Fu-Hsing Chang

Extraumbilical insertion of the operative laparoscope in patients with extensive intraabdominal adhesions.

In 12 patients who had known or suspected intraabdominal adhesions, we evaluated the benefit of using Palmers point for inserting the Veress needle and primary cannula during laparoscopic adhesiolysis to prevent direct intestinal injury. After inserting the laparoscope through this point, four women were found to have extreme intestinal adhesions around the umbilical area, and intestinal or severe omental injury might occur if the cannulas were inserted directly through the umbilical fossa. The other eight patients had omentum, partial to severe, adherent to the anterior abdominal wall. No complication occurred during insertion of the Veress needle and primary cannula through Palmers point. Nine patients had successful laparoscopic adhesiolysis and were discharged within 2 days. In the other three women the procedure was converted to laparotomy because of extensive intestinal adhesions (2 patients) and small bowel injury during laparoscopic adhesiolysis (1). Palmers point can be considered a safe and good alternative site for inserting the Veress needle and primary cannula to lyse dense intestinal and extensive omental adhesions. This technique should provide the surgeon with wider visual angel and surgical field, thus making adhesiolysis much easier to perform.

Efficacy of isotopic 13CO2 laser laparoscopic evaporation in the treatment of infertile patients with minimal and mild endometriosis: A life table cumulative pregnancy rates study

STUDY OBJECTIVE To assess the efficacy of 13CO2 laser laparoscopy in treating infertile women with minimal to mild endometriosis according the American Fertility Society classification in terms of pregnancy rates. DESIGN Prospective study. SETTING Medical school-affiliated hospital. PATIENTS One hundred seventy-six women whose infertility was associated with minimal or mild endometriosis diagnosed by laparoscopy. INTERVENTIONS The patients were treated with one of four methods: 49 underwent operative laparoscopy with newly developed 13CO2 laser vaporization and/or resection; 45 were treated by operative laparoscopy with simple monopolar electrocoagulation; 43 who had undergone only diagnostic laparoscopy did not receive any treatment; and 39 received danazol 800 mg/day for 3 months after diagnostic laparoscopy. MEASUREMENTS AND MAIN RESULTS Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among the treatments. A subgroup of 111 patients considered to have endometriosis as the only major infertility factor were also evaluated and compared among treatment options. Pregnancy rates in the CO2 laser laparoscopy group were significantly higher than in the other three groups and in endometriosis-only subset. CONCLUSIONS Advanced laparoscopic surgery with the CO2 laser can be more efficient than other modalities in treating infertile women with minimal to mild endometriosis in terms of pregnancy rates. It appears that in experienced hands, laser laparoscopy has more favorable results than the other treatments.

Life table analysis of pregnancy rates in women with moderate or severe endometriosis comparing danazol therapy after carbon dioxide laser laparoscopy plus electrocoagulation or laparotomy plus electrocoagulation versus danazol therapy only

STUDY OBJECTIVE To assess the effectiveness, in terms of pregnancy rates, of isotopic 13CO2 laser laparoscopy versus traditional laparoscopy or laparotomy in the treatment of infertile women with moderate or severe endometriosis. DESIGN Prospective 5-year study. SETTING Medical school-affiliated hospital. PATIENTS Three hundred nine infertile women with moderate to severe endometriosis. INTERVENTIONS The patients were treated with one of four options: operative laparoscopy with the 13carbon dioxide (13CO2) laser vaporization and/or resection, operative laparoscopy with simple electrocoagulation and sharp dissection, laparotomy with electrocoagulation and sharp dissection, and medical treatment with danazol. Estimated cumulative pregnancy rates using life table analyses were indicators of treatment of success and compared among treatments. A subgroup of 192 women considered to have endometriosis as the only infertility factor was also evaluated. MEASUREMENTS AND MAIN RESULTS Pregnancy rates in the laparoscopy group were equal to or higher than those of the laparotomy group, for both the entire population and the endometriosis-only subset. When the CO2 laser was used as an adjuvant option, the rates were better, especially in patients with advanced disease and with endometriosis as the only infertility factor. CONCLUSION In women with endometriosis as the only infertility factor, laparoscopic surgery with the 13CO2 laser was more effective than nonlaser treatment.

Use of Palmer's point for insertion of the operative laparoscope in patients with severe pelvic adhesions: Experience of seventeen cases

Seventeen patients who had known or suspected intra-abdominal adhesions underwent laparoscopic surgery with the use of Palmers Point for insertion of the operative laparoscope. Five of them were found to have extensive periumbilical adhesions. Intestinal or omental injury can occur if the trocar is inserted directly through the umbilical fossa. Though the incidence of direct trauma is reportedly low, there were still mild to moderate omental adhesions to the anterior abdominal wall, as we expected, in the remaining 12 patients. Possible inadequate aspiration and irrigation during laparoscopic removal of a dermoid cyst in one woman had resulted in severe postsurgical intraabdominal adhesions. More than two 10 mm incisions were used in our patients for insertion of the laparoscope interchangeablely to facilitate the procedure of laparoscopic adhesiolysis. The operative field can be expanded greatly. Fourteen patients completed the laparoscopic surgery, and the other 3 had alternative procedures eventually. No complications occurred during the laparoscopic procedure. The postoperative courses were uneventful in all 17 patients. Our experience suggests that Palmers Point is a good alternative for insertion of the Veress needle and laparoscope in patients with previous laparotomies and suspected severe pelvic adhesions.

