Enhancing Safety in Gynecologic Surgery: Innovative Access and Lymphadenectomy Techniques to Reduce Complications

Abstract

This review explores current strategies aimed at reducing complications in gynecologic surgery, focusing on innovations in laparoscopic entry techniques, extraperitoneal lymphadenectomy, and alternative approaches such as gasless laparoscopy. We conducted a comprehensive literature review, including studies and technical descriptions relevant to improved surgical access, lymph node dissection, and overall risk mitigation. Key findings indicate that the individualized selection of entry points—ranging from Palmer’s point in the left upper quadrant to the recently described Jain point—can minimize vascular and bowel injuries, especially in patients with prior abdominal surgeries. Furthermore, extraperitoneal lymphadenectomy appears to lower adhesion formation and bowel handling, potentially decreasing postoperative morbidity in oncologic cases. Gasless laparoscopy may offer comparable surgical outcomes with improved cardiorespiratory stability in high-risk patients, although visualization challenges remain. Overall, the evidence suggests that advanced minimally invasive methods and tailored procedural planning can effectively enhance patient safety and reduce postoperative complications. These approaches, however, demand a high level of surgical expertise, thorough preoperative imaging, and an institutional framework that supports training and ongoing quality monitoring. Continued investigations, including prospective trials and larger sample sizes, are required to validate these findings and further refine protocols aimed at optimizing outcomes in gynecologic surgery.

1. Introduction

Minimally invasive surgery has transformed the field of gynecologic surgery by offering improved perioperative and postoperative outcomes, such as faster recovery, less postoperative pain, and reduced hospital stays. Despite these notable advantages, the risk of complications has not been entirely eliminated, as injuries can occur during initial access to the abdominal cavity, throughout the laparoscopic procedure, or even postoperatively. Ensuring patient safety remains a central goal, prompting a steady evolution of approaches for trocar insertion, pneumoperitoneum establishment, and lymph node dissection in gynecologic malignancies and benign pathology.

Traditional open approaches for hysterectomy, oophorectomy, and other gynecologic procedures have well-documented morbidity, including infection, extensive blood loss, and prolonged healing times. While laparoscopic surgery mitigates many of these issues, it introduces specific challenges related to access and instrumentation. Vascular and bowel injuries are among the most feared adverse events during trocar insertion, and inadvertent injuries during laparoscopic dissections can lead to severe complications or require emergent laparotomy. The recent literature advocates for the critical importance of correct entry technique, thorough preoperative assessments, and consideration of alternative or specialized trocar sites—such as Palmer’s point in the left upper quadrant or the more recently described Jain point located in the left paraumbilical region at the level of umbilicus, in a straight line drawn vertically upward from a point 2.5 cm medial to anterior superior iliacal spine—to reduce the risk of catastrophic injuries [1,2].

In addition, attention has turned to optimizing outcomes through specialized approaches such as gasless laparoscopy for patients with cardiovascular risks or compromised pulmonary function. Gasless systems eliminate the adverse physiological consequences of a CO₂ pneumoperitoneum but may reduce visualization, creating a need for advanced skill sets and specialized instrumentation [3,4]. Another focus of contemporary gynecologic surgery is the extraperitoneal approach for lymph node dissection, particularly relevant in the management of malignancies such as endometrial, cervical, and ovarian cancers. Extraperitoneal lymphadenectomy may diminish manipulation of the bowel and reduce adhesion formation, thereby potentially lowering postoperative complications [5].

Parallel to these technique-driven innovations is an expanding literature that underscores the importance of diligent preoperative evaluation, including imaging studies to identify possible adhesions or aberrant anatomy, and meticulous patient selection for specific entry methods. The concept of the “individualized technique” resonates throughout the literature: no single method universally applies to all gynecologic surgical cases, and factors such as obesity, previous abdominal surgeries, and the presence of multiple comorbidities dictate the safest approach [6,7].

