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Diagnostic laparoscopy
Selected Scientific Abstracts
4.8 vs 25.4 +_ 5.5 yrs, 6.5 +_0.9 vs 6.8 +_0.8 vs 7.1 +_ 0.9 cm, p <0.05). Seven patients (63.6%) in the aspiration group, five (41.7%) in the fenestration group, and two (14.3%) in the resection group had cyst recurrence on the operated side. The difference in the rate of recurrences was significant (p <0.05), being significantly less in the resection group than in the others. Although the trend for cyst formation was less in the fenestration group than the aspiration group, the difference did not reach statistical significance. We conclude that managing ovarian cystic masses by aspiration and fenestration resulted in significantly greater recurrence than resection of the cyst wall. Therefore it is more appropriate to manage these masses by resection during laparoscopic surgery when feasible. This also provides sufficient material for pathologic diagnosis. Endometrial Ablation With the Nd:YAG Laser and Roller Ball RH Taylor. Department of Laser Surgery, Alta View Hospital, Salt Lake City, UT.
Endometrial ablation, an effective treatment for intractable uterine bleeding, can be performed with hysteroscopic rollerball cautery, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, and endomyometrial resection techniques. Between November 1990 and January 1995, 49 women underwent ablation with the Nd:YAG laser and a nontouch technique on the ostiae, uterine fundus, and upper one-third to one-half of the posterior uterine wall, in combination with rollerball cautery over the entire uterus after the 60-W Nd:YAG application. The power source of the rollerball was set at 80 W of pure coagulation current in most cases. Each patient was pretreated with a gonadotropin-releasing hormone agonist or an antiestrogenic compound. The complications were one uterine perforation with a dilator with no sequelae, and one severe infection requiring hysterectomy. There were no failures. Complete amenorrehea was achieved in 44 women (90%). Two continued to spot very slightly on occasion, but did not require pads. Three women had light flow requiring one to two tampons for 1 to 4 days every month. The technique continues to provide a very high rate of complete amenorrhea.
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Laparovaginal Treatment of Uterine Procidentia DA Tsin, G Whang, RE Granato. Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY.
A modified sling procedure done by laparoscopy achieves functional vaginal reconstruction and avoids the potentially dangerous bleeding associated with the sacral fixation. In our experience sacrospinous fixation affords limited visualization, and the laparoscopic vaginal sling procedure may be a better alternative. It allows the surgeon to perform a simultaneous laparoscopic correction of urinary stress incontinence that is frequently associated with vaginal eversion.
Laparoscopic Supracervical Hysterectomy in a Patient With von Willebrand Disease DA Tsin, RJ Sequeira, V Cepellos. Department of Gynecology, Astoria General Hospital, Astoria, NY.
A woman with von Willebrand disease, severe menorrhagia, adenomyosis, and pelvic adhesions underwent laparoscopic lysis of adhesions, laparoscopic supracervical hysterectomy with uterine hemisection, and extraction through a 3.3-ram port. We approached this case by first organizing a team that included experienced laparoscopists and a hematologist, thereby addressing preoperative hematologic preparation, intraoperative strategy, and postoperative management.
Diagnostic Laparoscopy VA Tzingounis, E Cardamakis, GP Lioutas, AP Pappas. Department of Obstetrics and Gynecology, Division of Gynaecologic Endoscopy, University of Patras, Rio, Greece.
From 1980 to 1994 we performed laparoscopies in 1805 women (age 16-56 yrs, mean 36 yrs) for primary or secondary sterility and acute or chronic pelvic pain. Of these, 1480 (81.99%) were diagnostic and 325 (18.01%) were operative. Findings were normal in 384 women (21.3%) and revealed pathology in 1421 (78.7%). The most frequent findings were adhesions (496, 27.5%), endometriosis (244, 13.5%), hydrosalpinges and pyosalpinges (54, 3%), and ovarian tumors (97, 5.4%). Indications for operative laparoscopy were adhesions (686, 38%), uterus resuscitation (104, 5.7%), electrocoagulation of endometrial focus (70, 3.9%), and removal of large periovarian cysts (54, 3%). Complications during the procedure were upper back pain (4,
August 1995, Vol. 2, No. 4. Supplement The Journal of the American Association of Gynecologic Laparoscopists
0.21%), cardiac arrhythmia (5, 0.27%), and escape of carbon dioxide in the peritoneum (2, 0.14%) and subcutaneously (3, 0.18%). In only one woman was it necessary to perform laparotomy to stop bleeding.
shows the role of hysteroscopy in detecting endometrial pathology.
