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Topic:Laparoscopy

Laparoscopy in horses is a minimally invasive surgical technique that involves the use of a laparoscope to examine the abdominal cavity. This technique allows veterinarians to diagnose and treat various conditions with reduced recovery times compared to traditional open surgery. Laparoscopy is commonly used for procedures such as cryptorchidectomy, ovariectomy, and the investigation of colic. The approach involves making small incisions through which the laparoscope and surgical instruments are inserted, enabling visual assessment and manipulation of internal structures. This page compiles peer-reviewed research studies and scholarly articles that explore the applications, methodologies, and outcomes of laparoscopic procedures in equine veterinary medicine.
Development of a new laparoscopic Foramen Epiploicum Mesh Closure (FEMC) technique in 6 horses.
Equine veterinary journal    April 27, 2015   Volume 48, Issue 3 331-337 doi: 10.1111/evj.12427
van Bergen T, Wiemer P, Bosseler L, Ugahary F, Martens A.Epiploic foramen entrapment (EFE) is, based on the number of reports in the literature, a relatively important life-threatening cause of colic in horses that could be prevented by closing the epiploic foramen (EF) in horses at risk of developing EFE. Objective: To describe the laparoscopic foramen epiploicum mesh closure (FEMC) technique and its outcome. Methods: Descriptive experimental study. Methods: The EF of 6 horses was closed with the FEMC technique. A diabolo-shaped constructed mesh was introduced into the omental vestibule through the EF under laparoscopic visualisation in the standin...
Peritoneal reactivity evaluation in horses subjected to experimental small colon enterotomy and treated with subcutaneous heparin.
Veterinary medicine international    November 11, 2014   Volume 2014 385392 doi: 10.1155/2014/385392
Alonso Jde M, Rodrigues KA, Yamada AL, Watanabe MJ, Alves AL, Rodrigues CA, Hussni CA.Heparin is routinely administered in postoperative abdominal surgery aiming to prevent adhesions formation; however, there is no consensus indicating its effectiveness. This study evaluated the effect of heparin on peritoneal reactivity after abdominal surgery, through the association between peritoneal fluid features and ultrasonographic and laparoscopic examination. Ten adult horses were used: control group (CG) and treated group (TG). Both groups underwent laparotomy and small colon enterotomy. TG received subcutaneous heparin at 150 IU/kg every 12 hours for 5 days. The animals underwent ...
A topographic anatomical study of the equine epiploic foramen and comparison with laparoscopic visualisation.
Equine veterinary journal    June 25, 2014   Volume 47, Issue 3 313-318 doi: 10.1111/evj.12282
van Bergen T, Doom M, van den Broeck W, Wiemer P, Clegg PD, Cornillie P, Martens A.There are no previous studies correlating the anatomy of the equine epiploic foramen and its defining structures with laparoscopic images. Objective: The purpose of this study was to describe the precise anatomy of the epiploic foramen and omental vestibule, to quantify the dimensions of the epiploic foramen and to relate these findings to laparoscopic images. Methods: Descriptive study of cadaver material and laparoscopic images. Methods: Thirty-two horses subjected to euthanasia for reasons unrelated to colic were studied. Two cadavers were used to make vascular casts of the coeliac artery a...
Standing male equine urogenital surgery.
The Veterinary clinics of North America. Equine practice    January 31, 2014   Volume 30, Issue 1 169-190 doi: 10.1016/j.cveq.2013.11.005
Adams A, Hendrickson DA.The advantages of performing standing male urogenital surgeries are numerous when compared with performing the same surgery in the anesthetized animal. Some traditional standing male urogenital surgeries, such as castrations, may be faster and cheaper to perform. Laparoscopic standing male urogenital surgeries may allow for improved visualization of the surgical field, decreased hemorrhage, and decreased morbidity and convalescence. Limitations of standing procedures may include increased danger to the surgeon because of fractious behavior of the patient, and increased expense and training ass...
Incisional hernia repair in horses: a cadaveric study of endoscopic component separation.
