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Safety of gas laparoscopy under low intraabdominal pressure
August 2002, Vol. 9, No. 3 Supplement TheJournal of the American Association of Gynecologic Laparoscopists
247. Classification of Hysteroscopic Adhesiolysisfor Uterine Synechiae
are a_nastomosed at three points, not four. Four women underwent this surgery. One had a live birth after surgery, and 2 years later underwent salpingectomy by laparotomy because of opposite side tubal ectopic pregnancy. Eight months after the second surgery she became pregnant by the preserved tube. Conclusion. We believe this relatively simple technique reduces the possibility ofpersitent ectopic pregnancy and tubal factors, and may be as effective as conventional microsurgery.
M Takashi. Nippon Medical School, Kawasaki, Kanagawa Prefec, Japan.
Objective. To investigate the relationship between difficulty ofhysterofiberscopic adhesiolysis and adhesive area of uterine synechia. Measurements and Main Results. Nineteen women underwent hysterofiberscopic direct adhesiolysis (HDA) or laser hysterofiberscopic adhesiolysis guided by laparoscopic-assisted intraabdominal sonohysterography (LHAD-GLAIS). Difficulty of hysterofiberscopic adhesiolysis was classified as follows: grade I, HDA successfully performed; grade II, LHAD-GLAIS successfully performed; grade III, LHAD-GLAIS incompletely performed; grade IV, LHAD-GLAIS abandoned because extensive pelvic adhesion interfered with intraabdominal sonohysterographic guiding. Preoperatively, in the 19 women adhesions were diagnosed as follows: 7 were limited at the internal uterine os area (IUO); 4 extended from the IUO to the uterine fundus (extensive adhesion, EXT); 4 were limited to the utero-tubal junction area (UTJ); 2 were limited to the lateral wall (LW); 1 was at the central area of uterine cavity (CENT); and 1 was observed between midfundus and lateral wall (MFLW). Five IUO and one MFLW were grade I. Four UTJ, two LW, one CENT, and one IUO were grade II. Three EXT were grade III. One IUD and 1 EXT were grade IV. Conclusion. Adhesiolysis of internal uterine os is not always easy, and adhesiolysis of extensive adhesion is difficult.
246. Risk Factors for Conversion to Laparotomy During Gynecologic Laparoscopy AI Sokol. Prentice Women's Hospital, Northwestern University, Chicago, Illinois.
Objective. To identify risk factors associated with conversion to laparotomy during gynecologic laparoscopic surgery. Measurements and Main Results. The surgical server database was used to identify all 2530 gynecologic laparoscopies, including 159 converted to laparotomy, at this institution. Laparoscopies not converted to laparotomy were used to select a representative control group of 323 cases picked by random number assignment from the remaining cases in the database. Of 2530 laparoscopies, 159 (6.3%) were converted to laparotomy. The following factors were significantly associated with conversion: surgeon experience (OR 0.41, 95% CI 0.22, 0.74), level of laparoscopic complexity (OR 3.19, 95% CI 1.20, 5.10), BMI above 30 kg/m2 (OR 2.45, 95% CI 1.40, 4.41), suspicion of malignancy (OR 17.45, 95% CI 7.32, 43.57), history of laparotomy (OR 1.34, 95% CI 1.02, 1.78), presence of adhesions (OR 2.30, 95% CI 1.37, 3.76), and intraoperative technical difficulty (OR 17.86, 95% CI 7.32, 43.57). Age, parity, bowel injury, vascular injury, and history of PID and endometriosis were not correlated with conversion. Converted cases were associated with significantly greater estimated blood loss (p <0.001), longer operating room time (p <0.001), and longer hospital stay (p <0.001). Conclusion. Both patient and surgeon factors predispose to failed laparoscopy. By understanding the risks of laparoscopic failure, surgeons will be able more accurately to select the best mode of surgical access and counsel patients during preoperative assessment.
248. Safety of Gas Laparoscopy under Low Intraabdominal Pressure A Takashirna, T Kinoshita, N Mauya, K Miyake, K Otaka, T Yano. Toho University, School of Medicine, Sakura, Japan.
