Minilaparotomy: A Minimally Invasive Alternative for Major Gynecologic Abdominal Surgery

Abstract

In the 1960s or 1970s, gynecology residency training emphasized vaginal hysterectomy as the preferred technique for treating many conditions now managed by less invasive alternatives. This led gynecologists to become very skilled at operating through very small incisions. More recently, as these less invasive procedures are rapidly becoming the standard of care, and women are having fewer babies, vaginal surgery is performed less often. Because our young colleagues are acquiring less experience with this technique, the skill of operating through a very small incision is becoming a lost art. Of the 600,000 hysterectomies done in the United States each year—a number which has remained stable for the past 20 years—65% to 75% are done through large abdominal incisions.1 Rates in the Kaiser Permanente Northern California (KPNC) Region are somewhat better: The rate of abdominal hysterectomy is 68%, the rate of vaginal hysterectomy is 21%, and 11% of these procedures are done laparoscopically. Although laparoscopic hysterectomy offers a minimally invasive alternative when vaginal hysterectomy is contraindicated or considered too difficult by the surgeon, laparoscopic hysterectomy has many drawbacks. The procedure is very costly because of its requirements for equipment and time in the operating suite and because the procedure has a very steep learning curve. However, when length of hospital stay and postoperative utilization of medical services are taken into account, laparoscopic hysterectomy in the KPNC Region is less expensive than abdominal hysterectomy but substantially more expensive than vaginal hysterectomy. In addition, compared with patients who have the more invasive (ie, abdominal) procedure, our patients who undergo vaginal or laparoscopic hysterectomy have better postoperative quality of life.2 Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy … Development of Minilaparotomy Techniques Use of minilaparotomy in surgery for benign gynecologic disease has been well established.3 Laparoscopically assisted myomectomy was first reported by Nezhat et al in 1994.4 In their review of 57 cases, these authors concluded that the use of the minilaparotomy incision is a safe alternative to myomectomy done by laparotomy. Minilaparotomy is technically less difficult to perform than laparoscopic myomectomy, allows better closure of the uterine defect, and may require less time to perform. Most women in the series reported by Nezhat et al4 returned to normal activity within three weeks. In 2002, we adopted the Pelosi minilaparotomy hysterectomy technique as an effective alternative to laparoscopic hysterectomy and standard open laparotomy hysterectomy. First presented at the Global Congress of Gynecologic Endoscopy in 2002 and described in OBG Management in April 2003,5 the procedure relies on traditional open techniques learned by all Ob/Gyn residents and relies also on use of an inexpensive, soft, sleeve-type self-retaining abdominal retractor. Minilaparotomy is a minimally invasive procedure ideal for gynecologists who are less skilled in vaginal or laparoscopic surgery and who are more comfortable with the (standard) abdominal approach. In addition to combining the surgical principles and techniques of vaginal and laparoscopic surgery, minilaparotomy requires the same postoperative care as less invasive procedures. Detailed description of the surgical technique would be more appropriate for an obstetrics/gynecology journal; here I describe some of the most important technical principles of minilaparotomy.