Laparoscopy and Laparoscopic Surgery

Laparoscopy and
laparoscopic surgery
Alex Swanton
Alex Slack
Enda McVeigh
Abstract
Today, laparoscopy is an alternative technique for carrying out many oper-
ations that have traditionally required an open approach. The benefits of
minimal access surgery have been well recorded, including lower post-oper-
ative morbidity, shorter duration of hospital stay and a shorter return to
work. Advancesin technology, specificallyin fibre opticsand videoimaging,
have made the relatively recent rapid progress in laparoscopic surgery
possible. Operative laparoscopy, however, requires a high degree of tech-
nical skill and training. The use of small instruments and imaging systems
that provide magnification allow for the high degree of precision that can
be achieved with laparoscopic surgery. This is often difficult to obtain by
a conventional laparotomy, as magnification is not available and the sur-
geon’s hands and large instruments often obscure the operative field. It is
this precision that has lead to advances in the treatment of conditions
such as endometriosis, adhesions and in the field of reproductive surgery.
It is unfortunate however that in reality very few major gynaecological
procedures are performed laparoscopically. They are technically difficult
and require the surgeon to master a whole new set of surgical skills and
in effect to return to the bottom of the surgical learning curve. A wide
range of simple laparoscopic procedures needs to be mastered to develop
the hand eye coordination required to perform complex tasks. These proce-
dures need to be performed on a regular basis to maintain skills and only
when these skills can be regularly performed accurately can complex
surgical tasks be carried out. As a result of this, most established gynaecol-
ogists have very little time and resources to be able to retrain in what is
essentially a new surgical field, although most experts throughout the
country agree that the vast majority of gynaecological surgery could safely
and efficiently be performed laparoscopically.
Keywords laparoscopy; laparoscopic surgery; minimal access surgery
Current practice
Hysterectomy
Hysterectomy remains one of the most common gynaecological
inpatient procedures. Since most hysterectomies are performed
for benign conditions, the choice of route almost entirely
depends upon the surgeon’s skill and experience. Avoiding
a laparotomy in the appropriately chosen patient is without
doubt beneficial. A recent Cochrane review has looked at the
evidence for which route is best for performing hysterectomy.
The conclusions were that the vaginal route is best. In patients
whom the vaginal route is not possible, laparoscopic hysterec-
tomy has benefits over the abdominal route. The benefits of
laparoscopic hysterectomy versus abdominal hysterectomy were
lower intra-operative blood loss (WMD 45.3 mls, 95%CI
17.9e72.7 ml) and a smaller drop in haemoglobin level (WMD
0.55 g/L, 95%CI 0.28e0.82 g/L), shorter duration of hospital
stay (WMD 2.0 days, 95%CI 1.9e2.2 days), speedier return to
normal activities (WMD 13.6 days, 95%CI 11.8e15.4 days),
fewer wound or abdominal wall infections (OR 0.32, 95%CI
0.12e0.85), fewer unspecified infections or febrile episodes (OR
0.65, 95%CI 0.49e0.87), at the cost of longer operating time
(WMD 10.6 min, 95%CI 7.4e13.8 min) and more urinary tract
(bladder or ureter) injuries (OR 2.61, 95%CI 1.22e5.60). There
was no benefit in performing a total laparoscopic hysterectomy
over a laparoscopically assisted vaginal hysterectomy.
In those patients where a vaginal hysterectomy is contra-
indicated or not technically possible, the default should therefore
be to use a laparoscopic approach.
The first hysterectomy using only laparoscopic techniques was
performed in 1988 by Harry Reich. Other milestones are shown in
Table 1. Total laparoscopic hysterectomy can be a technically
difficult procedure to perform. A number of alternative laparo-
scopic techniques to perform all or some of the hysterectomy have
therefore been introduced to simplify the procedure, but retain the
major advantages of the approach, i.e. avoidance of a laparotomy
wound. Laparoscopic sub-total hysterectomy is becoming an
increasingly common procedure and some units have reported
success in performing it as a day case.
