Eugenio Solima

Safe Technique for Laparoscopic Entry into the Abdominal Cavity

Abstract Study Objective To evaluate and compare the safety and efficacy of a new method to enter the abdominal cavity at laparoscopy. Design (Canadian Task Force classification II-2). Setting Referral center for reproductive surgery in a teaching hospital affiliated with a university-based residency program. Patients Twenty representative women of variable body habitus (body mass index 16.5–39 kg/m2). Intervention Laparoscopy and laparotomy. Measurements and Main Results We measured the thickness of the abdominal wall at the base of the umbilicus and just below its inferior border. We also measured distances traversed by the Veress needle or cannula from skin to peritoneal cavity at both sites when the piercing instrument was directed at 45- or 90-degree angle from the horizontal plane of the abdominal wall. Finally, we measured distances created between parietal peritoneum and underlying viscera when the abdominal wall was lifted manually or with towel clips placed laterally, 2 cm from the umbilicus and at the edges of the intraumbilical incision. Distances created between parietal peritoneum and underlying viscera while lifting the abdominal wall by each of these three techniques were measured with a calibrated probe inserted through the intraumbilical port and observed with a 5-mm laparoscope from the suprapubic port. These distances were measured before and after carbon dioxide insufflation at 15 mm Hg, as well as before and while inserting the cannula through the abdominal wall. Mean ± SD thickness of the abdominal wall at the base of the umbilicus and lower border of the umbilicus were 1.4 ± 0.5 and 3.0 ± 1.1 cm, respectively (p Conclusion Our technique of inserting the cannula perpendicularly through the base of the umbilicus traverses the shortest distance to the abdominal cavity through the least vascular area of the abdominal wall. Lifting the abdominal wall with towel clips placed at the edges of the intraumbilical incision achieves the greatest distance between parietal peritoneum of the abdominal wall and underlying viscera, thus maximizing the margin of safety in protecting peritoneal organs and retroperitoneal vessels from injury.

Ectopic pregnancy from surgical emergency to medical management.

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately

Outpatient diagnostic hysteroscopy.

3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high‐resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

A New Hysteroscopic Classification of and Nomenclature for Endometrial Lesions

STUDY OBJECTIVE To evaluate the feasibility, validity, indications, and results of a large series of diagnostic hysteroscopies performed without anesthesia. DESIGN Retrospective analysis of hysteroscopy charts performed between 1989 and 1996 (Canadian Task Force classification II-2). SETTING University-affiliated endoscopy unit. PATIENTS Four thousand consecutive women referred for different indications. INTERVENTIONS Diagnostic hysteroscopy was performed in 91% of patients without premedication or anesthetics. In some women premedication or general or local anesthesia was required to access the uterine cavity. MEASUREMENTS AND MAIN RESULTS The success rate, validity indication, complication rate, and number of biopsies were critically evaluated and assessed in relation to increased experience of operators. In 91% of women we accessed the uterine cavity at the first attempt without premedication, whereas 207 (5. 1%) patients required local anesthesia and 99 (2.4%) premedication. Only 1.6% required general anesthesia. In 52% intrauterine pathology was diagnosed and in 21% further surgical treatment was suggested. CONCLUSION Hysteroscopy was feasible when performed in an outpatient setting without general or local anesthesia in more than 90% of women. The operators experience seems a key factor both for accurate endometrial evaluation and to reduce failure and endometrial biopsy rates. The low frequency of further surgical treatment justifies performing the procedure in the office.

Pain Mapping During Minilaparoscopy in Infertile Patients without Pathology

STUDY OBJECTIVE To establish a hysteroscopic classification of endometrial lesions based on a combined score: DESIGN A prospective study to grade four features of endometrial lesions (thickness, surface, color, vascularization) and subdivide them as mild (low risk) and severe (high risk). SETTING Gynecologic endoscopy unit of an obstetric and gynecology clinic. PATIENTS Two hundred twenty-nine women with hysteroscopically diagnosed endometrial lesions. INTERVENTIONS Hysteroscopic inspection of endometriotic lesions, with grading performed on the four features. MEASUREMENTS AND MAIN RESULTS The sensitivity and specificity of our system were 86.9% and 87.4% for mild pathology, and 96% and 92.9% for severe pathology. CONCLUSIONS This hysteroscopic classification of endometrial pathology can be useful for a better definition of endometrial lesions. The method has good sensitivity and specificity.

