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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. As such, laparoscopy provides a minimally invasive option for women undergoing intraabdominal gynecologic surgery. And, with its technology improvements, almost all major intraabdominal gynecologic procedures can now be performed with MIS.
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Hysteroscopy uses an endoscope and uterine cavity distending medium to provide an internal view of the endometrial cavity. This tool permits both the diagnosis and operative treatment of intrauterine pathology.
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FACTORS IN CHOOSING LAPAROSCOPY
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In theory, laparoscopic surgery differs from laparotomy only by its mode of access to the operative field. However, inherent qualities can make some surgical steps more difficult. These include indirect palpation of tissue, counterintuitive motion, a finite number of ports for abdominal access, restricted movement, and replacement of normal 3-dimensional (3-D) vision by 2-dimensional (2-D) video images. In appropriately selected patients, the trade-off 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 laparoscopy is based on several parameters. Primary among these are patient factors, availability of appropriate instrumentation, and surgeon skill.
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Laparoscopy using a pneumoperitoneum is contraindicated in very few clinical conditions, but these include acute glaucoma, retinal detachment, increased intracranial pressure, and some types of ventriculoperitoneal shunts. Thus, laparoscopy is appropriate for many, although modifications are warranted for certain clinical situations. Several are discussed subsequently.
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With laparoscopy, adhesive disease increases the risk of visceral and vascular 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 notes the location of previous surgical scars and ascertains the risk of possible intraabdominal adhesive disease (Table 41-1). Similarly, a history of endometriosis, pelvic inflammatory disease, or radiation treatment may predispose to adhesions. In addition, abdominal wall hernias or hernia repairs and any reparative mesh are identified and avoided during trocar insertion. If abnormal findings are found during this preoperative evaluation, plans for an alternative entry site are considered.
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