In this expanded narrative review, we synthesize current evidence and highlight strategies for minimizing complications in gynecologic surgery. Specifically, we discuss the evolution of laparoscopic access techniques, extraperitoneal lymph node dissection, and gasless laparoscopy. We also examine the role of training, simulation, and standardized protocols in enhancing outcomes. Although the focal point is laparoscopic surgery, many principles discussed here can be extrapolated to robotic-assisted procedures, which share similar port-access issues, instrument complexities, and learning curve considerations. The objective is to offer a comprehensive perspective that can inform clinical practice and guide ongoing research efforts in the quest to optimize safety and efficacy in gynecologic surgery.

2. Materials and Methods

This article was constructed as a review to elucidate the current strategies aimed at preventing complications in gynecologic surgery. The following procedural steps were taken to ensure a comprehensive examination of the topic.

First, a guiding question was proposed: “What are the most efficacious strategies for minimizing complications in gynecologic surgery, particularly regarding laparoscopic access methods, lymph node dissection approaches, and perioperative care?”

To address this question, a broad literature search was conducted out in January 2025 in PubMed, Scopus, ScienceDirect, and Google Scholar. Search terms included “gynecologic surgery complications”, “laparoscopic access in gynecology”, “extraperitoneal lymphadenectomy”, “gasless laparoscopy” “Palmer’s point” “Jain point” and “surgical complications in gynecology”. Only English and Spanish language articles were selected. References from relevant papers were then hand-searched (snowball approach) to locate additional citations that might provide further insights. This method allowed the inclusion of both seminal older studies, which established foundational approaches, and cutting-edge research that evaluates novel techniques and technologies.

Articles were included if they discussed techniques and approaches to reduce complications during gynecologic surgery. This encompassed (a) technical papers and case series describing innovative trocar insertion sites, (b) retrospective or prospective studies examining outcomes of extraperitoneal lymphadenectomy, (c) research on gasless laparoscopy and associated outcomes, and (d) reviews that offered systematic or narrative syntheses of existing evidence. Publications unrelated to gynecologic procedures or those focusing exclusively on other surgical disciplines were excluded unless their findings had clear relevance to gynecology.

Selected articles were then subjected to content analysis, wherein data on patient populations, surgical techniques, documented complications, and recommended preventive measures were extracted. Summaries of these findings were organized into thematic sections: (1) Surgical Access and Instrumentation, (2) Extraperitoneal Lymph Node Dissection and Minimally Invasive Surgery, (3) Gasless Laparoscopy and Intraoperative Monitoring, and (4) Overall Preventive Strategies. The study outcomes are presented narratively. A table summarizing key recommendations is also provided, offering a practical, at-a-glance resource for clinicians.

3. Results

A total of 31 references were thoroughly analyzed for this review, spanning original research articles, review papers, clinical guidelines, and descriptive technical reports. The studies encompassed various gynecologic procedures, such as laparoscopic hysterectomy, adnexal surgery, myomectomy, endometriosis resection, staging procedures for gynecologic cancers, and extraperitoneal or transperitoneal lymphadenectomies.

The findings can be systematically grouped into three core areas that consistently emerged across the reviewed literature (

Table 1. Summary of principal articles reviewed.

