Compared to vaginal hysterectomy, there is a slightly higher risk of complications with laparoscopic hysterectomy, but this risk is probably lower than for abdominal hysterectomy (51). As experience is gained with laparoscopic hysterectomy, these outcomes may approach those of vaginal hysterectomy. The procedural costs of laparoscopic hysterectomy are greater than either vaginal or abdominal hysterectomy but can be dramatically reduced when reusable instruments are employed (4,52). Most studies show less postoperative pain, shorter hospital stays, and faster postoperative recovery with laparoscopic hysterectomy than with abdominal hysterectomy (51,53). There is evidence that pain scores and quality-of-life measures, including sexual activity and physical and mental functioning, were significantly better for women who underwent laparoscopic versus abdominal hysterectomy (54). These differences were present at 6 weeks following surgery and remained at the 12-month follow-up visit. When the societal benefits of faster return to work or family are considered, the cost of laparoscopic surgery is significantly less (4).
Selection of the route of hysterectomy must be done considering the anatomy, the disorder or disease state, the patient’s wishes, and the training and experience of the surgeon. Laparoscopic hysterectomy offers no advantage for women in whom vaginal hysterectomy is possible because the endoscopic approach is more expensive and probably has a higher risk for perioperative morbidity (51). The ideal place for laparoscopic hysterectomy is as a replacement for abdominal hysterectomy.
Outside of physician training, there are relatively few remaining indications for abdominal hysterectomy, which should be reserved for the minority of women for whom a laparoscopic or vaginal approach is not appropriate, including (i) patients with medical conditions, such as cardiopulmonary disease, where the risks of either general anesthesia or the increased intraperitoneal pressure associated with laparoscopy are deemed unacceptable; or (ii) where morcellation is known or likely to be required and uterine malignancy is either known or suspected. For both laparoscopic and vaginal hysterectomy the reasons include: (i) hysterectomy is indicated but there is no access to the surgeons or facilities required for vaginal or laparoscopic hysterectomy and referral is not feasible; or (ii) circumstances where anatomy is so distorted by uterine disease or adhesions that a vaginal or laparoscopic approach is not deemed safe or reasonable by individuals with recognized expertise in either vaginal or laparoscopic hysterectomy techniques (52,54). For surgeons without the skill and training to perform minimally invasive hysterectomy (either vaginal or laparoscopic), for benign indications, consideration should be given for referral to a gynecologist with such training.
Infertility Operations When infertility occurs secondary to disruption of the normal anatomy or anatomic relationships by an inﬂammatory process, laparoscopically directed operations used to restore anatomy include fimbrioplasty, adhesiolysis, and salpingostomy for distal obstruction (55). Fimbrioplasty is distinguished from salpingostomy because it is performed in the absence of preexisting complete distal obstruction. Endometriosis associated with adnexal distortion can be treated by laparoscopic adhesiolysis. Whereas there is no known additional benefit of medical treatment of coexistent active endometriosis, the evidence relating to ablation of minimal and mild endometriosis is mixed, although when subjected to meta-analytic technique, there is a slight fecundity benefit for those undergoing laparoscopic ablation (56–58). Laparoscopy is used for procedures in which gametes (gamete intrafallopian transfer) or zygotes (zygote intrafallopian transfer) are placed into the fallopian tube after oocytes are removed either via ultrasound-or laparoscopically guided technique.