Showing papers in "Journal of The American Association of Gynecologic Laparoscopists in 1998"
TL;DR: Laroscopic myomectomy improved pregnancy rates over nonsurgical management of myomas and their surgical removal on pregnancy rates in women investigated for infertility.
Abstract: Study Objective . To assess the role of leiomyomas and their surgical removal on pregnancy rates. Design . (Canadian Task Force classification II-1). Setting . Academic center. Patients . Two hundred twelve women who were investigated for infertility. Intervention . Laparoscopic myomectomy. Measurements and Main Results . Patients were divided according to case control criteria as those who underwent laparoscopic removal of myomas (106) and those who did not (106); both groups were compared with 106 women with unexplained infertility without myomas. Of the 318 women, 83 (26%) became pregnant and delivered live infants. The 44 (42%) who underwent surgical removal of leiomyomas had higher delivery rates than 12 (11%) who did not undergo surgery (p Conclusion . Laparoscopic myomectomy improved pregnancy rates over nonsurgical management of myomas.
138 citations
TL;DR: Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, the results suggest that recurrence of myomas may be higher with the Laparoscopic approach.
Abstract: Study Objective. To determine the recurrence rate of myomas after laparoscopic myomectomy. Design. Retrospective review (Canadian Task Force classification II-2). Setting. Tertiary referral center. Patients. One hundred fourteen women (age 25–51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6–120 mo). Intervention. Laparoscopic myomectomy. Measurements and Main Results. Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. Conclusion. Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.
138 citations
TL;DR: Pain of endometriosis has little relationship to location or color of lesions, and it can extend beyond visible lesions to normal peritoneum.
Abstract: Study Objective To determine by patient-assisted laparoscopy (PAL) the relationship of lesions of endometriosis to pelvic pain Design Prospective non-randomized study (Canadian Task Force classification II-1) Setting University based facility Patients Fifty women with endometriosis Intervention Lesions of endometriosis were examined as to color and size, and these areas were mapped for pain Measurements and Main Results Lesions in all categories of colors and shapes were palpated In lesions that did provoke a pain response, red and vascular lesions were most painful, followed by clear and white scar lesions Least painful were black lesions Pain extended beyond lesions to normal-looking peritoneum for up to 27 mm, but was not consistent with respect to type of lesion Conclusion Pain of endometriosis has little relationship to location or color of lesions It can extend beyond visible lesions to normal peritoneum Input from patients by PAL may be essential to achieve successful therapy and eliminate excessive surgery and risk
86 citations
TL;DR: Cryomyolysis may be an effective conservative surgical approach to uterine fibroids by freezing the structures, and all other uterine tissue returns to pretreatment size.
Abstract: Conservative surgical options for uterine myomata traditionally were abdominal myomectomy, laparoscopic myomectomy, and, more recently, myolysis. Each of these procedures has distinct advantages, but also apparent disadvantages. We attempted to introduce an additional option for conservative surgical treatment of fibroids by freezing the structures, a procedure termed cryomyolysis. In this pilot study, 14 women were pretreated with a gonadotropin-releasing hormone (GnRH) agonist for a minimum of 2 months preoperatively to minimize uterine and myoma size. Cryomyolysis was performed and the GnRH agonist was discontinued. Magnetic resonance imaging scans were performed in 10 of the 14 women after GnRH agonist treatment but before surgery, and 4 months postoperatively. Total uterine volume ranged from 41.3 to 1134.8 ml preoperatively, and 49.5 to 1320 ml postoperatively (mean increase 22% after discontinuation of GnRH agonist). Normal uterine volume ranged from 35.6 to 548.7 ml preoperatively and 45.1 to 729.6 ml postoperatively (mean increase 40%); however, myoma volume showed a mean decrease of 6% (range -87-28%). Analysis of only frozen myomata revealed a mean volume decrease of 10%. Cryomyolysis maintains at or slightly reduces these lesions to post-GnRH agonist size, and all other uterine tissue returns to pretreatment size. We believe cryomyolysis may be an effective conservative surgical approach to uterine fibroids.
84 citations
TL;DR: There is a definite trend, indicating that laparoscopy in pregnancy appears to be safe when performed by experienced practitioners, and six cases are added; three cholecystectomies, an adnexal procedure, and two for abdominal pain.
