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I distinctly remember, about 1985, a heated gynecology case conference about the best way to operate on a 6 cm ovarian dermoid cyst in a young woman. At that time, the main options and opinions regarding access to the abdomen were whether it was acceptable to do a Pfannensteil incision versus the traditional midline one. In fact, before that time, if you took your oral boards and you had a surgery for ovarian cyst on your case list, you had better say you did a midline incision. Sitting in on that conference was a young Dr Thierry Vancaille from Belgium, a future pioneer in minimally invasive surgery. He said that it was definitely possible and desirable to remove the dermoid through a laparoscope. This created a virtual uproar among the senior surgeons in the room, and it took over 10 years for this concept, which ultimately proved to be correct, to be accepted. Dr Vancaille’s, and other surgeons’, creative work in operative hysteroscopy, endometrial ablation, hysteroscopic sterilization, laparoscopic myomectomy and hysterectomy, laparoscopic reconstructive pelvic and oncologic surgery, and other surgeries, ultimately proved that minimally invasive approaches were the best patient-centered options for most gynecologic surgeries.
What is minimally invasive surgery? It turns out that this term does not really have a definition. It is more of a surgical concept in which the goal of the operation (remove fibroids, dissect lymph nodes, reconstruct vaginal support) is done in a way that is least invasive to the patient physically and emotionally. This is much more than just avoiding a laparotomy; it might involve using multiple smaller incisions, hiding a larger incision in the vagina, operating through the cervix, using a robot, or not removing organs if not necessary. “Minimally invasive” usually means “less painful,” and minimally invasive surgeons often try to add extra interventions to decrease the pain. Enhanced recovery care paths, better preoperative education, better anesthesia, nerve blocks, earlier discharge, and other ideas all try to make the surgical experience less invasive for the patient. Less invasive often does not mean easier, less complex, less costly, and easy to learn, so there are many important educational and health care controversies around minimally invasive surgery.
In this issue of Clinical Obstetrics and Gynecology, we present “New Developments in Minimally Invasive Surgery,” a compendium of what is new in various gynecologic surgery topics. The authors, all of whom are busy gynecologic surgeons and experts in their areas of interest, summarize the state of the literature and innovations for each type of surgery. Important topics for all gynecologists include minimally invasive surgeries for uterine bleeding, endometriosis, fibroids, and gynecologic cancer. We discuss issues around increasing the rates of vaginal and laparoscopic hysterectomy, how to safely extract a very large uterine specimen, and whether you even need to do a hysterectomy in a prolapse surgery. We discuss the current role and future innovations in the use of the surgical robot, and the concept of natural orifice transluminal endoscopic surgery (NOTES), in gynecology. Finally, and importantly, Dr Whiteside offers some insight into how minimally invasive surgery might offer higher value care within a value-based health care system. I hope you enjoy this monograph, not only for where we currently are in minimally invasive gynecologic surgery, but for where we hope to be.
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