A. Magos

Experience with the first 250 eridometrial resections for menorrhagia

234 patients with menorrhagia were treated hysteroscopically by transcervical resection of the endometrium (TCRE) instead of hysterectomy. 250 procedures were performed under general anaesthesia (63%) or under sedation plus local anaesthesia (38%). The endometrium was excised either totally (91%) or partially (9%) in all but one case, and 56 (22%) of the patients underwent simultaneous resection of submucous fibroids. Surgical time (range 10-100 min) varied with the gynaecologists experience. 479 ml was the average volume of uterine irrigant absorbed by the patient. Blood loss was usually slight. Operative complications were uncommon, but 4 (2%) women sustained a uterine perforation (without serious sequelae), 7 (3%) absorbed more than 2 litres of fluid, and 1 required tamponade to control postoperative bleeding. Hospital stay was short and full recovery usual by 1-2 weeks. Menstrual symptoms improved in over 90% of the patients throughout the follow-up of up to 2 1/2 years; 27-42% of the women became amenorrhoeic at some time after total TCRE. Results were best in women greater than 35 years of age, but was not influenced by the presence of fibroids or pretreatment dysmenorrhoea. 10 (4%) women later underwent hysterectomy. Hysteroscopy 3 and 12 months after surgery revealed a small, fibrotic uterine cavity in the majority.

Is laparoscopic hysterectomy a waste of time

Laparoscopic hysterectomy (LH) is a way to avoid laparotomy. However, there is evidence that most women treated by abdominal hysterectomy are suitable for vaginal surgery. To test this hypothesis, and to determine the relative merits of laparoscopic and vaginal hysterectomy (VH) and the best technique for LH, we prospectively studied 98 women who had relative contraindications for vaginal surgery by traditional criteria. 75 underwent LH and 23 VH. The LH group included 22 women who had been assigned to this route of surgery as part of a prospective randomised controlled comparison with VH (23 women). Surgery was completed with the intended technique in 93.9% of cases. 5 women in the LH group (6.7%) and 2 in the VH group required laparotomy or additional procedures. In the prospective randomised study LH took longer than VH (mean duration 131 vs 77 min). VH was the faster procedure, irrespective of uterine size and need for oophorectomy. With LH, the operative time increased as more of the hysterectomy was carried out with laparoscopic rather than vaginal dissection. Complication rates, blood loss, analgesia requirements, and recovery were similar for the two techniques. Our study confirms that most hysterectomies could be performed vaginally, and that LH is a much slower procedure. If LH is done, it should be converted to a vaginal procedure as early as possible to reduce the overall operating time. LH does seem to be a waste of time for most patients.

Randomized placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy

Outpatient hysteroscopy is now regarded as the investigation of choice for abnormal uterine bleeding as there is no longer any doubt that hysteroscopy is more effective than conventional curettage at identifying intrauterine pathology (Gimpelson, 1984; Goldrath & Sherman, 1985; Gimpelson & Rappold, 1988; Loffer 1989) as it allows direct inspection of the uterine cavity, directed biopsy and appropriate therapeutic management. Another important advantage of hysteroscopy is that it can be performed without general anaesthesia and, in our experience, only 28.5% of patients required local anaesthesia; this was significantly associated with the need to dilate the cervix (Hill et al. 1992). In order to assess the role and efficacy of local anaesthesia before hysteroscopy, a randomized placebo controlled double blind trial was performed comparing intracervical lignocaine with saline.

Outpatient hysteroscopy: traditional versus the ‘no-touch’ technique

Objective  To assess whether outpatient hysteroscopy using the ‘no‐touch’ technique confers any advantages in terms of patient discomfort over the traditional technique.

A randomised trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at ‘no-touch’ (vaginoscopic) hysteroscopy

Objectives  To evaluate the effectiveness and tolerance of H Pipelle compared with the standard Pipelle as an endometrial biopsy device at outpatient ‘no‐touch’ hysteroscopy.

Prospective randomised trial comparing gonadotrophin-releasing hormone analogues with triple tourniquets at open myomectomy.

Objective  To compare intra‐operative blood loss with triple tourniquets to occlude uterine blood supply against preoperative treatment with gonadotrophin‐releasing hormone (GnRH) analogues at open myomectomy.

Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature

This pilot case – control study was carried out to determine the value of intraperitoneal irrigation with a long-acting local anaesthetic agent in reducing postoperative analgesic requirements following gynaecological operative laparoscopy. Twenty women undergoing gynaecological laparoscopic surgery were recruited to receive dilute bupivacaine instilled into the peritoneal cavity at the completion of surgery. Analgesic requirements were assessed during the first 10 hours, and pain scores at 4 and 24 hours. Analgesic requirements were then compared with historical controls. Our results revealed that the total parenteral opioid requirement after bupivacaine was significantly less than in the control group (0.50 mg vs. 7.17 mg, P = 0.006). Oral analgesic requirements were not significantly different between the two groups. Pain scores in the bupivacaine group showed no difference at 4 and 24 hours postoperatively. Intraperitoneal irrigation with dilute bupivacaine at the end of gynaecological laparoscopic surgery appears to reduce early postoperative analgesic requirements in this pilot study.

Local anaesthesia and cervical dilatation for outpatient diagnostic hysteroscopy

SummaryOutpatient hysteroscopy was attempted on 400 patients and was successful in 373 (93-3 per cent). Intracervical and intra-uterine pathology was demonstrated in 2-3 and 38-8 per cent respectively. Cervical dilatation was performed in 18-5 per cent, but significantly more postmenopausal patients (28-6 per cent) required cervical dilatation compared to pre-menopausal patients (16-6 per cent; P<0.05). Local anaesthesia was required by 28-5 per cent of patients; 730 per cent required local anaesthesia if cervical dilatation was performed, compared with 18-5 per cent if no dilatation was performed (P<0.001). No major complications occurred in any patients. Outpatient hysteroscopy and endometrial biopsy should be considered the procedure of choice for the evaluation of abnormal uterine bleeding.

Laparoscopic excision of a noncommunicating rudimentary uterine horn

Case report A 34 year old PO+1 had an uncomplicated termination of pregnancy at 8 to 10 weeks of gestation in 1980 in Yugoslavia and she was then advised by her gynaecologist that she had a bicornuate uterus. After that, she started to have right sided abdominal and pelvic pains. The pain was colicky in nature and intermittent, occurring every three to four months and lasting from several hours to two to three days. She was referred to our unit because of increasing severity and frequency of her pelvic pain and severe dysmenorrhoea. Transvaginal ultrasound demonstrated a bicornuate uterus with a single cervix. A hysterosalpingogram showed a single uterine cavity with free flow of contrast through the left fallopian tube, and spill was seen into the peritoneal cavity on the left side. An intravenous urogram showed a single left kidney and ureter. A diagnostic hysteroscopy and laparoscopy were done. Laparoscopic evaluation revealed a bicornuate uterus, the right horn looking bigger than the left. Both uterine tubes and ovaries looked normal in appearance, but methylene blue filled and spilled from only the left side with no communication to the right. There was a 4 x 5 cm left para-ovarian cyst and evidence of mild endometriosis in both ovarian fossae and uterosacral ligaments. Hysteroscopic evaluation confirmed a single cervix and a left tuba1 ostium, but no communication to the right horn. In view of her progressive pelvic pain and severe dysmenorrhoea which failed to respond to nonsteroidal anti-inflammatory analgesics, laparoscopic excision of the right uterine horn under

Ovarian artery clamp: Initial experience with a new clamp to reduce bleeding at open myomectomy

We studied the effect of novel ovarian artery clamps on intraoperative bleeding in 46 women undergoing open myomectomy for large fibroids. The clamps were applied medial to the ovaries to occlude uterine blood flow from the ovarian arteries without compressing the fallopian tubes, and were used in conjunction with a pericervical tourniquet. Myomectomy was completed successfully in all patients, and an average of 10 fibroids weighing 588 g were removed per patient. The clamps could be applied bilaterally in all but three cases. In the 45 women when at least one ovarian artery clamp was used, the intraoperative blood loss averaged 500 ml, which was comparable with historic data with conventional tourniquets. Ovarian artery clamps appear to be as effective as tourniquets applied to the infundibulopelvic ligaments in reducing bleeding at open myomectomy but have the advantage that they do not occlude ovarian perfusion or crush the fallopian tubes.