The third reported case of pelvic gliomatosis found within foci of endometriosis is documented 16 years after the removal of a benign cystic teratoma. Grossly at laparoscopy the lesions appear as typical deep fibrotic endometriotic implants.

Traditionally, definitive treatment for symptomatic endometriosis has been total abdominal hysterectomy with bilateral salpingo-oophorectomy. However, aggressive excision of all endometriotic implants at the time of hysterectomy with preservation of one or both ovaries may be an acceptable alternative. All hysterectomies performed between 1988 and 1993 were retrospectively reviewed. Fifty-two women underwent laparoscopic hysterectomy for pelvic pain from advanced stage endometriosis with preservation of at least one ovary. The majority of women had significant to total relief of pelvic pain postoperatively. Average follow-up was 36 months. This series suggests that ovarian preservation at the time of hysterectomy can be considered in women with endometriosis. Patient benefits include avoidance of symptoms of surgical castration and subsequent exogenous hormone replacement.

We conducted a restrospective chart review of 22 laparoscopic tubal anastomoses performed between May 1987 and May 1991. The procedures were modeled after the two-stitch technique of Swolin. Overall fertility rates were disappointing in this small series, although the first live birth has occurred. The two-stitch method and available laparoscopic suture needles and needle holders limited the surgical results. Modifications of technique and instrumentation should improve fertility outcome.

A retrospective review of 3,200 advanced laparoscopic procedures demonstrated five brachial plexus injuries during a 5-month period in 1986 (0.16% incidence rate). Brachial plexus injury can occur during laparoscopic surgery using steep Trendelenburg's position with shoulder braces and the patient's arm extended at 90 degrees. Position modification can reduce the risk for upper extremity neuropathies.

Twenty-five women with pelvic abscess were treated laparoscopically. Following intravenous antibiotic coverage, laparoscopic surgical techniques were utilized to lyse bowel adhesions, drain purulent fluid, and excise acute and necrotic inflammatory adhesions, including tuboovarian adhesions. Treatment during the acute phase and results per second-look laparoscopy were documented in five cases, with photomicrographs revealing relatively normal pelvic anatomy. One postappendectomy abscess with a peritoneovaginal fistula in a 10-year-old girl was also managed laparoscopically. Four of seven women desiring pregnancy conceived, and two women had unplanned pregnancies. The treatment of choice for acute pelvic abscess may be a combination of intravenous antibiotics and an early laparoscopic surgical procedure.

Benign cystic teratoma (dermoid cyst) was managed laparoscopically in 25 cases (16 cyst excisions and 9 oophorectomies). Surgical procedures to avoid spill during ovarian cystectomy and oophorectomy were developed (14 cases). This series demonstrates a gradual evolution in surgical technique. Surgical outcome was good in all cases, complications were rare, and the procedure required a hospital stay less than 24 hours.

Increasing sophistication in laparoscopic instrumentation and techniques has led to an ever-expanding list of surgical indications that are no longer exclusive to gynecology. This report describes our experience with three women who had benign lesions of the liver edge found incidentally during laparoscopic surgery for gynecologic symptoms. The first woman was managed traditionally with subsequent exploratory laparotomy; she developed ileus postoperatively and required a 5-day hospital stay. The other two were managed laparoscopically without incident. Each was hospitalized less than 24 hours. All three liver lesions proved benign on histologic examination. Although not all liver lesions can or should be excised laparoscopically, selected superficial neoplasms can be managed expediently by a laparoscopic approach.

Laparoscopic resection of full-thickness lesions of the anterior rectum followed by repair using a two-layer suture technique is described. Anterior rectal laceration occurred in two bowel-prepped women during excision of deep fibrotic endometriosis. Neither patient required subsequent surgery nor suffered any postoperative sequela. While not all rectal injuries are suitable for laparoscopic suture repair, in selected cases, bowel injury can be effectively managed laparoscopically without resorting to major abdominal surgery.

