To the Editor:I read with interest the article by Crabtree JH (Heated, humidified CO2 gas is unsatisfactory for awake laparos-copy. JSLS. 2005;9:463–465) in the October - December issue of the journal. It was refreshing to see some work published about awake laparoscopy.Dr Crabtree concluded, in his experience during 2 cases, that heated and humidified CO2 used for the pneumoperitoneum “does not reduce pain sufficiently to permit satisfactory performance of laparoscopy with local anesthesia” and that “the theory that cold, dry insufflation gas is a source of peritoneal pain during laparoscopy needs to be reassessed.”Performing awake laparoscopy is an art with an inherent steep learning curve that requires the experience of more than 2 cases. Those of us who have performed and published extensively in the arena of awake laparoscopy have noted a significant improvement in the development of intraoperative pain when employing heated and humidified CO2, in contrast to cold, dry CO2.[1]Appropriate conscious sedation is a critical component for successful awake laparoscopy. It is not surprising that the patients in both cases experienced pain during laparos-copy, since only 50 µg of fentanyl citrate was administered in the first case, and 100 µg in the second case. The protocol used for conscious sedation must be of sufficient efficacy to allow the awake procedure to continue with little or no patient discomfort. I would recommend my protocol for conscious sedation[2] with the adjunct of heated and humidified CO2 for the successful performance of awake laparoscopy. The fact that Dr Crabtree's second patient experienced pain following insufflation with only 200 mL of CO2 suggests that his methodology needs to be refined.Finally, it is important to emphasize that a report of 2 cases provides a limited experience, and when these results vary significantly from that of other published work, [sic] should be looked at critically. I applaud Dr Crabtree for his efforts to advance awake laparoscopy.