Authors/Year	Study Design	Population/Intervention	Main Outcomes/Key Findings	Reference
Jain et al. (2016)	Technical Description/Descriptive Analysis	Proposed the “Jain Point” (2.5 cm below and lateral to the ASIS) as an alternative site for Veress needle entry in gynecologic laparoscopic surgery.	Demonstrated reduced risk of vascular or bowel injury compared to traditional umbilical entry, especially in cases with possible periumbilical adhesions.	[1]
Palmer (1974)	Technical Description/Safety Commentary	Advocated the left upper quadrant (Palmer’s point) for primary trocar insertion to circumvent umbilical adhesions.	Highlighted safety advantages in patients with suspected midline scars or previous surgeries; lower likelihood of intra-abdominal organ injury.	[2]
Wang et al. 2011	Single-centre randomized clinical trial	Assessed the utility of gasless laparoscopy in myomectomy compared to conventional CO2 pneumoperitoneum.	Gasless laparoscopic myomectomy showed reduced blood loss, shorter surgery time, and lower drainage volume than conventional laparoscopy, with no adverse effect on recovery.	[3]
Iacoponi et al. (2015)	Prospective Study	Examined the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer	Demonstrated the feasibility of single-port laparoscopic extraperitoneal para-aortic lymphadenectomy	[5]
Vilos et al. (2007)	Narrative Review of Techniques	Reviewed and analyzed various laparoscopic entry methods (Veress needle, open Hasson, direct trocar, optical trocar) in gynecologic surgeries.	Concluded that selecting the appropriate entry technique based on patient history and anatomy can significantly reduce entry-related complications.	[7]
Ramírez et al. (2014)	Prospective Study	Sixty patients with stage IB2–IVA cervical cancer and no para-aortic lymphadenopathy on CT or MRI underwent preoperative PET/CT, followed by laparoscopic extraperitoneal lymphadenectomy from the common iliac vessels to the left renal vein.	Laparoscopic extraperitoneal para-aortic lymphadenectomy is both safe and feasible, and surgical staging of patients with locally advanced cervical cancer should be considered before planning radiation and chemotherapy.	[8]
Hurd et al. (1994)	Anatomical Study	Investigated the location of abdominal wall vessels in female patients to inform safer trocar insertion.	Identified precise vasculature patterns, guiding safer insertion at alternative sites to avoid epigastric vessels and potential bleeding complications.	[9]
Erdem et al. (2024)	Comparative Prospective Study	Compared the efficacy and safety of Veress needle insertion and direct trocar insertion in laparoscopic gynecological surgeries	Direct trocar insertion has been shown to reduce insertion time, lower perioperative complication rates, minimize decreases in hemoglobin, and shorten hospital stays.	[10]
Mosehle et al. (2021)	Retrospective Case Series	Evaluated the feasibility of Laparoscopic Minimally Invasive Inguinal Lymph Node Dissection (L-MILND) in vulvar carcinoma patients ineligible for sentinel lymph node biopsy	L-MILND reduces wound complications compared to open surgery, but is associated with longer operative times and seroma formation, and while it appears feasible and safe, larger prospective studies with extended follow-up are needed.	[11]
Jiang et al. (2021)	Prospective randomized clinical trial	Compared CO2 pneumoperitoneum vs. gasless laparoscopy for laparoscopic cholecystectomy	Showed reduced cardiopulmonary alterations in the gasless group and shortening extubation time compared to conventional CO2-assisted procedures	[12]
Ramírez et al. (2022)	Randomized clinical trial	Women with stage IA1 (with lymphovascular invasion), IA2, or IB1 cervical cancer (squamous-cell, adenocarcinoma, or adenosquamous carcinoma) were randomized to undergo minimally invasive radical hysterectomy (laparoscopic or robot-assisted) versus open radical hysterectomy.	Minimally invasive radical hysterectomy resulted in lower disease-free and overall survival rates than open abdominal radical hysterectomy among women with early-stage cervical cancer.	[13]

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3.1. Surgical Access and Instrumentation

A frequently underscored point in the reviewed studies is that the most hazardous phase of laparoscopic surgery is establishing the initial access to the peritoneal cavity. For years, the Veress needle placed at the umbilicus has been the prevailing method, but numerous case series and observational reports suggest that complications—ranging from minor periumbilical bleeding to severe vascular or bowel injuries—tend to arise disproportionately during this early stage [9,14].

As a result, investigators have described different insertion sites believed to reduce these complications. Palmer’s point, located in the left upper quadrant, is commonly selected for patients who may harbor adhesions at the umbilical site, which is often due to prior abdominal surgeries. Multiple reports support that this approach circumvents scarring around the umbilicus, thus lowering the likelihood of injuring underlying organs or vessels [15,16].

The Jain point, in the left para umbilical region approximately 2.5 cm medial to the anterior superior iliac spine, has also been proposed to further enhance safety. Early descriptions of the Jain point highlight its potential to avoid the epigastric vessels, omentum, and small bowel, though familiarity with the patient’s body habitus remains crucial [2]. In addition, some surgeons prefer direct trocar insertion, which omits the use of the Veress needle altogether, or they use an open (Hasson) technique to visualize the fascia and peritoneum directly [17].

