Is Gynecologic Laparoscopy Too Risky?

George B. McClure, M.D. Instructor in Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School       YES The allure of a new technology such as laparoscopy can be seductive to practitioners trying to compete and patients seeking an edge.   Today's patients are medically savvy. They've read in magazines of the benefits of laparoscopic surgery over traditional procedures and have seen it demonstrated on TV.   This puts increasing pressure on surgeons to provide patients with the latest techniques in order to stay competitive. But without sufficient skill, training, and experience, laparoscopy is too risky.   Surgeons may turn for training to well-edited video presentations or to a course put on by a leader in the field. They may come away feeling confident that they too can do operative laparoscopy with the same deft hand. The time, training, and experience needed to acquire the skill of the redoubtable presenter may not have been emphasized.   Surgeons should complete formalized training with noted experts and then do more than a few procedures under the guidance of these authorities.   Complications from gynecologic laparoscopy include vascular injury, perforation of a hollow viscus, and nerve or ureteral transection. Published complication rates vary widely.   In reports from experienced operators working in laparoscopic-research centers, the complication rate for all advanced laparoscopic procedures was 3.08%.   But in a recent study of laparoscopic-assisted vaginal hysterectomy in a residency-training program, with residents as primary surgeons, the complication rate was 16%. The complication rate of the average gynecologist doing laparoscopy is unknown but probably lies in between.   An accepted complication rate for vaginal hysterectomy is 0.5%.

Ceana Nezhat, M.D. Associate Clinical Professor of Obstetrics and Gynecology, Mercer School of Medicine, Atlanta; Clinical Assistant Professor of Gynecology and Obstetrics, Stanford       NO When rubber surgical gloves were new, many surgeons decried the loss of tactile sensation, and some advocated wearing no gloves during surgery in the peritoneal cavity and when dealing with malignancy to achieve "neater and safer work." Laparoscopy, like surgical gloves, compromises the tactile sense.   Like any other surgical procedure, if the surgeon is not properly trained and not sufficiently familiar with the surgical anatomy, laparoscopy can turn into a risky ordeal.   However, laparoscopy's superior visualization combined with precise operative tools such as the CO2 laser ensure that practically all pelvic and abdominal gynecologic surgery can be safely and successfully done. We believe laparoscopy is going to supplant laparotomy.   Laparoscopy is associated with unique and serious complications, albeit rare, including vascular injury and laceration of abdominal organs when needles or trocars are inserted, and CO2 embolus if the gas is insufflated into a vessel.   But the early mobilization after laparoscopy substantially reduces common postop complications such as deep vein thrombosis and atelectasis.   Most laparoscopic surgeons are still at the rise of the learning curve, and this can compromise any attempt to determine complication risks. Series from single-expert centers such as ours show a complication rate of 3.0%, with no deaths, in 6,949 consecutive advanced gynecologic procedures. This is significantly lower than expected from laparotomy.   Although such results are impressive, they do not necessarily reflect the expected safety of advanced laparoscopic operations in the hands of the average gynecologist. Mastering laparoscopic surgery demands many new skills and several years of training.