Veterinary surgery : VS    December 4, 2013   Volume 43, Issue 1 1-5 doi: 10.1111/j.1532-950X.2013.12079.x
Caron JP.To report a technique for endoscopic component separation in horses and quantify the amount of body wall advancement obtained. Methods: Descriptive study. Methods: Fresh cadaveric horses (n = 14). Methods: After a preliminary anatomic study, 7 horses had unilateral endoscopic component separation involving transection of the external abdominal oblique fascia lateral to the rectus abdominis muscle. A laparoscope, placed using a balloon dissector, was used to create an intermuscular working space between the external abdominal oblique fascia and internal abdominal oblique muscle. A single instru...
Laparoscopic removal of a bladder urolith in a standing horse.
Journal of the American Veterinary Medical Association    October 19, 2013   Volume 243, Issue 9 1323-1328 doi: 10.2460/javma.243.9.1323
Lund CM, Ragle CA, Lutter JD.An 11-year-old Arabian gelding was evaluated for hematuria, stranguria, and pollakiuria that had been observed for 1 week. Results: Transrectal palpation revealed a 5-cm firm round mass in the urinary bladder. Cystoscopy and transrectal ultrasonography confirmed the diagnosis of urinary bladder urolithiasis. Results: A multiportal transparalumbar fossa laparoscopic approach was selected for cystotomy and urolith removal. Cystotomy and urolith removal was performed with sedation and local anesthesia with the horse standing. No perioperative complications were observed. Urination returned to nor...
Haptoglobin baseline value in jennies and the effect of ovariectomy on its serum concentration.
Animal reproduction science    April 4, 2012   Volume 132, Issue 1-2 83-87 doi: 10.1016/j.anireprosci.2012.03.018
Aziz DM, Hiss-Pesch S, Mielenz B, Sauerwein H.The study was conducted to determine the baseline concentration of serum haptoglobin (Hp) in jennies during the breeding and nonbreeding season and to evaluate the effects of ovariectomy on serum Hp concentrations in jennies. Eighteen adult jennies were divided in three groups: nine jennies (OVA) were ovariectomized using laparoscopic surgery, six jennies (LAP) were exploratory examined by laparoscopic surgery, and three jennies were used as a control group. Blood samples were collected from the animals at Day -6, -2, -1, 0, 1, 2, 5, 8, 15, 22, 29 and 36 of surgery. Serum samples were analyzed...
Surgical drainage and post operative lavage of large abdominal abscesses in six mature horses.
Equine veterinary journal. Supplement    August 4, 2011   Issue 39 123-127 doi: 10.1111/j.2042-3306.2011.00405.x
Mair TS, Sherlock CE.Six mature horses with large abdominal abscesses (defined as an abscess >15-20 cm in at least one dimension) were treated by surgical drainage and post operative lavage. The abscess was associated with previous intestinal surgery in one horse, and with Streptococcus equi spp. equi infection in the other 5. A Foley catheter was used to drain and lavage the abscess in all cases. The abscess was accessed by a ventral midline laparotomy in 5 cases and by standing flank laparoscopy in one. Two horses were subjected to euthanasia within 7 days due to persistent or recurrent colic. The other 4 hor...
Standing hand-assisted laparoscopic ovariectomy in 65 mares.
Veterinary surgery : VS    December 23, 2010   Volume 40, Issue 1 90-92 doi: 10.1111/j.1532-950X.2010.00771.x
Goodin JT, Rodgerson DH, Gomez JH.To review the efficacy and safety of unilateral ovariectomy by use of a standing hand-assisted laparoscopic approach and evaluate the effect of ovary size on posttransection hemorrhage after application of a linear stapling device. Methods: Case series. Methods: Horses (n=65) aged 2-20 years. Methods: Medical records of mares that had ovariectomy performed by use of a standing hand-assisted laparoscopic approach were reviewed. Data retrieved were signalment, ovary removed (left, right), ovarian size, ovarian pathology, intraoperative and postoperative complications, and length of hospitalizati...
Elevating the uterus (uteropexy) of five mares by laparoscopically imbricating the mesometrium.
Equine veterinary journal    November 3, 2010   Volume 42, Issue 8 675-679 doi: 10.1111/j.2042-3306.2010.00069.x
Brink P, Schumacher J, Schumacher J.There is a need for study of a method for restoring a ventrally positioned uterus to a horizontal position involving fertility of mares with delayed uterine clearance. Objective: A ventrally-angled uterus can be elevated to a horizontal position using a laparoscopic technique. Objective: To develop a laparoscopic technique of imbricating the mesometria to elevate the uterus to a horizontal position. Methods: The right and left mesometria of 5 pluriparous mares, all barren for 1-8 years (mean 3.8 years), with a pendulous, ventrally-angled uterus were shortened laparoscopically, by imbrication, ...
