Vulvar edema as a complication of laparoscopy is a rare condition. A 23-year-old woman was admitted with progressive dysmenorrhea and underwent laparoscopic bilateral endometrioma cystectomy. Twenty-seven hours after surgery, unilateral vulvar edema was observed. It resolved with the application of ice packs and insertion of a Foley catheter. We conclude that this is a rare, normally benign condition that is easy to manage.
Study Objective. To evaluate influence of hysteroscope type and media used during outpatient hysteroscopy on vasovagal syndrome risk.Study Design. Prospective observational. study (Canadian Task Force classification II-1).Setting. University hospital.Patients. Two thousand seventy-nine women undergoing outpatient hysteroscopy without analgesia.Intervention. Office hysteroscopy with a flexible or rigid hysteroscope and normal saline or CO2.Measurements and Main Results. Fifteen cases of vasovagal syndrome were reported. The rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%]), p =.00073; p =.009 after adjustment for medium used; and with the use of CO2 (10/426 [2.34%]) vs. saline solution (5/1653 [0.30%]), p <.0001; p = .014 after adjustment for hysteroscope type.Conclusion. Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.
"Deep endometriosis" includes rectovaginal lesions as well as infiltrative forms that involve vital structures such as bowel, ureters, and bladder. The available evidence suggests the same pathogenesis for deep infiltrating vesical and rectovaginal endometriosis (i.e., intraperitoneal seeding of regurgitated endometrial cells, which collect and implant in the most dependent portions of the peritoneal cavity and the anterior and posterior cul-de-sac, and trigger an inflammatory process leading to adhesion of contiguous organs with creation of false peritoneal bottoms). According to anatomic, surgical, and pathologic findings, deep endometriotic lesions seem to originate intraperitoneally rather than extraperitoneally. Also the lateral asymmetry in the occurrence of ureteral endometriosis is compatible with the menstrual reflux theory and with the anatomic differences of the left and right hemipelvis. Peritoneal, ovarian, and deep endometriosis may be diverse manifestations of a disease with a single origin (i.e., regurgitated endometrium). Based on different pathogenetic hypotheses, several schemes have been proposed to classify deep endometriosis, but further data are needed to demonstrate their validity and reliability. Drugs induce temporary quiescence of active deep lesions and may be useful in selected circumstances. Progestins should be considered as first-line medical treatment for temporary pain relief. However, in most cases of severely infiltrating disease, surgery is the final solution. Great importance must be given to complete and balanced counseling, as awareness of the real possibilities of different treatments will enhance the patient's collaboration.
Study Objective. To evaluate the effectiveness of a thermal uterine balloon therapy system in a specific group of patients with multiple morbidity.Design. Retrospective cohort analysis (Canadian Task Force classification II-2).Setting. Department of Obstetrics and Gynecology in two university teaching hospitals.Patients. Seventy women with severe systemic disease (American Association of Anesthesiologists physical status score greater than or equal to111) and severe menorrhagia.Intervention. Uterine balloon therapy under local anesthesia and 3 years of follow-up.Measurements and Main Results. The women had a mean age of 44.3 years (range, 24-76). After treatment, 25.7% of the patients had no bleeding, 45.7% hypomenorrhea, and 21.4% normal menstrual flow. The procedure was repeated successfully for one patient, and five failures (7.1%) were observed. The blood count values differed significantly (p <.001) before and after balloon therapy.Conclusion. Uterine balloon therapy is a suitable and useful option for women with severe uterine bleeding and concomitant severe systemic nongynecologic disease.
Study Objective. To evaluate the feasibility of fluorescence diagnosis of nonpigmented (red and white) endometriotic lesions with 20 mg/kg of 5-aminolevulinc acid (5-ALA) 5-7 and 10-14 hours before surgery.Design. Prospective analysis (Canadian Task Force classification II-2). Setting. University hospital.Patients. Twenty-four consecutive patients with suspected endometriosis undergoing laparoscopy.Intervention. Laparoscopic surgery under white light illumination and fluorescence diagnosis. Measurements and Main Results. The total number of endometriotic lesions detected under white light illumination was compared with the number of lesions detected with fluorescence diagnosis. Fluorescence diagnosis yielded an overall improvement of 35% in the detection of nonpigmented endometriotic lesions compared with white light illumination. Sensitivity (91%) and specificity (79%) were similar 5-7 and 10- 14 hours before surgery.Conclusion. The dosage of 20 mg/kg body weight of 5-ALA is feasible for fluorescence diagnosis of nonpigmented endometriosis. Sensitivity of fluorescence diagnosis with 20 mg/kg is similar to that achieved with a 30-mg/kg dose. Sensitivity does not change within the application period 5-7 and 10-14 hours before surgery.
