Dahlia Admon

Laparoscopic detorsion allows sparing of the twisted ischemic adnexa.

STUDY OBJECTIVE To determine the safety and outcome of laparoscopic detorsion in the management of the twisted ischemic, hemorrhagic adnexa. DESIGN Retrospective chart review and prospective follow-up (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Fifty-eight women with twisted black-bluish ischemic adnexa encountered at laparoscopy. INTERVENTION Laparoscopic detorsion with adnexal sparing. MEASUREMENTS AND MAIN RESULTS All patients had a benign immediate postoperative course. Transient temperature elevation occurred in seven women (12.1%). No signs of pelvic or systemic thromboembolism were detected in any patient. Long-term follow-up included transvaginal ultrasound, which revealed follicular development in the previously twisted adnexa in 54 women; normal macroscopic appearance at incidental subsequent surgery in 9; and in vitro fertilization with retrieval of oocytes from the previously twisted side in 4. CONCLUSION Laparoscopic detorsion of the twisted ischemic, hemorrhagic adnexa is a safe procedure with minimal postoperative morbidity and a potential for the ovary to recuperate fully with preservation of normal function. Laparoscopic adnexa-sparing procedures should be performed in place of traditional salpingo-oophorectomy in women with this disorder who desire future fertility. (J Am Assoc Gynecol Laparosc 6(2):139-143, 1999)

Life-threatening hypotension after vasopressin injection during operative laparoscopy, followed by uneventful repeat laparoscopy

Vasopressin may be associated with systemic hemodynamic changes, including severe myocardial ischemia, even in healthy patients. A 36-year-old woman underwent laparoscopy for the treatment of a uterine leiomyoma. After intravascular injection of vasopressin, she experienced life-threatening hypotension, and the procedure was subsequently aborted. After she recovered, she underwent successful laparoscopy without the use of vasopressin, and no complications occurred. As endogenous vasopressin levels sometimes rise during laparoscopy, patients may become susceptible to the drugs effects, and appropriate precautions must be taken.

Treatment of interstitial pregnancy with methotrexate via hysteroscopy

We present a case in which treatment of interstitial pregnancy with local MTX administration was performed successfully through hysteroscopic vision, without the need to operate. Decreased gestational sac dimension and increased or low beta-hCG level ( < 1,400 mIU/mL) facilitates the success rate. The follow-up showed disappearance of the gestational sac and decrease of beta-hCG levels to < 10 mIU/mL. We conclude that local MTX administration via hysteroscopy after tubal ostium visualization is feasible. The procedure should be considered in women during the reproductive age, especially in rare cases of interstitial pregnancy.

A new approach for the treatment of interstitial pregnancy

The surgical treatment of interstitial pregnancy consists of either cornual resection or hysterectomy, which may seriously impair future fertility. We report a new approach that avoids surgical intervention. This presents a major breakthrough in the management of interstitial pregnancy.

Proposed classification of hysterectomies involving laparoscopy

A common terminology for the use of laparoscopy at hysterectomy is necessary so that collected data can be interpreted and conclusions applied. Many procedures are termed laparoscopic hysterectomy regardless of the extent to which laparoscopy is performed. We divided hysterectomy into seven steps and propose a common nomenclature based on the number of steps performed laparoscopically.

The incidence of endometriosis in posthysterectomy women

One hundred consecutive patients, age 24-62, status post total hysterectomy with and without bilateral oophorectomy (BSO), presented with chronic pelvic pain. All underwent laparoscopy. Of those who did not have BSO, 30 had definite endometriosis found at laparoscopy and five had questionable endometriosis. Of the 30 patients found to have definite endometriosis, 24 had a positive history of endometriosis, five had a negative history and one had a questionable history. Sixty-four underwent total hysterectomy with BSO. Of these 64, definite endometriosis was found in 22 at laparoscopy, questionable endometriosis was noted in 3, and findings for 39 were negative. Of the 22 women with positive endometriosis, 19 had a positive history of endometriosis, 2 had a negative history and 1 had a questionable history. Of these 22 patients, 13 were on estrogen replacement therapy, 2 were on estrogen and progesterone, 2 were on testosterone estradiol pellets, 2 were on GnRH analogs, 1 was on danazol and 2 received no medication. In this group, the time between hysterectomy and our laparoscopy was eight months to 15 years. Twenty-four of the 100 patients had a positive history of endometriosis with negative findings at laparoscopy. Our findings support the view that endometriosis will be found at laparoscopy in a significant number of women with chronic pelvic pain status post hysterectomy with or without BSO, especially if the woman has a positive history of endometriosis.