Abstract: We reviewed the English literature regarding laparoscopic surgery during pregnancy and found that of 518 reported procedures, the most common was cholecystectomy (45%), followed by adnexal surgery (34%), appendectomy (15%), and other operations (6%). We add six cases to this list; three cholecystectomies, an adnexal procedure, and two for abdominal pain. Thirty-three percent were performed in the first trimester, 56% in the second, and 11% in the third trimester. This review demonstrates a definite trend, indicating that laparoscopy in pregnancy appears to be safe when performed by experienced practitioners.
80 citations
TL;DR: A technique and instrumentation that should enable gynecologists to do the operation successfully more often is developed, which consists of a pneumo-occluder and a cup, combined with a uterine manipulator.
Abstract: Because total laparoscopic hysterectomy (TLH) is technically challenging, laparoscopic-assisted vaginal hysterectomy is often the, operation of choice, even in patients in whom it may not be successful. To encourage greater performance of TLH, I developed a technique and instrumentation that should enable gynecologists to do the operation successfully more often. The system consists of a pneumo-occluder and a cup, combined with a uterine manipulator. The cup, which is both visible and palpable, is placed over the cervix to delineate vaginal fornices, thus ensuring safe desiccation and avoiding ureteral dissection. Acceptable operating times allow TLH to be combined with other procedures, including excision of endometriosis, colposuspension, and enterocele repair.
70 citations
TL;DR: Should pregnancy occur after myolysis, caution and intensive surveillance of mother and fetus must be applied, and cesarean section should be performed at earliest signs and symptoms of uterine rupture and at term before onset of labor.
Abstract: Laparoscopic myolysis, a procedure designed to shrink uterine myomas by coagulating their blood supply, is an alternative to myomectomy or hysterectomy in women who do not contemplate childbearing. Three patients conceived within 3 months after myolysis against the surgeon's advice. In two of these women the uterus ruptured at 32 and 39 weeks' gestation, respectively, associated with death of the 32-week fetus. The third patient had an uneventful elective cesarean section at 39 weeks' gestation. Until the risk of uterine rupture after myolysis has been accurately compared with that after myomectomy, women should not undergo myolysis if they wish to conceive. Should pregnancy occur after myolysis, caution and intensive surveillance of mother and fetus must be applied, and cesarean section should be performed at earliest signs and symptoms of uterine rupture and at term before onset of labor.
65 citations
TL;DR: Exposure to CO2 has adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms in adhesion formation.
Abstract: Study Objective . To investigate the effects of peritoneal exposure to carbon dioxide (CO 2 ) on peritoneal microcirculation and free radical scavenger (FRS) metabolism, and its role in potential adhesion formation after operative laparoscopy. Design . Randomized, controlled study (Canadian Task Force classification I). Setting . University-affiliated hospital. Patients . Twenty-eight women undergoing operative laparoscopy for adnexal masses. Intervention . For each patient, a 1×1-cm sidewall peritoneal flap was excised at the end of laparoscopy and numbered randomly. Similar flaps obtained from 24 women immediately after entering the abdomen during laparotomy served as controls. Measurements and Main Results . Changes in glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), catalase (CAT), and glutathione (GSH) levels were studied in homogenized peritoneal tissues. The duration of CO 2 exposure and amount of CO 2 used were correlated with levels of free radical scavengers and compared with controls. Mean CO 2 exposure, amount of CO 2 used, and CO 2 pressure (15 mm Hg) was similar between low irrigation and irrigated laparoscopy (118.3±25 and 39.2±8.81 min and 125±20 and 44.5±6.81 min, respectively). The change in FRS levels was significantly correlated with duration and amount of CO 2 exposure (r=−0.92). Levels of GSH-Px, SOD, CAT, and GSH were significantly lower in the CO 2 exposure group than in controls (0.57 els of GSH-Px, SOD, CAT, and GSH were significantly lower in the CO 2 exposure group than in controls (0.57 μmol, 1.8 ng, 48.5 μmol, 1.5 nmol vs 0.8 μmol, 2.6±0.4 ng, 79μmol, 3.6 nmol, respectively). Conclusion . Exposure to CO 2 has adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms in adhesion formation. Avoiding long CO 2 exposure and copiously irrigating the abdominal cavity throughout surgery may lessen these effects. The potential role of the peritoneal FRS system on postoperative adhesion formation and its relation to estrogen status mandates further studies.
