Andrew I. Brill

Cervical Pregnancy: Case Reports and a Current Literature Review

The increasing number of reports of successful conservative treatment of cervical pregnancy, such as using the folinic acid antagonist methotrexate, constitutes a breakthrough in the management of this unusual but potentially life-threatening complication of pregnancy. We are reporting two cases of cervical pregnancy, both diagnosed in the first trimester of pregnancy. The first one was successfully treated by transvaginal ultrasound-guided administration of 2 mEq KCI intraamniotically in order to stop the fetal heart activity, followed by administration of 84 mg of methotrexate intraaminiotically (1 mg/kg); whereas in the second case, we encountered a technical failure of the above method. Both patients expressed desire to maintain their reproductive capability. These two cases gave us the opportunity to review the recent literature on cervical pregnancy.

Hysteroscopic training guidelines

Safety and outcome of surgical procedures are clearly linked to adequate training. The criteria suggested below are minimal requirements and not absolute requirements as determined by the Board of Trustees of the American Association of Gynecologic Laparoscopists. Surgeons are responsible for obtaining adequate training. Surgeons should not request privileges for procedures or the use of new technologies in which they have not received adequate training. This is especially true when new technologies are used. The burden for satisfying the adequacy of training and surgical competence of the surgeon before allowing direct patient care ultimately falls on the hospital/facility medical staff. Physicians seeking hysteroscopic training should: a. Be board eligible/certified in gynecology, b. Have unsupervised gynecologic privileges for patient care, OR c. Be in an accredited residency program in obstetrics and gynecology. The components of hysteroscopic training ideally will include: a. Didactic training. b. Hands-on laboratory training. c. Case observation (highly recommended). d. Preceptorship (highly recommended). The didactic portion should initially include diagnostic and operative hysteroscopy and be a minimum of 6 hours. It should be a CME-approved program and include: 1. Uterine anatomy 2. Options of distention media 3. Management of distention media 4. Energy sources 5. Instrumentation 6. Surgical indications and techniques for: a. diagnostic hysteroscopy b. adhesiolysis c. metroplasty d. polycystic ovary e. fibroid resection/vaporization f. endometrial ablation 7. Prevention and management ofhysteroscopic complications.

Laparoscopic Appraisal of the Anatomic Relationship of the Umbilicus to the Aortic Bifurcation

STUDY OBJECTIVE To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy. DESIGN Prospective, consecutive study (Canadian Task Force classification II-1). SETTING Tertiary referral center. PATIENTS Ninety-seven women undergoing operative laparoscopy. INTERVENTIONS The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women. MEASUREMENTS AND MAIN RESULTS The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). CONCLUSIONS The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.

One-year results of the Vesta system for endometrial ablation

STUDY OBJECTIVE To compare a distensible multielectrode balloon for endometrial ablation with electrosurgical ablation performed by a combined resection-coagulation technique. DESIGN Randomized, prospective trial (Canadian Task Force classification I). Setting. Eight centers. PATIENTS Women with menorrhagia validated with a standardized pictorial blood loss assessment chart (PBAC), without intracavitary organic uterine disease, who failed or poorly tolerated medical therapy. Intervention. Results in 122 patients treated by Vesta and 112 treated surgically, evaluable at 1 year, were compared, with success defined as monthly blood loss of less than 80 ml and avoidance of additional therapy. MEASUREMENTS AND MAIN RESULTS Pretreatment PBAC scores for patients treated by Vesta and resection or rollerball were 535+/-612 and 445 +/- 313, respectively; at 1 year they were 18+/-37 and 28+/-60, respectively. With PBAC below 75 as the definition of success, 86.9% of Vesta-treated patients were successful compared with 83.0% treated by rollerball or resection. Total amenorrhea, defined as no visible bleeding and no use of protective products, was 31.1% and 34. 8%, respectively. None of the outcome comparisons between treatments showed statistical difference. Complications in both groups were few and minor. Most (86.6%) Vesta procedures were carried out with paracervical block with or without intravenous sedation in an office or outpatient setting, compared with 79.7% epidural or general anesthesia for rollerball or resection. CONCLUSION The Vesta system of endometrial ablation is equally effective and safe as classic resectoscopic methods. Potential advantages include avoidance of fluid and electrolyte disturbance associated with intravasation of distending media, and ability to perform the procedure under local anesthesia in an office setting with less total operating time.

Venous Air and Gas Emboli in Operative Hysteroscopy

Air and gas emboli have been reported in almost all areas of clinical and surgical practice. The literature is replete with observations and methods for treating these events. It is possible to mitigate the consequences of this risk, particularly in operative hysteroscopy. Recommendations include monitoring devices such as capnography to facilitate intraoperative diagnosis of these emboli.

Histologic characteristics of laparoscopic argon beam coagulation.

STUDY OBJECTIVES To describe histologic effects of laparoscopic argon beam coagulation and determine the extent of tissue necrosis at various power settings and exposure times. DESIGN Prospective experimental analysis (Canadian Task Force classification II-1). SETTING University animal laboratory. Subjects. Adult female domestic pigs. INTERVENTIONS Various power settings (40, 60, 80 W) at increasing exposure times (1, 3, 5 sec) were used during laparoscopic application of argon beam coagulation to different tissues (uterine horn, bladder, ureter, kidney, bowel, liver). Animals were sacrificed within 1 hour of coagulation for histologic tissue preparation. MEASUREMENTS AND MAIN RESULTS Histologic measurements of both depth and lateral extent of electrosurgical tissue effects (mm +/- SD) were ascertained and evaluated statistically by one-way repeated measures analysis of variance. Depth of tissue necrosis was confined to 1 mm or less in uterine horn, bladder, and ureter. Even at highest power settings, bowel had tissue necrosis no greater than 2 mm. Both liver and kidney showed a deeper histologic effect (4-5 mm). The lateral extent of tissue necrosis ranged from 2 mm (ureter) to 15 mm (liver). CONCLUSION Laparoscopic argon beam coagulation results in tissue effects that are dependent on both low power setting and duration of application, as well as on electrical and physical characteristics of target tissue. Thermal tissue penetration can be expected to be less than 2 mm in bowel, bladder, and ureter, and less than 5 mm in kidney and liver, even at 5 seconds of exposure time and at a power setting as high as 80 W. As with all thermal modalities used for hemostasis and tissue coagulation, laparoscopic argon beam coagulation can be performed safely as long as the potential for inadvertent thermal injury is understood.

