FERTILITY AND STERILITY Copyright
Vol. 42, No.4, October 1984 Printed in U.8A.
1984 The American Fertility Society
Evaluation of adhesion reformation by early second-look laparoscopy following microlaser ovarian wedge resection*t
David S. McLaughlin, M.D.t Department of Obstetrics and Gynecology, Wright State University; Miami Valley Reproductive Center, Dayton, Ohio
Early second-look laparoscopy, done 6 to 12 weeks postoperatively, was utilized to evaluate recurrent adhesion formation following microlaser ovarian wedge resection. Forty-nine ovaries in 25 consecutive infertility patients undergoing microlaser surgery for deep ovarian endometriosis or polycystic ovarian disease, refractory to medical treatment, were evaluated from October 1981 through March 1983. All patients subsequently underwent a second-look non laser laparoscopy to evaluate the extent of healing and to bluntly lyse any subsequent adhesions with the Olympus laparoscope (Olympus Corporation, Lake Success, NY) second-puncture probe: 36.7% of the ovaries had recurring adhesions, 83.3% of these adhesions were mild and filmy and 16.7% were moderate and dense. Additionally, four ovaries were viewed approximately 1 year postoperatively, with two ovaries that previously had mild and filmy adhesions lysed at 6 weeks having no recurrent adhesions. The actual pregnancy rate in this study is 60%, with 15 of the 25 patients conceiving at least once and 2 patients conceiving twice. The majority of pregnancies occurred within the first 6 months postoperatively, with the longest initial pregnancy occurring 22 months postoperatively. Thus, microlaser ovarian surgery, coupled with early second-look laparoscopy, appears efficacious in minimizing adhesion reformation and seems to have little adverse effect on subsequent conception. Fertil Steril42:531, 1984
During the past decade, the medical use of the carbon dioxide (C0 2 ) laser has made significant contributions to various surgical specialties-otolaryngology, ophthalmology, and neurosurgery. This has caused many gynecologic microsurgeons
Received April 4, 1984; revised and accepted June 19, 1984. *Presented at the Fortieth Annual Meeting of The American Fertility Society, April 2 to 7, 1984, New Orleans, Louisiana. tColor photographs supported in part by grants from Davis and Geck, Danbury, Connecticut; Olympus Corporation, Lake Success, New York; and American V. Mueller, Chicago, Illinois. :j:Reprint requests: David S. McLaughlin, M.D., Assistant Clinical Professor, Department of Obstetrics and Gynecology, Wright State University; Miami Valley Reproductive Center, 1520 South Main Street, Dayton, Ohio 45409. Vol. 42, No.4, October 1984
to begin to rethink their surgical strategies. However, the intraabdominal application of the CO 2 laser for promoting surgery remains the subject of controversy. 1 Ironically, mechanical sterility may result from adhesion formation following fertility-promoting procedures or conservative pelvic surgery in some patients who wish to maximize their reproductive potential. Ovarian surgery, particularly, is susceptible to peri adnexal adhesion formation, which may jeopardize ovum pickup and tubal transport following ovulation. 2 -4 In this study, the CO 2 laser, as part of a microsurgical procedure, was used to determine whether the incidence of peri adnexal adhesions could be reduced in those infertile women undergoing partial removal of ovarian tissue as treatment for either polycystic ovaries or endometriosis. McLaughlin Microlaser ovarian wedge resection
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MATERIALS AND METHODS
From October 1981 through March 1983, 25 infertility patients from 23 to 35 years of age with 1 to 6 years of infertility were selected by outpatient diagnostic laparoscopy to undergo wedge resection. Follow-up consisted of a minimum of 1 year. Forty-nine ovaries subsequently underwent ovarian surgery; one ovary was removed entirely because of a large endometrioma. Thus, 49 ovaries were evaluated by early second-look laparoscopy 6 to 12 weeks after laser surgery. Four patients had polycystic ovaries without endometriosis, 1 patient had endometriosis without polycystic ovaries, and 20 patients had both polycystic ovaries and endometriosis. The average duration of Clomid (clomiphene citrate, Merrell Dow Pharmaceuticals, Inc., Cincinnati, OR) therapy was 7.5 months in 20 patients. Additional pathology precluded the use of Clomid therapy in five patients. Six patients had been treated previously for endometriosis with Danocrine (danazol, Winthrop Laboratories, New York, NY), but that therapy had not been successful. Endometriosis by stage 5 was as follows: Stage I, one patient; Stage II-A, ten patients; Stage II-B, three patients; Stage II-C, no patients; Stage III, three patients; Stage IV, four patients (Table 1). The protocol used in this study parallels that developed by Daniell at Vanderbilt University for the Intra-abdominal Laser Study Group. The Vanderbilt Protocol included women undergoing intraabdominal infertility surgery (excluding tubal reanastomosis) in which a major portion of the procedure was conducted with the CO 2 laser followed by second-look laparoscopy done within 12 weeks. Nontuboperitoneal infertility factors were evaluated by postcoital tests and basal body temperature charts; these were corrected when necessary. Women who were sensitive to dextran or who had preexisting renal or hepatic disease were excluded. Microlaser surgery was accomplished with a Sharplan 733 CO2 laser (Sharplan, Tel Aviv, Israel), coupling the articulating arm via a micromanipulator to a Zeiss OpMi-6SP/R microscope (Zeiss, Oberkochen, West Germany). Surgical procedures were photodocumented by an Olympus OM10 35 mm camera attached to a beam splitter (Olympus Corporation, Lake Success, NY). The laser's energy was focused through a 300-mm laser lens in conjunction with the 300mm optical objective for the microscope. A sterile drape over the microscope was not used because 532