Hysteroscopic Treatment of Complete Uterine Septa With Septate Cervix
E Valli, D Marconi, E Zupi, E Solima, C Fabiani, C Romanini. Department of Obstetrics and Gynecology "Tor Vergata," University of Rome, Rome, Italy.
Indications for and Limitations of Diagnostic Hysteroscopy With Liquid Distention
RF Valle. Northwestern University Medical School, Chicago, IL.
Diagnostic hysteroscopy is a useful alternative to traditional dilatation and curettage. It is performed usually with carbon dioxide (CO2) distention of the uterine cavity, which allows good visualization of the endometrial surface except in the case of bleeding. It is associated with a 5% to 10% failure rate. We performed hysteroscopy with liquid medium distention in 46 women with mild or moderate uterine bleeding who had an an unsatisfactory CO2 hysteroscopy. No complications occurred. In 31 women (67.3%) lesions were detected, in 13 (28.2%) no endometrial abnormalities were found, and in 2 (4.3%) we could not perform any evaluation because of cervical stenosis. We believe distention with liquid medium is effective in cases of bleeding. It can provide good visualization of lesions often missed at dilatation and curettage, thus adding to the indications for hysteroscopy.
Hysteroscopy is the treatment of choice for symptomatic partial and complete uterine septa. As experience expanded, treatment of complete uterine septa with septation of the cervix has also been performed. One hundred twenty-four women with septate uterus were treated hysteroscopically. Seven of them had a uterine septum involving the uterus and cervix. All but nine women were infertile. Many previously pregnant patients experienced repeat pregnancy loss for no reason other than uterine septation. Preoperative reproductive performance included 299 pregnancies, of which 258 (86.2%) ended in spontaneous abortion and 28 (1.7%) resulted in preterm delivery of viable infants. After treatment, 101 (81.3 %) women achieved pregnancy. There were 84 term deliveries (83.1%) and 7 preterm deliveries of viable infants (6.9%). Twelve women (11.8%) had spontaneous abortions, all in the first trimester, and 23 (18.5 %) did not become pregnant. Of the seven patients with complete uterine septum, including the cervix, six delivered an infant at term, one by cesarean section at 41 weeks because of breech presentation, and the other five by vaginal delivery at 38, 37.5, 39, 39, and 40 weeks, respectively. Hysteroscopic treatment of the septate uterus can thus be extended to practically all types of uterine septa, including those involving the cervix.
Microsurgical Laparoscopy I'2BJ van Herendael, 2T Slangen. 1AZ Jan Palfijn Lange Bremstraat, Merksem, Belgium; 2Ospedale Del Circolo, University of Varese, Varese, Italy.
The use of small otolaryngology instruments such as needle holder and counter needle make it possible to manipulate 7-0 and 8-0 sutures. The position of the additional entry point has to be altered, as the instruments are shorter than the classic laparoscopic instruments. The grasping forceps used as a needle holder allows the small needles to be grasped correctly and with more ease than their larger counterparts. Moving the needle toward and in the tissue becomes feasible. In using these instruments is is possible to perform specific procedures microsurgically. The magnification of the laparoscope can be enhanced by a loupe between the eyepiece and the camera. The endoloupe allows twofold magnification. The zoom system of the camera allows even greater magnification. A digital visualization system allows for greater contrast so that it is easier to see small needles. We used the microsur-
Hysteroscopic Findings in Patients Treated With Tamoxifen E Valli, D Marconi, E Zupi, E Solima, C Fabiani, C Romanini. Department of Obstetrics and Gynecology "Tor Vergata," University of Rome, Rome, Italy.
