The most significant development in recent years has been minimally invasive surgery. In the early 1970s, the laparoscope became popular as a means of evaluating the pelvic organs for investigation of symptoms such as pelvic pain and infertility. At that time research showed that the pre-operative presumed diagnosis proved to be incorrect in more than 50% of cases! Since that time, however, there have been other developments. Ultrasound (Q4.7), for example, increases our ability to evaluate the structure of the pelvic organs without surgery reducing to some degree the need for laparoscopy

Minimally invasive surgery has been a significant development although its exact place is still under evaluation. Some gynaecologists now specialise in this form of surgery. At one time a diagnosis of an ectopic pregnancy necessitated a laparotomy to remove the tube. The patient would remain in hospital for a week and would be off work for another five weeks. We have learned from minimally invasive surgery that hospitalisation can be reduced.

A thirty year old lady presented with a second ectopic pregnancy in her right Fallopian tube. Two years earlier she had an ectopic in the same tube. The ectopic had been removed and the tube conserved. She now wished to have the tube taken away. Through a mini-laparotomy incision (conventional surgery rather than minimally invasive) the tube was taken away. The patient went home on the second post-operative day. Two weeks later she was back at work and had recommenced swimming. It is unlikely that she would have done better with minimally invasive surgery.  

Pilots specialise in the type of plane they fly: a Concorde pilot would not be expected to fly a jumbo nor a jumbo pilot a Concorde. Similarly, the accelerating developments in gynaecology should lead to the conclusion that individual gynaecologists should confine their interests and work with others in a team to ensure that patients receive the best possible options and treatments.

Robotic surgery is being developed. The instruments are moved by a robot with the surgeon sitting away from the patient at a console. The advantages are that there is less pain for the patient, the patient can return to normal activity more quickly and the scar is cosmetically better.

A  comparison of outcomes and cost for endometrial cancer staging via traditional laparotomy, standard laparoscopy and robotic techniques has been undertaken in Sanford, USA.

One hundred and ten patients underwent hysterectomy with bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy for endometrial cancer staging. All cases were performed by a single surgeon, at a single institution (40 robotic, 40 laparotomy, and 30 laparoscopic) and were retrospectively reviewed to compare demographics and peri-operative variables including, operative time, estimated blood loss, lymph node count, hospital stay, complications, and return to normal activity. Additionally, a cost comparison between all three modalities was performed. Patients undergoing robotic assisted hysterectomy and staging experienced longer operative time than the laparotomy cohort with no difference in comparison to the laparoscopic cohort. Estimated blood loss was significantly reduced for the robotic cohort in comparison to the laparotomy cohort and comparable to laparoscopic cohort. The complication rate was lowest in the robotic cohort (7.5%) relative to the laparotomy (27.5%) and laparoscopic cohorts (20%) (p=0.015, p=0.03).


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This is the personal website of David A Viniker MD FRCOG, retired Consultant Obstetrician and Gynaecologist - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.
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