Laparoscopy has been used effectively as a valuable diagnostic tool for a wide variety of abdominal and pelvic pathologies. It has been used for the assessment of acute or chronic pain, suspected ectopic pregnancy, endometriosis, adnexal torsion, or other extragenital pelvic pathologies. In most cases, the laparoscope is placed through an infraumbilical port, and a probe is placed through a second suprapubic port to manipulate the pelvic organs, if only a diagnostic laparoscopy is performed. However, for operative laparoscopy other than the simplest procedures, the suprapubic port is not useful and is quite uncomfortable. If operative laparoscopy is performed, the accessory trocars should be placed in the right and left lower quadrants. For advanced laparoscopy, an accessory trocar at the level of the umbilicus lateral to the rectus muscle will allow the principal surgeon to operate comfortably and have access to the pelvis. If tubal patency is a concern, a dilute dye can be injected transcervically, a procedure termed chromopertubation.

Before initiating any surgery, the peritoneal cavity should be thoroughly inspected using a systematic approach. With the surgeon controlling the movement of the laparoscope, each quadrant of the abdomen and then the pelvis should be carefully inspected. Care should be taken to inspect the appendix, omentum, peritoneal surfaces, stomach, surface of the bowel, diaphragms, and liver (◘ Figs. 21.4 and 21.5) [16]. The spleen is usually difficult to see except in thin women (see ◘ Fig. 21.3). If any suspicious lesions are observed, fluid should be obtained for cytology (pelvic washings) prior to biopsying the lesion for frozen section.

Laparoscopic pelvic assessment is often performed in a non-standardized fashion depending on the surgeon’s discretion. Reporting positive or negative findings is random and lesions in atypical locations such as anterior and posterior cul-de-sac, deep inguinal rings, and ovarian fossa may be missed, and patient care would be less than optimal. We proposed a method for systematic pelvic assessment based on anatomical landmarks [17].

In this system, the pelvis was topographically divided into two midline zones (zones I and II) and two paired (right and left) lateral zones (zones III and IV). Zone I is the area between the two round ligaments from their origin at the uterine cornua to their insertion in the deep inguinal rings. Zone II is the area between the two uterosacral ligaments from their origin from the back of the uterus to their insertions in the sacrum posteriorly. Zone III is the area between the uterosacral ligament inferiorly and the entire length of the fallopian tube and the infundibulopelvic ligament superiorly. Zone III contains the tubes and the ovaries. Zone IV is the triangular area lateral to the fallopian tube and the infundibulopelvic ligament and medial to the external iliac vessels up to the round ligament. This system was validated in a retrospective study and prospective evaluation is ongoing [17].

Tubal sterilization is one of the most commonly used methods of birth control. Laparoscopy is one of the most common techniques used for permanent sterilization in the world. Original laparoscopic techniques used electrocautery or electrosurgery to coagulate the midportion of the tubes. Other techniques, including clips and silastic bands, have gained popularity. The pregnancy rates vary by age of the patient, ranging from 1 to 3% after 10 years [18, 19]. Given the recent discoveries indicating that the Fallopian tube is the site of origin of ovarian cancer, the uptake of salpingectomy increased significantly as a method of sterilization in different parts of the world [20].

Adhesions are frequently encountered pelvic pathology. They are usually the result of previous pelvic infections secondary to PID or a ruptured appendix, endometriosis, or previous surgery. These adhesions may contribute to infertility or chronic pelvic pain. Lysis of adhesions is performed bluntly or by sharp dissection using scissors or a power source. Extreme caution should be used if adhesions <1 cm from ureter or bowel are lysed using unipolar electrosurgery because of the unpredictable nature of current arcing. The other power techniques, such as the ultrasonic scalpel, may be a better choice for adhesiolysis near bowel for surgeons that do not have experience with unipolar cautery.