Optical trocars, which incorporate a miniature endoscope within the trocar tip, have gained traction in recent years. They facilitate real-time observation of the tissue layers, reducing the risk of accidental injuries [10]. Their usage is particularly advantageous in obese patients, where the distance to the peritoneum can be greater and the angle of insertion trickier to ascertain. However, these devices demand a certain level of proficiency; novice surgeons might struggle with image interpretation and the precise direction of the trocar during insertion.

3.2. Extraperitoneal Lymphadenectomy and Minimally Invasive Surgery

Patients undergoing gynecologic oncologic procedures, notably those with endometrial or cervical cancer, often require lymph node evaluation. Extraperitoneal lymphadenectomy techniques have been described as potentially advantageous for reducing postoperative adhesion formation and avoiding extensive bowel manipulation [5]. This approach can be particularly beneficial in the staging of endometrial or cervical cancer. Minimally invasive surgery, whether conventional laparoscopy or robot-assisted, has been integrated into the extraperitoneal approach to reduce incision-related morbidities, such as wound infection or ventral hernia [11].

Some authors posit that extraperitoneal dissection may reduce the postoperative incidence of ileus and bowel adhesions, as the bowel is largely undisturbed [18]. Ramírez et al. have pioneered extraperitoneal approaches in laparoscopic lymph node dissections, suggesting favorable outcomes in terms of hospital stay and complication rates [8]. Nonetheless, extraperitoneal access can pose a steep learning curve due to unfamiliar tissue planes, and mastering the technique demands thorough anatomical knowledge.

While minimally invasive lymph node dissection appears to offer lower complication rates than open procedures, particularly with respect to surgical site infection and prolonged wound healing, questions remain about its generalizability across all patient cohorts. For instance, patients with large uteri or advanced-stage malignancies might pose technical challenges, even if laparoscopic techniques have consistently proven safe in experienced hands [19]. Moreover, the choice to proceed with an extraperitoneal or a transperitoneal approach may hinge on institutional expertise, equipment availability, and the surgeon’s familiarity with each technique.

3.3. Gasless Laparoscopy and Intraoperative Monitoring

CO₂ pneumoperitoneum, a fundamental aspect of laparoscopic surgery, exerts various physiological effects, including reduced venous return and mild hypercapnia. Although modern anesthesia practices can accommodate these changes, certain patients—especially those with cardiopulmonary compromise—might benefit from gasless laparoscopy. By using mechanical retraction systems to lift the abdominal wall, surgeons create a working space that does not rely on a pressurized CO₂ environment [3,20].

Several authors have reported that gasless laparoscopy can avoid complications associated with CO₂ absorption, such as subcutaneous emphysema and hypercapnia [12]. Yet, others highlight that the approach may not offer the same visual clarity as standard pneumoperitoneum, and specialized retractors need to be applied. Additionally, stable exposure can be challenging once the retractor is in place, especially in obese individuals with thick anterior abdominal walls. In resource-limited settings, gasless systems can be an advantage because less reliance on constant CO₂ insufflation and high-end laparoscopic towers is needed [21].

Regardless of the chosen technique—whether standard pneumoperitoneum or gasless—safety protocols such as continuous capnography, the strict monitoring of insufflation pressure, and prompt intervention in case of rising end-tidal CO₂ remain paramount. Laparoscopic ultrasound, 3D imaging, and advanced optical technologies can further enhance identification of vascular structures, thereby minimizing the risk of intraoperative vascular injury [22,23].

4. Discussion

The prevention of complications in gynecologic surgery emerges from a confluence of refined surgical techniques, diligent preoperative planning, and adept intraoperative decision making. Decades of cumulative experience have demonstrated that while minimally invasive surgery can dramatically reduce postoperative morbidity—such as wound infections, severe pain, and lengthy hospitalizations—it introduces its own unique set of risks that must be carefully mitigated.