Objective. To investigate the safety of gas laparoscopy performed under low-pressure pneumoperitoneum. Measurements and Main Results. Pneumoperitoneum was established at a pressure of 5 mm Hg using automatic pneumoperitoneum equipment through the Optiview inserted directly beneath the umbilicus. Arterial pressure of CO2 and blood pressure were evaluated
$75
Poster Presentations
250. Increased Activated Mast Cells in Stromal Lesions of Human Endometriosis 11Uchiide, 2T Ihara, 2M Sugamata. 1Department of Pathology, Japanese Red Cross Omori Hospital, Ota-Ku, Tokyo, Japan; 2Department of Pathology, Tochigi Institute of Clinical Pathology, Minamiakatsuka, Shimotsuga-Gun, Japan.
before and 30 minutes after inflation, and after deflation of CO2. In 11 patients surgery was completed with optimal visual field and without complications at 5 mm Hg pneumoperitoneum. Pneumoperitoneum pressure of 8 to 10 mm Hg was required in three cases to ensure optimal visual field. The BMI of these three women was over 25. Blood pressure did not fluctuate significantly in any patient. Increased PaCO2 at 30 minutes after inflation was 1.5 mm Hg in cases with 5 mm Hg pneumoperitoneum pressure. In three women who required 8 to 10 mm Hg of pneumoperitoneum, PaCO2 increased 3 mm Hg. Conclusion. Low pneumoperitoneum pressure of 5 mm Hg produced only transient changes in PaCO2, suggesting safety of gas laparoscopy.
Objective. To describe light and electron microscopy to examine in detail morphologic alterations of stromal endometriotic cells from 53 patients with classic endometriosis. Measurements and Main Results. Endometriotic lesions of women were identified and resected laparoscopically. Eutopic endometrium was obtained from patients both with and without endometriosis as a comparative control. In all endometriosis lesions, diffuse infiltration of numerous mast cells was observed throughout the stromal lesions, and most of these mast cells exhibited activation and degra3mlation. Scattered granules were also present. In eutopic endometrium of women with endometriosis, mast cells were rarely detected. Conclusion. These results suggest that abnormal immune responses, particularly hypersensitivity reactions, are strongly related to the occurrence and proliferation of endometriosis. We believe that our findings will be helpful in developing methods to prevent and treat endometriosis.
249. A New Uterine Manipulator for Laparoscopic Surgery H Tintara. Department of Obstetrics and Gynecology, Hat-Yai, Songkla, Thailand. Objective. To describe a new device to improve uterine manipulation during gynecologic laparoscopic surgery. Measurements and Main Results. The new uterine manipulator (Karl Storz Endoscope, Tuttlingen, Germany) consists of a shaft, pivoting head, locking system, and handle with ergonomic design. It allows anteversion of the uterus up to 90 degrees, with a marker indicating the position of the uterus, and is freely mobile bilaterally. The shaft, which consists of rods, is easy to clean and maintain. The changeable intrauterine obturator has a diameter of 5 mm with three standard lengths of 6, 8, and 10 cm connected to the pivoting head with a screw. All parts of the device are reusable and autoclavable. The device can be retained on the uterine cervix using spring-load hooking to the tenaculum. The device is lightweight, has an easy-to-operate locking system, and can be managed with one hand. Initial experience in 60 cases of adnexal surgery and 30 LAVH cases was good, without trauma to cervix or uterus. Conclusion. This hand-held, reusable uterine manipulator is expected to improve the ease of laparoscopic surgery, especially in cases in which it is not necessary to enter the vagina.
251. Laparoscopic Vaporization of PCOS with the Nd:YAG Laser T Yano, S Fukaya, T Kinoshita, K Otaka, A Yokoyama. Toho University, School of Medicine, Sakura, Japan. Objective. To assess the effectiveness of Nd:YAG laser vaporization for treatment of PCOS. Measurements and Main Results. Twelve infertile women whose PCOS did not respond to clomiphine citrate underwent laparoscopic vaporization with Nd:YAG laser, using multiform fiber for vaporization at power setting of 20 W. Their LH value decreased from 11.2 + 7.2 mlU/ml before to 5.9 + 3.0 mlU/ml after operation. The LH:FSH ratio also decreased from 1.8 + 7.2 to 0.8 + 0.3 before and after the operation, respectively. Of 24 ovaries of 12 women, follicles were observed in 22 (92%) after surgery. Seven patients (58%) conceived in an average of 7.4 months.