The advantages of this approach have been well documented,
but the laparoscopic route has been little used by general gynae-
cologists to date. Although it has been possible to reduce the
Milestones in hysterectomy
First vaginal hysterectomy Langenbeck (1810)
First abdominal hysterectomy Clay (1843)
Cautery to cervical stump Keith (1880)
Definition of sub-total technique Kelly (1896)
Low transverse incision Pfannenstiel (1900)
Myomectomy Bonney (1920)
Total hysterectomy Richardson (1929)
Dominance of total hysterectomy (1940s and 50s)
Endometrial ablation de Cherney, Hamou (1980s)
Laparoscopic hysterectomy Reich (1988)
Intra-uterine levonorgestrel Nilsson (1977)
Table 1
Alex Swanton MRCOG is at the Nuffield Department of Obstetrics and
Gynaecology, University of Oxford and the Department of Obstetrics,
Gynaecology, Women’s Centre, The John Radcliffe Hospital, Oxford, UK.
Conflicts of interest: none declared.
Alex Slack is at the Nuffield Department of Obstetrics and Gynaecology,
University of Oxford and the Department of Obstetrics, Gynaecology,
Women’s Centre, The John Radcliffe Hospital, Oxford, UK. Conflicts of
interest: none declared.
Enda McVeigh MB BCh MPhil FRCOG is a Senior Fellow in Reproductive
Medicine at the Nuffield Department of Obstetrics and Gynaecology,
University of Oxford, Women’s Centre, The John Radcliffe Hospital,
Oxford, UK. Conflicts of interest: none declared.
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OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 20:2 33 Ó 2009 Published by Elsevier Ltd.

laparotomy rate for hysterectomy to 10% in some units, there is
evidence from the UK (Table 2) and the USA that more than 70% of
all hysterectomies are still being performed by laparotomy.
Myomectomy
Uterine fibroids are responsible for a wide variety of symptoms,
including menorrhagia, pain/pressure symptoms, urinary tract
symptoms and have been implicated in subfertility. The
management of fibroids depends on the patient’s symptoms and
the location of the fibroid in the uterus (Figure 1).
Asymptomatic patients can be managed conservatively and
those in whom fertility is not an issue can be managed medically
or by hysterectomy. Where fertility needs to be conserved,
myomectomy is the treatment of choice.
Submucus fibroids can normally be resected hysteroscopically
but intramural and subserosal fibroids require an abdominal
approach.
Laparoscopic myomectomy has been demonstrated as
a feasible procedure in a number of observational studies. The
large spectrum of fibroid size and location, difficulty with mor-
cellation and removal, and the technical requirements of suturing
make the procedure difficult to perform. These difficulties also
complicate clinical outcome based evaluation and there is very
little data evaluating relevant outcomes of this procedure.
The principle potential advantage of laparoscopic myomec-
tomy over the open approach is a reduction in inpatient stay and
an earlier return to normal activities. Theoretically, the reduction
in tissue handling and manipulation and not using packs may
reduce tissue trauma and adhesion formation.
On the other hand it may not be possible to remove multiple
fibroids through the same incision and the surgeon looses the
ability to palpate the uterine tissue, detecting smaller fibroids. It
may also be more difficult to approximate myometrial and
serosal tissues, leading to poor healing of the uterine wall
potentially leading to complications in future pregnancies. A
recent survey of UK gynaecologists revealed that just over 10%
performed laparoscopic myomectomies as part of their normal
practice.
Ectopic pregnancy (Figure 2)
It is now accepted that minimal access surgery provides the best
and most efficient method of treating ectopic pregnancies (RCOG
Grade A recommendation). However, gynaecologists in the UK
have been slow to establish laparoscopic management of ectopic
pregnancies as standard practice. A recent audit on the
management of ectopic pregnancy in a Scottish teaching hospital
showed that only 62% of cases were managed laparoscopically
compared with over 90% in France. This disappointingly low
rate in the UK is most likely to be the result of a lack of training
among junior staff.