We performed transvaginal ultrasound, hysteroscopy, and endometrial biopsy to determine the prevalence and appearance of endometrial benign and malignant lesions in 79 postmenopausal women (mean age 61.5 yrs) treated with tamoxifen after surgery for breast cancer. Pathologic findings were seen in 68 patients, including adenocarcinoma in 2. Our results
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4.8 vs 25.4 +_ 5.5 yrs, 6.5 +_0.9 vs 6.8 +_0.8 vs 7.1 +_ 0.9 cm, p <0.05). Seven patients (63.6%) in the aspiration group, five (41.7%) in the fenestration group, and two (14.3%) in the resection group had cyst recurrence on the operated side. The difference in the rate of recurrences was significant (p <0.05), being significantly less in the resection group than in the others. Although the trend for cyst formation was less in the fenestration group than the aspiration group, the difference did not reach statistical significance. We conclude that managing ovarian cystic masses by aspiration and fenestration resulted in significantly greater recurrence than resection of the cyst wall. Therefore it is more appropriate to manage these masses by resection during laparoscopic surgery when feasible. This also provides sufficient material for pathologic diagnosis. Endometrial Ablation With the Nd:YAG Laser and Roller Ball RH Taylor. Department of Laser Surgery, Alta View Hospital, Salt Lake City, UT.
Endometrial ablation, an effective treatment for intractable uterine bleeding, can be performed with hysteroscopic rollerball cautery, neodymium:yttrium-aluminum-garnet (Nd:YAG) laser, and endomyometrial resection techniques. Between November 1990 and January 1995, 49 women underwent ablation with the Nd:YAG laser and a nontouch technique on the ostiae, uterine fundus, and upper one-third to one-half of the posterior uterine wall, in combination with rollerball cautery over the entire uterus after the 60-W Nd:YAG application. The power source of the rollerball was set at 80 W of pure coagulation current in most cases. Each patient was pretreated with a gonadotropin-releasing hormone agonist or an antiestrogenic compound. The complications were one uterine perforation with a dilator with no sequelae, and one severe infection requiring hysterectomy. There were no failures. Complete amenorrehea was achieved in 44 women (90%). Two continued to spot very slightly on occasion, but did not require pads. Three women had light flow requiring one to two tampons for 1 to 4 days every month. The technique continues to provide a very high rate of complete amenorrhea.
$54
Laparovaginal Treatment of Uterine Procidentia DA Tsin, G Whang, RE Granato. Department of Obstetrics and Gynecology, Flushing Hospital Medical Center, Flushing, NY.
A modified sling procedure done by laparoscopy achieves functional vaginal reconstruction and avoids the potentially dangerous bleeding associated with the sacral fixation. In our experience sacrospinous fixation affords limited visualization, and the laparoscopic vaginal sling procedure may be a better alternative. It allows the surgeon to perform a simultaneous laparoscopic correction of urinary stress incontinence that is frequently associated with vaginal eversion.
Laparoscopic Supracervical Hysterectomy in a Patient With von Willebrand Disease DA Tsin, RJ Sequeira, V Cepellos. Department of Gynecology, Astoria General Hospital, Astoria, NY.
A woman with von Willebrand disease, severe menorrhagia, adenomyosis, and pelvic adhesions underwent laparoscopic lysis of adhesions, laparoscopic supracervical hysterectomy with uterine hemisection, and extraction through a 3.3-ram port. We approached this case by first organizing a team that included experienced laparoscopists and a hematologist, thereby addressing preoperative hematologic preparation, intraoperative strategy, and postoperative management.
Diagnostic Laparoscopy VA Tzingounis, E Cardamakis, GP Lioutas, AP Pappas. Department of Obstetrics and Gynecology, Division of Gynaecologic Endoscopy, University of Patras, Rio, Greece.
From 1980 to 1994 we performed laparoscopies in 1805 women (age 16-56 yrs, mean 36 yrs) for primary or secondary sterility and acute or chronic pelvic pain. Of these, 1480 (81.99%) were diagnostic and 325 (18.01%) were operative. Findings were normal in 384 women (21.3%) and revealed pathology in 1421 (78.7%). The most frequent findings were adhesions (496, 27.5%), endometriosis (244, 13.5%), hydrosalpinges and pyosalpinges (54, 3%), and ovarian tumors (97, 5.4%). Indications for operative laparoscopy were adhesions (686, 38%), uterus resuscitation (104, 5.7%), electrocoagulation of endometrial focus (70, 3.9%), and removal of large periovarian cysts (54, 3%). Complications during the procedure were upper back pain (4,
August 1995, Vol. 2, No. 4. Supplement The Journal of the American Association of Gynecologic Laparoscopists
0.21%), cardiac arrhythmia (5, 0.27%), and escape of carbon dioxide in the peritoneum (2, 0.14%) and subcutaneously (3, 0.18%). In only one woman was it necessary to perform laparotomy to stop bleeding.
shows the role of hysteroscopy in detecting endometrial pathology.