[Diagnostic workup of chronic inflammatory bowel disease in the horse].
Schweizer Archiv fur Tierheilkunde    September 4, 2010   Volume 152, Issue 9 418-424 doi: 10.1024/0036-7281/a000093
Trachsel DS, Grest P, Nitzl D, Wunderlin-Stähli P, Wehrli Eser M.The present retrospective study describes the diagnostic workup and collected findings in 7 horses with chronic inflammatory bowel disease over the years 2000-2006. The diagnosis could be confirmed histologically with biopsies taken during laparoscopy or laparotomy or during post mortem examination. Weight loss and chronic diarrhoea were the most commonly reported clinical findings. Among ancillary examinations (fecal analysis, gastroscopy, abdominal ultrasonography, rectal mucosal biopsy) the D-xylose absorption test provided the most useful information. Although clinical signs and laboratory...
Hand-assisted laparoscopic removal of a nephroblastoma in a horse.
The Canadian veterinary journal = La revue veterinaire canadienne    September 3, 2010   Volume 51, Issue 6 637-639 
Romero A, Rodgerson DH, Fontaine GL.A 3-year-old Thoroughbred was presented for evaluation of hematuria post exercise. On physical examination, an enlarged kidney was identified, as well as serum biochemical abnormalities such as an elevated creatine kinase (CK) and hypoalbuminemia. The kidney was removed laparoscopically and a nephroblastoma was identified. Un Thoroughbred âgé de 3 ans est présenté pour évaluation de l’hématurie après l’effort. À l’examen physique, un rein enflé est identifié ainsi que des anomalies biochimiques sériques comme une créatine kinase (CK) élevée et l’hypoalbuminémie. Le rein...
Evaluation of a transvaginal laparoscopic natural orifice transluminal endoscopic surgery approach to the abdomen of mares.
Veterinary surgery : VS    August 12, 2010   Volume 39, Issue 7 873-878 doi: 10.1111/j.1532-950X.2010.00722.x
Alford C, Hanson R.To report natural orifice transluminal endoscopic surgery (NOTES) using laparoscopic and endoscopic instrumentation transvaginally into the mare's abdomen and identify structures visible using this approach. Methods: Descriptive experimental study. Methods: Mares (n=8). Methods: A standing, transvaginal approach was made in the cranial vaginal vault at either the 1 (right; 4 mares) or 11 (left; 4 mares) o'clock position relative to the cervix. The abdomen was visually explored and the viscera evaluated using a 2 m flexible endoscope followed by a 62 cm laparoscope. Incisional healing was monit...
Comparison of intraoperative behavioral and hormonal responses to noxious stimuli between mares sedated with caudal epidural detomidine hydrochloride or a continuous intravenous infusion of detomidine hydrochloride for standing laparoscopic ovariectomy.
Veterinary surgery : VS    April 29, 2010   Volume 39, Issue 6 754-760 doi: 10.1111/j.1532-950X.2010.00702.x
Virgin J, Hendrickson D, Wallis T, Rao S.To compare the presence or absence of pain, pain-related behavioral responses, and hormonal responses to noxious stimuli during standing laparoscopic ovariectomy in mares sedated with continuous intravenous (IV) detomidine infusion and caudal epidural detomidine. Methods: A double blind prospective study. Methods: Mares (n=12) Methods: Mares were divided into 2 treatment groups; 6 were sedated using continuous IV detomidine infusion and 6 were sedated with caudal epidural detomidine. All mares received IV xylazine (0.33 mg/kg) and butorphanol tartrate (5 mg) premedication before detomidine adm...
Evaluation of a motorized morcellator for laparoscopic removal of granulosa-theca cell tumors in standing mares.
Veterinary surgery : VS    March 25, 2010   Volume 39, Issue 5 649-653 doi: 10.1111/j.1532-950X.2010.00688.x
Kummer M, Theiss F, Jackson M, Fürst A.To describe a motorized morcellator technique for laparoscopic removal of granulosa-theca cell tumors (GCT) in standing mares and to evaluate long-term outcome. Methods: Case series. Methods: Mares (n=7) aged 4-15 years, with unilateral GCT. Methods: Tumor size was determined by transrectal palpation and ultrasonography. Standing sedated mares had 3 laparoscopic portal sites in the paralumbar fossa. After laparoscopic observation of the GCT, the mesovarium was desensitized, the ovarian pedicle transected with a LigaSure device, and the ovary grasped with forceps and cut in cylindrical tissue b...