Hospitals have addressed this issue by:
(a) Identifying experienced surgeons willing to be available to
train and supervise juniors.
(b) Establishing emergency gynaecological clinics with vaginal
ultrasound and serum beta human chorionic gonadotrophin
measurements.
Where these measures have been taken, the result is that the
vast majority of ectopic pregnancies can be managed lapa-
roscopically during normal working hours with senior input
readily available.
Laparoscopic surgery for pelvic organ prolapse
The traditional approach to treating pelvic organ prolapse has
been to correct it vaginally, using vaginal hysterectomy and
repairs of cystocele, rectocele, enterocoele and the vaginal vault.
These procedures have few complications and are relatively
easy to perform, however they have a relatively high recurrence
rate, with the risk of having to have repeat surgery reported to be
as high as 29%.
The other concern with the traditional vaginal approach to
prolapse repair is that it produces scarring and distortion of the
vaginal vault, potentially leading to sexual dysfunction, espe-
cially in younger women.
To overcome the problem of recurrence, synthetic, non-
absorbable meshes have been developed that allow the surgeon
to reinforce weak tissues and repair fascial defects.
Meshes have been used to repair prolapse via both the
abdominal and vaginal route, and recently specifically shaped
meshes with needle systems for placing them have been devel-
oped to repair anterior, posterior and vaginal vault prolapse.
Reported recurrence rates are much less than with conventional
surgery (<4%).
A major issue with the use of synthetic meshes in the repair of
prolapse is mesh erosion. This has been reported to be as high as
12% in vaginal procedures and can be difficult to manage. If the
repair is carried out laparoscopically without opening the vaginal
vault and a macroporous mesh is used, the erosion rate can be
reduced to 1e2%. The laparoscopic route also has the additional
benefit of not shortening or narrowing the vagina. Procedures
that are used commonly in the US and Europe include laparo-
scopic sacrocolpopexy with or without sub-total hysterectomy
and laparoscopic paravaginal repairs. These operations however
are rarely carried out in the UK for the same reasons as described
before.
Laparoscopic surgery for endometriosis
The diagnosis of endometriosis is based on the presence of
endometrial-like tissue outside the uterine cavity. Clinically,
three entities can be distinguished: peritoneal implants, endo-
metriotic cysts and deep nodular lesions. Laparoscopy and
biopsy remain the gold standard for diagnosis; however, the skill
of the surgeon is crucial to achieving an accurate diagnosis. The
surgeon who does not perform laparoscopic surgery routinely
will certainly diagnose typical endometriotic lesions, but risks
missing a substantial amount of subtle disease. The laparoscopic
surgeon should therefore adhere to a systematic approach and
RCOG UK hysterectomy audit
All hysterectomy operations in UK between October 1994 and
September 1995 in 343 hospitals
C 36 000 hysterectomy procedures
C 3% laparoscopic
C 20% vaginal
Table 2
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meticulous method of evaluating the pelvis to ensure complete
diagnosis of endometriosis. The laparoscope affords the surgeon
the capability of altering the field of view, depending upon the
proximity of the laparoscope to the tissue (Figure 3aec).
The definitive treatment of endometriosis for both pelvic pain
and fertility is through laparoscopic excision or vaporization of
the endometriotic tissue. For fertility, this was demonstrated
through the Canadian Collaborative Group in Endometriosis who
carried out a randomized controlled trial to determine whether
laparoscopic surgery enhanced pregnancy rates in infertile
women with minimal or mild endometriosis. They concluded
that laparoscopic resection or ablation of minimal and mild
endometriosis enhances pregnancy rates in infertile women
(cumulative probabilities, 30.7% in the treated group and 17.7%
in the untreated group).
