A vast field of surgery is called endoscopy. Its main difference from classical surgery is that no incisions are required. Surgical interventions on the abdominal and pelvic organs are called laparoscopy. It is performed through three to four small incisions in the anterior abdominal wall. A thin telescope is inserted through one of these incisions, located near the navel. This telescope transmits images via a digital mini-camera to a monitor, which displays everything happening inside the abdominal cavity. Thin manipulators, 40 cm long and 5 mm in diameter, are inserted through the other incisions. At one end of the tube is a convenient, functional handle for the surgeon, and at the other are miniature forceps, scissors, or another electrical or laser instrument. The development of modern surgery began in 1847. It was then that obstetrician Sir James Simpson first used chloroform anesthesia in Edinburgh, Scotland, making it possible to perform surgeries without putting the patient into shock. The first successful attempt to examine the abdominal cavity through an optical device was made in 1901 by the German surgeon K?lling on a dog, and less than 10 years later, Jacobus in Sweden reported the possibility of performing similar procedures on humans. Abdominal organs were examined using reflected light from a candle; the optical system became extremely hot, posing a very high risk of burns. Later, the candle was replaced by an incandescent lamp, which, however, did not reduce the incidence of burns. In 1963, a crucial event in the development of laparoscopy occurred: the German surgeon Kurt Semm, one of the founders of modern laparoscopy, used a cold light source—a halogen lamp, the light from which was transmitted through a light guide. This allowed operations to be performed for as long as necessary without the risk of burns to internal organs. Furthermore, in 1967, to improve visualization of internal organs and facilitate surgery, Zemm developed pneumoperitoneum, which involves filling the abdominal cavity with CO2 gas (3-4 liters). This creates an "air cushion," pushing the organs apart, creating space for instrument manipulation. This increases surgical safety. All this led to the widespread use of laparoscopy, initially solely as a diagnostic procedure—when any pathology was detected, open surgery was immediately performed. The first, and for a long time, the only, surgical intervention performed laparoscopically was sterilization, or the severing of the fallopian tubes. For a long time, laparoscopy was not accepted by most surgeons. For example, Zemm, who performed the first appendectomy in 1980, was immediately condemned by the abdominal surgical community. The advantages of laparoscopy over open surgery became apparent fairly quickly after the introduction of this new type of surgery. One of the most important is the absence of an abdominal incision, which is painful and takes a long time to heal after surgery, requiring a 10-15 day hospital stay. The patient can begin to stand upright within 2-3 hours after laparoscopy. Typically, by the evening or morning of the following day, she is able to return to normal physical activity, and within 2-3 days, she can return to work. Skin puncture marks heal fairly quickly and can be detected after several months only if you know where they were. Furthermore, laparoscopy, which displays images from the abdominal cavity on a monitor, allows for the examination of even the smallest pathologies that are not visible during traditional surgery. This is possible because the monitor can magnify the image of organs up to 10 times, allowing not only to visualize foci of pathology but also to remove them in the most delicate and gentle manner, without affecting healthy tissue. Laparoscopy stages: Laparoscopy is performed according to a clearly defined and strictly adhered to protocol. Despite its external differences from classic abdominal surgery, laparoscopy is the same surgery, performed according to all classical surgical principles and in accordance with all surgical requirements and standards. After the patient is sedated and the anesthesiologist gives the go-ahead, the first stage begins: establishing pneumoperitoneum. This involves injecting carbon dioxide (CO2) into the abdominal cavity through a thin, specialized needle (the Veress needle). Carbon dioxide was specifically chosen because it is completely safe. The gas is injected until the pressure in the abdominal cavity reaches 14-15 mmHg. This pressure is determined by the same sensitive device that delivers the gas, called an endoflator. This device operates throughout the surgery and continuously injects gas to maintain a constant pressure. This gas is necessary because it compresses the internal organs, protecting them from injury, and lifts the anterior abdominal wall, creating space for the procedure. After this stage, a trocar is inserted for an optical instrument—a telescope called a laparoscope. The laparoscope is inserted through a puncture below the navel. The abdominal cavity, including the liver and diaphragm, is examined sequentially. After this, the best place to insert the trocars for the manipulators is determined. The punctures for the manipulators are made along the pubic hairline, one to the right of the midline, the other to the left. After inserting the working manipulators, the female internal organs are examined strictly according