Applications of laser surgery in gynecology. Hype or high tech?

Despite the proliferation of the use of lasers in gynecology, physicians in both private practice and the academic setting remain skeptical about the role of these instruments. The laser has not made it possible to perform surgical procedures that have previously been impossible to carry out in the operating theater. Further, as yet, higher pregnancy rates have not been achieved with any reconstructive procedure using the laser rather than conventional or electrocautery surgery. On the other hand, surgeons such as Daniell reported on the impact of laser in decreasing the need for laparotomy in their practices. For instance, prior to the introduction of the laser, Daniell performed laparotomy on 80% of his patients with endometriosis, pelvic adhesive disease, or tubal disease, whereas currently he performs 80% of these procedures through the laparoscope. However, one could argue that this change simply represents the trend of performing more gynecologic procedures through endoscopes whether a laser is involved or not. Convincing evidence exists that pelviscopy results in savings in terms of morbidity and the cost of surgery. Whether endoscopic surgery can be performed more safely using the laser than with a traditional technique has not been addressed in a formal study. Whether laser surgery produces better pregnancy rates is unresolved. Ninety per cent of all clinical trials involving the laser have been uncontrolled. Those studies that have been controlled, reported by Tulandi, for example, have shown results at least equivalent to those achieved with diathermy, and it is of interest that the pregnancies tended to occur sooner in the laser-treated groups. The laser is at least as effective as electrocautery in the treatment of adhesions and distal tubal disease. Therefore, it is the author's recommendation that all types of lasers be used in conjunction with electrocautery and conventional sharp dissection in the treatment of various forms of pelvic pathology. It is important that surgeons become familiar with all types of lasers, as future devices may be vastly different and prove to be clearly superior in treating the various pelvic pathologies.