Clinically, the most difficult form of endometriosis to diagnose
and treat is deep infiltrating disease. Koninckx described three
types of lesion (Figure 4), as follows:
Type 1: Large lesion in the peritoneal cavity, infiltrating conically
with deeper parts becoming progressively smaller. It has been
suggested that this type of endometriosis is caused by infiltration.
a Diagram of uterine fibroid positions; b a fundal uterine fibroid; c an MRI of uterine fibroids.
Figure 1
Figure 2 Tubal pregnancy.
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Type 2: The main feature in this type of lesion is that the
bowel is retracted over the lesion, the latter becoming situ-
ated in the rectovaginal septum, although not really inﬁl-
trating it.
Type 3: The deepest and most severe lesions. They are
spherically shaped, situated deep in the rectovaginal septum,
and are often only visible as a small typical lesion at laparos-
copy. This lesion is often more palpable than visible, originates
a Endometriosis on utero-sacral ligament; b bilateral ovarian endometriosis with pelvic adhesions; c endometriosis on diaphragm.
Figure 3
Types of deep inﬁltrating lesions.
Figure 4
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from the rectovaginal septum tissue, and consists essentially of
smooth muscle with active glandular epithelium and scanty
stroma.
Laparoscopic excision of this severe form of endometriosis
requires significant skill. It is essential that the patient’s bowel
is appropriately prepared before the operation as there is
a significant possibility that the rectum will have to be opened
to excise the disease completely. It is therefore likely that this
degree of skill will only exist in a small number of centres
nationally. These centres should therefore be identified to
allow regional and national referral. In line with Clinical
Governance, centres undertaking this highly skilled surgery
should produce figures to demonstrate the numbers of cases
being performed, along with their success and complication
rates.
Laparoscopic surgery and infertility management
The success rates, based upon clinical pregnancies, of assisted
reproductive technologies (ART) have improved over the last 10
years. Operative endoscopy has also, however, made significant
advances, thereby ensuring its place in the ongoing management
of infertility. ART bypasses pelvic pathology to attempt to obtain
a pregnancy. Surgical approaches, however, improve natural
fertility by correcting pathological conditions, for example
endometriosis and adhesions. By correcting them, the patient
improves their fertility and also potentially improves other
related symptoms such as pain. After surgery, couples can have
unlimited attempts to conceive naturally without being subject to
the risk of multiple pregnancies and ovarian hyperstimulation,
stress and cost associated with ART.
Laparoscopic surgery in gynaecological oncology
Over the last decade, laparoscopic surgery has become an
acceptable alternative for the treatment of women with early-
stage endometrial carcinoma. Several studies have attested to the
feasibility and safety of laparoscopic surgery among select groups
of women with endometrial carcinoma. These studies have
found laparoscopic surgery to be associated with excellent
surgical outcome, shorter hospital stay, earlier recovery and
improved quality of life compared with traditional surgery per-
formed through laparotomy.
Several published studies have reported on the survival of
women with endometrial carcinoma after laparoscopic surgery,
and with three exceptions, these reports were retrospective
reviews of select groups of patients. These data show no signif-
icant differences in two- and five-year overall survival rates or
disease-free survival when comparing laparoscopic with
conventional open surgery. Among the reported, likely advan-
tages of the laparoscopic surgical technique are a reduced blood
loss and transfusion rate, and a higher lymph node harvest. One
of the concerns raised about the laparoscopic technique is that
a higher incidence of positive peritoneal cytology is noted among
women with low-risk endometrial carcinoma who were treated
with laparoscopy, but the clinical significance of this finding is
questionable since it appears to have no significant effect on the
survival rate.
Another area in which laparoscopic surgery is becoming
increasingly utilized in oncology is in performing lymp-
hadenectomy as a part of staging. Pelvic and para-aortic
lymphadenectomy can be performed laparoscopically with
hugely reduced morbidity when compared to the traditional
open approach.
Litigation and laparoscopic surgery
As the volume of laparoscopic procedures increases, so does the
number of actions for negligence against the surgeon. Compli-
cations following laparoscopic surgery may arise from poor
technique, poor judgement, inadequate instrumentation or
misadventure.
