Objective: To determine if the theoretic advantages of gasless laparoscopy are realized in direct comparison to laparoscopy with pneumoperitoneum. Methods: Fifty-seven patients undergoing laparoscopic surgery chose to participate in this trial and were randomized after the induction of general anesthesia. Twenty-nine of the 57 patients were randomized to the pneumoperitoneum group. Of the 28 patients in the gasless group, six were converted to pneumoperitoneum because of inadequate exposure. The adequacy of exposure and ease of surgery were assessed with a subjective score, and the times to exposure and for incision closure were recorded. Various anesthetic factors were measured. Patients completed an analog pain score in the recovery area and for the first 5 postoperative days. Analgesic and antiemetic use also was recorded, as was the number of days to return to normal activity. Results: Times to achieve exposure and close incisions were longer, and exposure and ease of surgery were worse in the gasless group. Patients in the gasless group had lower diastolic blood pressure, minute ventilation, peak inspiratory pressures, and end tidal pCO2. There were no differences in body temperature, systolic blood pressure or heart rate, postoperative pain scores, analgesic or antiemetic use, or times to hospital discharge or return to activity between the groups. Conclusion: Performing laparoscopy using the Laparolift device compromised surgical exposure and thus increased technical difficulty. Patients realized no benefits from its use in terms of postoperative discomfort or return to activity. Eliminating the pneumoperitoneum allowed lower minute ventilation and peak inspiratory pressures, and end tidal pCO2 was lower. Although the concept of gasless laparoscopy holds appeal, the current prototype is not well-suited for infertility procedures.