SURGICAL PRINCIPLES

Deliberate and thorough surgical planning and preoperative preparation is essential to successful surgical outcomes.  This process begins with patient evaluation with a thorough history, physical examination, and appropriate imaging.  Once the decision for surgery has been made, careful patient counseling and consent follows with clear definition of the goals of the surgical intervention.  It is essential to identify and optimize any medical conditions to decrease surgical morbidity and mortality. 

Multiple surgical approaches for the treatment of gynecologic pathology exist.  These include vaginal, hysteroscopic, laparotomic, laparoscopic, robotically assisted [MM1] laparoscopic, and combined techniques.  Given the variety of options, ensuring that the most appropriate approach is utilized is imperative.  Factors that can impact the approach selection include patient goals, surgical goals, anticipated pathology, and surgeon skillset and expertise.  Shared decision-making is critical to ensuring that the patient has a sound understanding of the surgical procedure, the recommended approach, and alternatives that may be available.  Preoperative evaluation and planning, including a thorough history, physical exam, and imaging studies as indicated, is essential to ensure that the most appropriate surgical route is recommended for each patient.

The vaginal approach to the uterus is the oldest and generally least morbid technique for the performance of hysterectomy. In selected instances, leiomyomas may be removed with vaginal techniques.

Despite the  fact that the first operative hysteroscopic procedure was published in 1869, hysteroscopic surgery is still relatively underperformed. Hysteroscopic myomectomy offers women the opportunity to treat leiomyoma-related  heavy menstrual bleeding or infertility in an outpatient fashion without incisions. In many instances, these procedures can be performed in a office setting.

Laparoscopic technique is used for hysterectomy, myomectomy, or, with intraoperative ultrasound, for radiofrequency ablation of leiomyomas. Safe and effective laparoscopic surgery requires appropriate training and the availability of general endotracheal anesthesia and the availability of the required equipment and supplies.

There remain clinical circumstances where laparotomy is necessary either for the performance of myomectomy or when hysterectomy is necessary. These situations generally occur with cases complicated because of the size or number of leiomyomas, or where previous surgery or intraperitoneal adhesions preclude the safe performance of laparoscopic surgery.