The surgical technique
Gynecologic laparoscopy is a minimally invasive surgical technique performed under general anesthesia, used for the diagnosis and treatment of many conditions of the female reproductive system.
The surgeon makes a small abdominal incision, generally at the umbilicus, through which an access port — known as a trocar, approximately 8–12 mm in diameter — is inserted. Carbon dioxide is then insufflated through this access to distend the abdominal cavity and provide adequate visualization of the operative field.
The laparoscope is introduced through the trocar. When a laparoscopic approach is indicated and technically feasible, the surgeon makes additional small abdominal incisions, generally between two and four, in which other 5 mm trocars are placed for the passage of the surgical instruments used during the procedure.
When performed, operative laparoscopy allows exploration of the entire abdominal cavity and execution of numerous procedures, both in benign gynecology and in gynecologic oncology.
Benefits of the laparoscopic approach
Compared with traditional open surgery, laparoscopy offers significant patient benefits documented by extensive scientific literature:
- Reduced intraoperative blood loss
- Shorter length of hospital stay
- Less postoperative pain
- Earlier patient mobilization
- Smaller scars with improved cosmetic outcomes
- Lower risk of wound infection
- Faster return to normal daily activities
The laparoscopic approach is currently considered the access of choice for many gynecologic procedures, both benign and oncologic, thanks to its favorable safety profile and the demonstrated oncologic equivalence to laparotomy in early-stage endometrial cancer.
Limitations of the procedure
Despite its many benefits, laparoscopy has technical limitations that the surgeon must evaluate in relation to the specific clinical case.
The surgeon operates through monitor visualization, working with a two-dimensional rather than three-dimensional image. Stability of the operative field may also depend on the second operator managing the camera, requiring an experienced and well-coordinated surgical team.
In selected clinical situations — such as severe obesity, extensive abdominal adhesions, unfavorable anatomy or uncontrollable intraoperative bleeding — conversion to laparotomy with traditional abdominal incision may be necessary in order to ensure patient safety.
Complications
Gynecologic laparoscopy is generally a safe procedure. However, like any surgical intervention, it carries a risk of complications which, overall, remains contained.
Minor complications
- Postoperative wound infections
- Recurrent bleeding and hematoma formation at the incision sites
- Nausea and vomiting related to general anesthesia
Major complications
- Injury to abdominal or pelvic organs
- Injury to major arterial vessels
- Deep vein thrombosis and pulmonary embolism
- Adverse reactions related to the presence of carbon dioxide in the abdominal cavity
- Formation of significant intra-abdominal adhesions — fibrous bands developing during the healing process that may alter the normal anatomy of internal organs
- Fever above 38°C (100.4°F) in the days following surgery
- Heavy or persistent bleeding from the incisions
- Worsening abdominal pain not controlled by analgesic therapy
- Breathing difficulties or chest pain
- Signs of local infection (redness, warmth, fluid discharge from the wounds)
Frequently asked questions
Gynecologic laparoscopy is a minimally invasive surgical procedure that allows visualization and treatment of conditions affecting the uterus, fallopian tubes and ovaries through small abdominal incisions, generally between 0.5 and 1 cm, using a dedicated camera and specialized surgical instruments.
To perform the procedure, carbon dioxide is insufflated into the abdominal cavity to create the working space required for adequate visualization of the pelvic and abdominal organs.
Ref.: [1, 2]
General anesthesia is the standard modality for gynecologic laparoscopy. Local anesthesia alone is generally not adequate; in selected circumstances, spinal or epidural anesthesia may be considered as possible alternatives.
Some studies have also evaluated the combination of spinal anesthesia and sedation, but general anesthesia remains the most widely used option, particularly for airway management during CO₂ insufflation.
Ref.: [1, 2, 3, 4, 5, 6]
The length of hospital stay depends on the type of procedure performed. For non-complex gynecologic laparoscopic interventions, same-day discharge is increasingly common and applies to approximately 70–80% of cases. For more complex procedures, such as laparoscopic hysterectomy, the average length of stay is 2–3 days.
ERAS (Enhanced Recovery After Surgery) protocols have further reduced hospitalization times, bringing them to approximately 4–5 days even for the most complex interventions.
Ref.: [7, 8, 9, 10, 11]
Return to work generally occurs within 2–4 weeks after surgery. For resumption of sport activities or intense physical exertion, a 3–4 week interval is usually recommended.
The literature reports return to normal daily activities on average between 13 and 28 days, depending on the complexity of the procedure performed.
Ref.: [8, 9]
Laparoscopic scars are generally small in size, approximately 0.5–1 cm, and tend to become barely noticeable over time. Because they involve small incisions, the scarring course is typically favorable, and scar appearance tends to fade in the months following surgery.
Ref.: [1, 12]
Shoulder pain after laparoscopy is a frequent symptom and may affect up to 80% of patients. It is mainly caused by phrenic nerve irritation due to residual carbon dioxide in the abdominal cavity. The gas can irritate the diaphragm, producing referred pain in the shoulder or cervical region.
Symptom intensity correlates positively with the amount of residual gas and may persist for up to 3 days.
Ref.: [2, 13, 14]
Resumption of sexual activity is generally recommended after 2–4 weeks, depending on the type of procedure performed and the recovery course. Timing may vary based on the complexity of the procedure and the patient's general condition.
It is essential to follow the instructions provided by the surgeon at discharge.
Ref.: [8, 9]
Diagnostic laparoscopy aims to visualize the pelvic and abdominal organs to identify any pathology, with the option of performing biopsies if needed. Operative laparoscopy, by contrast, also allows treatment of the identified condition during the same surgical session — for example, removal of ovarian cysts, treatment of endometriosis, lysis of adhesions or fibroid removal.
The modern approach favors the "see and treat" strategy: identifying and treating the pathology during the same procedure when clinical conditions allow.
Ref.: [1, 12, 15]
The effect on fertility depends on the condition treated and the type of procedure performed. Operative laparoscopy for endometriosis may increase the likelihood of pregnancy, although the level of available evidence is moderate. In the presence of ovarian cysts or pelvic adhesions, surgical treatment may improve fertility.
More extensive ovarian surgery, however, may result in reduced ovarian reserve. Overall, laparoscopy is generally preferred over laparotomy when the goal is to preserve reproductive potential.
Ref.: [12, 16]
The overall rate of major complications is low, with reported variability between 0.2% and 6.5%. The most frequent complications include:
- Vascular injuries (0.01–0.1%): damage to major vessels or vessels of the abdominal wall
- Bowel injuries (0.0–0.7%): bowel perforation, sometimes unrecognized during surgery
- Urinary tract injuries (0.5–2.5%): bladder or ureteral involvement, more frequent in laparoscopic hysterectomy
- Surgical wound, intra-abdominal or urinary infections
- Conversion to laparotomy (1.9–4.7%)
- Incisional hernias (0.3%)
Major risk factors include age over 38 years, operative duration exceeding 90–100 minutes, complex procedures and pre-existing comorbidities.
Ref.: [17, 18, 19, 20, 21]
Specialist Consultation
Prof. Di Donato evaluates each case individually to establish the indication for the laparoscopic approach and to plan the most appropriate surgical strategy.