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Operative laparoscopy: a second look after 18 years.

A 1992 editorial in Obstetrics & Gynecology titled “Operative Laparoscopy: Surgical Advance or Technical Gimmick?” raised a number of concerns about a then-nascent field, concerns based mainly on the paucity of evidence regarding the appropriateness and outcomes of performing gynecologic operations endoscopically.1 The editorial provoked considerable reaction, most of it variations on the theme “How dare you!” The journal received many letters about the editorial, far more than ever came in response to a single publication. It seems appropriate now to ask where we stand 18 years later. A substantial body of evidence has accumulated in recent years to support the laparoscopic approach to various gynecologic operations. Despite well-recognized difficulties in assessing surgical procedures by randomized trial, many of the reports have been based on this more rigorous and more meaningful design. Additionally, there have been several meta-analyses of randomized trials. From this extensive literature, it is now clear that many if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches to various operations, including tubal pregnancy surgery (salpingectomy or salpingostomy), myomectomy, hysterectomy (especially when vaginal hysterectomy is not feasible by itself), ovarian-cyst surgery, and certain gynecologic-cancer operations (including lymph node dissections). The benefits of the laparoscopic approach include less pain and shorter postoperative convalescence, both in-hospital and after discharge. Operative and postoperative complications are typically no more frequent with laparoscopy and often occur less frequently. In an era of concern regarding health care costs, considerable attention has been devoted to economic matters. All health care financial studies are complicated by inconsistencies and uncertainties regarding the meaning of “cost,” but the research is quite consistent in finding that hospital charges due to some increase in operating time with laparoscopic surgery and disposable instruments are offset, sometimes substantially, by decreased charges reflecting shortened postoperative hospital stays. If a “societal cost” that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater. All of this, of course, assumes that the disease in a given woman is amenable to either approach and that the surgeon is equally experienced and equally competent with the two. Choosing the best surgery or other treatment to recommend to a given patient is part of that ill-defined and often nebulous quality called “clinical judgment.” What about technical competence? That issue goes most directly to the formal training period— residency. When a relatively new surgical technique becomes popular, The authors are from the Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; e-mail: r.pitkin@earthlink.net.