62 citations
TL;DR: Laroscopic conservative cystectomy of dermoid cysts in premenopausal women is safe and effective and appears to be a valuable alternative to laparotomy.
Abstract: Study Objective. To compare outcomes of conservative laparoscopic treatment of dermoid cysts removed from the abdominal cavity without (group A) and with an endobag (group B). Design. Prospective, randomized, 4-year (June 1992–June 1996) study (Canadian Task Force classification I). Setting. Department of Obstetrics and Gynecology of the Catholic University of the Sacred Heart in Rome. Patients. Fifty-five premenopausal women with dermoid cysts. Intervention. Patients were randomly assigned to removal of dermoid cysts from the abdominal cavity with or without an endobag through a 10- to 12-mm cannula sleeve. Measurements and Main Results. We assessed surgical time, spillage, complications, length of hospitalization, recurrences, and pregnancies. In the 55 women, 58 dermoid cysts (mean diameter 5.6±2.03 cm) were enucleated and removed at operative laparoscopy through a 10- to 12-mm cannula sleeve without intraoperative or post-operative complications. Mean operating time was 73 minutes. When cysts were removed with an endobag, operating time was significantly reduced over removal without the endobag (63 vs 81 min, p Conclusions. Laparoscopic conservative cystectomy of dermoid cysts in premenopausal women is safe and effective and appears to be a valuable alternative to laparotomy. Removing cysts in an endobag significantly reduced both operating time and spillage. However, controlled intraperitoneal spillage of cyst contents does not increase postoperative morbidity as long as the peritoneal cavity is throughly washed.
58 citations
TL;DR: The Harmonic scalpel causes formation of bioaerosols that are composed of material of respirable size that should be activated to reduce exposure to blood, blood by-products, and potentially infectious materials.
Abstract: Study Objective. To determine the distribution and concentration of aerosol particles caused by an ultrasonic (Harmonic) scalpel during simulated surgical use. Design. Setting. Materials. Interventions. Measurements and Main Results. Conclusions.
57 citations
TL;DR: A 6-cm fibroid was lost at the time of laparoscopic-assisted supracervical hysterectomy and caused persistent, severe abdominal pain over the next 3 weeks.
Abstract: Laparoscopic myomectomy and, more recently, laparoscopic supracervical hysterectomy are practical alternatives to traditional surgical management of uterine fibroids. With the advent of mechanical morcellation these procedures are now much more feasible. A 6-cm fibroid was lost at the time of laparoscopic-assisted supracervical hysterectomy and caused persistent, severe abdominal pain over the next 3 weeks. The fibroid was lodged in the region of the liver and gallbladder and required removal by laparotomy. Although retention of fibroids after operative laparoscopy has been reported, it has not been associated with complications. Technical alternatives at the time of operative laparoscopy involving morcellation should be considered to prevent this event.
TL;DR: Hysteroscopy was feasible when performed in an outpatient setting without general or local anesthesia in more than 90% of women and the operator's experience seems a key factor both for accurate endometrial evaluation and to reduce failure andendometrial biopsy rates.
Abstract: Study Objective . To evaluate the feasibility, validity, indications, and results of a large series of diagnostic hysteroscopies performed without anesthesia. Design . Retrospective analysis of hysteroscopy charts performed between 1989 and 1996 (Canadian Task Force classification II-2). Setting . University-affiliated endoscopy unit. Patients . Four thousand consecutive women referred for different indications. Interventions . Diagnostic hysteroscopy was performed in 91% of patients without premedication or anesthetics. In some women premedication or general or local anesthesia was required to access the uterine cavity. Measurements and Main Results . The success rate, validity indication, complication rate, and number of biopsies were critically evaluated and assessed in relation to increased experience of operators. In 91% of women we accessed the uterine cavity at the first attempt without premedication, whereas 207 (5.1%) patients required local anesthesia and 99 (2.4%) premedication. Only 1.6% required general anesthesia. In 52% intrauterine pathology was diagnosed and in 21% further surgical treatment was suggested. Conclusion . Hysteroscopy was feasible when performed in an outpatient setting without general or local anesthesia in more than 90% of women. The operator's experience seems a key factor both for accurate endometrial evaluation and to reduce failure and endometrial biopsy rates. The low frequency of further surgical treatment justifies performing the procedure in the office.
