There are limitations to laparoscopy. The view of the operative field may be restricted, and if tissue or ﬂuid becomes attached to the lens, vision may be obscured. Soft tissues, intramural myomas, or the inside of a hollow viscus cannot be palpated. For assessment of these tissues, an imaging modality, such as ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI), is superior. Because of its ability to view soft tissue, ultrasonography is more accurate than laparoscopy for the evaluation of the inside of adnexal masses. The intraluminal contour of the uterus can be shown only by hysteroscopy or contrast imaging such as saline infusion sonography, hysterosalpingography, or MRI. Ultrasonography, in combination with serum assays of β-human chorionic gonadotropin (β-hCG) and progesterone, can be used to diagnose ectopic pregnancy, usually allowing medical therapy to be given without laparoscopic confirmation (3). As a result of the advances in blood tests and imaging technology, laparoscopy more often is used to confirm a clinical impression than for initial diagnosis.
Laparoscopy may disclose abnormalities that are not necessarily related to the patient’s problem. Although endometriosis, adhesions, leiomyomas, and small cysts in the ovaries are common, they are frequently asymptomatic. Thus, diagnostic laparoscopy must be performed prudently, interpreting findings in the context of the clinical problem and other diagnoses.
The role of laparoscopy in the operative management of gynecologic conditions is evolving. Many procedures previously performed as traditional abdominal and vaginal operations are feasible or even readily performed under laparoscopic direction. Operative laparoscopy has the benefit of shorter hospital stays, less postoperative pain, and faster return to normal activity. These general features of laparoscopic procedures contribute to a reduction in the “indirect costs” of surgical care, including less time away from work and a diminished need for postdischarge supportive care in the home (4). In addition to the other benefits of endoscopic procedures, adhesions are less likely to form with laparoscopic surgery than with laparotomy. Because sponges are not used, the amount of direct peritoneal trauma is reduced substantially, and contamination of the peritoneal cavity is minimized. The reduced exposure to the drying effect of room air allows the peritoneal surface to remain more moist and, therefore, less susceptible to injury and adhesion formation.
Despite these advantages, there are potential limitations: exposure of the operative field can be reduced; instruments are small and can be used only through fixed ports; and the ability to manipulate the pelvic viscera is limited. In some cases, the cost of hospitalization increases, despite a shortened stay, because of prolonged operating room time and the use of more expensive surgical equipment and supplies. Efficacy may be reduced if a surgeon cannot adequately replicate the abdominal operation. In some patients, there is an increased risk of complications, which can be attributed to the innate limitations of laparoscopy, the level of surgical expertise, or both. With an adequate combination of ability, training, and experience, however, operative time is comparable to those of traditional abdominal surgery and complications may be reduced.