A 28-year-old woman with severe right lower abdominal pain and vaginal bleeding at 7 weeks' ( 2 days) gestation was seen in the emergency room of our institution. The pregnancy was the result of natural conception after ovarian stimulation with gonadotropins. Transvaginal sonography revealed five intrauterine gestational sacs containing five live embryos. A positive fetal heartbeat was detected in the fallopian tube on the right. Laparoscopic findings disclosed the enlarged uterus with the unruptured right ectopic pregnancy in the ampullary region and an extrauterine pregnancy in the left tube as well. A linear salpingotomy was performed on the right tubal pregnancy. We decided to perform salpingectomy on the left tube because it was impossible to preserve the tube, and exploration of it showed the existence of another gestational sac.It is necessary to decry inappropriate and injudicious use of assisted reproductive technologies, especially by individuals with little or no training in monitoring the agents and treatments prescribed. In 2003, still waiting for official legislation from the Italian Parliament on assisted reproductive technology, we have to face dramatic situations, such as this very unique case of heterotopic pregnancy.
Study Objective: To study the usefulness of and applications for frozen section in the laparoscopic management of adnexal masses.Design. Historical prospective study (Canadian Task Force classification II-3).Setting. Large tertiary care hospital with university affiliation.Patients. One hundred forty-one women undergoing laparoscopy for a suspicious adnexal mass.Intervention. Adnexal masses suspicious on ultrasound were managed by laparoscopy. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible.Measurements and Main Results. The results of frozen section were compared with the results of permanent sections, and the consequences of the intraoperative diagnosis on the surgical management were evaluated. The frozen section diagnosis was correct in 125 of the 741 patients (88.7%). In one patient, the result was false negative. Specifically, frozen section diagnosis was correct in 96.8% of cases when a cyst or biopsy was sent for pathologic examination and in 86.4% when the whole adnexa was sent. It was correct in 93% of the cases involving tumors smaller than 100 mm and in 74% of larger tumors. It was correct in 92.3% of the women younger than 50 years and in 81.6% of women older than age 50. Intraoperative pathologic diagnosis was correct in 95.5% of benign tumors, 77.8% of low-malignancy tumors, and 75% of cancer cases.Conclusion. Frozen section is a useful examination for surgical management decision making; however, the limitations and the difficulties should be taken into account.
Thermal balloon endometrial ablation (BEA) was introduced approximately 10 years ago as the first automated replacement for hysteroscopic endometrial ablation (HEA) in women with chronic abnormal uterine bleeding. Putative advantages included similar or improved clinical outcomes, and reduction of both adverse outcomes and the total cost of care, all with reduced requirements for operator skill. The published literature contains 1191 cases of BEA performed with instruments from 4 manufacturers, including a number of randomized clinical trials (RCTs) comparing the devices with HEA, usually performed by experts. In comparative RCTs, clinical and health-related quality of life outcomes as well as patient satisfaction and rate of subsequent uterine surgery appear similar in follow-up intervals that ranged from 1 to 5 years. There is a suggestion of reduced risk of adverse events with BEA, but the differences are small. There are no rigorous evaluations of resource use. The level of surgeon expertise in HEA arms of available RCTs potentially improves quality and decreases complications over what might be expected in the general population. Thus BEA seems equivalent to HEA when performed by expert surgeons with respect to most outcomes. Effectiveness studies of the two interventions should be conducted in community settings and should evaluate resource use.
STUDY OBJECTIVE:To evaluate, by means of serial transvaginal ultrasound (US) examinations, the ovary after laparoscopic excision of endometriomas with the stripping technique. DESIGN:Prospective, controlled, single-blind clinical trial (Canadian Task Force classification II-1). SETTING:Tertiary care university hospital. PATIENTS:Forty-seven patients, from 21- to 35-years old, undergoing laparoscopic excision of a monolateral ovarian endometrioma. INTERVENTION:The patients underwent serial US scans performed by a blinded observer during the first, third, and sixth menstrual cycle after surgery. MEASUREMENTS AND MAIN RESULTS:At the first follow-up US examination, an abnormal finding, namely the presence of an ovarian cyst on the operated ovary, was diagnosed in five of 47 patients (10.6%; p = .03 when compared with the nonoperated ovary). In the remaining 42 patients (89.4%), no gross abnormalities were evident. No differences were present between the two ovaries as to ovarian volume or follicular development pattern. During the third follow-up US, in 47 patients (100%) no gross abnormalities were present. CONCLUSION:The US follow-up of ovaries operated on for endometriomas by laparoscopy demonstrates that the evidence of an ovarian cyst in the early postoperative period is not an uncommon event. This finding, occurring in approximately 10% of cases, seems to be a transient one occurring during ovarian healing after surgery, since no evidence of such anomaly was present on subsequent US scans. Therefore, treatment for US evidence of recurrence of an ovarian endometrioma should be deferred for at least 3 to 6 months if the diagnosis of recurrence is made in the early postoperative period. Apart from this finding, the operated ovary is indistinguishable from the contralateral one, even 1 month after surgery.