Hysteroscopic Treatment of Complete Uterine Septa With Septate Cervix
E Valli, D Marconi, E Zupi, E Solima, C Fabiani, C Romanini. Department of Obstetrics and Gynecology "Tor Vergata," University of Rome, Rome, Italy.
Indications for and Limitations of Diagnostic Hysteroscopy With Liquid Distention
RF Valle. Northwestern University Medical School, Chicago, IL.
Diagnostic hysteroscopy is a useful alternative to traditional dilatation and curettage. It is performed usually with carbon dioxide (CO2) distention of the uterine cavity, which allows good visualization of the endometrial surface except in the case of bleeding. It is associated with a 5% to 10% failure rate. We performed hysteroscopy with liquid medium distention in 46 women with mild or moderate uterine bleeding who had an an unsatisfactory CO2 hysteroscopy. No complications occurred. In 31 women (67.3%) lesions were detected, in 13 (28.2%) no endometrial abnormalities were found, and in 2 (4.3%) we could not perform any evaluation because of cervical stenosis. We believe distention with liquid medium is effective in cases of bleeding. It can provide good visualization of lesions often missed at dilatation and curettage, thus adding to the indications for hysteroscopy.
Hysteroscopy is the treatment of choice for symptomatic partial and complete uterine septa. As experience expanded, treatment of complete uterine septa with septation of the cervix has also been performed. One hundred twenty-four women with septate uterus were treated hysteroscopically. Seven of them had a uterine septum involving the uterus and cervix. All but nine women were infertile. Many previously pregnant patients experienced repeat pregnancy loss for no reason other than uterine septation. Preoperative reproductive performance included 299 pregnancies, of which 258 (86.2%) ended in spontaneous abortion and 28 (1.7%) resulted in preterm delivery of viable infants. After treatment, 101 (81.3 %) women achieved pregnancy. There were 84 term deliveries (83.1%) and 7 preterm deliveries of viable infants (6.9%). Twelve women (11.8%) had spontaneous abortions, all in the first trimester, and 23 (18.5 %) did not become pregnant. Of the seven patients with complete uterine septum, including the cervix, six delivered an infant at term, one by cesarean section at 41 weeks because of breech presentation, and the other five by vaginal delivery at 38, 37.5, 39, 39, and 40 weeks, respectively. Hysteroscopic treatment of the septate uterus can thus be extended to practically all types of uterine septa, including those involving the cervix.
Microsurgical Laparoscopy I'2BJ van Herendael, 2T Slangen. 1AZ Jan Palfijn Lange Bremstraat, Merksem, Belgium; 2Ospedale Del Circolo, University of Varese, Varese, Italy.
The use of small otolaryngology instruments such as needle holder and counter needle make it possible to manipulate 7-0 and 8-0 sutures. The position of the additional entry point has to be altered, as the instruments are shorter than the classic laparoscopic instruments. The grasping forceps used as a needle holder allows the small needles to be grasped correctly and with more ease than their larger counterparts. Moving the needle toward and in the tissue becomes feasible. In using these instruments is is possible to perform specific procedures microsurgically. The magnification of the laparoscope can be enhanced by a loupe between the eyepiece and the camera. The endoloupe allows twofold magnification. The zoom system of the camera allows even greater magnification. A digital visualization system allows for greater contrast so that it is easier to see small needles. We used the microsur-
Hysteroscopic Findings in Patients Treated With Tamoxifen E Valli, D Marconi, E Zupi, E Solima, C Fabiani, C Romanini. Department of Obstetrics and Gynecology "Tor Vergata," University of Rome, Rome, Italy.
We performed transvaginal ultrasound, hysteroscopy, and endometrial biopsy to determine the prevalence and appearance of endometrial benign and malignant lesions in 79 postmenopausal women (mean age 61.5 yrs) treated with tamoxifen after surgery for breast cancer. Pathologic findings were seen in 68 patients, including adenocarcinoma in 2. Our results
$55