Most complications have occurred during operative laparo-
scopic procedures (rate 17.9/1000). However, as more diagnostic
laparoscopic procedures (complication rate 2.7/1000) and ster-
ilization procedures (complication rate 4.5/1000) are carried out,
it is these simple procedures that tend to account for most of the
overall litigation.
A Cochrane database comparison of laparoscopic sterilization
compared with mini-laparotomy concluded that there was no
difference in major morbidity between the two groups. Minor
morbidity was significantly less in the laparoscopy group (odds
ratio 1.89); 95% confidence intervals (CI 1.38, 2.59), and the
duration of operation was about 5 min shorter in the laparoscopy
group (WMD 5.34; 95%CI 4.52, 6.16). Litigation following
laparoscopic sterilization may result due to a complication of the
procedure or, more often, as a result of failure of the technique.
Although we all almost universally advise patients of the risk of
failure of the procedure and the potential complications of the
operation, such a disclaimer does not prevent legal action
because the surgeon owes a duty of care to the patient, and
inappropriate or unacceptable surgery will therefore result in
litigation. Appropriate preoperative planning, correct patient
selection and the use of suitably skilled surgeons carrying out or
supervising the procedure should decrease the litigation
following this and other laparoscopic procedures.
Table 3 lists the major complications that arise with operative
laparoscopies. The majority arise because of:
(a) Difficulties obtaining a pneumoperitoneum.
(b) Bleeding, usually as a result of accessory trocars.
(c) Problems with ectopic pregnancies.
Most complications of minimal access surgery can be avoided
with good technique. Where patients are known to be at risk,
they must be fully informed of all complications, and the
operation should be carried out by a senior, appropriately
trained surgeon.
A 9-year survey of seven French laparoscopic centres,
including 29 966 diagnostic and operative laparoscopies, showed
similar results to those in Table 1. As might be expected, this
survey found that the complication rate correlated significantly
with the complexity of the procedure (P < 0.0001), with one out
of four of the complications not being diagnosed during surgery.
This survey also showed that increased experience of the
surgeons had three consequences: a statistically significant
decrease in the number of bowel injuries (P < 0.0003); a signifi-
cant decrease in the number of conversions to laparotomy
(P < 0.01); and a change in the way that complications were
managed, with more being managed by laparoscopy
(P < 0.0001).
Recommendations from a medical defence perspective for
minimizing risk include the following:
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1. Advising the patient of the risks and benefits of laparoscopic
procedures and discuss alternatives, including conventional
surgery.
2. Discuss the risk of failure with laparoscopic sterilization and
record this in the notes.
3. Careful post-operative monitoring and prompt investigation
of suspected sepsis. Make sure patients know what signs of
post-operative complications to look out for and what steps
to take following discharge from the hospital.
4. Adequate training and supervision before carrying out
laparoscopic surgery independently. Only delegate proce-
dures to those with an appropriate level of skill.
Difficulties with obtaining and maintaining
a pneumoperitoneum
Difficulties in establishing a satisfactory pneumoperitoneum can
occur, particularly in obese patients. Superficial introduction of the
needle can lead to extraperitoneal insufflation and emphysema,
which can dissect the peritoneum from the posterior rectus sheath
and limit entry into the peritoneal cavity. If the standard umbilical
entry fails because of the patient’s obesity, or the approach is
inappropriate because of previous abdominal surgery or the
presence of a large pelvic mass (including pregnancy), alternative
techniques can be used. These include open laparoscopy, passage
of the needle through the posterior cul-de-sac or the uterine
fundus, introduction in the left upper quadrant or supra-pubic
insertion with or without visualization with a laparoscope.
Surgeons carrying out laparoscopic surgery should familiarize
themselves with these different methods so that the most
appropriate can be used as necessary.
The loss or partial loss of the pneumoperitoneum during
surgery can result in an increased risk of complications.
