Review 241Introduction Extra-abdominal relevant anatomy Anatomical basis: The anterior abdominal wall has four muscles that are penetrated at all entries: rectus abdominis, external obliquus abdominis, internal obliquus abdominis, and transversus abdominis. Although the penetrating areas are variable in laparoscopy, the usual trocar placement uses similar inserting areas. Therefore, it is obligatory for any surgeon to be experienced in the anatomy of the abdominal wall and its consecutive relevant anatomical structures. There are no significant vascular structures that need to be respected upon insertion of the subumbilical trocar. Solely, strict attention has to be given to holding to the median line to avoid any accidental damage to paramedian structures. There are two arteries in the superficial abdominal wall that should be visualized. Damage to these arteries should be avoided because even superficial incisions can lead to severe bleeding that requires the conversion from laparoscopy to laparotomy. Both vessels can be visualized by diaphanoscopy (Figures 1-4). Trocar placement is performed, dependent on the corresponding internal site, at a 90° angle to the abdominal wall once the aiming point has been located. The superficial epigastric artery arises from the femoral artery approximately 1 cm below the inguinal ligament through the fascia cribrosa, turns upward in front of the inguinal ligament, and then ascends while spreading out between the two layers of the superficial fascia of the abdominal wall, nearly as far as the umbilicus. The circumflex iliac superficial artery originates from the femoral artery close to the superficial epigastric artery. After perforating the fascia lata, it runs parallel to the inguinal ligament and laterally to the iliac crist while spreading into smaller branches (1). Places for trocar insertionThe laparoscope and optic trocar should be inserted, whenever possible, in the subumbilical region using a semilunar or straight incision (Figure 1). Only if trocar placement is not possible, e.g., due to severe adhesions or large intra-abdominal tumors, are alternative entry sites negotiated, e.g., above the umbilicus or Palmer's point (Figure 5), as a precursor entry site.The placement for the working trocars depends on the operation. If the operative focus is located in the pelvis and no large tumor is expected to be touching the umbilical region, the two working trocars can be inserted in the lower abdominal wall in a vessel-free area, as confirmed by diaphanoscopy. Any auxiliary trocar can be placed in the midline suprasymphysically or left of the midline. A maximum distance between the optic trocar and the working trocars should be Although the anatomy of the human being has not changed, technical developments in operating materials and methods demand a simultaneous development in operative management. Developments in electronic and optical technologies permit many gynecological operations to be performed laparoscopically. One fundamental distinction between any other operating...

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Uterine leiomyomas are the most frequent benign tumors of the female genital tract. Fibroids are associated with a variety of clinical problems, e.g. bleeding disorders, bulk-related symptoms or infertility. For women wishing to preserve their uterus, fibroids can be surgically removed by hysteroscopy, laparoscopy or laparotomy. The purpose of our review is to show that hysterectomy offers the only definitive solution. The indication for treatment has to be taken carefully after weighing up alternative treatment methods, such as expectant management, medical treatment or interventional radiologic methods, and after obtaining informed consent. The optimal method of treatment takes into account the patient's interests and wishes and the practical feasibility in the clinical setup. Surgical skills and experience play an important role as surgical procedures on the uterus are not without risk and can lead to severe complications. The decision to operate anticipates an improvement of the initial situation; therefore, the ideal surgical approach is of utmost importance.

Cytokines are key modulators of the immune system and play an important role in the ovarian cycle. IL-18 levels in serum and follicular fluid were analyzed in women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment. The cohort study group consisted of 90 women, who were undergoing IVF or ICSI. The body mass index (BMI) was determined in all patients; IL-18 levels were measured in follicular fluid and serum. IL-18 levels in serum were significantly higher than those in follicular fluid. The median level in serum was 162.75 (80.21) pg/mL and that in follicular fluid, 138.24 (91.78) pg/mL. Women undergoing IVF treatment had lower IL-18 levels in serum (median, 151.19 (90.73) pg/mL) than those treated with ICSI (median, 163.57 (89.97) pg/mL). The correlation between IL-18 levels in serum and BMI was statistically significant, as well as the correlation between IL-18 levels in follicular fluid and ovarian stimulation response (p = 0.003). IL-18 was correlated with the response to ovarian stimulation and was the reason for successful pregnancy after IVF or ICSI treatment. Among other cytokines, IL-18 appears to be a promising prognostic marker of success in reproductive treatment and should be evaluated as such in further prospective studies.