Following a 10 mm vertical incision in the umbilicus, the Verres needle (KARL STORZ SE & Co. KG, Tuttlingen, Baden-Württemberg, Germany) was inserted into the abdomen after the anterior abdominal wall was suspended upwards using underwear clamps. Fourteen mmHg pressure was utilized to create pneumoperitoneum. The abdominal cavity was entered with a 10 mm trocar followed by a 10 mm zero-degree telescope (KARL STORZ SE & Co. KG, Tuttlingen, Baden-Württemberg, Germany). Second and third incisions were performed in the avascular lower part of the abdomen, 3 cm medial to the anterior superior iliac spine, followed by insertion of 5 mm trocars. If additional access was required, a third 5 mm trocar was inserted on the patient’s left side at 12–13 cm above the umbilicus [8]. Instruments used included a zero-degree telescope, advanced bipolar electrocoagulation (Ligasure, Covidien, MA, USA), conventional bipolar electrocoagulation (KARL STORZ SE & Co. KG, Tuttlingen, Baden-Württemberg, Germany), monopolar hook (KARL STORZ SE & Co. KG, Tuttlingen, Baden-Württemberg, Germany), Cohen cannula (KARL STORZ SE & Co. KG, Tuttlingen, Baden-Württemberg, Germany) and a Rumi II uterine manipulator (Cooper Surgical Inc., Trumbull, CT, USA). The same surgical team completed all procedures.

The night prior to surgery, all patients received enemas for mechanical colon cleansing. All procedures were performed under general anesthesia in the dorsal lithotomy position. One gram of cefazolin was administered to all patients 1 hour before and the six hours after the operation. All patients had a Foley catheter and an orogastric tube. We discharged patients who had spontaneous urination and defecation after surgery and had no significant complaints. Operative time was determined from the first umbilical incision to the removal of the primary trocar. Length of hospital stay was determined from the day of the procedure to the day of discharge. All patients were followed for one month after surgery.

The study comprised female patients between the ages of 18 and 75 who underwent gynecological laparoscopy for benign reasons (uterine myoma, adenomyosis, cervical intraepithelial neoplasia, endometrial polyp, para ovarian cyst, benign ovarian cyst, endometrial hyperplasia, atrophic endometrium, endometrioma) and who had complete records.

Patients who underwent gynecological laparoscopy and had cancer discovered in the specimen as well as those with incomplete records were excluded from the study.

SPSS 24.0 for Windows (SPSS Inc., Chicago, IL, USA) was used for statistical calculations in the study. Chi-square or Fisher’s exact tests was used to examine categorical variables presented as frequencies and percentages. The Mann-Whitney or Student t-test was used as appropriate for continuous variables and presented as mean $\pm$ standard deviation or median (range). The Kruskal-Wallis test was used when comparing data. Parameters predictive of the occurrence of complications were determined using the receiver operating characteristic (ROC) curve. p values less than 0.05 was accepted for statistical significance.

A direct relationship was observed between the duration of surgery and the complication rates. This study revealed that problems dramatically increased, particularly in gynecological laparoscopic procedures lasting longer than 110 minutes. However, regardless of the type of laparoscopic procedure, significant complications had arisen before the procedure or during the insertion of the abdominal trocars. The initial stage of laparoscopy, such as pneumoperitoneum formation and placement of trocars, should be performed carefully. Furthermore, even in the simplest forms of laparoscopic surgery, complications may occur before the operation begins or during the abdominal insertion of trocars.

Although laparoscopic surgery is becoming common in gynecology, complications are frequently noted. It has been reported that laparoscopic gynecological surgeries intraoperative and postoperative complication rates were 5.6% and 6.5%, respectively [9]. The complication rate in operative laparoscopy cases ranges from 0.2% to 10.3% [10].

In this study, of the 28 complications that occurred, 5 (0.73%) developed during the insertion of the Verres needle and the primary trocar. This rate is compatible with the rate of 0.05%–2.8% published in the literature [11]. An inferior epigastric vessel injury occurred in 3 (0.44%) cases during conversion to laparotomy, indicating the importance of paying attention to the placement of accessory trocars. Uterine perforation occurred in 1 (0.14%) patient during the placement of a uterine manipulator. However, the operation was completed with no other problems. Complications related to abdominal entry are rare; however, the associated mortality rate is 13% [12]. The complication rate was significantly higher in the advanced laparoscopy group (n = 17 (9.88%)), with 24 of the 28 complications (85.71%) occurring in the major and advanced surgery groups. The advanced laparoscopy group had a complication rate of ~10, ~6, and ~4 times higher than the diagnostic, minor, and major laparoscopy groups.