to a proven pattern—clockwise: starting from the anterior uterine space—right appendages—retrouterine space—left appendages. All types of pathologies are noted. After this, the removal of any identified pathology begins. Approximate range of surgeries performed laparoscopically: Fallopian tubes. Sterilization was the very first surgery performed laparoscopically. During this procedure, the fallopian tubes are cut or cauterized with bipolar current, and then resected. This form of contraception is considered the most reliable, but unfortunately, irreversible, so it is only performed on patients over 35 who have had at least two children. Ectopic pregnancy – 98% of pregnancies are tubal. This means the fertilized egg is located within the lumen of the fallopian tube. Ectopic pregnancies are considered conditions that pose a risk of intra-abdominal bleeding, so surgery is mandatory, and urgently. Two main techniques are used for tubal pregnancy surgery: the first involves incising the tube longitudinally, removing the fertilized egg from the lumen, and leaving the tube in place. The second technique involves removing the tube immediately, regardless of the time of detection of the tubal pregnancy, assuming the tube is already affected and the next pregnancy will again be ectopic. Adhesions around the fallopian tubes (peritubal adhesions) are coagulated with electric forceps (bipolar coagulator) and then dissected with scissors. Such adhesions occur after previous surgery (90-95% of cases after abdominal surgery, very rarely after laparoscopy) and after sexually transmitted infections, primarily chlamydia. Adhesions are the most common factor in infertility and are called the tuboperitoneal factor of infertility. Obstruction of the fallopian tubes is a significant factor in infertility. This is confirmed during surgery by passing a bright blue solution through the tubes. If the section of the fallopian tube distal to the uterus, located near the ovary, is obstructed, procedures are performed to restore tubal patency, which quite often results in pregnancy (according to some data, up to 30% of cases with mild adhesions). Hydrosalpinx is a fluid accumulation in the fallopian tube, the external opening of which is sealed off. The tube becomes a fluid-filled sac, which is an ideal environment for bacterial growth. The affected tube is dysfunctional and dangerous for the patient, as it can become inflamed and twisted, causing severe pain, preventing pregnancy, and also impairing the quality of the endometrium. Therefore, such fallopian tubes are subject to laparoscopic removal. The ovaries are also a classic target for laparoscopic intervention. Ovarian cysts are divided into functional (follicular or corpus luteum), which resolve spontaneously within a few months, and organic cysts, which require removal because they can grow, possibly causing torsion of the ovary enlarged by the cyst, rupture, disruption of the cyst's blood supply, or cyst degeneration. Laparoscopy aims to enucleate the cyst from its capsule, preserving as much ovarian tissue as possible. Ovarian torsion is possible because the ovary has a long "pedicle," or ligaments that attach it to the pelvic wall. When torsion occurs, the blood supply to the ovary is severely reduced, disrupting its nutrition and causing acute abdomen syndrome—severe pain that requires emergency hospitalization and surgery. Apoplexy, or bleeding from the ovary, typically occurs mid-cycle, around ovulation. Acute lower abdominal pain is common, requiring hospitalization and surgery—the ovary is sutured or the bleeding site is coagulated. Polycystic ovary syndrome (PCOS), described by Stein and Leventhal back in the 1930s, is one of the most common causes of infertility. Classic symptoms include absent or irregular periods from the onset, excess weight, and excessive hair growth. It is one of the most common causes of infertility. In this syndrome, the ovaries are large, round, with a thick capsule and numerous small follicles. Laparoscopy is a recognized method of treating infertility in patients with PCOS who have failed conservative treatment. There are many laparoscopic treatment techniques. Classic methods include wedge resection, in which a watermelon-shaped section is excised from the ovary along its long axis. More gentle techniques have recently been used, such as punctate coagulation of the ovarian surface (monopolar coagulation of the capsule), which leaves dots on the ovarian surface that reduce the capsule's density. After such procedures, most patients ovulate within a few months. During this period, known as the "lucid interval," intensive infertility treatment is administered. If infertility treatment is unsuccessful during this period, IVF is recommended. Uterus. Uterine fibroids are benign, hormone-dependent tumors of the uterus, consisting of smooth muscle cells and altered cells of the myometrium—the main lining of the uterus. They occur in 25–40% of women, according to various studies. In a significant number of women, fibroids are asymptomatic and are discovered incidentally during routine checkups. They can cause infertility, especially if they are large—more than 3–4 cm. At this size, fibroids can distort the uterine cavity, worsen the condition of the endometrium, and, if located in certain locations, can block the entrance to the fallopian tube. Besides infertility, indications for uterine fibroid