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Identification of “subtle” adhesions?
Douglas and the abnormalities that might be present, specifically endometriosis or tumors. J. Marik, M.D. Institute for Reproductive Medicine and Genetic Testing Los Angeles, California June 4, 2001
Reference 1. Brosens I, Gordts S, Campo R. Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriatic adhesions of the ovary. Fertil Steril 2001;75:1009 –12.
PII S0015-0282(01)02849-7
Reply of the Authors: The comments of a seasoned laparoscopist such as Dr. Marik on our paper (1) are well received, and we appreciate the opportunity to specify the characteristics of transvaginal hydrolaparoscopy (THL) versus laparoscopy and culdoscopy. There is indeed much truth in the old wisdom that “a poor workman blames his tools.” When culdoscopy was criticized and eventually abandoned for laparoscopy, Decker and Cherry (2) probably thought that failures and complications were to be blamed on the surgeon. However, they are now more frequently attributed to the surgical approach. Why, after more than 50 years, is the culdoscopic approach being revived? Transvaginal hydrolaparoscopy uses the same approach as culdoscopy but differs in major aspects. First, THL is safer. Whereas bowel injury during culdoscopy or laparoscopy requires diagnosis and repair, the nonleaking rectal injury of less than 5 mm caused by the THL needle can be managed expectantly. In contrast with culdoscopy, surgery is performed without exteriorization of tissues. Second, THL is more acceptable to the patient because it is done in the dorsal lithotomy position; saline (which provokes no irritation) is used and local anesthesia, conscious sedation, or general anesthesia may be given (3). Finally, the transvaginal access in combination with the hydro-technique allows strict application of the principles of atraumatic surgery. The latter includes physiologic exposure of the tuboovarian structures, manipulation without grasping, visualization of the microvasculization, and accurate coagulation to achieve bloodless reconstructive surgery (4). The indications for THL are likely to be the same as for culdoscopy. Culdoscopy was found to be a superior technique for diagnosis of infertility and study of physiology (2). Recent studies, such as that by Darai et al. (5), have confirmed the accuracy of THL in infertility diagnosis, and for the first time, the process of fimbrial ovum retrieval in the human was observed and documented during THL (6). Clearly, a patient with suspected bladder or diaphragmatic endometriosis will not benefit from THL, but in other instances, the preoperative assessment and the choice of the FERTILITY & STERILITY威
appropriate technique will make the difference between the poor and the experienced surgeon. I. Brosens, M.D., Ph.D. S. Gordts, M.D. R. Campo, M.D. Leuven Institute for Fertility and Embryology Leuven, Belgium June 23, 2001
References 1. Brosens I, Gordts S, Campo R. Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriatic adhesions of the ovary. Fertil Steril 2001;75:1009 –12. 2. Decker A, Cherry TH. Culdoscopy. Am J Surg 1944;64:40 – 4. 3. Gordts S, Campo R, Brosens I. Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions. J Am Assoc Gynecol Laparosc 2000;7:45–9. 4. Gordts S, Campo R, Brosens I. Operative transvaginal hydrolaparoscopy of a large ovarian ondometrioma. Gynaecol Endosc 2000;9:227–31. 5. Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study. Hum Reprod 2000;15:2379 – 82. 6. Gordts S, Campo R, Rombauts L, Brosens I. Endoscopic visualization of the process of fimbrial ovum retrieval in the human. Hum Reprod 1998;13:1425– 8.
PII S0015-0282(01)02850-3
Tissue damage variables: energy source and operator To the Editor: While we support efforts at improving our understanding of the tissue effects of the various energy sources used at surgery, including endoscopic surgery, we have several concerns about the paper by Tulikangas et al. (1). The authors purport to show that “monopolar cautery” has “the most lateral spread of thermal energy,” whereas the CO2 laser causes the least deep-tissue injury. The first concern is the lack of a defined goal for the investigation. It would seem that the authors are not evaluating the tissue injury associated with transection of tissue, but instead, are evaluating coagulation effects associated with prolonged and subjective application of the energy source. This is not stated in the objectives and is critically important in the interpretation of these results. With respect to the infundibulopelvic ligament, the authors are apparently simulating coagulation of a narrow blood vessel before transection, a procedure that is frequently performed clinically using ultrasonic instruments or, more commonly, electrosurgery (bipolar or monopolar instrumentation). By using visual cues alone, coagulation and transection were successively performed intuitively rather than by standardization for waveform, power setting, application time, electrode surface area, and coaptive force. However, CO2 laser energy is not used clinically for this purpose, in part because of a lack of clinical efficacy at coaption of blood vessels for hemostasis. Consequently, it is unclear why this method was evaluated in 1081
Reference 1. Brosens I, Gordts S, Campo R. Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriatic adhesions of the ovary. Fertil Steril 2001;75:1009 –12.