Restricting the operator’s view of the surgical field can result in
an inability to secure haemostasis or repair trauma to the bowel
which is now closer to the end of the laparoscope. This loss of
pneumoperitoneum may be the result of defective equipment
(e.g. leaking trocar valves) or due to the continuous suction
necessary to remove blood/smoke from the pelvis. The devel-
opment of high flow insufflators capable of insufflating up to 30
l/min has helped greatly and proved to be essential for certain
procedures, especially those involving the use of lasers where
continuous smoke extraction is necessary.
Injury to bowel when creating pneumoperitoneum or during
insertion of trocar
Inadvertent injury to the bowel on insertion of the Verres needle
or trocar should be avoided in patients without a history of
previous surgery. Obese patients, thin patients and those who
have had previous abdominal surgery are most at risk. Bowel
injury by the Verres needle is usually insignificant and closes
spontaneously, but unrecognized injury with a trocar can lead to
faecal peritonitis and potential death.
Confirmation of peritoneal entry by the Verres needle can be
obtained by a number of tests. The syringe test is the most
popular; this involves attaching a 10-ml syringe filled with saline
to the Verres needle, and injecting 5 ml into the peritoneal cavity.
The syringe plunger is then withdrawn. No aspirate should be
obtained if the needle is in the correct place as the fluid will have
dispersed between loops of bowel. If the needle lies in the
abdominal wall, clear fluid will be obtained, but if the aspirate is
stained red or brown, perforation of the bowel or a blood vessel
has probably occurred.
Vascular injuries
Whereas some gastrointestinal injuries at laparoscopy may be
unavoidable, the majority of injuries to the great vessels of the
abdomen and pelvis should be avoidable. The usual sites of
trauma to the large vessels are the terminal aorta near its bifur-
cation and the common iliac arteries. The vena cava and the iliac
veins may also be lacerated and may be more difficult to repair.
In thin women, the distance between the umbilicus and the aortic
bifurcation may be less than 3 cm, and the umbilicus is directly
over the bifurcation in 53% of women. The Verres needle and the
trocar should be inserted with the patient in a flat position and
not in the Trendelenberg position, since this displaces the
umbilicus upwards, brings the common iliac vessels closer to the
horizontal plane, and decreases the distance between the umbi-
licus and the aortic bifurcation.
Injury to the inferior epigastric vessels is the most common
vascular injury at operative laparoscopy. Inferior epigastric
vessels are adjacent to the umbilical ligament and beneath the
lateral margin of the rectus muscle. The inferior epigastric
vessels can be seen through the laparoscope intra-abdominally.
Placement of trocars lateral to these regions will minimize the
risk of injury.
Training
Training in general obstetrics and gynaecology has changed
significantly over the past 10 years. With the introduction of the
Calman training system, and more recently the European
Working Time Directive, trainees have made significant gains in
Major complication per 1000 operative laparoscopies
By instrument
Verres needle 2.7
Large trocar 2.4e2.7
Accessory trocar 2.5e6.0
Electrocautery 0.5e2.8
Laser 1.2
Pneumoperitoneum 7.4
By site of injury
Vessel/bleeding 2.6e11.0
Bowel 0.6e2.0
Genitourinary 0.6e1.6
Nerve 6.1
Uterine perforation 3.7
Other indicators
Death 0.05e0.3
Hospitalization 472 h 4.2e27.0
Hospital readmission 3.1e5.0
Persistent beta-hCG titres 63.2e144.0
Infection 1.4e6.5
Febrile 2.0
Table 3
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quality of life, but have also lost some important aspects of
training. Working hours have been reduced and training is now
structured and includes a specific appraisal programme. In order
to comply with the European Working Time Directive, which
forms part of health and safety law, working patterns have had to
be changed, with most trainees working a ‘shift’ pattern rather
that the old ‘on-call’ system. These changes have lead to
a reduction in the time available for training as conflicts inevi-
tably arise between service provision and training. Trainees have
also lost the close working relationships they once had with
individual consultants as the NHS service has become increas-
ingly consultant based as opposed to consultant led.
