Modified laparoscopy without prior pneumoperitoneum.

4100 of the 6900 outpatient laparoscopic sterilizations performed in Sri Lanka at the Family Health Bureau over an 18-month period were done without induction of pneumoperitoneum prior to trocar insertion. This method made it possible to avoid the problems associated with induction of pneumoperitoneum; to use the minimum necessary amount of carbon dioxide thereby avoiding the dangers of increased intraabdominal pressure and reducing the chances of causing hypercarbia and its consequences as well as reducing the cost per procedure; and to cut down the operating time taken for a straightforward laparoscopic sterilization using Falope rings to less than 2 minutes. All patients ranging in age from 23-44 years were multiparous with reasonably lax abdominal walls. All patients selected for sterilization were properly counseled and informed consent was obtained from both husband and wife. A detailed history was taken and a complete physical and vaginal examination was performed. Patients were premedicated with 50-75 mg of Pathidine and .5 mg of atrophine given intramuscularly 15-20 minutes before the procudure. 1 of the trained nurses also adminstered 10-12 cc of the local anesthetic 1% lignocaine subcutaneously. The operator wore fresh gloves and made an incision 10-12 mm long in the lower border of the umbilicus. The trocar and sleeve connected to the gas supply with its valve closed was held in the right hand and inserted through the incision for about 1/2 inch in the subcutaneous tissue almost parallel to the surface. The patient was put in the Trendelenberg position and the lower abdomen was held up with the left hand and released a couple of times before it was firmly and finally stabilized. This avoided the bowel or omentum being caught in the grip particularly in a patient with a thin abdominal wall. The trocar was then directed toward the center of the pelvis and pushed in with a carefully controlled screwing movement of the wrist. Once the peritoneum had been penetrated the trocar was withdrawn and the sleeve alone was pushed further inward. The laprocator which was loaded with 2 Falope rings and local anesthetic lignocaine jelly was connected to the light source and inserted through the sleeve. Once the procedure was completed the instruments were withdrawn after allowing the gas to escape. The wound was sutured with a single stitch. The patient can usually go home in 1-2 hours. In the series of 4100 cases there wqas not a single failure in the attempt at direct insertion of the trocar. There was no damage seen to the blood vessels bowel bladder omentum uterus or any other structures during the procedure. With perfect coordination of activity and a highly trained team the entire operative procedure can be completed safely under 2 minutes. All of the over 9/% of the patients seen 1 week after the operation were well. None had any complaints symptoms or signs related to bowel injury.