5/11/2023 0 Comments Stapled vagina![]() When less experienced physicians became acquainted with the techniques during brief courses, they found that their implementation represented a greater challenge than perhaps they had anticipated. Many of the early results of operative laparoscopy were reported from those who were expert in this type of surgery. Having tried virtually all of these methods in most of the advanced endoscopic surgical procedures currently performed, I have gradually moved back to a laparoscopic surgical approach that closely replicates the techniques used during standard open procedures.Īnother substantial area of concern in the field of operative laparoscopy is how new knowledge and techniques have been taught to physicians in practice. It would seem that the particular advantages of one method of dividing tissue over another lie not so much in the method itself as with the experience and comfort of the user in employing the technique. Staples, monopolar and bipolar cautery scissors, carbon dioxide laser, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, harmonic scalpel, the argon beam coagulator, and instruments that combine cautery and cutting functions each have their advocates as well as particular surgical situations in which an individual method may have advantages over the others. The technologic advantages taking place between 19 were largely aimed at simplifying these approaches and making them usable in the hands of endoscopic surgeons with more average skills. Kurt Semm of Germany developed many approaches for basically replicating open surgery techniques using laparoscopic instruments. Our challenge is to promulgate these new approaches and skills in a manner that minimizes the potential for complications. Combined with preemptive analgesic techniques, true improvements in patient care are possible. We are now poised at a moment when new innovations such as the supercervical laparoscopic hysterectomy and the total laparoscopic hysterectomy promise to be constructive forward steps. Several recent series have suggested that in these early years, complications in general, and injuries to the urinary tract in particular, were more common with LAVH than with other approaches. Others less inherently inclined to laparoscopic procedures and with smaller patient volumes experienced frustration, difficulties, and complications. Those surgeons with the natural skills suited to the task, as well as sufficient patient volume to allow a rapid climb up the learning curve, experienced remarkable success. These rapid developments placed the practicing gynecologist in the difficult position of needing to learn an entirely new set of surgical techniques, usually without the opportunity of learning them in the way surgical techniques have traditionally been taught: by direct tutoring at the hands of those who developed the procedures, or who were well skilled in their performance. Patient demand was fostered by the labeling of such procedures as “minimally invasive,” which was hardly the case. Finally, with the development of the laparoscopic stapling devices, the strongest proponents of operative laparoscopy believed that virtually every gynecologic procedure done for benign disease could and should be performed laparoscopically. With the introduction of lasers in the early 1980s, operative laparoscopy entered an exponential phase of growth and development. ![]() These were employed in progressively more difficult laparoscopic surgical procedures over an approximately 10- to 15-year period. Starting in the 1970s, innovative laparoscopists teamed up with surgical instrument manufacturers to devise many new laparoscopic surgical tools. 5 The purpose of this chapter is to review what we have learned and to propose ways of preserving the advantages of laparoscopic surgery while minimizing its risks. 2, 4 Appreciation of the challenges of laparoscopic surgery seems to have prompted a reevaluation of LAVH and attempts to define its appropriate niche. Initial innovation was followed by widespread adoption, which in turn produced new information about complication rates 2, 3 and cost-effectiveness. 1 In that time span, the procedure seems to have followed the typical course of any new medical intervention. It has now been approximately 10 years since laparoscopically assisted vaginal hysterectomy (LAVH) was first performed.
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