Furthermore, 3 patients underwent conversion from laparoscopy to laparotomy in the advanced laparoscopy group. History of a previous abdominal surgery increases the conversion rate from laparoscopy to laparotomy [13]. The main associated concerns are the injuries at the entrance to the abdomen and complications caused by adhesiolysis [14]. The rate of diffuse subcutaneous emphysema is 2.3% as reported in the literature [15]. This condition occurs owing to the inability of the needle to reach the abdominal cavity when inserted horizontally into the abdomen. The 0.29% rate noted in our study could be attributed to increased surgical experience, and the emphysema regressed spontaneously within a day without treatment.

Multiple studies have reported that the bladder is the most frequently injured visceral organ in laparoscopy [16, 17, 18], ranging between 0.03% to 0.24% of cases. Prolonged use of the monopolar energy source, improper placement of the uterine manipulator, or trocar entry from the suprapubic region may result in bladder injury [19]. In our study, bladder injury occurred during the dissection of the anterior peritoneum from the bladder during a total laparoscopic hysterectomy in 3 patients with a previous history of abdominal surgery. All 3 complications were managed at the time of occurrence. While laparoscopic bladder repair was performed in 2 patients, laparotomy was performed in 1 of the patients as the defect was unsuitable for laparoscopic repair. Bladder catheterization was continued for ten days for all 3 patients. No vesicovaginal or ureterovaginal fistulae were observed during the postoperative follow-up period.

It has been reported that a higher level of experience is associated with lower complication rates [20]. One report has 214 complications noted in 3724 laparoscopic procedures. The complication rate was 0.31% for diagnostic laparoscopy and 3.2% for sterilization surgeries, with an overall complication rate of 5.8% [21]. It was reported that 34 of 3572 patients who underwent laparoscopy between 1996 and 2003 were converted to laparotomy (0.95%). The complication rate was significantly higher in the advanced laparoscopy group (1.88%), with a total complication rate of 4.88% [22]. It was reported that 7 (1.39%) of 503 patients who underwent laparoscopy between 2003 and 2006 were converted to laparotomy, and the overall complication rate was 3.37% [23]. Compared with laparotomy, laparoscopy has a lower overall complication rate [24]. The overall complication rate in gynecological laparoscopy was 1.96% [25].

In our study, of the 680 laparoscopic procedures, conversion to laparotomy was required in 3 (0.44%) cases due to bleeding and bladder perforation, and our overall complication rate was 4.11%. Therefore, prevention and early diagnosis are essential during laparoscopic procedures [26].

The laparoscopic approach is widely preferred in early-stage endometrial cancer [27]. Laparoscopic cervical cancer trials clearly showed that minimally invasive radical hysterectomy is associated with worse survival [28]. It has been understood that the 5-year survival rates for early-stage endometrial cancers are no different from total abdominal hysterectomy when factors such as the necessity of lymph node dissection are considered [29]. Unfortunately, laparoscopic hysterectomy has worse outcomes than open hysterectomy in cervical cancer, regardless of stage [30]. Metastases at port entry sites have been reported in oncological cases undergoing laparoscopic surgery [31]. Laparoscopic operations of myomas with malignant potential yield poor results even if morcellation is not applied. Therefore, laparoscopic morcellation of myomas with uncertain diagnoses is not recommended [32].

During laparoscopic surgery, complications may occur before the operation begins or during the abdominal insertion of trocars.

The laparoscopic complication rates vary according to the difficulty and complexity of the procedure. There is a direct relationship between procedure difficulty and complication rates. More studies are needed to add to the results obtained from this single-center study.

The information used in this study was carefully gathered. A major weakness of this study is the short follow-up duration. The investigation was retrospectively conducted in a single tertiary care center in Turkey which impacts the generalizability of the study, as well as the capacity to identify causal correlations.