Behavioural and cardiorespiratory effects of a constant rate infusion of medetomidine and morphine for sedation during standing laparoscopy in horses.
Equine veterinary journal    May 8, 2009   Volume 41, Issue 2 153-159 doi: 10.2746/042516408x342984
Solano AM, Valverde A, Desrochers A, Nykamp S, Boure LP.Standing surgical procedures are performed commonly in horses under sedation. This approach minimises the morbidity/mortality risks associated with general anaesthesia. The use of a medetomidine and morphine combination has not been investigated in horses despite the usefulness of each drug individually. Objective: To determine the efficacy of a medetomidine and morphine combination to produce standing sedation with minimal cardiorespiratory changes and adequate analgesia for exploratory laparascopy in mature horses. Objective: The combination of medetomidine and morphine will induce reliable ...
Cardiopulmonary effects of diazepam-ketamine-isoflurane or xylazine-ketamine-isoflurane during abdominal surgery in foals.
American journal of veterinary research    May 2, 2009   Volume 70, Issue 5 574-580 doi: 10.2460/ajvr.70.5.574
Kerr CL, Bouré LP, Pearce SG, McDonell WN.To evaluate cardiopulmonary effects of anesthetic induction with diazepam and ketamine or xylazine and ketamine, with subsequent maintenance of anesthesia with isoflurane, in foals undergoing abdominal surgery. Methods: 17 pony foals. Methods: Foals underwent laparotomy at 7 to 15 days of age and laparoscopy 7 to 10 days later. Foals were randomly assigned to receive diazepam, ketamine, and isoflurane (D/K/Iso; n = 8) or xylazine, ketamine, and isoflurane (X/K/Iso; 9) for both procedures. Results: During anesthesia for laparotomy, cardiac index, and mean arterial blood pressure ranged from 110...
Electrosurgery as the sole means of haemostasis during the laparoscopic removal of pathologically enlarged ovaries in mares: a report of 55 cases.
Equine veterinary journal    May 25, 2007   Volume 39, Issue 3 210-214 doi: 10.2746/042516407x17116522
Lloyd D, Walmsley JP, Greet TR, Payne RJ, Newton JR, Phillips TJ.There is little published clinical evidence on the use of a laparoscopic approach for the removal of pathologically enlarged ovaries in standing mares. Objective: To show the orders of success and complication rates that can be expected if pathologically enlarged ovaries are removed from standing, sedated mares under laparoscopic guidance using only electrosurgical means of haemostasis. Methods: A retrospective analysis was made of 55 mares in which the removal of an enlarged ovary was attempted by applying a standard laparoscopic procedure for routine ovariectomy in standing mares including a...
Comparison of intraoperative pain responses following intratesticular or mesorchial injection of lidocaine in standing horses undergoing laparoscopic cryptorchidectomy.
Journal of the American Veterinary Medical Association    December 6, 2006   Volume 229, Issue 11 1779-1783 doi: 10.2460/javma.229.11.1779
Joyce J, Hendrickson DA.To compare pain responses in stallions undergoing standing laparoscopic cryptorchidectomy following intratesticular or mesorchial infiltration of lidocaine. Methods: Clinical trial. Methods: 20 stallions with 1 or 2 undescended testes. Methods: Standing horses were administered a nonsteroidal anti-inflammatory drug and a caudal epidural injection of detomidine hydrochloride and underwent laparoscopic cryptorchidectomy. The undescended testis (1/horse) was grasped to determine the preoperative pain response (present vs absent) and assess severity of pain (by use of a visual analog scale [VAS])....
Laparoscopic cryptorchidectomy and ovariectomy in horses.
The Veterinary clinics of North America. Equine practice    November 30, 2006   Volume 22, Issue 3 777-798 doi: 10.1016/j.cveq.2006.08.006
Hendrickson D.Laparoscopic surgery has become commonplace in the field of equine urogenital surgery. As with most surgical procedures, the limiting factors in developing new surgical techniques are limited to the patient size and demeanor, the skills of the surgeon, and the available equipment. Some of the greatest benefits of laparoscopic surgery in the horse include better visualization of the important structures; tension-free amputation of the testes or ovaries,which generally leads to less postoperative pain; and the ability to evaluate the transected stump carefully to make sure there is no hemorrhage...