Tubal reconstructive surgery is still performed even in the era of in vitro fertilization (IVF) and is almost exclusively performed laparoscopically. Fertility-enhancing procedures include adhesiolysis, fimbrioplasty, and terminal neosalpingostomy. Prior to and during these procedures, chromopertubation is carried out to document proximal tubal patency by injecting dilute indigo carmine dye through the cervix using a cannula. Laparoscopic surgery is performed using the principles of microsurgery to avoid tissue damage, including delicate handling of tissues and minimal use of electrosurgery for hemostasis.

Laproscopic fimbrioplasty or neosalpingostomy has been shown to be effective in young women with hydrosalpinges with no other infertility factors, however, the evidence is fair. On the other side, there is a good evidence to recommend laparoscopic salpingectomy or proximal tubal occlusion in case of r surgically irreparable hydrosalpinges to improve IVF outcome. In addition, there is enough evidence to support the value of microsurgical anastomosis for tubal ligation reversal even in women above the age of 40 years old [21].

Patients with mild tubal disease and preservation of fimbria have excellent pregnancy rates after laparoscopic surgery. Although these patients remain at risk for subsequent ectopic pregnancy, the risk of multiple gestations associated with IVF is avoided for patients who subsequently achieve a viable intrauterine pregnancy.

Unfortunately, adhesions often reform after lysis. Multiple techniques have been used in an effort to decrease reformation. Gentle tissue handling and good hemostasis also appear to be important. Barrier methods have been shown in clinical trials to decrease adhesions but have yet to be proven to improve pain relief or future fertility.

Laparoscopy is the primary surgical approach used to treat endometriosis. Endometriosis lesions may be resected or ablated, using scissors or any of the power instruments. These treatment approaches have been shown in randomized controlled trials to improve fertility and decrease pelvic pain.

Laparoscopy has become the surgical approach of choice for most ectopic pregnancies [22]. The embryo and gestational sac are removed either through a longitudinal incision (linear salpingotomy) or by removing the tube (salpingectomy). Both were compared in a recent RCT. The cumulative ongoing pregnancy rate was similar after salpingotomy (60.7%) compared to 56.2% after salpingectomy. However, persistent trophoblast occurred more frequently following salpingotomy compared to salpingectomy. Recurrent ectopic pregnancy rate was 8% following salpingotomy and 5% following salpingectomy [23]. Even a ruptured tubal pregnancy can be treated laparoscopically, as long as the patient is hemodynamically stable.

Ovarian pathological conditions, including cysts, commonly result in gynecologic complaint such as pain. The underlying pathology ranges from physiologic and self-limiting functional cysts to ovarian torsion and other benign conditions, to ovarian malignancy. Ovarian cysts are usually characterized ultrasonographically and treated when necessary by laparoscopy or laparotomy, depending upon the size of the cyst and the level of suspicion for malignancy [24]. The most important concept in adnexal surgery is to avoid spilling the cyst content whenever possible.

Many women with symptomatic fibroid uterus prefer a myomectomy over hysterectomy to preserve fertility or the uterus [25]. In some cases, myomectomy can be performed laparoscopically. The challenges in the case of intramural myomas are related to hemostasis, effective closure of the resulting myometrial defect, and removal of the specimen from the abdomen. Vasopressin can be injected into the uterus to help maintain hemostasis. The excised fibroid can be removed by morcellation or colpotomy. Power morcellators are available to expedite the process. Barrier techniques may be used to decrease subsequent adhesion formation. Some early case series have reported increased risk of subsequent uterine rupture during pregnancy after laparoscopic myomectomy compared to those performed by laparotomy [26]. However, several randomized clinical trials have shown no increased risk in expert hands [26]. A totally laparoscopic approach should be attempted only by gynecologists skilled in laparoscopic suturing. Recently, the uptake of the laparoscopic approach for laparoscopic myomectomy and laparoscopic hysterectomy was challenged by the FDA recommendation against power morcellation [27].

Many women have severe dysmenorrhea that is unresolved despite medical management but wish to maintain future childbearing potential. In these patients, two laparoscopic approaches have been attempted with some success. Laparoscopic uterosacral nerve ablation (LUNA) is performed by stretching and dividing each uterosacral ligament using electrosurgery or laser alone or in combination with scissors. Care must be taken to avoid injuring the ureters. This procedure has been shown to have some temporary success, but a Cochrane review has questioned the validity of this procedure [28].