McLaughlin Microlaser ovarian wedge resection
Table 1. Profile of 25 Infertility Patients Undergoing Microlaser Ovarian Wedge Resection Polycystic ovaries
Primary factor(s) Adhesions Fibroids Adhesions and fibroids Bicornuate uterus Adhesions and bicornuate uterus Stage Stage Stage Stage Stage Stage
I II-A II-B II-e III IV
Endome· triosis
1 2
Polycystic ovaries + Endome· endometriosis by stage triosis
9 6 3 1
1 1
1 1
10 3
o 3 4
the laser's energy would melt the plastic at the exit port. A sterile field was maintained by using sterile rubber knobs to cover the microscope adjustments; the end of a sterile straight urinary catheter to cover the joystick on the microslad; and shortened, ebonized stainless steel instruments specifically designed to prevent accidental contamination by the nonsterile microslad. 6 Although technically more difficult to learn, the improved magnification and light offered with the microscope increased the precision in ablating abnormal tissue. 7 After the abdomen was opened with sharp and electrocautery dissection, the microscope was brought over the surgical field. Moistened nonwoven packs were used to insulate vital intraabdominal structures. 8 Shortened ebonized laser instruments were used to prevent reflection of the laser's beam to bowel, bladder, and blood vessels, as well as to prevent contamination of the instruments from the non sterile microscope. McLaughlin quartz rods (American V. Mueller, Chicago, IL) which have been shown to safely absorb tbe CO 2 laser's energy with a minimum of laser fatigue, were used as a backstop. McLaughlin rhodium mirrors (American V. Mueller) were also used to reflect the laser beam to inaccessible pelvic areas. 6 The CO2 laser was used in the continuous mode with a spot size of 0.5 mm. Low-power densities at 1200 W/cm 2 were used to vaporize superficial ovarian adhesions and endometriosis, and higher power densities at 18,000 W/cm 2 were used to excise ovarian tissue. The site was irrigated with a heparinized Ringer's solution (1000 U heparin/lOOO ml Ringer's lactate). If bleeding was encountered, electrocautery was used, delivFertility and Sterility
Table 2. Pregnancies TIme from laser surgery
No.ofpatients pregnant
Pregnancies
mo
0-6 6--12 12-18 18-24 24--30 Total
8 5 1 1
8 5 2 1 1
15
17
ered by a needle electrode from a Bovie unit (Valleylab, Boulder, CO) with the coagulation power set at 20. In removing a wedge for polycystic ovaries, a posterior-lateral elliptical incision was made on the ovary after grasping the ovarian ligament with carbide-tipped Babcock clamps (American V. Mueller) (Fig. 1). Micro-Allis clamps (American V. Mueller), which are carbide-tipped to prevent avulsion of the ovarian cortex, were used to provide traction and countertraction to the laser incision. If troublesome bleeding occurred after removing the wedge, electrocautery was judiciously utilized, with a hemostatic 4-0 Surgilon (Davis and Geck, Danbury, CT) figure-eight suture placed as needed. When hemostasis was assured, two layers of continuous 4-0 Surgilon were placed prior to closing the ovarian cortex with continuous 6-0 Surgilon (Fig. 2). If an endometrioma > 2 cm was encountered, the endometrial cyst was unroofed by making an elliptical incision with the laser with a power density of 18,000W/cm2 (Fig. 3). The cyst was dissected free from the normal ovarian tissue with the same power density. If the entire cyst wall could not be removed at the base, the remainder of the endometriosis tissue was vaporized at a power density of 1200 W/cm 2 • Hemostasis was assured, and the ovary was closed in simi1ar fashion with two subcortical layers of continuous 4-0 Surgilon and a cortical layer of continuous 6-0 Surgilon. The uteroovarian ligament was foreshortened with interrupted 2-0 Surgilon by attaching it to the posterior-lateral aspect of the uterus. The remainder of the surgical procedure was accomplished for other disease; and prior to closing the peritoneum, 200 ml of Hyskon (32% dextran 70, Hyskon Division, Pharmacia, Piscataway, NJ) was used. Although systemic antibiotics were used prophylactically, no systemic or intraperitoVol. 42, No.4, October 1984
neal steroids, progesterone, antihistamines, or antiprostaglandin agents were used. Six to 12 weeks following intraabdominal microlaser ovarian wedge resection, each patient underwent an outpatient laparoscopy to evaluate pelvic findings, which were photographed. The ovarian incisions were evaluated; and if adhesions were present, they were categorized as mild and filmy (thin, translucent, nonvascular, easily lysed by blunt dissection with the laparoscope probe), or moderate and dense (thicker, opaque, moderately vascular, requiring no hemostatic efforts after lysis). All adhesions were lysed bluntly by using the second-puncture laparoscope probe without the application of any laser energy; the pelvis was then irrigated with normal saline (Figs. 4 and 5).