During laparoscopic surgery, the operator relies on the skills of an assistant, particularly during laparoscope manipulation. If possible, the surgeon would prefer to hold the scope while at the same time operating with both hands similar to open surgery conditions. A palm electronic interface (Lapman) was developed to allow remote control of a laparoscope manipulator and to make laparoscope displacement and instrument manipulation synchronous for the surgeon. It was tested in gynecologic surgery, where it restored vision and instrument manipulation and allowed laparoscopic surgery to be performed with fewer personnel.
Study Objective. To prospectively analyze the learning curve of laparoscopic-assisted vaginal hysterectomy (LAVH) in a surgical team and evaluate if length of surgery can be reduced safely.Design. Prospective observational study (Canadian Task Force classification II-2).Setting. Department of obstetrics and gynecology in a university-affiliated hospital.Patients. One hundred and sixty consecutive women undergoing LAVH performed between January 1, 1998 and April 30, 2001.Intervention. LAVH (AAGL Classification System for Laparoscopic Hysterectomy III-B-3).Measurements and Main Results. The primary parameter evaluated was length of surgery. Patients were grouped in cohorts of 10, in order to perform a time curve that would assist us in evaluation of the learning process. Once the plateau was reached, we evaluated the process before and after this plateau (groups 1 [learning stage] and 2 [second stage], respectively). Average length of surgery was 126 minutes (range, 60-260). Length of surgery was 138 minutes (range, 75-260) in the learning stage (first 80 cases) and 112 minutes (range, 60-225) in the second stage (p <.0001). Total rate of complications was 11.6%. There were three major complications, and they occurred before the plateau. There were 15 minor complications (9.67%), 8 during the first stage and 7 in the second stage, (p = .9; NS). A second learning curve excluding LAVH with associated surgeries was obtained. The average length of surgery for the first stage was 133 minutes (range, 75-205) and 102 minutes for the second stage (range, 60-130) (p >.0001).Conclusion. Analysis of the learning curve demonstrated that the length of surgery in LAVH could be reduced without increasing the number of complications.
The rate of fluid intravasation may abruptly and alarmingly increase during endometrial resection. Left unchecked, this may lead to complications of fluid overload. In 20 patients, temporary cessation of surgery in the form of a 10-minute glycine-free interval reduced the rate of fluid intravasation by 38.75% to 85.81% (mean 67.09%) in the later part of surgery. This was possibly due to hemostatic sealing of open blood vessels which prevented further intravasation of distending medium into systemic circulation.
Development of 3-D models of human anatomy for use in virtual reality simulators is anticipated to enhance surgical training. These models may be a valuable resource for gaining mastery of minimal-access procedures. The pelvis portion (hip to upper-thigh) of a 32-year-old female cadaver was frozen and sectioned axially in approximately 2-mm increments as the first step in producing an accurately representative 3-D model of the human female pelvis. Photographic exposures of the entire series of 95 sections were then converted to digital format. Adobe PhotoShop masks for each structure were created and converted into wire-frame and surface-textured models; this aggregate model set was named "LUCY." To date, 3-D representations of 40 pelvic structures (over 2200 individual masks) have been modeled In conjunction with haptic technology, these virtual anatomic models will enable users to practice fundamental surgical manipulations and procedures such as tubal ligation and ovariectomy. The deployment of surgical-simulation models such as LUCY may facilitate technical-performance aspects of surgical training, particularly those associated with minimal-access procedures. Manipulations and procedures can be practiced over the Internet, providing a host of flexible options to enhance the surgical curricula.
Study Objective. To determine the location and depth of uterine arteries from the vaginal fornix using a Doppler-guided non-incisional transvaginal approach.Design. Observational study (Canadian Task Force classification II-3).Setting. Two women's health and fertility centers.Patients. One hundred nine healthy premenopausal women (age >18 yrs).Intervention. Transvaginal uterine artery identification.Measurements and Main Results. After uterine size and position were determined, with a standard bivalve speculum in place, uterine arteries were located bilaterally using the DWL Multi-Dop B+ system with 8-MHz probe (Sipplingen, Germany) in toggle mode. Continuous Doppler mode was used to locate uterine arteries, and pulsed Doppler to estimate depth of the arteries from the vaginal fornix. The average uterine size was less than 8 weeks, with the largest measuring 18 weeks' gestational size. The right uterine artery could be identified between 8 and 11 o'clock positions, and was most commonly found at the 9 o'clock position (average depth 9.30 mm, range 4-17 mm). The left uterine artery could be identified between 1 and 4 o'clock positions and was most commonly found at the 3 o'clock position (average depth 8.88 mm, range 4-15 mm).Conclusion. Due to ease of identification of uterine arteries transvaginally, despite differences in parity, uterine size, and position, access to and occlusion of uterine arteries with a Doppler-guided device might offer an alternative to invasive procedures intended to occlude uterine artery blood flow in women with symptomatic uterine leiomyomas.