Laparoscopic presacral neurectomy (LPSN) is a second approach for central pain. This technically challenging procedure is performed by careful retroperitoneal dissection between the common iliac artery on the right and the inferior mesenteric artery where it crosses over both left common iliac artery and vein on the left. The superior hypogastric plexus, which includes the presacral nerves, is dissected from the left common iliac vein and periosteum of sacral promontory and a 2–3-cm segment is resected. Surgical risks include vascular complications, and long-term risks, such as constipation, are more common than with LUNA. Although both LUNA and LPSN appear to give some patients at least temporary relief from central pain, many clinicians believe that there is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhea, regardless of the cause [28].

Laparoscopy hysterectomy, first described by Dr. Harry Reich in 1992, is commonly performed today [29]. The three basic laparoscopic approaches for hysterectomy are laparoscopic-assisted vaginal hysterectomy (LAVH), laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy (LSH). Although the basic techniques for each of these approaches are fairly standardized, controversy exists over the risks, benefits, and most appropriate indication of each.

LAVH is the most commonly employed and technically straightforward of the three. Using 3–4 ports, the peritoneal cavity is surveyed and lysis of adhesions is performed if necessary. Then the infundibulopelvic or utero-ovarian ligaments are occluded and divided, depending on whether the ovaries will be removed. The round ligament is divided, the utero-vesicle peritoneum is incised, and the bladder dissected from the anterior uterus. This step results in an increased risk of bladder injury compared to either abdominal or vaginal hysterectomy. At this point, the uterine arteries laparoscopically are sometimes occluded and divided, although this is associated with an increased risk of ureter injury compared to either abdominal or vaginal hysterectomy. Finally, the posterior cul-de-sac is incised.

The surgeon proceeds vaginally for the remainder of the case, dissecting the vesicovaginal septum anteriorly to enter the anterior cul-de-sac, ligating the uterine vessels if not previously done, removing the uterus and ovaries if appropriate, and closing the vaginal cuff.

Laparoscopic hysterectomy (LH), the common second approach, is performed initially like the LAVH, except that the entire hysterectomy is performed laparoscopically. This approach is often used when there is little or no uterine descent, which makes the vaginal approach unfeasible.

After the infundibulopelvic (or utero-ovarian) and round ligaments are occluded and divided, the bladder is dissected away from the anterior uterus. The ureters are identified, and the uterine vessels and uterosacral ligaments are occluded and divided. The posterior cul-de-sac is incised, the vagina is circumferentially separated from the cervix, and the specimen is removed vaginally. The cuff is closed laparoscopically or vaginally.

The LSH is a third common laparoscopic approach to hysterectomy for benign indications [30]. The technique begins in a manner identical to LAVH and LH. However, prior to reaching the level of the uterine arteries, the fundus is transected at the uterocervical junction. In order to minimize residual cyclic vaginal bleeding and decrease the risk of developing cervical dysplasia or cancer, the glandular tissue endocervix is cored out or cauterized. The uterine specimen is removed through a 12-mm port abdominal using a power morcellator. The recent debate about tissue extraction following the laparoscopic approach for myomectomy and hysterectomy is yet to be settled [27].

This approach eliminates both the vaginal and abdominal incision, thus decreasing the risk of infection. The risk of ureteral injury is also decreased, since the procedure stops above the level of the uterine artery. However, a risk of subsequently developing cervical dysplasia or cancer remains due to the presence of the cervical stump. For this reason, routine Pap smears are required, and some patient will require additional surgery related to cervical abnormalities. Furthermore, at least two randomized clinical trials have failed to show superior results in bladder function or sexual function [31, 32]. These studies did show a higher reoperation rate for bleeding and prolapse.