RESULTS Nine patients were followed for 12 to 18 months after surgery, eight patients were followed for 18 to 24 months after surgery, and nine patients were followed for 24 to 30 months after surgery. Four of the 25 patients were advised to use contraception for 6 months because of concomitant uterine surgery. Seventeen pregnancies occurred in 15 patients, for an actual pregnancy rate of 60% (Table 2). At second-look laparoscopy, adhesion reformation was found to the ovarian suture line in 18 of 49 ovaries (36.7%). Mild and filmy adhesions occurred in 83.3%, and moderate and dense adhesions occurred in 16.7% (Table 3). All were lysed at the time of second-look laparoscopy. Two patients with suspected ectopic pregnancies underwent laparoscopy at approximately 1 year after original laparotomy. These long-interval laparoscopies allowed for review and evaluation of previous surgery. Although each had pain Table 3. Recurrent Adhesions to Ovarian Incision at Early Second-Look Laparoscopy %By % Total type of ovaries adhesion
No. of patients
No. of ovaries
Mild and filmy" Moderate and dense b
11
3
15 3
30.6 6.1
83.3 16.7
Total
14
18
36.7
100.0
"Thin, translucent, nonvascular, easily lysed by blunt dissection with the laparoscope probe. ~icker, opaque, moderately vascular, requiring no hemostatic efforts after lysis.
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All photographs were taken with an Olympus OM2 N camera with CLE-F light source or with an Olympus OMIO camera.
Figure 1 View of microlaser ovarian incision. Notice the hemostasis and moistened nonwoven sponges.
Figure 2 Continuous 6-0 Surgilon suture approximates the ovarian cortex after placement of two continuous subcortical .4-0 Surgilon sutures.
Figure 3 Unroofed endometrioma showing the base of an endometrial cyst. 534
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Figure 4 Early second-look laparoscopic view of mild pelvic adhesions before lysis.
Figure 5 Early second-look laparoscopic view of an ovarian adhesion after lysis. Notice the healing suture line.
Figure 6 Long-interval laparoscopic view of ovarian incision 1 year after microlaser ovarian wedge resection. (Note: No subsequent adhesions had reformed after lysis at early second-look laparoscopy.) Vol. 42, No.4, October 1984
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due to a hemorrhagic corpus luteum cyst and neither was found to have an ectopic pregnancy, both were free of periadnexal adhesions. Particularly revealing was the fact that one patient who had mild adhesions lysed at the 6-week interval was free of adhesions 1 year later (Fig. 6). Also, the other patient, who had no adhesions at the 6week interval, appeared to have no subsequent adhesions 1 year later. DISCUSSION POLYCYSTIC OVARIES
Although it has been observed since 1906 that wedge resection of a polycystic ovary stimulated ovulation, 9 bilateral ovarian wedge resection for polycystic ovaries has been done less frequently to induce ovulation because of the availability of clomiphene citrate as well as the risk of subsequent adhesions following surgery.2-4,9-11 However, with the introduction of microsurgical technique, several authors2, 3, 9, 11 echo the need for reevaluation of this surgical adjunct for anovulation. This is due to the fact that bilateral ovarian wedge resection effectiveness has been shown to be quite therapeutic, with actual pregnancy rates varying from 47.8% to 66%.9-11 ENDOMETRIOSIS
Endometriosis has been shown to be present in up to 21% of infertile patients, as opposed to 4% of control subjects. 12 Medical and surgical treatment have been shown to be effective, depending on the severity of disease. 13 Recently, Baggish and Chong1, 7, 14 have adapted the CO2 laser to eradicate endometriosis, the laser's advantages being precision, hemostasis, and the ability to reach inaccessible areas. In five cases evaluated by early second-look laparoscopy, no adhesions were present. 14 The pregnancy rate reported by these two authors 14 was 60.8%, and less than onethird were followed for more than 1 year. LASER
Although the first laser was devised by Schawlow and Townes in 1958,15 it was not adapted to gynecology until 1974. Since then, it has been used in many human and animal experiments. 1, 7, 14, 16-19 Because the application of the CO 2 laser to human reproductive biology is unique, the gynecologist must have an adequate 536
McLaughlin Microlaser ovarian wedge resection
