Clifford R. Wheeless

A preliminary report on a new laparoscopic sterilization approach: The silicone rubber band technique

Abstract A preliminary report is given of a new laparoscopic sterilization approach with the use of silicone rubber bands. A description of the laparoscope silicone rubber band applicator, as well as its operative utilization, is provided. One hundred cases have been completed without any major problems. No statement can be made at this time as to the incidence of failure. The described technique eliminates the need for the thermoenergy which is used in tubal occlusion and thus removes the cause of intestinal burns. The potential for successful future tubal reopening procedures should be greater with this procedure.

Salvage of the reproductive potential of women with anomalous development of the Müllerian ducts: 1868-1968-2068.

This discussion will be confined to four major problems associated with Mullerian anomalies: absence of the vagina (1) without or (2) with uterine development and (3) incomplete fusion of the Mullerian ducts with obstruction to one side and (4) incomplete fusion without obstruction. The discussion will review these disorders as they were known in 1868 and their contemporary management and submit our projection for 2068.

Hyaluronic acid-carboxymethylcellulose film and perianastomotic adhesions in previously irradiated rats.

OBJECTIVE Postoperative intra-abdominal adhesions are a major source of postsurgical morbidity. Pelvic irradiation increases the likelihood of adhesion development. The purpose of this study was to evaluate the effects of hyaluronic acid-carboxymethylcellulose film, which was designed as a barrier to prevent adhesions, on the healing of ileal anastomoses performed on irradiated rat bowel. STUDY DESIGN Sixty-eight female Sprague-Dawley rats underwent whole pelvic irradiation with a single fraction of 1700 cGy. Twenty weeks later the rats underwent exploratory laparotomy with segmental ileal resection and reanastomosis. Eighteen of the anastomoses were wrapped in hyaluronic acid-carboxymethylcellulose film. Fifty anastomoses were not treated with any adhesion-inhibiting barrier. On the fifth postoperative day the animals underwent another laparotomy for evaluation of the anastomotic sites. RESULTS At the second laparotomy 93% of the rats treated with hyaluronic acid-carboxymethylcellulose film were found to have perianastomotic abscesses. In the non-hyaluronic acid-carboxymethylcellulose film group the perianastomotic abscess rate was 24% (P <.0001). CONCLUSION Among previously irradiated rats undergoing small-bowel resection and anastomosis, hyaluronic acid-carboxymethylcellulose film was associated with a markedly increased rate of abscess formation at the operative site.

Complex obstetric fistulas

Obstetric fistulas are rarely simple. Most patients in sub‐Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto‐vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Obstetric vesico‐vaginal fistulas at the National Hospital of Niamey, Niger

To determine the epidemiologic and therapeutic characteristics of obstetric vesico‐vaginal fistulas at the National Hospital of Niamey, Niger.

Abdominal hysterectomy for surgical sterilization in the mentally retarded: A review of parental opinion

Between the years 1950 and 1973, 152 abdominal hysterectomies were performed for surgical sterilization in patients who were mentally retarded. A retrospective follow-up study was performed to ascertain the opinions of parents, guardians, and institutional care workers charged with the care and responsibility of these patients since the time of the original operation. In the categories evaluated, over 90 per cent of those charged with the care of the patient were enthusiastic for the benefits achieved by hysterectomy rather than tubal ligation for the purpose of surgical sterilization.

Use of the automatic surgical stapler for intestinal anastomosis associated with gynecologic malignancy: Review of 283 procedures

Abstract Between the years 1974 and 1980, 283 intestinal stapling procedures involving the large and small bowel have been performed on the Gynecologic Oncology service. The automatic surgical staplers used in this series were: the gastrointestinal anastomosis (GIA), the thoracoabdominal (TA-55/30), and the end-to-end anastomosis (EEA) stapler (United States Surgical Corp., Stamford, Conn.). The 283 stapling operations were performed on 162 patients. Fifty-three of the patients had received pelvic irradiation prior to the intestinal operations. The complication rate was low, and compared very favorably with other techniques of gastrointestinal anastomosis which were performed by the same authors. There was one disruption of a small-bowel anastomosis, temporary stricture in three anastomoses of rectum to colon, a leak in a low colonie-rectal anastomosis which resulted in a pelvic abscess, and a rectovaginal fistula. Fifty-two patients underwent urinary diversion by bowel conduit. In all of these cases the conduit was fashioned with the aid of the automatic stapler. The low complication rate in gastrointestinal anastomoses performed with the automatic surgical staplers supports the conclusion that this is a technically superior method which provides better utilization of operating time on radical pelvic procedures.

Problems with Tubal Reconstruction following Laparoscopic Sterilization Using the Electrocoagulation and Resection Technique

This paper reviews the results of attempted tubal reconstruction following laparoscopic sterilizations using the electrocoagulation and excision technique in the isthmic portion of the fallopian tube. The surgical technique, complications, and results are presented.

The Goebell-Stoeckel operation for universal cases of urinary incontinence

Abstract The Goebell-Stoeckel fascia lata strap operation for stress incontinence of urine has been used for 30 years. This is a review of eight cases from our practice using this operation for problems of total urinary incontinence secondary to congenital defects and complications of vaginal surgery. The Goebell-Fragenheim-Stoeckel 1–3 operation was first described in 1917. In the original operation, strips of fascia lata were not used for the strap. In later modifications of the procedure, a strip of fascia lata and a small transverse suprapubic incision were employed. The basic principle of the operation is having a supporting structure beneath the urethrovesicle junction that slightly elevates the urethra in this area upon downward or caudad movement of the bladder. Such movement occurs in all Valsalva maneuvers such as coughing, sneezing, laughing, lifting heavy objects, and many body movements. During these movements, the intravesical pressure is raised. If the intraurethral pressure is lower than the intravesical pressure, at that particular moment, urine in the bladder moves to the lower pressure area in the urethra and drains to the outside. The strap procedure, by supporting the suburethral tissue and the urethral vesical angle, probably increases the intraurethral pressure to a level greater than the intravesical pressure preventing urinary incontinence associated with Valsalva maneuvers but the pressure is not elevated to such a level as to retard urinary drainage during detrusor muscle contraction for voluntary voiding. If the above physiologic explanation is true for stress incontinence, how can the Goebell-Stoeckel strap procedure be explained for total incontinence, particularly secondary to congenital defects such as total bladder exstrophy and epispadias? A physiologic explanation of the success of the strap operation in congenital defects cannot be given. This physiologic explanation remains to be answered. However, the clinical results achieved in these eight cases deserve further study. Consideration of this operation may be warranted in these severe cases of incontinence.