Although small trials have tried to assess the value of laparoscopic hysterectomy, a large multicenter, randomized trial that compared laparoscopic with abdominal hysterectomy and laparoscopic with vaginal hysterectomy has provided insight into the role of this procedure [33]. The study confirmed that the laparoscopic approach offers no advantage over the vaginal approach. It also confirmed that the laparoscopic approach is associated with less postoperative pain, shorter hospital stay, and faster convalescence compared with the abdominal approach. It demonstrated that the laparoscopic approach was associated with a slightly higher risk of urinary tract injury. The shorter length of hospitalization with laparoscopic hysterectomy offsets some of the additional costs incurred by longer operating room times and the expense of disposable instruments [34].

Morcellation is used to allow removal of large specimens that cannot be retrieved otherwise. It enabled the laparoscopic option to treat patients with large uteri or uterine myoma. One of the major limitations of this technology is the possible spread of undiagnosed cancer. This concern led the FDA to issue a warning against the use of such technology [27]. That led to many gynaecologists to refrain and many institutions to recommend against the use of the minimally invasive for women where tissue morcellation is required. In the USA, there was a significant decrease in the proportion of minimally invasive hysterectomies and myomectomies performed during the 8 months after the FDA warning statement on the use of power morcellation [35].

Overall, uterine sarcomas are difficult to diagnose preoperatively. The risk of an unexpected uterine sarcoma following surgery for a presumed benign indication is approximately 1 in 350, and the rate of leiomyosarcoma is 1 in 500 [36]. If undiagnosed sarcoma is morcellated that will indeed worsen the prognosis and negatively affect the overall survival. It is imperative that preoperative endometrial biopsy and cervical assessment to avoid morcellation of potentially detectable malignant and premalignant conditions is strongly recommended [37]. Morcellation is contraindicated for patients with hereditary cancer syndromes, and in women with established or suspected cancer where a gynaecologic oncology consultation is mandatory. Irrespective of the current local hospital policy about power morcellation, each patient should be counselled about the possible risks associated with the use of morcellation, including the risks associated with underlying malignancy. Modified morcellation techniques including the use of bags for containment are currently being tested for safety and efficacy. Despite the fact that the FDA has approved the first tissue containment system for use with certain laparoscopic power morcellators to isolate uterine tissue that isn’t suspected to be cancerous, there is no clear evidence to support that their use would nullify or prevent the dissemination of undiagnosed uterine sarcomas [38].

Laparoscopy originally was used in gynecologic oncology for second-look procedures after surgical and chemical treatment of the malignancy. More recently, laparoscopy has been used for the initial staging of gynecologic cancer, including hysterectomy, peritoneal washes with biopsy, partial omentectomy, and pelvic and periaortic lymphadenectomy. Techniques have also been developed for laparoscopically assisted radical vaginal hysterectomy.

The laparoscopic approach to gynecologic cancer remains controversial. There is some concern that laparoscopy might increase the risk of intraperitoneal spread of ovarian cancer. Until the risk, benefits, and the effect on long-term prognosis have been shown to be equal to laparotomy, the laparoscopic approach will remain under close scrutiny.

Robotic technology has attempted to address the limitations of conventional laparoscopic surgery. The use of a remotely controlled robot has the potential to facilitate these procedures by allowing the surgeon to be seated comfortably while providing the surgeon a three-dimensional view with improved dexterity and access.

The most commonly used robotic system is the “da Vinci system ” (Intuitive Surgical, Mountain View, CA, USA). The FDA approved it for use in abdominal surgeries in 2000. There are three main components: the surgeon console, the surgical cart, and the vision cart. The surgeon sits at a console separate from the surgical field. Movement of handles at the console results in movement of surgical instruments at the operative field. In this system, the surgeon looks into a console that has a dual lens system within the 12-mm laparoscope. The system provides true binocular 3D vision that is similar to looking into a microscope that enables the surgeon to see fine structures up to a tenfold magnification. Movement of the laparoscope is accomplished through the movement of the handles at the console.

The most impressive part of the system is the intra-abdominal articulation of the microinstruments 2 cm from the tip. This articulation serves the same function as a human wrist, mimicking the movements of a hand. This articulating wrist has 7 degrees of freedom of the instruments, providing an opportunity for better suturing, dissection, and reconstructing tissue by allowing the surgeon access to deep pelvic structures. The movement of the instrument tip is intuitive and requires minimal training.

