Spotlight on… minimally invasive surgery

Minimal access surgery has become the mainstay of treatment in gynaecological surgery. It is correlated with shorter hospital inpatient admissions, quicker recovery time, and reductions in blood loss, post-operative pain and infection as well as reduced scarring.1 Enhanced recovery maximises its benefits, and in 2021, Bryant-Smith et al.'s article provided a framework on how to implement it.2 Over the past decade, there has been a significant shift in the United Kingdom to treat most gynaecological pathology through minimal access interventions.3 The Obstetrician & Gynaecologist (TOG) has featured several articles covering these developments. Following the Hippocratic principle of ‘First do no harm’, TOG has published articles that focus on how to safely use laparoscopic equipment and prevent complications associated with laparoscopic surgery. Brierley et al.4 remind us of the high morbidity and mortality attributed to major vessel injury during laparoscopic entry and teach us the importance of prevention, focusing on patient risk factors and proficiency in different entry techniques. They also urge all units to have standardised management protocols and rehearsed drills, similar to obstetric emergencies, to manage vascular injuries effectively. El-Sayed et al.5 in their comprehensive article explain the importance of understanding the physics behind electrosurgery and the thermal spread of different equipment to prevent inadvertent injuries to important structures. They also highlight that in the United States, there is a validated programme that needs to be completed during training called FUSE (Fundamental Use of Surgical Energy) and raise the issue that no similar programme exists in the United Kingdom. Bryant-Smith et al.6 also emphasise how laparoscopic simulation training can flatten the learning curve of minimal access surgery and how this should be delivered within a structured national curriculum. Richardson et al.7 remind us of the importance of reproductive surgery to optimise fertility and the evidence behind it as an adjunct to assisted reproductive treatment. They explore different types of pelvic pathology and help clinicians counsel patients regarding when a surgical intervention is clearly indicated or not and the nuances behind conflicting evidence. Morris et al.8 focus more deeply on the effect on endometriosis on fertility and describe validated scoring systems like the endometriosis fertility index as a predictor of reproductive outcomes post-surgery, aiding in pre-surgery and post-surgery counselling about spontaneous conception chances. They also discuss how fertility preservation needs to be part of the conversation with patients before treating ovarian endometriomas. Grammatis et al.9 in their article promote a personalised approach of managing ovarian endometriosis focusing on different population groups and analyse the evidence on pain and fertility outcomes with each technique. Their review highlights how certain techniques that are not used commonly in the United Kingdom, such as alcohol sclerotherapy or drainage and ablation with Plasma Jet, can be beneficial, particularly for patients with fertility aspirations. TOG always tries to provide a platform for clinicians to demonstrate surgical techniques that can be educational to gynaecologists worldwide. Fleisher et al.10 provide a systematic, stepwise approach on how to use the SOSURE technique to manage effectively even severe types of endometriosis in a safe manner. Morton et al.11 describe how to perform operative laparoscopy on a surgically complex group of patients in advanced pregnancy. Their illuminating article outlines that laparoscopic surgery is not only safe if specific steps are followed but beneficial for these patients. Interventional radiology can offer many solutions to manage various gynaecological conditions. Davies et al.12 describe not only established techniques, such as uterine artery embolisation for the management of fibroids but also less commonly used techniques, such as magnetic resonance-guided focused ultrasound for uterine fibroids and fallopian tube recanalisation as an option for treating infertile women with proximal tubal obstruction. We would also welcome articles on the use of Sonata treatment for fibroids, which has started being used in the United Kingdom. vNOTES (vaginal Natural Orifice Transluminal Endoscopic Surgery) has attracted considerable attention as a technique that is associated with reduced morbidity and minimal scarring and Yoong et al.,13 in their commentary, describe how it can become an established technique for gynaecological surgery. Finally, while the last TOG article on robotic surgery was in 2016,14 there have been efforts to increasingly incorporate the use of robotic surgery in gynaecology in the United Kingdom. The recent RCOG Scientific Impact Paper on Robotic Surgery in Gynaecology15 clearly describes how robotic-assisted laparoscopy has addressed numerous limitations associated with conventional laparoscopy by offering enhanced dexterity, improved ergonomics and a reduced learning curve. These advancements, along with educational initiatives such as introducing the SITM in robotic-assisted gynaecological surgery, facilitate the broader adoption of this minimally invasive surgical technique in gynaecology.