Minimally invasive surgery (MIS) is characteristically performed through a small incision or no incision, and visualization is provided by endoscopes. Both laparoscopy and hysteroscopy are considered in this category. With laparoscopy, small abdominal incisions provide access to introduce an endoscope and surgical instruments into the abdomen. To increase operative space, a pneumoperitoneum is created through one of these incisions. As such, laparoscopy provides a minimally invasive option for women undergoing intraabdominal gynecologic surgery. Initially used in diagnostic and sterilization procedures, laparoscopy and its improvements in technology, instrumentation, and surgical technique now allow almost all major intraabdominal gynecologic procedures to be performed in a minimally invasive manner. With advancements in robotic technology, options continue to expand and enable surgeons to perform more complex procedures.
Hysteroscopy uses an endoscope and uterine distending medium to provide an internal view of the endometrial cavity. This tool permits both the diagnosis and operative treatment of intrauterine pathology. During the past two decades, the role of hysteroscopy has expanded rapidly with development of more effective instruments and smaller endoscopes. Indications for hysteroscopy vary and include evaluation as well as treatment of infertility, recurrent miscarriage, abnormal uterine bleeding, amenorrhea, and retained foreign bodies. Additionally, for those seeking sterilization, tubal occlusion devices can serve as an effective and safe method of contraception.
Decision for Laparoscopy versus Laparotomy
Theoretically, laparoscopic surgery differs from laparotomy only by its mode of access to the operative field. However, inherent qualities can make it more difficult to perform. These include counterintuitive motion, indirect palpation of tissue, finite number of ports for abdominal access, restricted tool movement, and replacement of normal three-dimensional vision by two-dimensional video images. The trade-off in appropriately selected patients, however, is a faster recovery, improved cosmesis, less postoperative pain, diminished adhesion formation, and at least equivalent surgical results (Ellström, 1998; Falcone, 1999; Lundorff, 1991; Mais, 1996; Nieboer, 2009). The decision to perform a laparoscopic procedure is based on several parameters. Primary among these are patient factors, availability of appropriate instrumentation, and surgeon skill.
Laparoscopy using a pneumoperitoneum is contraindicated in very few clinical conditions, but these include acute glaucoma, increased intracranial pressure, and peritoneal shunts. Thus, laparoscopy is appropriate for many patients, although modifications may be warranted for certain clinical situations. Several are discussed subsequently.
With laparoscopy, adhesive disease increases the risk of visceral injury during abdominal entry. Adhesions are also associated with higher conversion rates to laparotomy because long and tedious adhesiolysis may be completed by some surgeons more quickly with open surgical dissection techniques. Thus, during preoperative physical examination, a surgeon should note the location of previous surgical scars and ascertain the risk of possible intraabdominal adhesive disease (Table 42-1.1). Similarly, a history of endometriosis, pelvic inflammatory disease, or radiation treatment may predispose ...