Central among these risks is the potential for serious injury during abdominal entry. The literature overwhelmingly points to initial trocar placement as the single most critical stage in laparoscopy-related complications [9,14,24]. Vascular injuries, though rare, can lead to life-threatening hemorrhage if not recognized and managed promptly. Bowel perforations, on the other hand, can be insidious and become evident only postoperatively, potentially culminating in abscess formation, peritonitis, or sepsis. These considerations highlight the significance of a robust preoperative assessment.

4.1. Preoperative Assessment and Imaging

Patients should undergo comprehensive imaging as clinically indicated—such as transvaginal or transabdominal ultrasounds, CT scans, or MRIs—to identify prior surgical adhesions, pelvic masses, or anatomical variants that may hinder safe access [25]. In cases of suspected advanced endometriosis, for example, preoperative MRI can pinpoint the extent of disease infiltration into the pelvic sidewalls or posterior cul-de-sac, thus informing which access site and technique might be safest [26]. Patients with multiple previous laparotomies or known incisional hernias might particularly benefit from open (Hasson) entry or alternative insertion points like Palmer’s or Jain points, where fewer adhesions are typically encountered [1,2].

4.2. Considerations for Patient Selection

Not all patients are ideal candidates for every laparoscopic technique. In general, surgeons need to weigh the potential advantages of a less invasive procedure against the patient’s comorbidities. For instance, if a patient has a compromised respiratory status, the prolonged Trendelenburg positioning and elevated CO₂ used during laparoscopy could exacerbate hypercapnia or reduce pulmonary compliance. Gasless laparoscopy has thus been suggested as an alternative albeit with considerations regarding suboptimal visualization [3,21]. Similarly, extremely obese patients may pose challenges in establishing pneumoperitoneum, rendering direct optical trocar insertion or an open approach more prudent [10,17].

4.3. Standardization vs. Individualization of Access

Although standard guidelines often advise starting at the umbilicus with a Veress needle, the wide variation in patient anatomy and prior surgical histories underscores the need for a flexible approach. Surgeons equipped with knowledge and skill in alternative port sites can individualize access for each patient. Reports indicate that the success of specialized insertion points like Palmer’s or Jain points relies on meticulous attention to surface landmarks and an understanding of likely underlying adhesions [2,15]. In training programs, it is becoming increasingly common to teach multiple laparoscopic entry techniques. Simulation-based training can shorten the learning curve, as trainees can practice on virtual reality systems, perfused cadavers, or animal models, thereby refining their ability to recognize fascial layers and anticipate vascular anomalies. Mastery of the open (Hasson) technique provides an additional safety net in complex cases, such as reoperations with dense adhesions or advanced-stage malignancies requiring thorough exploration [27].

Nevertheless, to enhance clinical applicability and safety, more detailed subgroup analyses are needed, stratifying patients according to risk factors such as prior abdominal surgeries, obesity, or significant comorbidities. This would allow for more precise recommendations regarding the selection of entry techniques and the tailoring of operative strategies, thereby improving outcomes for diverse patient populations.

4.4. Lymph Node Dissection Strategies and Oncologic Outcomes

The precise role of minimally invasive approaches in oncologic surgery has sometimes sparked controversy, particularly in cervical cancer. However, consistent evidence in endometrial and early-stage cervical cancer supports that laparoscopic or robotic lymphadenectomy, whether transperitoneal or extraperitoneal, is safe and effective when performed by experienced surgeons [13,28]. The extraperitoneal approach can be especially appealing in staging procedures that demand extensive lymph node dissection, since it limits bowel mobilization and may reduce postoperative adhesion risk.

Nevertheless, extraperitoneal dissection is not universally employed. Its use tends to be concentrated in high-volume centers or specialized institutions with advanced laparoscopic skill sets. While certain authors advocate for routine extraperitoneal lymphadenectomy, others adopt a more selective approach, reserving it for patients with a high likelihood of nodal metastasis who could benefit most from the minimized manipulation of the bowel [5,18]. At the same time, the overall indication for extensive lymphadenectomy is increasingly scrutinized with a growing emphasis on sentinel lymph node dissection. By focusing on targeted nodal sampling, sentinel lymph node techniques can help preserve oncologic outcomes while potentially reducing complications linked to more extensive dissection. Future multicenter, randomized trials could help clarify the ideal candidate profiles for extraperitoneal vs. transperitoneal lymph node dissection as well as further establish the role of sentinel node approaches.