TL;DR: A reusable cone suitable for use with existing laparoscopy cannulas was designed to provide means for sealing and stabilizing the operative site throughout the procedure, and for repairing the surgical site after the surgery is completed.
Abstract: A reusable cone suitable for use with existing laparoscopy cannulas was designed to provide means for sealing and stabilizing the operative site throughout the procedure, and for repairing the surgical site after the surgery is completed. The device consists of a moveable laparoscopic cannula cone fitted with suture holders. The cone contains tunnels terminating at its distal end that serve as passages for sutures loaded on a special needle to traverse the abdominal wall. When sutures are pulled into suture holders they stabilize the cannula and seal the puncture site. When sutures are tied at the end of the procedure, they achieve full-thickness closure of the operative site. The laparoscopic cannula cone stabilizes the cannula on the abdominal wall, maintains an air-tight seal, controls potential hemorrhage from the cannula puncture site, and achieves satisfactory closure of the surgical defect. Preliminary experience with the instrument and method has been most satisfactory.
TL;DR: It is believed that this procedure could be an alternative to abdominal radical hysterectomy for selected women, especially those who have stage Ib1 cervical cancer, and acceptable in accordance with the standards of gynecologic oncology.
Abstract: Study Objective . To demonstrate the feasibility and evaluate the efficacy of laparoscopic radical hysterectomy with pelvic lymphadenectomy for early, invasive cervical cancer. Design . Prospective study (Canadian Task Force classification II-2). Setting . University-affiliated hospital. Patients Eighteen women (age range 29–70 yrs) with early, invasive cervical cancer. Intervention Laparoscopic radical hysterectomy with pelvic lymphadenectomy. Measurements and Main Results Diagnoses were squamous cell carcinoma in 15 patients and adenocarcinoma of the cervix in 3; these were graded microcarcinoma in 6 and stage lb ( Conclusion In our experience, laparoscopic radical hysterectomy with pelvic lymphadenectomy is acceptable in accordance with the standards of gynecologic oncology. Despite the longer operating time than traditional abdominal radical hysterectomy, all patients recovered as quickly as they would after laparoscopic-assisted vaginal hysterectomy. We believe that this procedure could be an alternative to abdominal radical hysterectomy for selected women, especially those who have stage lb1 cervical cancer.
TL;DR: Hysteroscopic endometrial ablation is effective for relief of menorrhagia and associated dysmenorrhea in selected patients and success may decline with increasing length of follow-up.
Abstract: Study Objective . To assess long-term outcome of endometrial ablation for treatment of menorrhagia. Design . Five-year, prospective longitudinal study (Canadian Task Force classification II-1). Setting . University teaching hospital. Patients . The first 301 women in a continuing series of over 550 patients undergoing hysteroscopic endometrial ablation. Intervention . Hysteroscopic endometrial ablation. Measurements and Main Results . Patients were followed at regular intervals for 24 to 60 months (mean 28 mo). Outcomes were reported in terms of control of menstrual blood loss and menstrual pain with respect to normal uterus, fibroid uterus, dysmenorrhea, and patient age. Conclusion . Hysteroscopic endometrial ablation is effective for relief of menorrhagia and associated dysmenorrhea in selected patients. Success may decline with increasing length of follow-up.
TL;DR: Patients undergoing gasless laparoscopy and traditional laparoscope experience similar postoperative pain, and no statistical difference was seen in scores for shoulder, periumbilical, and pelvic pain between techniques.
Abstract: Study Objective To compare pain after laparoscopic tubal ligation by gasless laparoscopy versus carbon dioxide (CO 2 ) pneumoperitoneum Design Prospective, randomized, single-blind comparison (Canadian Task Force classification I) Setting Private obstetric-gynecology hospital associated with a university resident teaching program Patients Women age 21 to 42 Intervention Single-puncture laparoscopic tubal ligation was performed with a silicone elastomer band Gasless laparoscopy was performed with a Laprolift and traditional laparoscopy with CO 2 pneumoperitoneum Postoperative pain in the shoulder and periumbilical and lower pelvic regions was measured by visual analog scale on the day of surgery and postoperative days 1, 2, 3, 7, and 14 Measurements and Main Results Of the 67 patients, 54 provided visual analog scales for analysis, 30 in the gasless group and 24 in the traditional group No statistical difference was seen in scores for shoulder, periumbilical, and pelvic pain between techniques Conclusion Patients undergoing gasless laparoscopy and traditional laparoscopy experience similar postoperative pain
TL;DR: Reduced exposure to and amount of CO2 during microlaparoscopy may result in decreased adhesion formation compared with conventional laparoscope, and micro Laparoscopic or laparoscopic ovarian coagulation of the ovaries may be a cost-effective alternative to conventional lapARoscopy.
