The future of laparoscopy
Laparoscopy has come to be the gold standard for many gynaecological techniques such as management of ectopic pregnancy and adnexal surgery. For many newer techniques such as robot-assisted laparoscopy, the comparator is often this minimally invasive approach and throughout the world, women, their doctors, and healthcare institutions have an increasing body of evidence to demonstrate the utility and efficacy of this approach over laparotomy.
It remains to be seen if single incision laparoscopy can produce superior outcomes to current multiport laparoscopy with comparative trials reporting no significant difference in postoperative pain, length of stay, and cosmetic results (106-108). Robotic-assisted laparoscopy is a technological platform with advantages including better proprioception, improved precision with articulating instrumentation, and reduction of the surgeon's hand tremor (109). Disadvantages include increased cost, the lack of tactile feedback to the surgeon, the presence of bulky robotic arms, and the inability to move the surgical table once the robot arms are attached (109). Robotic surgery has been shown to have longer operating times (110-113) and overall higher costs (113-115). There is limited evidence on the relative benefits of robotic surgery at this stage (113). Robotic surgery is designed to assist operation for more challenging cases while keeping the minimally invasive approach, rather than replacing conventional laparoscopy (116). Further high- quality studies are required before the widespread integration of robotic-assisted laparoscopic surgery into the existing gynaecological services (113).
Table 47.4 Studies comparing methods to minimize residual pneumoperitoneum
| First author and year | Study type | No. of patients | Methods | Principal outcomes | Comments |
| Abbott 2001 (95) | RCT | 158 | Intraperitoneal drain and dummy drain | Postoperative nausea, vomiting, site of pain, analgesic and antiemetic use, analgesic, costs | Significantly more shoulder pain at 4 and 8 hours and more total analgesia requirement in the placebo group. No significant difference in overall pain scores, postoperative nausea and vomiting. The use of simple oral analgesia is more cost effective than the insertion of intraperitoneal drain |
| Swift 2002 (103) | RCT | 67 | Non-suction drain vs occluded drain | Postoperative pain, energy level | Significant reduction of shoulder tip pain at 12-72 hours post operation in patent drain group |
| Shen 2003 (96) | RCT | 164 | Suction drain vs no drain | Postoperative pain, total analgesic requirement, cost | Significant reduction of total analgesia and shoulder tip pain at 24 and 48 hours in suction drain group. Simple oral analgesia is more cost effective than suction drain |
| Raymond 2010 (104) | RCT | 168 | Suction vs nonsuction drain | Postoperative pain, nausea, vomiting, total analgesic requirement | No significant difference in all outcomes, but suction drain is significantly more painful on removal |
| Kerimoglu 2015 (105) | Prospective | 111 | Non-suction drain vs no drain | Postoperative pain, postoperative complication | No significant difference |