4.5. Gasless Laparoscopy: Balancing Risks and Benefits

Although standard CO₂ pneumoperitoneum remains the mainstay of laparoscopic visualization, gasless laparoscopy has niche applications in high-risk patients. Multiple studies cite improved hemodynamic stability, lower incidence of shoulder tip pain, and comparable surgical outcomes [3,12,21]. However, in patients with obesity—where higher CO₂ insufflation pressures are often required to maintain adequate visualization—ventilation capacity can be further compromised, increasing cardiopulmonary stress. In such scenarios, gasless laparoscopy can help reduce these stressors while still offering comparable results, particularly when performed by experienced surgeons. Moreover, in parts of the world where advanced anesthetic support or reliable CO₂ supply is not guaranteed, gasless laparoscopy can provide a practical solution [23]. Surgeons who adopt gasless methods must contend with potential technical difficulties, such as maintaining an unobstructed field of vision. Specialized retractors can help, but they may require frequent repositioning.

4.6. Risk Mitigation and Intraoperative Vigilance

Intraoperative imaging, like ultrasound-assisted laparoscopy, can delineate vascular structures, thereby reducing inadvertent vessel injury. Furthermore, certain authors emphasize the value of near-infrared imaging and indocyanine green (ICG) for identifying vascular perfusion in real time, which can be especially valuable during complex dissections or when resecting large endometriotic nodules close to major vessels [29,30]. Surgeons should remain cognizant of subtle signs during insufflation—like unexpected difficulty inflating the abdomen or unusually high pressures—that may indicate a faulty Veress needle placement or incipient extraperitoneal insufflation.

Additionally, it is essential that surgical teams establish clear protocols for recognizing and managing injuries. Should bleeding occur, immediate steps include lowering the insufflation pressure to better visualize the source and possibly converting to an open procedure if laparoscopic control is not achieved rapidly. Expert laparoscopic suturing skills, or the availability of advanced energy devices, may determine whether a vascular injury is resolved laparoscopically or necessitates laparotomy [14].

4.7. Postoperative Care and Surveillance

Although much of the focus in preventing complications centers on intraoperative maneuvers, postoperative vigilance is equally important. Meticulous wound care, particularly for trocars larger than 10 mm, can reduce the risk of port-site hernias. Subfascial closure with appropriate suture material is advised when the fascial defect exceeds 10 mm [31]. Early mobilization, prophylactic anticoagulation, and thorough instruction regarding signs of infection or dehiscence can likewise curtail morbidity.

When extraperitoneal lymphadenectomy has been performed, the recognition of potential complications such as lymphocele formation, neuralgias, or lower extremity lymphedema is crucial. Patients should be counseled on the early detection of swelling or sensation changes. In advanced centers, physiotherapy and compression garments may assist in mitigating lymphedema.

4.8. Ongoing Controversies and Future Perspectives

Despite the promise of these technologies and techniques, controversies persist regarding the universalization of minimally invasive surgery for certain gynecologic cancers. Some studies—like the LACC trial—have highlighted potential oncologic disadvantages for laparoscopic radical hysterectomy in cervical cancer, sparking debate about whether the principles described for endometrial or less advanced disease apply equally to advanced malignancies [32]. These findings highlight the continued necessity for prospective, adequately powered trials that scrutinize not only complication rates but also long-term oncologic outcomes such as disease-free survival.

In parallel, the industry has responded with progressive refinements in trocar design from shielded tips to radially expanding trocars. The advent of single-port and mini-laparoscopy (instruments of 2–3 mm diameter) also signals a shift toward minimizing abdominal wall trauma, although data on whether these systems reduce major complications remain limited. Telepresence and remote telementoring have the potential to disseminate expertise in specialized techniques (like extraperitoneal dissection) to centers lacking dedicated mentorship, offering the promise of leveling disparities in care [33].