Indications, surgical technique, and long-term experience with laparoscopic closure of the nephrosplenic space in standing horses.
Veterinary surgery : VS    December 14, 2005   Volume 34, Issue 6 637-641 doi: 10.1111/j.1532-950X.2005.00098.x
Röcken M, Schubert C, Mosel G, Litzke LF.To describe surgical technique and outcome after laparoscopic closure of the nephrosplenic space for treatment of recurrent left dorsal displacement of the left colon (LDDLC) in standing horses. Methods: Retrospective study. Methods: Forty-four horses with LDDLC. Methods: Laparoscopic portals were located in the left flank region. After administration of etilefrin intravenously to contract the spleen, the dorsal splenic margin was sutured to the nephrosplenic ligament to obliterate the nephrosplenic space. Horses were re-examined (< or = 3 years) for history of recurrence. In addition, medical...
Epidural migration of new methylene blue in 0.9% sodium chloride solution or 2% mepivacaine solution following injection into the first intercoccygeal space in foal cadavers and anesthetized foals undergoing laparoscopy.
American journal of veterinary research    September 22, 2005   Volume 66, Issue 8 1324-1329 doi: 10.2460/ajvr.2005.66.1324
Lansdowne JL, Kerr CL, Bouré LP, Pearce SG.To determine the relationship between epidural cranial migration and injectate volume of an isotonic solution containing dye in laterally recumbent foal cadavers and evaluate the cranial migration and dermatome analgesia of an epidural dye solution during conditions of laparoscopy in foals. Methods: 19 foal cadavers and 8 pony foals. Methods: Foal cadavers received an epidural injection of dye solution (0.05, 0.1, 0.15, or 0.2 mL/kg) containing 1.2 mg of new methylene blue (NMB)/mL of saline (0.9% NaCl) solution. Length of the dye column and number of intervertebral spaces cranial and caudal t...
Intraoperative pain responses following intraovarian versus mesovarian injection of lidocaine in mares undergoing laparoscopic ovariectomy.
Journal of the American Veterinary Medical Association    August 25, 2005   Volume 227, Issue 4 593-596 doi: 10.2460/javma.2005.227.593
Farstvedt EG, Hendrickson DA.To compare intraoperative pain responses following intraovarian versus mesovarian injection of lidocaine in mares undergoing laparoscopic ovariectomy. Methods: Randomized controlled trial. Methods: 15 mares between 4 and 20 years old. Methods: Standard bilateral laparoscopic ovariectomy was performed. Prior to manipulation of the ovary, 2% lidocaine (10 mL) was injected into the ovary and saline (0.9% NaCI) solution (10 mL) was injected into the mesovarium on 1 side, with saline solution (10 mL) injected into the ovary and 2% lidocaine (10 mL) injected into the mesovarium on the other side. Pr...
Recent advances in equine abdominal surgery.
Veterinary journal (London, England : 1997)    July 5, 2005   Volume 170, Issue 1 41-51 doi: 10.1016/j.tvjl.2004.03.019
Smith CL, Dowling BA, Dart AJ.Laparoscopy is a minimally invasive procedure that has applications as a diagnostic, therapeutic and prognostic technique. Specialized equipment is necessary to perform equine laparoscopy, and there is a large range of instruments, both disposable and non-disposable available. Laparoscopic procedures described include ovariectomy, cryptorchidectomy, adhesiolysis and herniorrhaphy. Laparoscopy can be performed in a standing or dorsally recumbent position, depending on surgeon preference, patient status and the procedure to be performed. Stapling equipment is frequently used in gastrointestinal ...
Use of high-power ultrasonic shears for laparoscopic ovariectomy in mares.