The cart contains the instrument arms and camera arm. The vision cart allows all members of the surgical team to visualize the procedure. Not only does this system provide visual advantages for more precise surgery, improved dexterity, surgeon comfort with less hand fatigue, and improved instrument articulation but also it eliminates unintentional hand tremors.

There are some limitations with the use of robotic technology. One is the initial system cost, maintenance costs, and expense of disposable instruments. Another is the lack of tactile feedback during the procedure, requiring the use of visual cues to properly carry out surgical tasks. For appropriate docking of the robot, it is imperative that a dedicated staff specifically trained on the device is available during all procedures.

Another limitation of the robotic system is its bulky size. Increased surgical operation time is a main limitation of the robotic system. This is attributed to the time required for robot preparation and docking as well as console time. Sait reported an operative time of 92.4 min for a laparoscopic hysterectomy, compared to 119.4 min for a hysterectomy with robotic assistance. However, they also showed a significant learning curve, shortening the length of operation times with increasing robotic experience [39]. Similar results were independently corroborated in a randomized controlled trial [40].

Cost is an important limitation that should be considered. Robotic surgical systems are very costly, adding approximately $3500 per procedure and approximately $2.5 billion nationally per year. This is a huge expense considering little evidence of improved outcomes over standard laparoscopy. Added to these costs, Medicare and most US private insurers do not pay additional fees for use of robotics. To overcome this, hospitals most likely will increase charges for procedures or diagnoses for which robots are used [41, 42]. The reality is that robotics overall is more costly than laparoscopy, but if it allows more surgeons to perform MIS, then maybe in the end it will end up being less costly. Wherever and whenever feasible, robotic-assisted laparoscopic surgery should not replace conventional laparoscopic or vaginal procedures for women undergoing benign gynecologic diseases. This was supported by the findings of a 2012 Cochrane Review [43]. The advantages and the disadvantages of the robotic systems are summarized in ◘ Table 21.1.

Robotic systems have the potential to convert surgical procedures that we presently perform by laparotomy to laparoscopy and are currently utilized in the fields of reproductive endocrinology and fertility, gynecologic oncology, and female pelvic medicine/reconstructive surgery (◘ Table 21.2). It has been used in robotically assisted tubal anastomosis.

For a variety of reasons, sterilization reversal is an alternative to IVF, particularly for patients younger than the age of 35. The immediate and the long-term postoperative outcomes were compared with laparoscopic tubal anastomosis without robotic assistance [44]. The operative times were longer with the use of the robot. The tubal patency rates and clinical pregnancy rates were not significantly different. The major difficulty with laparoscopic tubal anastomosis, with or without robotic assistance, is the limited needle angles to the tubes due to operating through fixed ports. It has been reported that robotic technology is successful in facilitating laparoscopic tubal anastomosis using the da Vinci system. All of the tubal anastomoses were performed with the use of three or four robotic arms, three or four robotic instruments, and one assistant trocar. While the use of robotics prolonged surgical and anesthesia times as well as increased cost, there was no significant difference in pregnancy outcomes compared to a laparotomy technique. Additionally, patients were able to return to normal activities faster than after a laparotomy [45, 46].

Myomectomy remains the best choice of treatment of symptomatic fibroids in patients desiring to preserve their fertility, even with the new modalities such as uterine artery embolization [26, 47]. Open myomectomy used to be the treatment modality until the emergence on minimally invasive technique. Laparoscopy yielded better cosmesis and shorter postoperative pain and hospital stay. However, this procedure was very challenging. A limitation included needing to precisely dissect the fibroid without unnecessary breaching of the endometrial cavity. Since laparoscopic suturing is a difficult skill to master, it is complicated to suture the fibroid beds in layers with precise approximation of edges, which is needed to prevent uterine rupture during labor. These challenges limited the enthusiasm and acceptance of this technique.