Showing papers by "Anthony A. Luciano published in 2001"

Safe technique for laparoscopic entry into the abdominal cavity.

Abstract: Study Objective To evaluate and compare the safety and efficacy of a new method to enter the abdominal cavity at laparoscopy. Design (Canadian Task Force classification II-2). Setting Referral center for reproductive surgery in a teaching hospital affiliated with a university-based residency program. Patients Twenty representative women of variable body habitus (body mass index 16.5–39 kg/m2). Intervention Laparoscopy and laparotomy. Measurements and Main Results We measured the thickness of the abdominal wall at the base of the umbilicus and just below its inferior border. We also measured distances traversed by the Veress needle or cannula from skin to peritoneal cavity at both sites when the piercing instrument was directed at 45- or 90-degree angle from the horizontal plane of the abdominal wall. Finally, we measured distances created between parietal peritoneum and underlying viscera when the abdominal wall was lifted manually or with towel clips placed laterally, 2 cm from the umbilicus and at the edges of the intraumbilical incision. Distances created between parietal peritoneum and underlying viscera while lifting the abdominal wall by each of these three techniques were measured with a calibrated probe inserted through the intraumbilical port and observed with a 5-mm laparoscope from the suprapubic port. These distances were measured before and after carbon dioxide insufflation at 15 mm Hg, as well as before and while inserting the cannula through the abdominal wall. Mean ± SD thickness of the abdominal wall at the base of the umbilicus and lower border of the umbilicus were 1.4 ± 0.5 and 3.0 ± 1.1 cm, respectively (p Conclusion Our technique of inserting the cannula perpendicularly through the base of the umbilicus traverses the shortest distance to the abdominal cavity through the least vascular area of the abdominal wall. Lifting the abdominal wall with towel clips placed at the edges of the intraumbilical incision achieves the greatest distance between parietal peritoneum of the abdominal wall and underlying viscera, thus maximizing the margin of safety in protecting peritoneal organs and retroperitoneal vessels from injury.

Ectopic pregnancy from surgical emergency to medical management.

Abstract: During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

A system of credentialing physicians in advanced gynecologic endoscopy.

Abstract: As advanced endoscopic surgery becomes more readily accepted and more eagerly requested by patients, credentialing of properly trained surgeons in advanced procedures becomes an ever-important issue. Granting privileges in surgical procedures is the prerogative and responsibility of each individual institution, frequently delegated to credentialing committees. However, because of rapid changes in endoscopic surgical techniques and constant introduction of new instruments, credentialing endoscopic surgeons is becoming more and more difficult; a process Dr. Keye aptly described as like “hitting a moving target.” Consequently, hospitals, medical insurance companies, and government health agencies have looked to professional societies for guidance in establishing policies regarding credentialing and monitoring endoscopic surgeons. Several professional societies responded by establishing guidelines for this purpose. These guidelines reflect current surgical techniques and teaching methods, and are useful reference points for developing credentialing criteria for each institution. Although they must be modified to meet specific policies, medical staff bylaws, and rules and regulations of each individual institution, they are useful in developing a credentialing process that is extremely important in ensuring quality of care. The importance of proper credentialing of surgeons in advanced gynecologic endoscopy is underscored by a publication reporting the experience of an urban teaching hospital with a comprehensive gynecologic endoscopic privileging program. After implementation of the program, gynecologic surgeons were invited to apply on the basis of their case lists. Of 45 gynecologists who applied for advanced endoscopy privileges, only 5 qualified for advanced laparoscopy and only 3 for advanced hysteroscopy. Intermediate privileges were granted to 35 in laparoscopy and to 3 in hysteroscopy. The rest qualified only for basic endoscopic procedures. Yet all 45 applicants believed that they were advanced endoscopic surgeons. With unqualified surgeons excluded,