Journal of the American Veterinary Medical Association    December 1, 2004   Volume 225, Issue 10 1578-1548 doi: 10.2460/javma.2004.225.1578
Alldredge JG, Hendrickson DA.A method for performing laparoscopic ovariectomy with high-power ultrasonic shears in mares is described, along with results in 10 mares. Briefly, after epidural administration of detomidine and local anesthesia with mepivacaine, 3 cannulas were placed in each paralumbar fossa. A laparoscope was placed through the most dorsal cannula, and a grasping forceps was placed through the most ventral cannula and used to grasp and manipulate the ovary. The ultrasonic shears was then placed through the middle cannula. The jaws of the ultrasonic shears were closed across a portion of the ovarian pedicle,...
Use of a hand-assisted laparoscopic technique for removal of a uterine leiomyoma in a standing mare.
Journal of the American Veterinary Medical Association    October 16, 2004   Volume 225, Issue 6 911-880 doi: 10.2460/javma.2004.225.911
Janicek JC, Rodgerson DH, Boone BL.A 20-year-old Thoroughbred mare was evaluated because of a 2-year history of infertility. The mare had normal estrous cycles and had been bred 7 times by different stallions. Ultrasonographic examination revealed a homogeneous hyperechoic intramural mass in the tip of the right uterine horn; the mass was also detected via hysteroscopy Unilateral ovariectomy and partial hysterectomy were performed by use of a hand-assisted laparoscopic technique. Leiomyoma was diagnosed via histologic examination of the mass. Unilateral ovariectomy and partial hysterectomy are recommended in mares with leiomyom...
[Subperitoneal cyst in a Friesian mare].
Tijdschrift voor diergeneeskunde    September 4, 2004   Volume 129, Issue 14-15 468-470 
Scheffer CJ, Drijfhout PN, Boerma S.The case of a 5-year-old Friesian mare with a mass in her abdomen and a gait irregularity of the left hind limb is discussed. At rectal ultrasonogrphic examination the mass appeared to be a thin-walled, anechogenic cavity in the left abdomen. By means of laparoscopy the mass could be visualized as a smooth structure, covered by peritoneum and fat. Under laparoscopic guidance the mass was punctured and fluid was aspirated. Cytological and bacteriological findings of the fluid were indicative of a cyst. After drainage of the cyst the locomotion disorder of the left hind limb disappeared. It is c...
Comparison of two laparoscopic treatments for experimentally induced abdominal adhesions in pony foals.
American journal of veterinary research    May 15, 2004   Volume 65, Issue 5 681-686 doi: 10.2460/ajvr.2004.65.681
Lansdowne JL, Bouré LP, Pearce SG, Kerr CL, Caswell JL.To compare laparoscopic dissection with-laparoscopic dissection combined with abdominal instillation of ferric hyaluronate gel for the treatment of experimentally induced adhesions in pony foals. Methods: 12 healthy pony foals. Methods: A serosal abrasion method was used to create adhesions at 4 sites on the jejunum (day 0). At day 7 laparoscopy was performed and the adhesions observed in each foal were recorded. In group-1 foals (n = 6), the adhesions were separated laparoscopically (treatment 1). In group-2 foals (n = 6), 300 mL of 0.5% ferric hyaluronate gel was infused into the abdomen aft...
Gastrointestinal endoscopic surgery.
The Veterinary clinics of North America. Equine practice    February 27, 2004   Volume 16, Issue 2 329-341 doi: 10.1016/s0749-0739(17)30108-6
Trostle S.A working knowledge of normal endoscopic anatomy and the effects of positioning must be mastered to take advantage of endoscopic procedures involving the gastrointestinal system. Endoscopic procedures involving the gastrointestinal system offer advantages over conventional surgery in that they are less invasive and provide direct visualization. Laparoscopy can be used to evaluate horses with abdominal pain before and after surgery. It can be used to evaluate and biopsy abdominal masses and parenchymal organs such as the spleen, liver, and kidney. Endoscopic gastrointestinal surgical procedures...
Dorsally recumbent female equine urogenital endoscopic surgery.
The Veterinary clinics of North America. Equine practice    February 27, 2004   Volume 16, Issue 2 317-vi doi: 10.1016/s0749-0739(17)30107-4
Ragle CA.The ventral abdominal approach for laparoscopy is versatile. Reported techniques using a ventral approach in the mare include bilateral ovariectomy and granulosa cell tumor removal. Laparoscopic ovariectomy is performed by way of four instrument portals in the caudoventral aspect of the insufflated abdomen. The procedure has several advantages over the traditional approaches of colpotomy and celiotomy, including tension-free closure of all incisions and minimal invasiveness.