Background:
The first case of laparoscopic cholecystectomy was introduced to National Taiwan University Hospital since more than 20 years. There are still some limitations and difficulties of laparoscopic surgery when applied for complicated operation, such as gastric cancer, pancreas cancer etc. Our general surgery department has overcome some technical difficulties with aids of self-designed devices in undergoing advanced MIS.

Methods and Results:
Multiple modalities of MIS are applied in our department, including hand-assist, minilaparotomy, total-scope, total intracorporeal anastomosis, single- port or incision, and modified NOTES. More than 500 cases of gastrectomy, 3 cases of Whipple’s operation were done using multiple hybrid MIS methods. We also developed gasless equipment（Lin’s Ring）with high retractors and a self designed retractor ring. Our gasless device needs no CO2 and most of the equipment and instruments are reusable. It reduced the production of greenhouse gas and is harmless to the environment, so we also named it “Green Laparoscopy”. The equipment has been successfully applied to many advanced operations, including gastrectomy, intestinal resection, splenectomy, hepatectomy, and even pancreaticoduodenectomy. The application of hybrid laparoscopy for advanced MIS and some MIS devices with patent designed by our team will be illustrated. Single port and modified NOTES were applied in selected cases. Hybrid gas plus gasless setting combined the advantages of traditional open surgery and gas-filling laparoscopic surgery, and can provide a friendly bridge for the traditional surgeon to start laparoscopic surgery.

Conclusion:
We recommend multi-modality personalized MIS according to patient condition and surgeon ability.