Abstract: Study Objective To compare the effects of microlaparoscopy and decreased CO 2 exposure on peritoneal microcirculation and potential adhesion formation after ovarian surgery with those of conventional operative laparoscopy Design Prospective, randomized study (Canadian Task Force classification I) Setting Teaching hospital Patients Eighteen women with polycystic ovary disease Interventions Microlaparoscopic or laparoscopic ovarian coagulation of the ovaries Measurements and Main Results Approximately 10 to 12 coagulation points were applied to each ovary Two to 3 weeks after the initial surgery second-look microlaparoscopy was performed to determine the extent of adhesions in both groups The frequency of adhesion formation and changes in glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), catalase (CAT), and glutathione (GSH) levels were studied in homogenized peritoneal tissues obtained during surgery in each group Results Clinical profiles were similar between groups Mean exposure, amount, and pressure of CO 2 were significantly less in the microlaparoscopy group (p Conclusion Reduced exposure to and amount of CO 2 during microlaparoscopy may result in decreased adhesion formation compared with conventional laparoscopy This effect may possibly be due to lack of or minimal adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms for adhesion formation and closely related to peritoneal injury In addition, microlaparoscopy may be a cost-effective alternative to conventional laparoscopy
TL;DR: A new instrument for laparoscopic access consists of a trocarless, reusable, visual-access cannula with an external thread that ends in a blunt tip that may decrease the frequency of hernias and postoperative access site pain.
Abstract: A new instrument for laparoscopic access consists of a trocarless, reusable, visual-access cannula with an external thread that ends in a blunt tip. The device has no sharp ends or moving parts. The cannula does not transect but radially stretches and elevates vessels, fascia, and muscle fibers, preserving the fascia's natural gridiron shutter mechanism at the access site. The outer thread stabilizes the cannula, and no fascial suture is necessary. In a prospective clinical trial between 1994 and 1997, the instrument was used in 203 patients requiring 234 access ports for diagnostic and operative laparoscopies. No device-related complications or failed attempts were recorded. The cannula caused less tissue trauma at access sites, and may decrease the frequency of hernias and postoperative access site pain.
TL;DR: In the authors' opinion, CISH is preferred in cases of benign uterine diseases because it lowers major operative complications, especially in women who have large masses with no pathologic lesions of the cervix.
Abstract: Study Objective . To evaluate the efficacy of laparoscopic hysterectomy and compare classic intrafascial supracervical hysterectomy (CISH) with total laparoscopic hysterectomy (TLH) and laparoscopic-assisted vaginal hysterectomy (LAVH). Design . Retrospective review (Canadian Task Force classification II-2). Setting . University-affiliated hospital. Patients . Six hundred fifty women who underwent laparoscopic hysterectomy from August 1993 to August 1996. Interventions . Charts of 231 women undergoing CISH, 102 TLH, and 317 LAVH were reviewed regarding patient characteristics, indications, uterine weight, associated procedures, estimated blood loss, operating time, and complications. Measurements and Main Results . Among the three groups, despite having the largest specimen weight and highest number of associated procedures, women undergoing CISH had the lowest complication rate and smallest amount of estimated blood loss (p 0.05). The CISH group had relatively shorter operating times when compared with similar average specimen weights. Patients who underwent total hysterectomy by either TLH or LAVH had more postoperative visits than those having CISH (p Conclusion . Among the three groups, CISH resulted in lowest blood loss and fewest complications; these values were also lower for TLH than for LAVH. If the cervix is removed along with the uterus, TLH is recommended. In our opinion, CISH is preferred in cases of benign uterine diseases because it lowers major operative complications, especially in women who have large masses with no pathologic lesions of the cervix.
TL;DR: Excess absorption of liquid distending media is one of the most frequent complications of operative hysteroscopy and is seeing cases of permanent morbidity or death resulting from this complication.
Abstract: Excess absorption of liquid distending media is one of the most frequent complications of operative hysteroscopy. Although most women recover uneventfully, we are seeing cases of permanent morbidity or death resulting from this complication.
