Matthew T. Siedhoff* Pages 4 - 10 ( 7 )
Background: Important innovations in laparoscopy have come in the form of technological advances and improvements in best practice for patients in need of minimally invasive gynecologic surgery.
Objective: To review recent advancements in laparoscopic instrumentation and emerging best practices around gynecologic laparoscopy.
Results: New instrumentation reviewed include sub-5 mm instruments, three-dimensional imaging, narrow band imaging (NBI), and articulated instruments. Smaller (mini-laparoscopy and percutaneous) instruments can provide equivalent outcomes for certain operations with less abdominal wall trauma. Three-dimensional imaging may be particularly helpful for learners in the laparoscopic environment. NBI may pick up more endometriosis lesions but the clinical impact the small increase in sensitivity appears to be negligible over conventional white light laparoscopy. Adding articulation to certain advanced energy devices may facilitate division of vascular pedicles difficult to reach with standard straight instruments.
Evidence suggests that mechanical bowel preparation before gynecologic laparoscopy and the routine use of adhesion barriers in myomectomy have doubtful value and can likely be abandoned. Preventative salpingectomy at the time of hysterectomy does not afford additional complications but likely has a role in prevention of some ovarian cancers. Good fetal outcomes are seen with laparoscopic cerclage, equivalent to outcomes seen with the traditional abdominal approach. Achieving hemostasis with electrosurgical energy is more detrimental to ovarian function than other methods, such as suturing. Excision may be superior to ablation of endometriosis lesions, and excision of bowel and bladder disease may be aided with the use of transanal staplers and barbed suture. Pretreatment with Gonadotropin Releasing-Hormone Analogues may have a role in laparoscopic myomectomy for large fibroids. The risk of uterine rupture after laparoscopic myomectomy appears to be low when proper technique is used.
Conclusion: Gynecologic laparoscopists should consider available new technology in instrumentation and practice as the field continues to evolve.
Laparoscopy, endometriosis, fibroids, myomectomy, hysterectomy, salpingectomy, three-dimensional imaging, narrow band imaging.
Department of Obstetrics and Gyncology, Center for Minimally Invasive Gynecologic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048