$76
247. Classification of Hysteroscopic Adhesiolysisfor Uterine Synechiae
are a_nastomosed at three points, not four. Four women underwent this surgery. One had a live birth after surgery, and 2 years later underwent salpingectomy by laparotomy because of opposite side tubal ectopic pregnancy. Eight months after the second surgery she became pregnant by the preserved tube. Conclusion. We believe this relatively simple technique reduces the possibility ofpersitent ectopic pregnancy and tubal factors, and may be as effective as conventional microsurgery.
M Takashi. Nippon Medical School, Kawasaki, Kanagawa Prefec, Japan.
Objective. To investigate the relationship between difficulty ofhysterofiberscopic adhesiolysis and adhesive area of uterine synechia. Measurements and Main Results. Nineteen women underwent hysterofiberscopic direct adhesiolysis (HDA) or laser hysterofiberscopic adhesiolysis guided by laparoscopic-assisted intraabdominal sonohysterography (LHAD-GLAIS). Difficulty of hysterofiberscopic adhesiolysis was classified as follows: grade I, HDA successfully performed; grade II, LHAD-GLAIS successfully performed; grade III, LHAD-GLAIS incompletely performed; grade IV, LHAD-GLAIS abandoned because extensive pelvic adhesion interfered with intraabdominal sonohysterographic guiding. Preoperatively, in the 19 women adhesions were diagnosed as follows: 7 were limited at the internal uterine os area (IUO); 4 extended from the IUO to the uterine fundus (extensive adhesion, EXT); 4 were limited to the utero-tubal junction area (UTJ); 2 were limited to the lateral wall (LW); 1 was at the central area of uterine cavity (CENT); and 1 was observed between midfundus and lateral wall (MFLW). Five IUO and one MFLW were grade I. Four UTJ, two LW, one CENT, and one IUO were grade II. Three EXT were grade III. One IUD and 1 EXT were grade IV. Conclusion. Adhesiolysis of internal uterine os is not always easy, and adhesiolysis of extensive adhesion is difficult.
246. Risk Factors for Conversion to Laparotomy During Gynecologic Laparoscopy AI Sokol. Prentice Women's Hospital, Northwestern University, Chicago, Illinois.
Objective. To identify risk factors associated with conversion to laparotomy during gynecologic laparoscopic surgery. Measurements and Main Results. The surgical server database was used to identify all 2530 gynecologic laparoscopies, including 159 converted to laparotomy, at this institution. Laparoscopies not converted to laparotomy were used to select a representative control group of 323 cases picked by random number assignment from the remaining cases in the database. Of 2530 laparoscopies, 159 (6.3%) were converted to laparotomy. The following factors were significantly associated with conversion: surgeon experience (OR 0.41, 95% CI 0.22, 0.74), level of laparoscopic complexity (OR 3.19, 95% CI 1.20, 5.10), BMI above 30 kg/m2 (OR 2.45, 95% CI 1.40, 4.41), suspicion of malignancy (OR 17.45, 95% CI 7.32, 43.57), history of laparotomy (OR 1.34, 95% CI 1.02, 1.78), presence of adhesions (OR 2.30, 95% CI 1.37, 3.76), and intraoperative technical difficulty (OR 17.86, 95% CI 7.32, 43.57). Age, parity, bowel injury, vascular injury, and history of PID and endometriosis were not correlated with conversion. Converted cases were associated with significantly greater estimated blood loss (p <0.001), longer operating room time (p <0.001), and longer hospital stay (p <0.001). Conclusion. Both patient and surgeon factors predispose to failed laparoscopy. By understanding the risks of laparoscopic failure, surgeons will be able more accurately to select the best mode of surgical access and counsel patients during preoperative assessment.
248. Safety of Gas Laparoscopy under Low Intraabdominal Pressure A Takashirna, T Kinoshita, N Mauya, K Miyake, K Otaka, T Yano. Toho University, School of Medicine, Sakura, Japan.
