June 1999 Volume 5, Issue 1 Editor: James E. Carter, M.D., Ph.D., F.A.C.O.G Inside this Issue Letter from the President The Editor's Corner ISGE 8th Annual Congress Chair Report ISGE 8th Annual Congress Coordinator's Report ISGE 8th Annual Congress Highlights and Summary Report Laparoscopic Management of Genital Prolapse Evolution in Laparoscopy Letters to the Editor Preliminary Announcement: ISGE 10th Annual Congress 2001 Report from Thai Society for (TSGE) to the ISGE ISGE Secretariat Spaarne Hospital P.O. Box 1644 2003 BR Haarlem The Netherlands

THE ISGE NEWS EVOLUTION IN LAPAROSCOPY By: Marco A. Pelosi, III, M.D. As the millennium approaches, progress in both laparoscopic techniques and technology has resulted in myriad options for the treatment of pelvic conditions. None will dispute the obvious qualities of this modality - the rapid recoveries, the excellent field of vision, and the superb cosmesis celebrated by the mass media. The evolution of laparoscopy, like the evolution of species, is the product of dominant influences exerted over a period of time. The aggressive advancement of operative laparoscopy was the product of stalwart, talented individuals who defied the status quo in the face of formidable criticism. Rule breakers by necessity, many of these pioneers were driven by the challenge to create endoscopic counterparts to traditional procedures and developed the skills to do so over years of incremental progression from simple maneuvers. Although exceptions exist, feasibility, not efficiency, was the primary goal of the first wave of advanced gynecologic laparoscopy. The second generation of laparoscopic innovation comes with the realization that laparoscopy is not an end unto itself. A truly flexible armamentarium for the advanced surgeon draws upon efficiency-based minimally-invasive combinations incorporating laparoscopy, minilaparotomy and vaginal surgery as dictated by specific circumstances. For instance, the prototypical laparoscopic myomectomy was rendered inefficient by the perceived need to reconstruct the uterus exclusively by endoscopy. The more refined, minimally-invasive myomectomy utilizes the laparoscope to enucleate myomas, then utilizes a tiny, minilaparotomy to efficiently repair the uterus by the best method available without compromising a mild recovery. The same strategy has become a common approach to bowel surgery and recent methods of nephrectomy and splenectomy. Extending the reach (no pun intended) of minimally-invasive surgery to conditions considered beyond the realm of laparoscopy is the concept of hand-assisted laparoscopy. The strategy is as follows: where the only alternative is a large laparotomy extending to the upper abdomen (e.g. the harvest of a donor kidney), a small (and much less morbid) transverse suprapubic incision no wider than the surgeon's hand is made, the hand is introduced through an air-tight glove system, and the laparoscope is simultaneously used to guide and assist in the required tasks. Current applications in gynecology are few, but include the disimpaction of otherwise immobile pelvic tumors, cholecystectomy at cesarean section, and finally, a less invasive means of upper abdominal palpation for the surgical evaluation of malignancy. The laparoscopic challenge has been met for nearly all-gynecologic operations. For some situations, the benefits of the laparoscope are obvious, but for others, an advantage is questionable. The same is true for minilaparotomy and vaginal surgery. As the worldwide experience with minimally invasive surgery matures, efficiency and cost effectiveness will shape the further development and assimilation of this technology.