Operating through the Eye of the Needle

As all medical technologies evolve, so has gynecologic surgery. Since 1910 when Dr. Hans Christian Jacobaeus performed the first human laparoscopic surgery in Stockholm(1), emerging advances in technique and instrumentation have led to the inception of the microlaparoscopy.

Abolishing the need for "big scar" macrosurgery, microlaparoscopy represents truly scarless surgery without incision. Now well used with previously operated patients and as an aid to NOTES, it also brings aesthetics (of particular importance in the pediatric/early adolescent population) to the laparoscopic forum.

Defined as the use of instruments with an outer sheath of less than 2 mm, microlaparoscopic surgery represents the leading edge of fiberoptic and instrument design technology. Already the approach of choice in awake laparoscopy, it is heralded as the new standard for abdominal entry and performance of many pelvic diagnostic and therapeutic procedures(2). Micro-instrumentational developments continue to evolve and afford ways in which to gain truly minimal access and avoid possible complications found in early laparoscopy i.e. incisional hernias, fascial hematoma, bowel and major epigastric vessel industry.

Since the early 1990s, wide improvements in instrumentation have occured, permitting ever-increasing minimally invasive, advanced surgery. Today, instruments ranging from 1.2–3.3 mm are the standard.(3) The acme of minimally invasive gynecologic surgery, microlaparoscopy facilitates safe, successful - and cost-saving - procedures that once required open surgery. Benefits are abundant and include smaller incisions, reduced local pain, less wound hematoma, no visible scarring and reduced costs.(4)

Despite progress in non-invasive diagnostic imaging, accurate diagnosis of some pelvic disease still depends on direct visualization. Microlaparoscopy provides a definitive diagnosis with low morbidity and cost and is appropriate for procedures related to pelvic pain evaluation. Microlaparoscopy is appropriate for the diagnosis of a variety of gynepathologies, including endometriosis, ruptured cysts and inguinal hernia. Second-look microlaparoscopy can also be done after ovarian cancer treatment or adhesiolysis to assess recurrence. It also facilitates diagnosis of peritoneal factor causes of infertility, including tubal adhesions and results of chromopertubation.(5)

Widely peformed in the operating room theater, microlaparoscopy is also increasingly being performed at the office level under local anesthesia, though this may lead to some disadvantage in therapeutic options. Issues relating to field of view, the delicate nature of graspers, scissors and other instrumentation, and difficulty in removing bulky tissue through the smaller trocars (6) can lead to limitations in the office setting. Similarly, the moderate learning curve for laparoendoscopic surgeons who are used to larger, less delicate tools may also contribute to drawbacks.(7) Developing technologies and training will continue to play an ever-increasing role in the refinement of microlaparoscopy as the emerging standard. 
Overall, microlaparoscopy causes less pain, requires lower consumption of analgesics and permits quicker return to daily activities. Similarly, the procedure contributes to shorter hospital stays and reduced healthcare costs. (8) This evolving procedure represents the next generation of minimally invasive, advanced gynecologic laparoscopic capabilities for the surgeons of today and tomorrow across a wide range of subspecialties.

(1) Hatzinger M, Häcker A, Langbein S, Kwon S, Hoang-Böhm J, Alken P. Hans-Christian Jacobaeus (1879-1937): The inventor of human laparoscopy and thoracoscopy. Urologe A. 2006 Sep;45(9):1184-6.

(2) O'Donovan PJ. Microlaparoscopy. SURG INNOV June 1999 vol. 6 no. 2 51-57.

(3) Abrao M, Ikeda F, Podgaec S, Pereira P. Microlaparoscopy for an intact ectopic pregnancy and endometriosis with the use of a diode laser: Case report. Hum. Reprod. (2000) 15 (6): 1369-1371.

(4) Nezhat, Camran. Operative gynecologic laparoscopy: principles and techniques. Mcgraw-Hill, TX. February 1995.

(5), (6) "Microlaparoscopy" by Ceana H. Nezhat, MD. June 30, 2011. Onlinehttp://hcp.obgyn.net/laparoscopy/content/article/1760982/1894821. Last accessed 11/2/11.

(7) "Microlaparoscopy in the 21st Century: AWAKE MICROLAPAROSCOPY" by Oscar D. Almeida, Jr, MD, FACOG, FACS. Onlinehttp://www.laparoscopytoday.com/2003/01/microlaparoscop.html. Last accessed 11/2/11.

(8) Ikeda F, Vanni D, Vasconcelos A, Podgaec S, Abrão MS. Microlaparoscopy vs. conventional laparoscopy for the management of early-stage pelvic endometriosis: a comparison. J Reprod Med. 2005 Oct;50(10):771-8.

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