Coculture of Human Spermatozoa with Reproductive Tract Cell Monolayers Can Enhance Sperm Functions Better than Coculture with Vero Cell Monolayers

AbstractPurpose: In order to develop a better system for support of human sperm function in vitro, we conducted studies to evaluate whether reproductive tract cells are better than non-reproductive tract cells as an adjunt in that regard. Methods: Human spermatozoa were cocultured with Vero cells, with human oviduct cells and endometrial cells, and without cells (control) for either 1, 4, or 24 hr. Sperm motility was then analyzed with a computer-aided sperm analyzer (CASA-Hamiliton Thron, HTM IVOS Motility Analyzer). Aliquots of spermatozoa incubated for 24 hr were also stained with Hoechst 33258 and FITC-PNA to evaluate the status of acrosome in live cells. Results: Significant differences (P<0.05) between the oviduct cell and the control groups after 24 hr were evident in the curvilinear velocity (VCL) (81.4±13.4 vs 60.0±14.1 µm/sec) and amplitude of lateral head displacement (ALH) (5.2±0.6 vs 4.1±0.5 µm). The incidence of acrosome reaction of live sperm was significantly higher in the endometrial cell group than in the controls (25.4±9.9 vs 6.6±2.4%;P<0.001). Conclusions: Coculture with human reproductive tract cells seems to improve some functional parameters of human spermatozoa. Coincubation with such cell lines, especially oviduct cells, might be a feasible approach to optimization of human spermatozoa for assisted fertilization using subfertile or frozen-thawed samples. We think coincubating human spermatozoa with a human reproductive tract cell line, especially oviduct cells, might be a feasible approach in preparing human spermatozoa for assisted fertilization in subfertile and frozen-thawed semen samples.

Extra-umbilical incisional hernias after operative laparoscopy: prevention and management

defined by the American College of Obstetricians and Gynecologists (ACOG) criteria [3]. Statistical analysis was performed using the X2-test and a P value of < 0.05 was considered significant. Among 26 266 pregnant women, 1121 (4.3%) were diagnosed with pre-eclampsia at our institution. The fetal gender ratio (male/female) between pregnant women with and without pre-eclampsia were not significantly different (1.02 vs. 1.04, P > 0.05, Table 1). When the pre-eclamptic pregnancies were further segregated into mild and severe preeclamptic groups, 565 (50.4%) were classified as mild and 556 (49.6%) were classified as severe. We found no significant difference in fetal gender ratio between normotensive pregnant women and mild pre-eclamptics (1.04 vs. 1.01, P > 0.05) or severe pre-eclamptics (1.04 vs. 1.04, P > 0.05). After adjusting for the potential confounding factors of race and parity, the fetal gender ratio between norLetters IO the Editor I61

A Twin pregnancy with a hydatidiform mole and an alive, coexistent baby after in vitro fertilization and embryo transfer

The coexistence of a hydatidiform mole and a fetus is extremely rare even in Taiwan, where the incidence of molar pregnancy is reported to be higher than in Western countries. Such a condition is even rarer in infertile patients receiving in vitro fertilization and embryo transfer (IVF-ET) treatment. There are only four case reports in the literature of a hydatidiform mole and a coexisting fetus after IVF-ET (1-4). We now describe a case of twin pregnancy with a hydatidiform mole and an alive, coexistent baby after IVF-ET. To the best of our knowledge, this is the first case report of a hydatidiform mole with a coexistent, alive baby after IVFET. The baby, grossly normal (internal and external), is still alive and doing well 5 months after delivery.

Laparoscopic repair of bowel herniation through previous cannula insertion sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Laparoscopic Repair of Bowel Herniation Through Previous Cannula Insertion Sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Laparoscopic removal of a large leiomyoma using airlift gasless laparoscopy

Some discrepancies still exist with regard to the efficacy of laparoscopic removal of large symptomatic leiomyomas. In our experience, when performing myomectomy, airlift gasless laparoscopy has several advantages. First, a small incision can be made, through which conventional surgical instruments (endoscopic equipment is not required) are inserted and the myomectomy is efficiently performed. Second, the large excised leiomyoma can be cut into strips easily with a conventional long knife and removed through a small abdominal incision. Third, sutures can be placed easily, and the surgeon can place fingers through a small surgical wound to palpate the organ and tie the knot directly. Fourth, high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum. Finally, the potential risks of metabolic and hemodynamic instability due to carbon dioxide insufflation to establish pneumoperitoneum are avoided.