The myoma pseudocapsule is a surgical-anatomical entity surrounding the fibroid that separates the myoma from normal uterine tissue. The myoma pseudocapsule has a delicate vascular network rich with neurotransmitters analogous to the neurovascular bundle surrounding the prostate. The pseudocapsule neurovascular bundle is extremely important during myomectomy to promote uterine myometrial healing and, consequently, for uterine reproductive function. New advancements in surgery, including the use of laparoscopic myomectomy by an intracapsular technique and magnification of the myoma pseudocapsule to enhance visualization are comparable to the dissection during a radical prostatectomy. Fibroid detachment occurring inside the pseudocapsule causes less bleeding, spares the neurovascular bundle and promotes better uterine healing. The maintenance of myometrial integrity after laparoscopic myomectomy maintains uterine function and therefore improves reproductive outcomes, including labor.

The technical development of instruments for endoscopic surgery started in the field of gynecology. In the early 1970s, with the improvement of optics and instruments for laparoscopic surgery, gyne-endoscopic surgery developed and set milestones for all other surgical fields. However, the general surgeons propagated the advantages of 2D or 3D imaging surgery much better than the conservative gynecologists. Surgery on a 2D screen without direct vision is regarded as more advantageous than open surgery and has achieved wide acceptance. Several schools of gynecologic endoscopy in Europe (in Kiel, Giessen, Clermont Ferrand and Strasbourg) have set guidelines for gyne-endoscopic surgery. Our catalog of indications in the areas of gyne-endoscopic surgery, published in 2002, reveals the broad application of these techniques today. 3D vision, robotic instruments and systems, such as the da Vinci(®) Surgical System from Intuitive Surgical, Inc. (CA, USA), round up the picture of endoscopic surgery. The advantages of endoscopic surgery over open surgery (more precision, less trauma, less postoperative pain, shorter hospital stays and a faster recovery period) are becoming more accepted. The present healthcare systems and hospital administrations understand the challenges of imaging in surgery, particularly in endoscopic surgery.

Cross-linked sodium hyaluronate is highly effective in the prevention of adhesions at laparoscopic and hysteroscopic surgery.

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Are hysterectomies still necessary in 2010 and why and how should they be performed? As every now and then a critical evaluation of routine surgical procedure is necessary, there it is: This review follows the "Perspectives on laparoscopic hysterectomy" by Michelle Nisolle (Gynecol Surg 7:105-107, 2010). Hysterectomies performed in the field of obstetrics and gynaecology until the nineteenth century had always a lethal end. In the twentieth century, they were perhaps too frequently performed whereas the twenty-first century has witnessed a steep decline in hysterectomy numbers. It is therefore an opportune time to review the indications for hysterectomies, hysterectomy techniques and the present and future status of this surgical procedure. There is a widespread consensus that hysterectomies are primarily to be performed in cancer cases and obstetrical chaos situations even though minimal invasive surgical technologies have made the procedure more patient-friendly than the classical abdominal opening. Today, minimally invasive hysterectomies are performed as frequently as vaginal hysterectomies, and the vaginal approach is still the first choice if the correct indications are given. It is no longer necessary to open the abdomen; this procedure has been replaced by laparoscopic surgery with multiple and single port entries. Laparoscopic and roboticassisted laparoscopic surgery can also be indicated for hysterectomies in selected patients with gynaecological cancers. For women of reproductive age, laparoscopic myomectomies and numerous other uterine-preserving techniques are applied in a first treatment step of menometrorrhagia, uterine adenomyosis and submucous myoma. These interventions are only followed by a hysterectomy if the pathology prevails.