Laparoscopic management of genitourinary endometriosis

We treated 17 patients with severe endometriosis involving the genitourinary tract. Eight women presented with persistent right or left flank pain, two presented with known ureteral obstruction, and five presented with urinary frequency and burning, and/or hematuria with their periods. Presented are the results of laparoscopic management in these patients. We performed segmental bladder resection in six patients and ureteral resection and reanastomosis in two. Nine additional patients underwent partial resection of the ureteral wall for complete removal of endometrial implants. The ureter was repaired with 4-0 PDS in seven patients and a stent was left in place for 4 to 6 weeks. Two required only a stent due to the small size of the ureterotomy. The postoperative course of these patients was uneventful. Following ureteral repair/reanastomosis, all women underwent an intravenous pyelogram at follow-up, and normal bilateral excretion was demonstrated. Cystoscopy revealed no abnormal findings in five patients who had undergone partial bladder resection. All patients reported significant pain relief or complete resolution of symptoms. Operative laparoscopy can be safely used to achieve relief from severe symptomatic endometriosis of the genitourinary tract.

Complications of 361 laparoscopic hysterectomies

We evaluated the results and complications of 361 hysterectomies performed at operative laparoscopy to treat a variety of benign gynecologic conditions. The hysterectomies were classified according to the number of steps performed endoscopically. There were no conversions to laparotomy for the hysterectomy, although one required laparotomy for rectosigmoid resection and anastomosis due to severe stricture of the rectosigmoid colon. There were no cases of mortality during the hospitalization nor during 42 postoperative days. The overall complication rate was 10.23 per 100 women. Intraoperative complications included three inferior epigastric vessel injuries, two hemorrhages requiring blood transfusion, one small bowel injury and one bladder injury. The overall complication rate in this series is lower than that reported for abdominal or vaginal hysterectomy. Laparoscopically assisted hysterectomy allows the surgeon to directly visualize uterine artery pedicles, to clearly delineate ureteral paths, to accomplish immediate and precise hemostasis, to use hydrostatic lavage and irrigation to continuously disperse microclots and tissue debris, and to operate with accuracy. While this procedure seems to offer several advantages such as reduced devitalized tissue, near elimination of the potential for suture reaction, and diminished inflammatory responses during the healing phase, complications can be encountered.

Treatment of Ovarian Endometriosis

Ovarian involvement occurs in 50% to 70% of all cases of endometriosis.1 Lesions appear differently at the ovary than at other sites. Superficial ovarian endometriosis, like endometriosis of other parts of the pelvis, can be treated by excision, vaporization or coagulation. Irrigation is performed and all of the charcoal is removed to be sure that the disease is completely treated. Aggressive use of the laser or electrocoagulation should be avoided to decrease the chance of ovarian damage. Ovarian endometriosis may form cystic structures known as endometriomas.

10 Videolaseroscopy and videolaparoscopy

Summary Laparoscopic surgery is not a new idea, but it has only recently found widespread acceptance. The introduction of technological advances such as improved light sources, lasers and video capability has made laparoscopy a surgical technique that offers many advantages to the patient and the surgeon. Because videolaseroscopy must be performed using a completely different set of skills, the only limit to the expansion of this type of surgery is training enough surgeons to meet the growing demands of the public. We believe that videolaseroscopy will become a larger part of the surgical operations performed in the future as technology becomes available to improve upon the instruments and methods.