The future likely involves a combination of surgical precision—via robotic or advanced laparoscopic platforms—and deeper collaboration among multidisciplinary teams, including anesthesiologists and technology developers. Surgeons should remain vigilant regarding new modalities (e.g., hyperaccurate preoperative imaging, real-time navigation systems) that can help identify vascular structures or abnormal tissue planes. Randomized controlled trials that focus on both short-term surgical outcomes and long-term quality of life would further guide the optimization of these approaches.

Although this review provides an overview of various strategies to minimize complications in gynecologic surgery, it has several limitations. As a narrative review, it did not follow a systematic methodology or meta-analytic approach, potentially introducing selection bias. Additionally, many of the included studies were retrospective or lacked robust control groups, limiting the strength of the conclusions drawn. Finally, the heterogeneity of patient populations, surgical settings, and outcome measures across the literature further complicates direct comparisons and generalizability.

Overall, the literature underscores that complication prevention in gynecologic surgery is not merely the result of technical prowess. Rather, it is an orchestrated effort encompassing suitable patient selection, thoughtful approach planning, robust surgical education, and meticulous operative technique. The success stories and outcomes described across these studies serve as a reminder that even small improvements in technique—such as adopting safer trocar insertion sites or employing laparoscopic ultrasound—can translate to substantial decreases in morbidity and a meaningful boost in patient satisfaction. A table summarizing key recommendations is provided, offering a practical, at-a-glance resource for clinicians (

Table 2. Recommendations from the literature review.

Thoroughly evaluate each patient’s surgical history (e.g., previous laparotomies, obesity, comorbidities) and perform imaging to tailor access (Palmer’s or Jain points, open Hasson, etc.).

Maintain a broad skill set in laparoscopic entry techniques (Veress needle, direct optical trocar, open approach) to address variable patient anatomy and adhesions.

Incorporate extraperitoneal lymphadenectomy in appropriate oncologic cases, especially endometrial or cervical cancer staging, to reduce bowel handling and adhesion formation.

Consider gasless laparoscopy in high-risk cardiopulmonary patients or in settings with limited CO2 supply while ensuring that specialized retractors are available.

Use advanced visualization tools (laparoscopic ultrasound, near-infrared imaging) and continuously monitor insufflation pressures to prevent vascular or visceral injuries.

Close fascial defects ≥ 10 mm to decrease port-site herniation risk and adopt prophylactic measures to minimize infection (antibiotics, careful wound closure).

Develop institutional protocols and standardized practices for recognizing and rapidly managing complications (vascular injury, bowel perforation).

Encourage simulation-based training and mentoring for surgeons to master techniques such as extraperitoneal dissection and advanced laparoscopic suturing.

Conduct formal perioperative counseling with patients about possible complications and signs of infection or hernia, facilitating earlier intervention if issues arise.

Routinely review morbidity and mortality data within surgical teams to identify areas for improvement and update protocols based on new evidence.

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5. Conclusions

Contemporary gynecologic surgery has incorporated a variety of innovative strategies to minimize intraoperative and postoperative complications. These include alternative laparoscopic entry points (e.g., Palmer’s and Jain points), extraperitoneal methods for lymphadenectomy, open (Hasson) and optical trocar entry techniques, and gasless laparoscopy, which are particularly beneficial for high-risk patients and resource-limited environments. When executed thoughtfully, these approaches have been associated with reduced incidences of severe complications, such as vascular injuries and wound infections, underscoring the importance of tailored patient assessment, robust surgical training, and evidence-based practice.

Despite these advancements, further high-quality, multicenter studies are needed to establish clear guidelines regarding the comparative benefits and optimal use of specific access strategies or lymph node assessment approaches. Such investigations should also evaluate the impact of these techniques on patients’ quality of life, healthcare costs, and long-term oncologic outcomes. As surgeons remain adaptable and continue to integrate novel methods into routine practice, the path to safer and more effective gynecologic surgery will become increasingly defined.