For most of the history of surgery, it has been necessary to make incisions in the patient's body large enough to insert the surgeon's hands. Beginning in the early part of this century with Gynecologists and mainly Urologists, the practice of operating through endoscopes, mainly cystoscopes, but also laparoscopes, was originated. The difficulties of limited visibility because of deficiencies in the lenses and light sources, lack of good instruments and the problem of letting the assistants see what the surgeon sees, limited the spread of laparoscopic surgery. In the late 1970's and early 1980's the availability of the video camera opened a new door for the specialty. Now the assistants could follow and help in the procedure and the surgeon could work without having to keep his head bent to the eyepiece of the scope. New instruments specialized to the operations proliferated and procedures were adapted to endoscopy like never before. Now, almost any gynecological operation can be done through a laparoscope with enormous reductions in the pain and period of disability experienced by the patient.

In laparoscopic, minimally invasive surgery, the patient is anesthetized and positioned as usual but instead of making a large incision to expose the operative site, a small, one-centimeter incision is made near the umbilicus. Through this opening, a sheath and scope containing a light, carried by optical fibers, and lens system is inserted. The camera projects the picture on one or two television monitors. Carbon dioxide is pumped into the abdomen under automated pressure control to provide space to operate. Secondary sheaths are inserted in the sides of the abdomen or in the midline, depending on the procedure planned. These may be from five to twelve millimeters in diameter. As the surgeon and his assistant watch on the video monitors, the procedure is done through the small sheaths. Many different ingenious instruments have been designed to work through these ports. The variety of graspers, forceps, scissors, tubes, needle holders and knot tie-ers is almost limitless and more appear daily. There are mechanical, motorized devices that can morcellate tissue so that it can be removed piecemeal. In this way a uterus as large as a four-month pregnancy can come out through a one centimeter opening. There are devices for tying knots, suturing,  removing tissues and organs, and stapling and sealing blood vessels.

Operations that formerly required weeklong stays in the hospital and six weeks out of work, not to mention much more severe discomfort, are now done as outpatient or short stay procedures. Comfort levels are much higher and disability is drastically .

Gynecologic procedures that are commonly done through the laparoscope are, drainage and removal of ovarian cysts, removal of ovaries and fibroid tumors, diagnosis and treatment of adhesions, endometriosis and other causes of pelvic pain and infertility. Hysterectomy, both total and supracervical can be done, as well. Pelvic floor repairs and bladder operations for incontinence are new and exciting field for the gynecologist.

Currently, we tend to avoid operations when very severe adhesions are anticipated because of the possibility of perforating the bowel. Extremely large fibroid tumors and ovarian tumors may be best approached by an open route. Most cancers, lymph node dissection and removal of tumors that would be dangerous if the contents spilled into the abdomen may be best approached by conventional surgery, for now,  though this is changing rapidly. In general, the surgeon needs to be aware of his own experience and limitations in approaching an operation that may prove to be too ambitious. However, daily, procedures that were thought to be too cumbersome or complicated to do laparoscopically pass into the category of simply routine. In 1989, Harry Reich in Pennsylvania did the first laparoscopic hysterectomy. It took four hours. Now, the procedure is commonplace and requires an hour or less. It is now quite rare to hear of an open gallbladder operation or open removal of an ovary or endometriosis. The benefits to patients are great. Instead of the pain of a six or eight-inch incision into the abdomen through muscle and fascia, there is a small perforation the size of a finger. Postoperatively there are no cut or torn muscles to heal or cause pain with deep breathing. The actual operative injury is relatively small and confined to the pelvis where the discomfort is less. Because it is not necessary to handle the intestines in the course of laparoscopic surgery, there is less postoperative nausea. People are out of bed in six to twelve hours and eating normally. Hospitalization is typically 6 to 36 hours, depending on the procedure and the patient. Recovery from hysterectomy can be as little as two weeks for a person who has a less physically active occupation. Costs are less because of the decrease in hospitalization and disability. There are surgical advantages beyond the improvement in patient satisfaction and well-being. With the laparoscope, it is possible to view pelvic structures from a very short distance. In open surgery it would be impossible for the surgeon to inspect the depths of the pelvis from a distance of one inch in looking for small amounts of endometriosis. But, this is exactly what one does with the laparoscope. In this manner it is possible to inspect at very close range the depths of the pelvis and areas under other structures that would normally be inaccessible. Organs and tissues are viewed in more normal circumstances than is possible at open surgery.

There is a revolution in progress in surgery today. The traditional methods and skills are rapidly becoming obsolete and cumbersome. Daily, the principles of minimally invasive surgery are applied to more and more procedures. Virtually all gynecological operations can be done laparoscopically, now subject only to the special circumstances of the individual's condition and anatomy and the skill and experience of the surgeon.

When I finished my residency in Obstetrics and Gynecology in 1983, laparoscopic and hysteroscopic surgery was in its' infancy. We did laparoscopic tubal ligations but if there were any adhesions or if the person was obese or has had previous surgery, an open approach was preferred. For the next few years, I was a solo practitioner in a small town and somewhat insulated from day to day contact with other practices. My only conversations about problems in surgery were with specialists in infertility and oncology so I was exposed to their ideas about how surgery should be done. Gradually I began to use the laparoscope more aggressively to attack adhesions and more complex problems. I began to use the urologist's cystoscope as a makeshift hysteroscope to inspect the inside of the uterus. After I came to Burlington, I became acquainted with academic specialists nearby, notably Dr. John Steege, now at Chapel Hill, and Dr. A.F. Haney, in the Division of Reproductive Endocrinology and Infertility at Duke, who is now Chairman of Ob-Gyn at the University of Chicagol. Referring patients to them and then accompanying them to the OR as an assistant showed me the expanding world of minimally invasive surgery and stimulated me to improve my own skills. I have tried to use every opportunity to improve and broaden my horizons through continuing education courses. I have done preceptorships with Dr. C.Y. Liu in Chattanooga and Dr. Jim Dorsey in Baltimore and remain in awe of their dexterity and surgical judgment. Currently,  I perform most of my surgical procedures in a manner consistent with the minimally invasive principles. I do laparoscopic removal of masses and ovarian cysts. I do vaginal hysterectomy, supracervical hysterectomy, Burch bladder suspension and, in selected circumstances, paravaginal repair laparoscopically. I do myomectomy both laparoscopically and hysteroscopically. I do endometrial resection and enterocele repairs endoscopically. I attempt to keep my hospitalization rates at a minimum, compatible with patient well-being and I try to allow people to return to work, fit and well, as soon as possible to minimize the interruption of their lives. I strongly feel that this type of surgery benefits people by minimizing the injury to the body and allowing speedier healing. This has obvious physical and psychological benefits. By minimizing hospitalization and disability, I can decrease financial expenditures for the patient and her employers and her time out from family.