilatation of the cervix is 
carried out to pass the uterine manipulator 
comfortably. Several types are available. A simple 
one can be made by lengthening a cervical (Hegar) 
dilator. The manipulators used for total laparoscopic 
Gas Insufflation-less Laparoscopic Surgery 
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hysterectomies 
differ 
from 
those 
used 
for 
laparoscopic-assisted vaginal hysterectomy.  
Starting the lifting process with the lifting 
part at the lowest position is paramount. After 
making the connections and tightening them, the 
apparatus is lifted under vision so that there is no 
omentum or bowel caught in the intra – abdominal 
portion of the apparatus. Surgeries are usually 
possible with single incisions, especially while using 
a vessel sealing device 
Staying close to the uterus, the tubo-ovarian 
ligaments and the round ligaments are divided. 
Modern tools like vessel sealing systems, harmonic 
shears or regular mono-polar or bipolar energy 
sources could be used. Once well coagulated, the 
tissues appear white and sufficient stretch offered by 
the uterine manipulator is essential. The uterine 
manipulator holds the uterus pushed in superior / 
anterior direction and to the opposite side of the 
vessels that are being divided. The broad ligaments 
are then dealt with by coagulating and dividing. Then 
the bladder is dissected off the uterus by holding it 
with an atraumatic forceps and holding the uterus 
down and pushed in with the manipulator. Then the 
posterior fornix can be entered by cutting over a large 
Hegar dilator pushed from below in the posterior 
fornix. Finally, the uterine manipulator holds the 
uterus anteverted.  
Skeletonizing the broad ligament leads to the 
uterine vessels. They could be tied using multiple 
trocars or sealed using the vessel sealing systems. 
Staying close to the uterus avoids injury to the ureters 
and bladder. The cervicovaginal junction can be 
identified using the delineator portion of the uterine 
manipulator or, if such instruments are not available, 
using Hegar’s dilator in the anterior fornix. The 
division can be carried out using a hook electrode. 
Suturing the vaginal walls is easy with Lift 
laparoscopy and using the regular long needle 
holders. Doing this operation through a single 
incision requires a little practice.  
A circumferential incision is made using the 
coagulating current with monopolar cautery and 4 
retractors are used for good exposure. Ellis’s forceps 
is used to hold the vaginal wall and dissect the 
bladder off the uterus. The earlier dissection of the 
bladder from above helps in finding the correct 
planes for dissection. Once the anterior and posterior 
fornixes are dissected, the lateral ligaments can be 
divided using vessel sealing equipment having the 
finger then a Kelly clamp to isolate the lateral 
ligaments. These lateral ligaments can be tied 
together later to offer support, and the vagina is 
closed below it.  
A recent advance is the use of robotic surgery 
for hysterectomy. The advantage is that it would be 
advisable in COVID 19 setting with minimal staff in 
the operating room or doing the surgeries remotely. 
However, the technology is costly and unsuitable for 
low-resource settings. 
 
Jesudian Gnanaraj MCh (Urology), FARSI, FICS, 
FIAGES  
Association of Rural Surgeons of India 
Karunya University, Coimbatore 
Corresponding Author: jgnanaraj@gmail.com 
India 
 
Prof. Anurag Mishra MBBS, MS, FACS, FIAS 
Maulana Azad Medical College, Delhi 
India 
 
Lovenish Bains MS, FNB, FACS, FIAGES 
Maulana Azad Medical College, Delhi 
India 
 
Biju Islary MBBS, MS, FIAGES 
Crofts Memorial Hospital, Assam 
India 
 
Peter Culmer MEng, PhD 
School of Mechanical Engineering 
Global Technologies Group, University of Leeds 
United Kingdom 
 
Noel Aruparayil MD, MRCSEd, 
School of Medicine 
Global Technologies Group, University of Leeds 
United Kingdom 
 
July 2022 