understanding ofthe laser's advantages and limitations in order to use this new, "no-touch" technique safely. For example, the laser is particularly advantageous when reflecting it off a rhodium mirror to precisely ablate endometriosis adhering an ovary to the pelvic side walls. 6, 7,14 The laser is also able to unroof and partially excise a large endometrioma by vaporizing the remaining endometriosis in the base of the cyst while preserving more surrounding normal ovarian tissue. 7, 14 Its precision and hemostatic properties may also be advantageous in performing a wedge resection for polycystic ovaries. Additionally, by using early second-look laparoscopy to evaluate surgical healing following laser surgery, the infertile couple may be better informed regarding their prognosis for conception, and any adhesions which may develop following microlaser surgery can be lysed prior to vascularization. In summary, it is apparent from this study that the CO2 laser, coupled with the operating microscope, is another useful instrument in the performance of ovarian surgery. As seen from this small number of patients with short follow-up, adhesion reformation appears minimal, and there has been no deleterious effect on subsequent conception. These findings indicate that further studies using the CO2 laser are warranted. Moreover, this study seems to indicate that microlaser ovarian wedge resection may be considered therapeutic for females with polycystic ovaries refractory to previous medical treatment.
REFERENCES 1. Baggish MS: Status of the carbon dioxide laser for infer-
tility surgery. Fertil Steril 40:442, 1983 2. Eddy CA, Asch RH, Balmaceda JP: Pelvic adhesions following microsurgical and macrosurgical wedge resection of the ovaries. Fertil Steril 33:557, 1980 3. Buttram VC Jr, Vaquero C: Post-ovarian wedge resection adhesive disease. Fertil Steril 26:874, 1975 4. Toaff R, Toaff ME, Peyser MR: Infertility following wedge resection of the ovaries. Am J Obstet Gynecol 124:92, 1976 5. Kistner RW, Siegler AM, Behrman SJ: Suggested classification for endometriosis: relationship to infertility. Fertil Steril 28:1008, 1977 6. McLaughlin DS: Advanced surgical instrumentation needed for intraabdominal application of the carbon dioxide laser in reproductive biology. Lasers Surg Med 2:241, 1983 7. Chong AP, Baggish MS: Management of pelvic endometriosis by means of intraabdominal carbon dioxide laser. Fertil Steril 41:14, 1984 Fertility and Sterility
8. Swolin K, Bendz A, Larsson B, Tronstad SE, Bengtsson R, Hamberger L, Svanberg S: Traumatization of the abdominal serosa: a comparison between non-woven and cotton abdominal swabs. Acta Curr Scand 140:203, 1974 9. Yen SSC: The polycystic ovary syndrome. Clin Endocrinol (Ox!) 12:177, 1980 10. Lunde 0: Polycystic ovary syndrome: a retrospective study of the therapeutic effect of ovarian wedge resection after unsuccessful treatment with clomiphene citrate. Am ChiI' Gynecol 71:330, 1982 11. Adashi EY, Rock JA, Guzick D, Wentz AC, Jones GS, Jones HW Jr: Fertility following bilateral ovarian wedge resection: a critical analysis of 90 consecutive cases of the polycystic ovary syndrome. Fertil Steril 36:320, 1981 12. Strathy JH, Molgaard CA,. Coulam CB, Melton LJ III: Endometriosis and infertility: a laparoscopic study of endometriosis among fertile and infertile women. Fertil Steril 38:667, 1982 13. Buttram VC Jr: Conservative surgery for endometriosis in the infertile female: a study of 206 patients with implications for both medical and surgical therapy. Fertil Steril31:117,1979
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14. Baggish MS, Chong AP: Intra-abdominal surgery with the CO 2 laser. J Reprod Med 28:269, 1983 15. Schawlow AL, Townes CH: Infra-red and optical lasers. Physiol Rev 112:1940, 1958 16. Baggish MS, Chong AP: CO2 laser microsurgery of the uterine tube. Obstet Gynecol 58:111, 1981 17. Klink F, Grosspietzsch R, von Klitzing L, Endell W, Husstedt W, Oberheuser F: Animal in vivo studies and in vitro experiments with human tubes for end-to-end anastomotic operation by a CO2 laser technique. Fertil Steril30:100, 1978 18. McLaughlin DS: Micro-laser myomectomy technique to enhance reproductive potential: a preliminary report. Lasers Surg Med 2:107,1982 19..Bellina JH: Microsurgery of the fallopian tube with CO2 laser: 82 cases with follow-up. Lasers Surg Med 2:129, 1982
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