Positive pressure pneumoperitoneum (12 mm Hg) is associated with adverse physiologic effects that can prove detrimental to certain high-risk patients with diminished cardiorespiratory reserve. Mechanical abdominal wall lift (AWL) has been proposed as an alternative method of exposure in laparoscopic surgery to obviate or minimize these adverse physiologic effects, the risk of CO2 embolism in trauma patients, and tumor dissemination in patients undergoing laparoscopic surgery for cancer. This article reviews the systems available for AWL, the clinical applications of the technique, and the findings of the randomized controlled trials that compare AWL with conventional pneumoperitoneum. AWL systems do appear to reduce the adverse cardiovascular and respiratory effects, but they do so at the expense of surgical exposure, which is less optimal than that provided by the positive-pressure pneumoperitoneum. This reduced exposure increases the execution difficulty of the operation and, hence, the operating times. This problem is overcome by combination of AWL with low-pressure (3 to 4 mm Hg) pneumoperitoneum. This combination provides good surgical exposure without adverse cardiovascular consequences. Copyright © 2001 by W.B. Saunders Company.