Objective. To investigate the safety of gas laparoscopy performed under low-pressure pneumoperitoneum. Measurements and Main Results. Pneumoperitoneum was established at a pressure of 5 mm Hg using automatic pneumoperitoneum equipment through the Optiview inserted directly beneath the umbilicus. Arterial pressure of CO2 and blood pressure were evaluated
$75
Poster Presentations
250. Increased Activated Mast Cells in Stromal Lesions of Human Endometriosis 11Uchiide, 2T Ihara, 2M Sugamata. 1Department of Pathology, Japanese Red Cross Omori Hospital, Ota-Ku, Tokyo, Japan; 2Department of Pathology, Tochigi Institute of Clinical Pathology, Minamiakatsuka, Shimotsuga-Gun, Japan.
before and 30 minutes after inflation, and after deflation of CO2. In 11 patients surgery was completed with optimal visual field and without complications at 5 mm Hg pneumoperitoneum. Pneumoperitoneum pressure of 8 to 10 mm Hg was required in three cases to ensure optimal visual field. The BMI of these three women was over 25. Blood pressure did not fluctuate significantly in any patient. Increased PaCO2 at 30 minutes after inflation was 1.5 mm Hg in cases with 5 mm Hg pneumoperitoneum pressure. In three women who required 8 to 10 mm Hg of pneumoperitoneum, PaCO2 increased 3 mm Hg. Conclusion. Low pneumoperitoneum pressure of 5 mm Hg produced only transient changes in PaCO2, suggesting safety of gas laparoscopy.
Objective. To describe light and electron microscopy to examine in detail morphologic alterations of stromal endometriotic cells from 53 patients with classic endometriosis. Measurements and Main Results. Endometriotic lesions of women were identified and resected laparoscopically. Eutopic endometrium was obtained from patients both with and without endometriosis as a comparative control. In all endometriosis lesions, diffuse infiltration of numerous mast cells was observed throughout the stromal lesions, and most of these mast cells exhibited activation and degra3mlation. Scattered granules were also present. In eutopic endometrium of women with endometriosis, mast cells were rarely detected. Conclusion. These results suggest that abnormal immune responses, particularly hypersensitivity reactions, are strongly related to the occurrence and proliferation of endometriosis. We believe that our findings will be helpful in developing methods to prevent and treat endometriosis.
249. A New Uterine Manipulator for Laparoscopic Surgery H Tintara. Department of Obstetrics and Gynecology, Hat-Yai, Songkla, Thailand. Objective. To describe a new device to improve uterine manipulation during gynecologic laparoscopic surgery. Measurements and Main Results. The new uterine manipulator (Karl Storz Endoscope, Tuttlingen, Germany) consists of a shaft, pivoting head, locking system, and handle with ergonomic design. It allows anteversion of the uterus up to 90 degrees, with a marker indicating the position of the uterus, and is freely mobile bilaterally. The shaft, which consists of rods, is easy to clean and maintain. The changeable intrauterine obturator has a diameter of 5 mm with three standard lengths of 6, 8, and 10 cm connected to the pivoting head with a screw. All parts of the device are reusable and autoclavable. The device can be retained on the uterine cervix using spring-load hooking to the tenaculum. The device is lightweight, has an easy-to-operate locking system, and can be managed with one hand. Initial experience in 60 cases of adnexal surgery and 30 LAVH cases was good, without trauma to cervix or uterus. Conclusion. This hand-held, reusable uterine manipulator is expected to improve the ease of laparoscopic surgery, especially in cases in which it is not necessary to enter the vagina.
251. Laparoscopic Vaporization of PCOS with the Nd:YAG Laser T Yano, S Fukaya, T Kinoshita, K Otaka, A Yokoyama. Toho University, School of Medicine, Sakura, Japan. Objective. To assess the effectiveness of Nd:YAG laser vaporization for treatment of PCOS. Measurements and Main Results. Twelve infertile women whose PCOS did not respond to clomiphine citrate underwent laparoscopic vaporization with Nd:YAG laser, using multiform fiber for vaporization at power setting of 20 W. Their LH value decreased from 11.2 + 7.2 mlU/ml before to 5.9 + 3.0 mlU/ml after operation. The LH:FSH ratio also decreased from 1.8 + 7.2 to 0.8 + 0.3 before and after the operation, respectively. Of 24 ovaries of 12 women, follicles were observed in 22 (92%) after surgery. Seven patients (58%) conceived in an average of 7.4 months.
$76