D. Alan Johns

The medical and economic impact of laparoscopically assisted vaginal hysterectomy in a large, metropolitan, not-for-profit hospital☆

OBJECTIVE Our purpose was to evaluate the medical and economic impact of of operative laparoscopy on the surgical approach to hysterectomy for benign disease in a large, metropolitan, not-for-profit hospital. STUDY DESIGN Retrospective analyses were performed on 2563 hysterectomies (without vaginal or bladder repair) for benign disease, performed by 37 gynecologists between January 1991 and December 1993. Disposable laparoscopic instruments and stapling devices were not used at any time during the study period. Electrosurgery and sutures were used for hemostasis. Parameters analyzed included surgical approach (total abdominal hysterectomy, vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and failed laparoscopically assisted vaginal hysterectomy), operative time, postoperative diagnosis, operative blood loss, length of stay, complications, uterine weight, and hospital changes. Charges in each of these parameters were analyzed and compared in 6-month increments. RESULTS During the study period the percent of hysterectomies performed abdominally declined from 65% to 36%. Laparoscopically assisted vaginal hysterectomy increased from 12% to 45%, and vaginal hysterectomy varied from 23% to 19%. Average operative time was 82 minutes (+/- 2 minutes) for total abdominal hysterectomy, 102 minutes (+/- 2.3 minutes) for laparoscopically assisted vaginal hysterectomy, and 63 minutes (+/- 2 minutes) for vaginal hysterectomy. Hospital stay was 68 hours (+/- 1.5 hours) for total abdominal hysterectomy, 44 hours (+/- 1.2 hours) for laparoscopically assisted vaginal hysterectomy, and 43 hours (+/- 4.1 hours) for vaginal hysterectomy. The average hospital charge was

Use of Crinone vaginal progesterone gel for luteal support in in vitro fertilization cycles.

6552 (+/-

Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients?

108) for total abdominal hysterectomy,

Reduction of postoperative adhesions by N,O-carboxymethylchitosan: a pilot study

6431 (+/-

Adequacy of laparoscopic oophorectomy

100) for laparoscopically assisted vaginal hysterectomy, and

Clomiphene citrate-induced gamete intrafallopian transfer with diagnostic and operative laparoscopy

5869 (+/-

Prostaglandin E2 Stimulates Aromatase Expression in Endometriosis-Derived Stromal Cells

116) for vaginal hysterectomy. CONCLUSIONS Contrary to previously published studies, our study demonstrates (1) laparoscopically assisted vaginal hysterectomy is a cost-effective procedure when performed with reusable instruments, (2) laparoscopically assisted vaginal hysterectomy is a safe procedure, even when performed by a variety of gynecologists with different skill levels, and (3) the number of hysterectomies performed abdominally was decreased by 29% without incurring more complications or reducing the number of vaginal cases.

Management of unruptured ectopic pregnancy with laparoscopic carbon dioxide laser

OBJECTIVE To investigate the efficacy and safety of intravaginal Crinone 8% (Columbia Research Laboratories, Miami. FL) versus IM progesterone for luteal phase support after IVF-ET. DESIGN Prospective open trial with comparison to historical controls. SETTING University hospital. PATIENT(S) Two hundred six women undergoing IVF-ET. INTERVENTION(S) One hundred patients received Crinone vaginal progesterone gel (90 mg once daily) and 106 patients received IM progesterone (50 mg once daily) beginning on the evening of oocyte retrieval. MAIN OUTCOME MEASURE(S) Pregnancy and miscarriage rates, and midluteal serum progesterone levels. RESULT(S) Positive beta-hCG pregnancy rates, clinical pregnancy rates per transfer, and ongoing pregnancy rates were similar for the Crinone and IM progesterone groups. Women who received Crinone had higher rates of biochemical pregnancy loss but lower rates of clinical pregnancy loss (i.e., spontaneous abortion) than women who received IM progesterone. Midluteal serum progesterone concentrations were significantly higher in the IM progesterone group (94.3+/-8.8 ng/mL versus 57.7+/-7.4 ng/mL). Several women who received Crinone had vaginal bleeding 11-13 days after oocyte retrieval. CONCLUSION(S) For all age categories, positive beta-hCG and ongoing pregnancy rates were similar when Crinone or IM progesterone was given for luteal phase support in IVF-ET cycles, despite lower serum progesterone concentrations and higher rates of biochemical pregnancy loss with Crinone. Although the results of this study support the use of Crinone as an acceptable alternative for luteal support after IVF-ET, differences in bleeding patterns and rates of biochemical pregnancy loss demonstrate the need for a prospective randomized study.

Report of the Study Group: Advanced Operative Laparoscopy (Pelviscopy)

OBJECTIVE The objective of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) in establishing tubal patency or blockage and evaluating the uterine cavity by comparing it with hysteroscopy laparoscopy (HLC) or hysterosalpingography (HSG). STUDY DESIGN This study was a chart review evaluating infertility patients and patients who had undergone hysteroscopic sterilization who underwent both HyCoSy and HLC or HyCoSy and HSG at private offices associated with university hospitals. Sensitivity, specificity, positive predictive value, and negative predictive value of HyCoSy were calculated. RESULTS HyCoSy compared with HLC had a sensitivity of 97% and specificity of 82%, and HyCoSy compared with HSG was 100% concordant. Uterine cavities evaluated by sonohysterography and hysteroscopy were 100% concordant. CONCLUSION HyCoSy is accurate in determining tubal patency and evaluating the uterine cavity, suggesting it could supplant HSG not only as the first-line diagnostic test in an infertility workup but also in confirming tubal blockage after hysteroscopic sterilization.

Laparoscopic Neosalpingostomy in a Patient with Bilateral Congenital Distal Fallopian Tube Absence: Case Report and Review

OBJECTIVE To examine the logistics, safety, and efficacy of N,O-carboxymethylchitosan (NOCC) in reducing adhesions in women. DESIGN Multicenter, prospective, randomized, reviewer-blinded clinical trial. SETTING Gynecologic practices. PATIENT(S) Thirty-four patients were enrolled; 17 in each group were available for the safety analysis and 16 for the efficacy analysis. INTERVENTION(S) Adhesion reduction by administration of NOCC vs. Ringers lactate at the conclusion of the initial surgical procedure, as assessed at second-look laparoscopy. The NOCC was applied as 200 mL of a 1% NOCC gel that was tamped in place, followed by 100 mL of 2% NOCC solution. Efficacy was assessed by covariate analysis. MAIN OUTCOME MEASURE(S) Safety and postoperative adhesion formation. RESULT(S) Groups did not differ in age, ethnicity distribution, height, weight, or body mass index. No deaths or serious adverse events were attributable to NOCC, and no adverse events were definitively or probably related to NOCC administration. Adhesions recurred at 61% of sites in controls and 38% of sites in NOCC recipients. De novo grade 1a and 1b adhesions tended to occur more commonly in controls than NOCC recipients. Adhesion extent and severity at second look were also less in NOCC recipients. CONCLUSION(S) Intraperitoneal use of NOCC gel and solution appears to be safe. Despite the small sample, strong trends were identified for reduction of occurrence, extent, and severity of adhesion recurrence and de novo adhesion formation.