Training in laparoscopic surgery varies considerably across
the UK. Twenty years ago, most consultant gynaecologists could
perform practically all operations in gynaecology. Today,
however, with the increase in minimal access surgery, a signifi-
cant proportion of senior gynaecologists have limited experience
in this area. This results in an inability to ‘train’ their juniors in
these procedures.
In 1994, the Royal College of Obstetricians and Gynaecologists
(RCOG) published the report from its Working Party on ‘Training
in Gynaecological Endoscopic Surgery’. The report was produced
partly because endoscopic surgery was becoming an increasingly
important component of gynaecological surgery, and partly
because of surgical complications resulting from these proce-
dures. The Working Party felt that training in endoscopic surgery
would begin with conventional open surgery, and then subse-
quently proceed to laparoscopic surgical techniques. If trainees
did not demonstrate an aptitude, they should not progress. The
award of a certificate of completion of specialized training
(CCST) at the end of 5 years of general training would include
a statement that competence up to a certain level in endoscopic
surgery had been achieved.
In 1994, the various laparoscopic and hysteroscopic proce-
dures were divided into four levels, with the skills required for
Levels 1 and 2 being assessed at the place of work by the MRCOG
trainer as an integral part of the formative and summative
assessment for the membership examination.
The acquisition of skills for Level 3 and 4 procedures was
not necessarily a prerequisite for the membership examination
or CCST. Those who wished to attain the necessary skills would
be expected to attend RCOG-recognized advanced courses,
obtain expert supervision by a preceptor recognized by the
RCOG, and be involved in compulsory audit. The classification
then changed with the introduction of three levels of compe-
tence. Level 1 is Basic-level Endoscopy (previously classified as
Levels 1 and 2). This is concerned with basic diagnostic and
elementary operative hysteroscopic and laparoscopic tech-
niques. Every candidate for the MRCOG examination must
demonstrate knowledge and practical competence in procedures
at this level.
They must attend an approved course and be observed and
declared competent by a preceptor. These skills should be
acquired during all gynaecological training programmes.
Level 2 is Intermediate-level Endoscopy (previously classified
as Level 3). This level is concerned with intermediate-level
procedures in laparoscopic surgery involving the tubes, ovaries,
mild peritoneal endometriosis and laparoscopic-assisted
hysterectomies.
Demonstration of competence in these areas is not compul-
sory, but it is expected that all who undertake this type of
minimal access surgery can demonstrate that they have been
appropriately trained in the procedures they undertake, and have
attended an appropriate course and have been accredited
competent by an approved RCOG preceptor. These techniques
require additional skills above those acquired in routine training,
and are best achieved as a special-interest module in an appro-
priate surgical centre as part of the Calman training programme.
Special skills modules in laparoscopic and hysteroscopic surgery
have just been introduced by the RCOG to allow trainees to
undergo a formalized training in laparoscopic surgery to a level
that is the equivalent of the Level 2 certification.
Level 3 is set as Advanced-level Endoscopy (previously clas-
sified as Level 4), that will encompass a number of different areas
such as oncology, urogynaecology, reproductive medicine and
pelvic dysfunction. Due to the expertise needed in each area, it
has been suggested that it would be ‘both inappropriate and
impractical to expect any individual to become competent in all
areas’.
There is, as yet, no agreed mechanism for training and
accreditation in any of these advanced endoscopic procedures.
Each of these groups requires complex surgical, particularly
laparoscopic, skills that need considerable time to acquire.
Specialist training in endoscopic surgery now takes place in
the form of Advanced Training Skills Modules (ATSM) through
the RCOG in association with the British Society of Gynaeco-
logical Endoscopy (BSGE). The intermediate laparoscopy skills
ATSM (achievable in 1 year) and the advanced laparoscopy skills
ATSM (achievable in 2 years) are available. Registration and
completion of these modules depend on availability and oppor-
tunity of an approved preceptor which can vary depending on the
Deanery. Alternative options include undertaking a specialized
fellowship post (in the UK or abroad) either as time out of pro-
gramme (OOPE) or after completion of specialist training. In
addition to this it is also possible to undertake an MSC in
endoscopic surgery.
