Adhesiolysis may be accomplished by blunt or sharp dissection with scissors, ultrasonic shears, or an electrosurgical electrode. There is no evidence that laser-based instruments provide any additional value over less expensive techniques such as electrosurgery (59–61). The dissecting instruments are usually passed through an ancillary port; when laser energy is used, the channel of the operating laparoscope may be used for this purpose. Although there is controversy regarding the most appropriate modality for adhesiolysis, these methods are probably equally effective in appropriately trained hands.
Laparoscopic operations for the treatment of mechanical infertility are probably equally effective to similar procedures performed by laparotomy. In patients with extensive adhesions, successful outcomes are unlikely regardless of the approach. Consequently, assisted reproductive technologies such as in vitro fertilization and embryo transfer are necessary in these situations (see Chapter 32) (13,55).
Endometriosis The laparoscopic management of endometriomas parallels that of adnexal masses, although the ultrasonographic complexity of endometriomas sometimes makes it difficult to distinguish them preoperatively from a neoplasm (62). The close attachment of the endometrioma to the ovarian cortex and stroma may make it difficult to find surgical dissection planes, and incomplete removal increases the risk of recurrence. In such instances there may be a tendency either to compromise the function of the remaining ovary by attempting complete removal or to risk recurrence by leaving part of the endometrioma in place. A Cochrane review found good evidence that excisional surgery for endometriomas decreases the recurrence of the endometrioma, decreases the recurrence of pain symptoms, and in women who were previously subfertile, increases subsequent spontaneous pregnancy (63). Consequently, where possible the excisional approach should be the goal. Multifocal endometriosis may be treated by mechanical excision or ablation, the latter using coagulation or vaporization with either electrical or laser energy. With proper use, each energy source creates about the same amount of thermal injury (59–61). Endometriosis frequently is deeper than appreciated initially, making excisional techniques valuable in many instances (64,65).
Pelvic Floor Disorders Laparoscopy can be used to guide procedures to treat pelvic support defects, including culdoplasty, enterocele repair, vaginal vault suspension, paravaginal repair, and retropubic cystourethropexy for urinary stress incontinence. Although these conditions can be treated vaginally, the laparoscopic approach may offer benefits, particularly with retropubic urethropexy. There is some evidence that the laparoscopic approach is effective when compared with the traditional methods, but, in most instances, vaginal or laparoscopic mesh-based techniques seem to be the most frequently used approaches (66,67). Using the same surgical principles applied during traditional pelvic ﬂoor repair, laparoscopy promises better access to key anatomical landmarks and potentially more accurate suture placement (68). Whereas apical and anterior compartment defects can be successfully corrected via laparoscopy, posterior and perineal defects are best visualized and repaired using vaginal techniques. The laparoscopic treatment of enterocele and vault prolapse may be useful in patients who require abdominal approaches after failure of a previous vaginal procedure. Because of the anatomical proximity of the pelvic ureter to the uterosacral ligament and anterolateral vagina, bilateral ureteral patency should be confirmed cystoscopically after laparoscopic vaginal vault suspension, enterocele repair, culdoplasty, cystourethropexy, or paravaginal repair.