THE NEED AND INDICATIONS FOR DEVELOPING AN APPROACH AND TECHNIQUE FOR PERFORMING LAPAROSCOPIC GYNECOLOGICAL SURGERIES AT ZERO INTRA-ABDOMINAL PRESSURE WITHOUT THE USE OF A LAPAROLIFT UNDER SPINAL ANESTHESIA ONLY

Abstract

Background. Traditional gynecological laparoscopy performed under CO₂ pneumoperitoneum and general anesthesia provides a predictable operative space, but is associated with cardiorespiratory changes due to Trendelenburg and significant drug load, limiting the applicability of this method in high-risk patients and in resource-constrained regional hospitals. Gasless laparoscopy is considered an alternative; however, it is more often performed with a laparolift, which increases technological dependence, complicates organization, and may limit the versatility of pelvic exposure in certain clinical situations. Aim of the study. To substantiate the need and clinical indications for developing an approach and technique for performing laparoscopic gynecological surgeries at zero intra-abdominal pressure without the use of a laparolift under spinal anesthesia only, and to formulate requirements for the safety and reproducibility of the future algorithm. Materials and Methods. A problem-based analytical review of the literature was conducted, including a qualitative synthesis of data on the physiological effects of CO₂ pneumoperitoneum and positioning, low-pressure strategies, neuraxial anesthesia in laparoscopy, gasless approaches, and the early recovery profile (pain, PONV). A patent information analysis of the state of the art was performed, including an international search of the PATENTSCOPE (WIPO) and Espacenet (EPO) databases, to identify technical solutions related to creating a CO₂-free operating space and dependence on lifting systems. Results. According to the literature, two "incomplete" models predominate: a gasless approach with a laparolift and neuraxial anesthesia with preserved CO₂ pneumoperitoneum. Laparolift, despite eliminating the CO₂ factor, creates a new "bottleneck" in scaling: dependence on specialized equipment, a prolonged preparatory phase, and variability in pelvic exposure in some patients. The combination of zero intra-abdominal pressure, elimination of a laparolift, and true spinal anesthesia represents a clinical and technological niche that potentially reduces CO₂- and GA-associated load and improves the early recovery profile (including PONV). A key condition for the clinical feasibility of this approach is preliminary standardization: positioning strategy, "adequate exposure" criteria, conversion protocol, and a uniform set of safety and efficacy endpoints. Conclusion. The "0 mmHg" approach. The concept of "laparoscopy without a laparolift under spinal anesthesia only" has sound clinical and organizational justifications and requires further development of a reproducible approach and a safety algorithm, followed by clinical evaluation.