Electrosurgery-Induced Generation of Gases: Comparison of in Vitro Rates of Production Using Bipolar and Monopolar Electrodes

STUDY OBJECTIVE To compare rates of production of gases generated by VersaPoint bipolar hysteroscopic vaporizing electrodes using normal saline and monopolar vaporizing electrodes using 1.5% glycine. DESIGN In vitro study (Canadian Task Force classification II-1). SETTING Laboratory. MATERIAL Bovine cardiac muscle. INTERVENTION Fresh morbid bovine cardiac muscle was fully immersed in normal saline for the bipolar system and in 1.5% glycine for monopolar systems. Loop and bulk vaporizing electrodes were activated by radiofrequency electrosurgical units (ESUs) appropriate for each system, at standard powers and at settings higher than those in clinical use. MEASUREMENTS AND MAIN RESULTS Rates of gas production were calculated and data analyzed by analysis of variance. For bulk vaporizing electrodes, the highest gas production rates at standard settings occurred with monopolar electrodes and the Force 2 generator at 300 W, and the Force FX at 200 W. At slightly higher than standard 200-W settings, the VersaPoint bipolar bulk vaporizing electrode was associated with lowest gas production rates in this category. Although there were statistically significant differences between loop electrodes, the magnitude remained small at similar ESU settings, and differences are thought to be clinically insignificant. CONCLUSION Rates of gas production in this model appeared to vary most with ESU power output settings and relatively little with electrosurgical modality (bipolar or monopolar).

Fundamentals of Peritoneal Access

The art of laparoscopic surgery is anticipating requirements for completing contemplated procedures. Patient safety and technical efficacy are inextricably linked to how carefully the patient is evaluated preoperatively. Choosing the best method for accessing the peritoneal cavity depends on patient phenotype, abdominal wall morphology, and anatomic configuration of underlying vital anatomy. Since no particular method is necessarily the safest approach for every patient, it is incumbent on every laparoscopic surgeon to be well-versed in alternative procedures for insufflation and entry into the peritoneal cavity. The laparoscopic surgeon must be forever mindful that most life-threatening surgical accidents to small and large bowel as well as to retroperitoneal vessels occur during insertion of the Veress needle and primary cannula. Review of a nationwide analysis of access-related complications in Finland revealed 256 complications during more than 70,000 laparoscopic procedures performed over 4 years; the frequency of bowel perforation was 0.1%, including 20 small and 16 large bowel injuries caused by either an umbilical trocar or Veress needle. 1 Injury to iliac vessels and aorta occurred in five patients. Complications during 1033 laparoscopic surgeries performed at one center over 6 years had an overall rate of 3%, of which 23.5% occurred during Veress needle or first trocar insertion. 2 A group in Switzerland prospectively followed 14,243 patients over 2 years and found 22 trocar and 4 Veress needle injuries (0.18%), including 19 injuries to large and

Normal variations of abdominal and pelvic anatomy evaluated at laparoscopy.

OBJECTIVE To describe certain anatomic relationships in the pelvis and abdominal wall at laparoscopy and the effect of body mass index (BMI) on those parameters. METHODS In 103 patients we determined the following: distances from the midline to each medial umbilical ligament and the respective inferior epigastric vessels; distances between each ureter and the ipsilateral uterosacral and the infundibulopelvic ligament; relative visibility of the ureters, umbilical and uterosacral ligaments, and the sacral promontory; and the presence and location of congenital bowel attachments to the pelvic walls. RESULTS The right ureter ran significantly closer to the infundibulopelvic and uterosacral ligaments than the left ureter. The right inferior epigastric vessels and umbilical ligament coursed more laterally than did those on the left. Both sets of inferior epigastric vessels, and the left umbilical ligament and ureter were significantly more difficult to identify in overweight women. In 69% of the subjects, the uterosacral ligaments were found to be thick or moderately thick. In two thirds, the sacral promontory was more than 75% visualized. Congenital bowel attachments were observed in 74.8% of subjects on the left pelvic sidewall, and 48.5% on the right. CONCLUSION Left and right pelvic anatomy are not necessarily mirror images laparoscopically. The course of the inferior epigastric vessels can be more difficult to identify in overweight patients. Despite marked obesity or congenital bowel attachments to the pelvic side walls, both ureters can usually be identified. The proximity of the ureter to the uterosacral and infundibulopelvic ligaments reaffirms the need to identify them before dissection.

Endoscopic management of incidental cystotomy during operative laparoscopy.

Operative laparoscopy is rapidly becoming an important technique used by all surgical specialties. More sophisticated and difficult procedures are continually being performed endoscopically. Complications from these procedures are inevitable and are more frequently being managed with the laparoscope. We describe a case of inadvertent cystotomy during a laparoscopic gynecological operation, which was subsequently repaired endoscopically. The technique and patient followup are presented.