One hundred women with cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis (48 partial, 52 complete) were treated laparoscopically for infertility (46 cases), pain (46), hypermenorrhea (7) and a mass (1). The surgical techniques included aqua-dissection, electrosurgery, CO2 laser, scissors, probes to identify the upper posterior vagina and rectum, and multiple rectovaginal examinations. In all the procedures the anterior rectum was freed to the loose areolar tissue of the rectovaginal septum prior to excising deep fibrotic endometriosis. The viable intrauterine pregnancy rate among patients with infertility was 70% (32/46). Of patients presenting with pain, 89% (41/46) reported significant relief. The average operating time was 178 minutes. Laparoscopic cul-de-sac dissection, though time intensive, offers increased fertility potential and significant symptom relief.

The purpose of this communication is to report laparoscopic treatment of ruptured interstitial pregnancy. Laparoscopic surgical techniques included aspiration, desiccation of major vessels, and wedge excision of the myometrium. Histologic examination confirmed the location of the pregnancy in the myometrial wedge and documented the absence of products of conception in the right tube cornua. Most ectopic pregnancies, including ruptured interstitial pregnancy, can be managed laparoscopically by an experienced endoscopist. (J GYNECOL SURG 6:135, 1990)

Problems with currently available trocar sleeves are listed. A second-puncture, lower-quadrant sleeve of a special design that eliminates these problems is described: short, self-retaining because of a screw grid on its external surface, and without a trap. Suggestions for modification of the umbilical sleeve trocar are advanced.

A woman with stage I ovarian cancer refused traditional treatment and was managed laparoscopically. Both ovaries were removed intact via a culdotomy incision. Vaginal hysterectomy, omentectomy and laparoscopic lymphadenectomy followed. With the increasing frequency of laparoscopic oophorectomy, it clearly seems prudent to remove ovaries intact through the cul-de-sac whenever ovarian pathology is in doubt. Although the laparoscopic approach is as yet unproven, it is an alternative for a select group of well-informed women with borderline or low-grade ovarian malignancy.

This case report describes laparoscopic suturing for bladder repair. This technique affords the laparoscopic surgeon another means of managing a surgical complication without resorting to laparotomy.

Laparoscopic hysterectomy is a substitute for abdominal hysterectomy and not for vaginal hysterectomy. Most hysterectomies currently performed with an abdominal approach may be performed with laparoscopic dissection of part or all of the abdominal portion followed by vaginal removal, including fibroids of 1000 g. There are many surgical advantages, particularly magnification of anatomy and pathology, easy access to the vagina and rectum, and the ability to achieve complete haemostasis and clot evacuation during underwater examination. Patient advantages are multiple and are related to avoidance of a pain producing abdominal incision. They include a reduced period of hospitalization and recuperation and an extremely low rate of cuff infection and ileus. It must be emphasized that conversion to laparotomy when the surgeon becomes uncomfortable with the laparoscopic approach should never be considered a complication; it is rather a prudent surgical decision that will profoundly decrease patient risk. The laparoscope can be used in combination with hysterectomy in a variety of ways with significant surgical and patient advantages. With few exceptions, laparoscopic hysterectomy can replace abdominal hysterectomy. Surgical outcome is the same. In experienced hands, the complication rate is low. Patient benefits are related to avoidance of an abdominal incision and include improved cosmetics and more rapid recovery.

A persistent serum titer of beta-hCG 4 weeks after laparoscopic removal of an intratubal pregnancy may be due to PEP (1 case) and/or peritoneal trophoblastic tissue implants (2 cases). In these three patients, a second laparoscopy detected the cause of the elevated hormonal levels and enabled therapy to be carried out at the same time.

Seventeen tubal pregnancies were treated successfully with a laparoscopic procedure over the past four years. Four different laparoscopic techniques were used: salpingectomy, partial salpingectomy (midtube resection), fimbrial expression, and salpingotomy. "Preventive hemostasis" using vasopressin has made salpingotomy our treatment method of choice. Ruptured tubal pregnancy was not considered a contraindication to laparoscopic treatment. Four of the six women who were trying to conceive and were followed for longer than six months have had documented intrauterine pregnancies; one woman subsequently developed a contralateral tubal pregnancy which was treated by laparoscopic salpingotomy. Tubal ectopic pregnancy, even in the presence of rupture, can be managed effectively by a variety of laparoscopic techniques with benefits including minimal incision, short hospitalization, early return to full activity, and in many cases, a patent tube.