removal include: rapid fibroid growth, large tumor size, and disruption of adjacent organs, such as urinary problems, constipation, and bleeding caused by the fibroid. Previously, before the advent of laparoscopy, the entire uterus was often removed to treat fibroids. Laparoscopy offers a much better opportunity to perform a conservative myomectomy, which involves removing fibroids from the uterine wall, thereby preserving the uterus. This is crucial because, in addition to supporting pregnancy, the uterus also supports the pelvic floor. Uterine malformations, such as a bicornuate uterus, are common. This type of uterus often makes it impossible to carry a pregnancy to term. Classic surgeries developed to restore the shape of the uterus are successfully used in laparoscopy. Endometriosis is a common condition in women of childbearing age. In this condition, cells similar to those found in the endometrium, the lining of the uterus, are found outside the uterus, for example, on the pelvic peritoneum, fallopian tubes, and ovaries. These cells proliferate, forming microcysts, and eventually causing adhesions of the pelvic organs. Growing on the ovaries, these cells often lead to the development of endometrioid cysts. Furthermore, endometriosis is a very common cause of infertility, even in so-called minor forms. It is now generally accepted that endometriosis develops when endometrial cells enter the abdominal cavity through patent fallopian tubes during menstruation. A unique feature of this disease is that it cannot be reliably diagnosed by conventional methods. Indirect signs of endometriosis include spotting before and after menstruation, pain during a gynecological examination, and intermittent pain during intercourse. Accordingly, the WHO recognizes laparoscopy as the only reliable method for diagnosing endometriosis. During surgery, endometrioid ovarian cysts are destroyed. A two-stage treatment regimen for endometriosis is considered the most effective: after surgery, the patient receives Diphereline, Zoladex, or Decapeptyl for several months. If the patient undergoes IVF after such surgery, she may be prescribed a super-long protocol, which involves ovulation stimulation after several months of taking these medications. Infertility. According to the WHO classification, the cause of infertility cannot be fully determined until diagnostic or therapeutic laparoscopy is performed. Laparoscopy is indicated for patients with tubal obstruction detected by hysterosalpingography (X-ray examination). It is also indicated for patients who, despite confirmed tubal patency, a regular menstrual cycle, normal hormonal levels, and a normal husband's sperm count, fail to conceive. This also applies to patients with uterine tumors, adnexal cysts, or suspected pelvic adhesions. Furthermore, if a patient with hydrosalpinx undergoes IVF, removal of the affected tube is strongly recommended, as during stimulation, the hydrosalpinx often empties into the uterine cavity, damaging the endometrium, preventing implantation, and negatively affecting the embryos. Pelvic floor prolapse, or prolapse, usually begins during menopause due to decreased tissue tone. Gradually, internal organs begin to protrude, causing the pelvic floor to sag, disrupting bowel and urinary function and uterine blood flow. However, sometimes, for example, after the birth of a large fetus or after multiple births, it can also occur at a younger age. There are specialized laparoscopic surgeries to strengthen the pelvic floor. These involve suturing ligaments together and attaching special strengthening artificial bands. Urogynecology is a branch of gynecology that studies the female urinary system, its dysfunctions, and methods for correcting these disorders. The characteristics of the female urinary system (a short and almost straight urethra, branching from the bladder at a specific angle, the canal's location near the uterus, which rapidly enlarges during pregnancy) often lead to stress urinary incontinence in women. This means that even the slightest increase in abdominal pressure—lifting a heavy bag or child, laughing, coughing, sneezing, etc.—leads to the involuntary leakage of a small amount of urine. This is a severe ordeal, leading to constant stress, social isolation, and often to abstinence from sexual activity due to fear of leaking urine during intercourse. Given the particular relevance of this problem, surgeons have developed a vast number of surgical treatments for stress urinary incontinence. The vast majority of these are not commonly used, but some have proven highly effective and are therefore widely used. An example of the latter is the laparoscopic Burch procedure. The urethra is tightened with a special band within the pubic bones of the pelvis, creating the angle between the bladder and urethra necessary for urine continence and providing the necessary support for a prolapsed urethra. Complications. Despite its effectiveness and delicate nature, laparoscopy is a major surgical procedure that can be associated with complications. Complications can be divided into those related to anesthesia, infections, and surgical complications. Surgical complications include: - subcutaneous emphysema – occurs when gas enters the subcutaneous fat and resolves within 1-2 days. - vascular or intestinal injuries during trocar insertion or during surgery – requiring suturing of the injured organ.