The clinical advantages of laparoscopy over laparotomy have been well established over the last several years. As the acceptance and use of laparoscopic approaches have increased among gynecologic surgeons, attention to cosmesis has also evolved.
Laparoscopy has been appealing for its cosmetic benefits as well as reductions in complications and recovery times. Women not only want to resume their normal activities sooner; they also want to take advantage of the smaller incisions that laparoscopy entails, as these incisions do not alter abdominal wall appearance as significantly as do laparotomy incisions.
Dr. Aarathi Cholkeri-Singh
Still, depending on an individual’s body mass index and wound healing, scars can be disturbing for patients. Some women who have had more than one laparoscopic surgery requiring different port placements have jokingly spoken about "connecting the dots," but such comments reflect concern about aesthetics and should be taken seriously. Although we have improved surgical outcomes with laparoscopy and reduced the size of the surgical scar, we can still create disfigured abdomens.
Last year, the AAGL Fellowship in Minimally Invasive Gynecologic Surgery at Newton-Wellesley (Mass.) Hospital published an article about a survey of women and their preferred abdominal incision choices, based solely on cosmesis (J. Minim. Invasive Gynecol. 2011;18:640-3). The survey participants were shown three photographs of incisions that were commonly performed at their institution and among several Boston-area gynecologic surgeons, and were asked to rank the incisions in order of preference.
The photograph depicting a single incision or single-site laparoscopy showed a vertical 25-mm incision. The robotic laparoscopy photo showed five incisions: umbilical and right midabdomen (paraumbilical) incisions of 12-mm length, and 8-mm incisions in the right lower quadrant, left lower quadrant, and left midabdomen. The incision configuration in the photo of a conventional four-port laparoscopy consisted of a 10-mm incision in the right lower quadrant and 5-mm incisions in the umbilicus, left lower quadrant, and suprapubic area.
The conventional laparoscopy incisions were most preferred by approximately 56% of the 241 women who completed the survey, whereas preference for a single incision was approximately 41% and for robotic surgery was 2.5%.
Granted, there are variable configurations and incision sizes for each of the laparoscopic techniques, and further strides are being made to make the approaches more cosmetically acceptable. Experienced gynecologic surgeons are developing techniques to minimize the number of ports used robotically, for instance, and smaller incision sizes for robotic laparoscopy are anticipated.
In any case, the overarching lesson from this survey is that aesthetics is of value to many women and should be an important consideration for us as treating physicians.
Miniaturization
The use of mini- or microlaparoscopic instrumentation enables us to address aesthetic concerns and take the issue of cosmesis to the next level, as well as to further minimizing trauma. Although conventional laparoscopy involves instruments of 5-mm diameter or larger, the term "minilaparoscopy" usually refers to the use of instruments greater than 2 mm up to less than 5 mm in diameter, and "microlaparoscopy" involves instrumentation of 2 mm or less in diameter.
In gynecology, minilaparoscopy has been utilized diagnostically since the mid-1990s to perform conscious pain mapping with local anesthesia. With a 2.5 mm–diameter scope and 3 mm–diameter trocars, surgeons have used a blunt probe to map trigger sites with the patient’s assistance and response, and to aid in identifying pelvic disease suspected of causing pain (Int. J. Gynaecol. Obstet. 2008;100:94-8).
The diagnostic accuracy of the mini- or microlaparoscope has been reported in various scenarios (including cases of endometriosis and adhesive disease) to be comparable to that of the 10-mm scope that is used in conventional laparoscopy.
In one small study, investigators compared the diagnostic accuracy of 2-mm and 10-mm laparoscopes, with two physicians independently reporting findings to a third person (Fertil. Steril. 1997;67:952-4). Although they had a small sample size, the researchers observed no significant differences between the two laparoscopes or the two physicians. (Scores for endometriosis and adnexal adhesions, for instance, did not differ in any significant way.) This suggested that the diagnostic accuracy achieved with the microlaparoscope was comparable to that of the standard 10-mm laparoscope.
Another study in which 87 consecutive women underwent microlaparoscopic evaluation for chronic pelvic pain similarly found that microlaparoscopy provides comparable efficacy for diagnosing endometriosis and evaluating for the presence of occlusive salpingitis isthmica nodosa. Evaluation through a 2-mm port affords "an excellent minimally invasive view of the pelvis," the investigator wrote (JSLS 2005;9:431-3).