TL;DR: This surgical treatment of cervical cancer which associates a radical procedure complying with oncological rules with a decreased morbidity seems very promising, however, laparoscopic radical hysterectomy should be considered investigational and reserved for oncology surgeons trained in extensive Laparoscopic procedures.
Abstract: A laparoscopic approach for radical hysterectomy is described. The laparoscopic procedures are similar to those achieved previously by laparotomy, the extent of surgery being adapted to the volume of the tumour and to the associated treatments. From the results obtained in a preliminary study of 15 patients, this approach appears to be safe. This surgical treatment of cervical cancer which associates a radical procedure complying with oncological rules with a decreased morbidity seems very promising. However, laparoscopic radical hysterectomy should be considered investigational and reserved for oncology surgeons trained in extensive laparoscopic procedures. Large studies with long follow-up are necessary before this approach can be proposed as an alternative to conventional surgical approaches.
TL;DR: This pilot study suggests that endometrial cryoablation may be performed simply and effectively, and future studies should be designed to optimize the technical aspects of the procedure, determine its relative efficacy, and investigate the indications.
Abstract: Study Objective. Design. Setting. Patients. Intervention. Measurements and Main Results. Conclusion.
TL;DR: Uterine septa are frequently composed of myometrial tissue, and histology reviewed from four resected septa (2 partial, 2 complete) reported myometricrial tissue.
Abstract: Study Objective. To assess the frequency of myometrial tissue in the septa of septate uteri. Design. Retrospective review (Canadian Task Force classification II-2). Setting. University-affiliated tertiary referral center. Patients. Twenty-nine consecutive women with uterine septa diagnosed by magnetic resonance imaging (MRI). Interventions. The MRI examination was performed with a 1.5 Tesla scanner using high-resolution phased array coils with multiplanar fast-spin echo and T1-weighted sequences. Of resected septa, tissue was available in four for histologic evaluation for the presence of myometrial tissue. Measurements and Main Results. In 17 women MRI showed a partial septum, all containing myometrium. The 12 patients with complete septum had evidence of myometrium in the upper part of the septum, with fibrous tissue constituting the lower part. Histology reviewed from four resected septa (2 partial, 2 complete) reported myometrial tissue. Conclusion. Uterine septa are frequently composed of myometrial tissue.
TL;DR: Pretreatment with GnRH analogs may prevent the adverse effects of estradiol on endometrial Na+, K+-ATPase and creates a protective mechanism against iatrogenic hyponatremia, which is more critical in women than men in case of absorption of irrigating fluid.
Abstract: Study Objective . To investigate the effects of gonadotropin-releasing hormone (GnRH) analog pretreatment on endometrial Na + , K + -adenosine triphosphatase (ATPase) pump function and peripheral blood vasopressin levels, and their role in fluid absorption and mechanisms of hyponatremia in patients undergoing hysteroscopic endometrial ablation. Design . Prospective, randomized, placebo-controlled study (Canadian Task Force classification I). Setting . University-affiliated hospital. Patients . Seventeen women with dysfunctional uterine bleeding. Intervention . Nine women received a GnRH analog and eight received saline approximately 6 to 8 weeks before hysteroscopic ablation by electrosurgery. Measurements and Main Results . Both before randomization and immediately before surgery, endometrial biopsy samples were obtained and numbered consecutively without patient identification. Operative hysteroscopy was performed with glycine 1.5% mixed with 2% alcohol. The amount of irrigant and irrigant deficit; blood levels of albumin and ethanol; hematocrit and hemoglobin; changes in sodium levels; and central venous pressure were compared. The Na + , K + -ATPase pump activity was significantly increased in the GnRH analog group compared with the saline group and correlated with decreased estradiol levels (0.4±0.08 vs 0.26±0.06 μmol/min/ml). Vasopressin levels were significantly lower in the GnRH group (3.2±0.9 vs 7.6±1.7 μmol/L). Mean volume of irrigant used and operating time were similar in both groups. Volume deficit, decrease in protein, and hematocrit
TL;DR: Fluorescence detection of small cancer nodules after intravenous injection of ALA is feasible for nodules smaller than 0.5 mm on the peritoneum, and one to 3 hours after drug injection is optimal for diagnosis of metastases.
