Advances in Gynecological Laparoscopic Surgery

Abstract

Laparoscopic operations in gynecology performed globally include benign hysterectomy, myomectomy, adnexal surgery, and staging operations with lymph node dissections for early gynecologic cancer. Around 20 years ago, Harry Reich demonstrated the first case of a laparoscopically assisted vaginal hysterectomy (LAVH).1 At present, with the dramatic advances in equipment and skills, we have the option of total laparoscopic hysterectomy. In gynecological surgery, uterine fibroids are the most common cause of benign uterine tumors.2 The traditional primary treatment for symptomatic myomas is hysterectomy or myomectomy. Laparoscopic myomectomy (LM) is an alternative and advanced technique that can also take the place of traditional open surgery. However, LM becomes time-consuming and difficult in cases where extra-large symptomatic myomas are present. Moreover, the risk of intraoperative hemorrhage and conversion to laparotomy has greatly increased.3 Recently, we have used the novel surgical technique, in situ morcellation (ISM), while the myoma is attached to the uterus4 after hemorrhage control with subcapsular injection of vasopressin,5 and/or bilateral ligation of the uterine artery.6,7 We have demonstrated that the ISM technique can easily and efficiently resolve the issue of treating extra-large myomas, including those greater than 10 cm in mean diameter. Because LM with concurrent block of uterine arteries is a novel technique in the treatment of uterine myomas, the impact of this technique on the blood flow profile of the uterus during the postoperative period has been studied.8,9 Using a prospective three-dimensional (3D) power Doppler ultrasound study, we can illustrate that concurrent uterine artery ligation during LM causes no additional decrease of myometrial perfusion.8 The healing of uterine scars after LM has also been evaluated by 3D power Doppler ultrasound. The adequate perfusion demonstrated by 3D power Doppler ultrasound encourages both good uterine scar healing and dissolving of hematomas.9 This technique will bring many benefits to new and substitutive surgical techniques. In view of the relatively shorter operative time and decreased blood loss, we would like to clarify that transvaginal hysterectomy is better for dealing with uteri weighing less than 350 g, whereas LAVH is preferable for those weighing 350 g or more.10 However, the increased operative time associated with LAVH cannot be ignored, especially with large uteri.6,11,12 For the most part, LAVH for large