PII S0015-0282(01)02849-7
Reply of the Authors: The comments of a seasoned laparoscopist such as Dr. Marik on our paper (1) are well received, and we appreciate the opportunity to specify the characteristics of transvaginal hydrolaparoscopy (THL) versus laparoscopy and culdoscopy. There is indeed much truth in the old wisdom that “a poor workman blames his tools.” When culdoscopy was criticized and eventually abandoned for laparoscopy, Decker and Cherry (2) probably thought that failures and complications were to be blamed on the surgeon. However, they are now more frequently attributed to the surgical approach. Why, after more than 50 years, is the culdoscopic approach being revived? Transvaginal hydrolaparoscopy uses the same approach as culdoscopy but differs in major aspects. First, THL is safer. Whereas bowel injury during culdoscopy or laparoscopy requires diagnosis and repair, the nonleaking rectal injury of less than 5 mm caused by the THL needle can be managed expectantly. In contrast with culdoscopy, surgery is performed without exteriorization of tissues. Second, THL is more acceptable to the patient because it is done in the dorsal lithotomy position; saline (which provokes no irritation) is used and local anesthesia, conscious sedation, or general anesthesia may be given (3). Finally, the transvaginal access in combination with the hydro-technique allows strict application of the principles of atraumatic surgery. The latter includes physiologic exposure of the tuboovarian structures, manipulation without grasping, visualization of the microvasculization, and accurate coagulation to achieve bloodless reconstructive surgery (4). The indications for THL are likely to be the same as for culdoscopy. Culdoscopy was found to be a superior technique for diagnosis of infertility and study of physiology (2). Recent studies, such as that by Darai et al. (5), have confirmed the accuracy of THL in infertility diagnosis, and for the first time, the process of fimbrial ovum retrieval in the human was observed and documented during THL (6). Clearly, a patient with suspected bladder or diaphragmatic endometriosis will not benefit from THL, but in other instances, the preoperative assessment and the choice of the FERTILITY & STERILITY威
appropriate technique will make the difference between the poor and the experienced surgeon. I. Brosens, M.D., Ph.D. S. Gordts, M.D. R. Campo, M.D. Leuven Institute for Fertility and Embryology Leuven, Belgium June 23, 2001
References 1. Brosens I, Gordts S, Campo R. Transvaginal hydrolaparoscopy but not standard laparoscopy reveals subtle endometriatic adhesions of the ovary. Fertil Steril 2001;75:1009 –12. 2. Decker A, Cherry TH. Culdoscopy. Am J Surg 1944;64:40 – 4. 3. Gordts S, Campo R, Brosens I. Office transvaginal hydrolaparoscopy for early diagnosis of pelvic endometriosis and adhesions. J Am Assoc Gynecol Laparosc 2000;7:45–9. 4. Gordts S, Campo R, Brosens I. Operative transvaginal hydrolaparoscopy of a large ovarian ondometrioma. Gynaecol Endosc 2000;9:227–31. 5. Darai E, Dessolle L, Lecuru F, Soriano D. Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study. Hum Reprod 2000;15:2379 – 82. 6. Gordts S, Campo R, Rombauts L, Brosens I. Endoscopic visualization of the process of fimbrial ovum retrieval in the human. Hum Reprod 1998;13:1425– 8.
PII S0015-0282(01)02850-3
Tissue damage variables: energy source and operator To the Editor: While we support efforts at improving our understanding of the tissue effects of the various energy sources used at surgery, including endoscopic surgery, we have several concerns about the paper by Tulikangas et al. (1). The authors purport to show that “monopolar cautery” has “the most lateral spread of thermal energy,” whereas the CO2 laser causes the least deep-tissue injury. The first concern is the lack of a defined goal for the investigation. It would seem that the authors are not evaluating the tissue injury associated with transection of tissue, but instead, are evaluating coagulation effects associated with prolonged and subjective application of the energy source. This is not stated in the objectives and is critically important in the interpretation of these results. With respect to the infundibulopelvic ligament, the authors are apparently simulating coagulation of a narrow blood vessel before transection, a procedure that is frequently performed clinically using ultrasonic instruments or, more commonly, electrosurgery (bipolar or monopolar instrumentation). By using visual cues alone, coagulation and transection were successively performed intuitively rather than by standardization for waveform, power setting, application time, electrode surface area, and coaptive force. However, CO2 laser energy is not used clinically for this purpose, in part because of a lack of clinical efficacy at coaption of blood vessels for hemostasis. Consequently, it is unclear why this method was evaluated in 1081