Abstract: Study Objectives. To determine the feasibility of macroscopic visualization of small ovarian cancer metastases in vivo by fluorescence after intravenous administration of 5-aminolevulinic acid (ALA); to assess the time after drug injection when fluorescence of small metastases is maximum; and to correlate macroscopic in vivo fluorescence with both microscopic ex vivo fluorescence and histologic findings. Design. Controlled animal study (Canadian Task Force classification I). Setting. University-based facility. Subjects. Twenty-four healthy, female Fischer rats. Intervention. Diffuse peritoneal metastatic cancer was induced in Fischer 344 rats by intraperitoneal injection of 1 million syngeneic ovarian cancer cells (NuTu-19). Four weeks after induction ALA100 mg/kg was injected intravenously, and diagnostic laparotomy was performed 1, 3, 6, or 9 hours thereafter. Measurements and Main Results. The peritoneal cavity was illuminated with the Wood's lamp (ultraviolet light). Fluorescence was determined by direct visualization and compared with a calibrated fluorescent disk. Tissues were collected, sectioned, and examined by fluorescence and conventional light microscopy. Within 1 to 3 hours after intravenous injection of ALA, in vivo fluorescence of tumor nodules (diameter 0.4–5.0 mm) was macroscopically visible. Tumor-free peritoneum did not show fluorescence and was significantly distinguishable from cancer nodules. Fluorescence from intestinal tissues was comparable with tumor nodules. Microscopic fluorescence analysis showed similar values for tumor nodules and peritoneum. Stained histologic specimens of peritoneal surface revealed a superficial layer of cancer cells responsible for fluorescence. The time course of the fluorescence curve in the intestine peaked twice, at 1 and 6 hours after ALA injection. Macroscopically fluorescing nodules were histology confirmed as malignant.
TL;DR: A new, powered, disposable instrument was developed to morcellate the entire uterus for easy removal through a 15-mm cannula, and can be made more cost and time effective with a single-use powered morcellator.
Abstract: Laparoscopic supracervical hysterectomy (LSH) can be performed more easily with a powered morcellator for removal of the uterus. Available laparoscopic morcellators are expensive and may be difficult to use, but a new, powered, disposable instrument was developed (Diva; FemRx, Sunnyvale, CA) to morcellate the entire uterus for easy removal through a 15-mm cannula. Twelve consecutive women for whom subtotal hysterectomy was indicated underwent LSH by standard laparoscopic protocol and were monitored postoperatively for a minimum of 1 month. In the current trend of less is more, LSH is an emerging option for less extensive hysterectomies and can be made more cost and time effective with a single-use powered morcellator.
TL;DR: Pelvic pain mapping during laparoscopy performed under conscious sedation can provide useful information about visceral and somatic sources of chronic pelvic pain.
Abstract: Pelvic pain mapping during laparoscopy performed under conscious sedation can provide useful information about visceral and somatic sources of chronic pelvic pain. Diagnostic superior hypogastric plexus block can be performed under direct laparoscopic visualization and the pelvis then remapped to determine if painful areas are supplied by hypogastric plexuses. Results of mapping may allow more informed selection of patients for presacral neurectomy.
TL;DR: In selected women, several laparoscopic procedures traditionally done in a hospital or ambulatory surgery center under general anesthesia can be performed safely in the office laparoscopy suite under local anesthesia with conscious sedation.
Abstract: Study Objective. To evaluate the safety of diagnostic and operative microlaparoscopy performed in the office under local anesthesia in the diagnosis and treatment of chronic pelvic pain. Design. Prospective study (Canadian Task Force classification II-2). Setting. Office-based, free-standing private obstetrics and gynecology practice. Patients. Twenty women with chronic pelvic pain. Intervention. Diagnostic and operative microlaparoscopy performed under local anesthesia with conscious sedation. Measurements and Main Results. All 20 patients had diagnostic microlaparoscopy and 19 had conscious pain mapping. Nine of 14 patients with endometriosis underwent fulguration of lesions and 7 of 8 with pelvic adhesions had lysis of adhesions. Four women with uterosacral ligament involvement had laparoscopic uterosacral nerve ablation. All patients tolerated office diagnostic and operative procedures without difficulty and had no complications. Conclusion. In selected women, several laparoscopic procedures traditionally done in a hospital or ambulatory surgery center under general anesthesia can be performed safely in the office laparoscopy suite under local anesthesia with conscious sedation.