Study Objective. To assess changes in serum hormone levels and ovarian stromal blood flow after laparoscopic ovarian drilling (LOD) in young adult women with polycystic ovary syndrome (PCOS).Design. Prospective, nonrandomized study (Canadian Task Force classification II-1).Setting. Tertiary care, major teaching hospitals.Patients. Anovulatory young women with PCOS who were resistant to clomiphene citrate.Intervention. Laparoscopic ovarian drilling.Measurements and Main Results. To evaluate the endocrinological effects of LOD, serum leptin, insulin-like growth factor-1, estrone (E1), and estradiol were measured before and after ovarian drilling in the early follicular phase. Three-dimensional transabdominal power Doppler examinations were performed to determine the effects of LOD. Serum leptin was correlated with body mass index (BMI) before LOD. Levels of BMI, fasting blood sugar, and leptin were higher and LH, LH/FSH, and the sugar/insulin ratio were lower in the obese group. There were significant decreases in the free androgen index, and total testosterone, luteinizing hormone (LH), and LH/follicle-stimulating hormone (FSH) levels, and a significant increase in sex hormone-binding globulin (SHBG) concentration in the 3 months after the operation. The vascularization index and vascularization flow index of the intraovarian stroma significantly decreased after treatment. Reversed correlations between leptin and LH, LH/FSH, E1, thyroid-stimulating hormone, and SHBG were noted 3 months after the operation compared with levels obtained before the operation.Conclusions. Treatment of young adult women with PCOS using LOD did not influence leptin levels but changed the ovarian stromal blood flow dynamics during short-term follow-up. The surgical procedure may be beneficial both to endocrine profiles and to intraovarian stromal flow in patients with PCOS.
Several techniques of laparoscopic hysterectomies have been described, but loss of carbon dioxide (CO(2)) pneumoperitoneum is still a problem when the vagina is incised and the specimen has been removed. Our technique allows maintenance of CO(2) pneumoperitoneum by inserting a silicone tube into the vagina. The McCartney tube is open at its vaginal (proximal) end and a cap covers the outer distal end. The total hysterectomy specimen, adnexa, and, if necessary, lymph nodes can be easily removed through the tube.
The randomized controlled trial (RCT) is considered the highest level of medical evidence. In this brief overview, we discuss several key principles of the RCT. First, balance is paramount. Comparison groups must have similar proportions of participants with “important” prognostic and confounding factors. Randomization may or may not achieve this balance; if it does not, statistical adjustments should be used. Second, a statistical analysis should emphasize comparability and not mask dissimilarity. If the trial was indeed randomized, certain analysis techniques, such as an intention to treat analysis, should always be presented. Third, additional bias-reducing techniques, such as concealing treatment assignments from treating physicians and participants (i.e., masking) and using clearly defined exclusion and inclusion criteria, should be used wherever possible.
Although it is an easy diagnosis to eliminate, pregnancy is rarely considered in a woman with acute abdominopelvic pain and history of hysterectomy. A 37-year-old woman was seen because of acute onset of pelvic pain. Her history was significant for laparoscopic supracervical hysterectomy performed 4 months previously. A urine pregnancy test was positive. At diagnostic laparoscopy, an area in the right tube was consistent with ectopic pregnancy. Bilateral salpingectomy was performed, and pathology confirmed an ectopic pregnancy in the right tube. A diagnosis of ectopic pregnancy should be entertained in any woman with pain and intact ovaries.
Technical aspects of laparoscopic insufflation technique and interaction among patient, technique, and physician can affect the performance of laparoscopy and patient safety. A variety of laparoscopic equipment was evaluated regarding insufflation performance in laboratory measurements and/or in an intraoperative computer-based data-acquisition model for intraabdominal pressure, gas flow, and temperature. In this article, we present 25 suggestions for improving insufflation performance and increasing patient safety. These tips may help avoid and solve insufflation problems and malfunction, over- and under-pressure peaks, laparoscopic hypothermia, and gas embolism, and shorten operation room and anesthesia time, thereby saving time, money, and physician stress.
