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Low pressure laparoscopic procedure in morbidly obese patients with endometrial carcinoma using a new subcutaneous abdominal wall-retraction device: a surgical challenge
  1. Antonino Ditto,
  2. Giulia Chiarello,
  3. Umberto Leone Roberti Maggiore,
  4. Fabio Martinelli,
  5. Giorgio Bogani and
  6. Francesco Raspagliesi
  1. Department of Gynecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  1. Correspondence to Dr Giulia Chiarello, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy; giuli.chiarello{at}

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A minimally invasive approach is considered the standard treatment for early-stage endometrial cancer,1 but laparotomy remains an option in morbidly obese patients whose laparotomic conversion rate after initial laparoscopic approach is still high. The main reasons for laparotomic conversion in obese patients are inadequate viscera exposure due to adiposity and an intolerance of the Trendelenburg position. Additionally, laparoscopic surgery using high pressure CO2 in the peritoneum could induce several hemodynamic and cardiorespiratory changes and is not indicated in high-risk patients suffering from cardiorespiratory dysfunction or renal impairment that can occur in most obese patients.

Figure 1

Components of the wall-retraction device for low pressure laparoscopic surgery.

In order to overcome these limitations for the treatment of gynecological cancer in these patients, in our department we adopted a technique that combines different approaches and consists of a low-pressure laparoscopy technique using a subcutaneous abdominal wall-retraction device called Laparo-Tenser (Lucini Surgical Concept srl, Milan, Italy).2

Figure 2

Video image: an example of the operating field that it is possible to create with the abdominal wall-retraction device.

The strength of this device, among other existing surgical instruments which are suitable such as wall-lifters (ie, KeyLoop, Wall lifting system by Mizuho Medical Inc, Kent retractor set), lies in the structure of its subcutaneous needles; this is obtained with a mathematical model derived from an analysis of abdominal tissue tension caused by gas expansion, adapted to avoid local microtrauma or tissue tension and thus helping to improve anesthesiological parameters without complications,3 and avoiding the disadvantages of intraperitoneal high pressure and C02 absorption. In our experience no complications related to subcutaneous insertion have occurred.

This, in addition to recent evidence4 about a non-inferiority, in terms of complications, of gasless laparoscopy compared with a conventional one, makes this type of surgery a very interesting approach for obese patients with gynecological malignancy.

Patients eligible for this type of treatment are obese with a body mass index >35 kg/m2 or >30 kg/m2 plus obesity-related comorbidities (diabetes, sleep apnea syndrome, hypertension, ischemic heart disease). The procedures performed using low-pressure laparoscopy in our center are: hysterectomy (simple and radical), bilateral salpingo-oophorectomy, pelvic and para-aortic sentinel node biopsy, systematic lymph node dissection, and comprehensive peritoneal staging.

In this video we show in detail how this device can be used during a low-pressure laparoscopy procedure in an obese patient with endometrial cancer.

Video 1 Low-pressure laparoscopic procedure in an obese patient with endometrial carcinoma using the Laparotenser device. All permissions to include images in the video obtained. Patient consent for publication not required.

Data availability statement

All data relevant to the study are included in the article.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants but consent for participation was not obtained as any personal information and images were anonymized.



  • AD and ULRM are joint first authors.

  • Twitter @DrFMartinelli

  • Contributors AD, GC, ULRM, FM, GB and FR; supervision. AD; writing. GC, AD, ULRM; writing, review and editing. AD;

    guarantor. All authors have read and agreed to the published version of the manuscript.

  • Funding The authors have not received a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.