Is local anesthesia an affordable alternative to general anesthesia for minilaparoscopy

STUDY OBJECTIVE To draw a map of pelvic pain and quantify the level of provoked pain during minilaparoscopy under local anesthesia and conscious sedation. DESIGN Observational study (Canadian Task Force classification II-2). SETTING University hospital. PATIENTS Twenty infertile women. INTERVENTIONS Minilaparoscopy was performed under local anesthesia and conscious sedation, and cognitive performance was evaluated with the Rey auditory verbal learning task. MEASUREMENTS AND MAIN RESULTS The diagnostic procedure was performed with one 2-mm micrograsper and one 2-mm microprobe to evaluate the pelvis. In particular we grasped utero-ovarian ligaments; we touched, grasped, and distended fallopian tubes with blue dye; we moved the uterus with a manipulator inserted at the cervix; and we touched and grasped bowel and omentum. Level of pain was recorded on a visual analog scale. Patients had no pathologic findings, including minimal endometriosis and pelvic adhesions. The highest level of pain was recorded when we distended the tubes. No pain was elicited when we touched and grasped ovary, omentum, and bowel. In 10% of women when we stretched the tubo-ovarian ligament we provoked a minimal vagal reaction. CONCLUSION Minilaparoscopy under conscious sedation for pelvic pain mapping in women without pain or pathology revealed consistently negative findings, validating the value of this measurement. (J Am Assoc Gynecol Laparosc 6(1):51-54, 1999)

Costs and benefits of office diagnostic hysteroscopy

STUDY OBJECTIVE To determine if minilaparoscopy under local anesthesia is at least as reliable and affordable as that performed under general anesthesia. DESIGN Prospective, randomized study (Canadian Task Force classification I). SETTING University-affiliated hospital. PATIENTS One hundred sixty-four consecutive women evaluated for infertility. INTERVENTION Diagnostic minilaparoscopy performed after women were randomized to receive general or local anesthesia with conscious sedation. MEASUREMENTS AND MAIN RESULTS Levels of postoperative pain measured by visual analog scale; volume of CO(2) used; length of procedure, complete pelvic evaluation, and hospitalization; complications; and pathologic diagnosis were evaluated. The groups were comparable in age, years of infertility, and symptoms. For women receiving local anesthesia, 5.5% required general anesthesia to complete the procedure. Women in both groups required postoperative analgesics. The groups had no statistically significant differences in pain level 1 hour after the procedure, number of complications, and pelvic pathology. Patients who had local anesthesia required a smaller volume of CO(2) (p <0.01) and their hospitalization was significantly shorter (p <0.01). However, in 15% of these women pelvic visualization was incomplete, compared with 7.2% in the general anesthesia group. CONCLUSION Minilaparoscopy performed under local anesthesia was as reliable and affordable as when performed under general anesthesia.

How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study

In Italy, the main location for performing diagnostic hysteroscopy is the office. The success of office hysteroscopy is related to savings of time and money and the convenience for the physician and patient. We evaluated 4000 diagnostic hysteroscopies performed between January 2, 1989, and March 1, 1996. In 17.8% of these patients we subsequently performed operative hysteroscopies (metroplasty, synechiolysis, myomectomy, polypectomy for polyps >2 cm), and in 5.2% a total abdominal hysterectomy for abnormal uterine bleeding or endometrial cancer. The low percentage of operations underlines the efficacy of office diagnostic hysteroscopy, especially if we evaluate costs and accuracy of this procedure in detecting uterine pathologies.