As at other levels of training, RCOG-approved preceptors and
courses should be identified. The numbers requiring such
specialized training would be small and should perhaps be
provided on a national basis. Training should be from within
a given subspecialty, but with help, where appropriate, from
other specialities.
Laparoscopic training: virtual reality as an option for the
future?
Recent studies investigating the effectiveness of computer-based
virtualtraining models have been encouraging. These experimental
settings show a high-quality surgeonecomputer interface and
might be useful in assessing the laparoscopic skills of a surgeon.
Another development that is closely related to this virtual
technique is the use of microsurgical robots in laparoscopy,
although because of the limited availability and high costs
involved, this application remains experimental.
Conclusion
Over the past 20 years, technology has allowed minimal access
surgery to progress at a rapid rate. The development of superior
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light sources and microchip video cameras has resulted in
superior imaging of the operative field, allowing ever-increasing
precision, far greater than could be expected at open surgery.
Current work on the use of three-dimensional technology, inte-
grated minimal access theatre suites, new methods of suturing
and new generations of lasers will continue to advance the field.
However, the major challenge facing laparoscopic surgery is
training. Unlike the general gynaecologist of 20 years ago,
current gynaecologists would not and should not be expected to
be able to undertake most gynaecological operations. The
establishment of an approved national training programme with
a small number of audited, specialized centres to which the most
complex cases are referred will hopefully be established soon.
Through training and audit, the confidence and experience both
inside the profession and within the public will grow, resulting in
the minimal access approach as the preferred option of choice.A
FURTHER READING
Asch R, Studd J. In: Nezhat CR, Nezhat F, Nezhat CH, eds. Progress in
reproductive medicine. New York: Parthenon Publishing, 1996.
Cofman RS, Diamond MP, De Cherney A. Complications of laparoscopy
and hysteroscopy. Oxford: Blackwell Scientific Publications, 1993.
Claims analyses. MDU Journal January 2009; 25: 18e20.
Kononickx PD. Deeply infiltrating endometriosis. In: Brosens I, Donnez J,
eds. Endometriosis: research and management. New York: Parthenon
Publishing, 1994: 437e46.
Royal College of Obstetrician and Gynaecology. MAS Training
Sub-committee recommendations.
Royal College of Obstetrics and Gynaecology. Hysterectomy Audit, UK,
1995.
Sutton C, Diamond M, eds. Endoscopic surgery for gynaecologists.
London: W.B. Saunders Company, 2000.
Sutton C, Philips K. RCOG Green-top Guideline 49, Preventing entry-
related gynaecological laparoscopic injuries, May 2008.
Tulandi T, ed. Atlas of laparoscopic and hysteroscopic techniques for
gynecologists. 2nd edn. London: W.B. Saunders Company, 1999.
TRAINING INFORMATION
British Society for Gynaecological Endoscopy. http://www.bsge.org.uk.
Royal College of Obstetricians & Gynaecologists. http://www.rcog.org.uk,
http://www.rcog.org.uk/curriculum-module/atsm-benign-
gynaecological-surgery-laparoscopy.
Practice points
Benefits
Less post-operative morbidity, shorter hospital stay and
quicker return to work.
Magnification allows for greater surgical precision.
Most procedures that are carried out through a laparotomy can
now be performed by laparoscopy.
Problems
Operative laparoscopy, however, requires a higher degree of
technical training and skill.
A lack of skill or training can result in increasing medico legal
claims.
Solutions
Structured RCOG/BSGE training programme for advanced
laparoscopic skills.
Development of regional centres for more advanced surgical
cases.
REVIEW

Laparoscopy and Laparoscopic Surgery

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