Indications and general techniques for lasers in advanced operative laparoscopy

SUMMARY Lasers are but one of the several energy delivery systems used by the operative laparoscopist in the performance of advanced operative laparoscopy. Safety is a key factor in the selection of a laser because the tissue damage produced by this instrument is absolutely predictable. The surgeon must be totally familiar with the chosen wavelength and its tissue reaction if this safety factor is to be realized. Other instruments complement the use of lasers in advanced operative laparoscopy, and without thorough knowledge of all available techniques and instruments, the operative laparoscopist will not achieve the full potential of this specialty. It is beyond the scope of this issue on gynecologic laser surgery to present all of the useful nonlaser techniques. Suffice it to say that we often use laser, loop ligature, sutures, hemoclips, bipolar electricity, hydrodissection, and endocoagulation during the course of a day in the operating room and sometimes during one case. As enthusiasm for advanced operative laparoscopy grows and endoscopic capability increases, more complicated and prolonged surgical feats are reported. Radical hysterectomy and lymphadenectomy have been performed by the laparoscopic route, and endoscopic management of ovarian tumors also has been reported. At this moment, these must be viewed as “show and tell” procedures unsupported by statistics to demonstrate any advantage (or disadvantage) when compared with conventional surgical methods. The time required of advanced operative laparoscopy for any given procedure is certainly an important factor. Prolonged operative and anesthesia time certainly can negate the supposed benefit of small incisions and minimally invasive surgery. What goes on inside the abdomen is certainly the most important part of advanced operative laparoscopy. Good surgeons must recognize their own limitations and the limitations of available technology. The operative laparoscopist must know when to quit and institute a laparotomy. In general, when the magnitude of the operative laparoscopy greatly increases the time required to perform the surgery or exceeds the capability of the surgeon, laparotomy is necessary. Patients should never be promised that an operation will be done by laparoscopy. In advanced operative laparoscopy, informed consent means that the patient has had a reasonable explanation of the method, its benefits and its dangers, and has also been told that laparotomy is always a possibility. In our large series, the laparotomy rate is about 3%. It is also wise not to promise the patient that advanced operative laparoscopy will be done by the laser. Although it remains our energy system of choice, lasers may fail to function and the surgeon then faces the unpleasant dilemma of deciding whether or not to proceed without the laser. Subsequent articles describe the techniques and results of surgeons who use different types of laser for gynecologic advanced operative laparoscopy. Many of these techniques have been developed within the past 5 years and serve to demonstrate the tremendous progress in this field.