Harrith M. Hasson

Laparoscopic cannula cone with means for cannula stabilization and wound closure.

A reusable cone suitable for use with existing laparoscopy cannulas was designed to provide means for sealing and stabilizing the operative site throughout the procedure, and for repairing the surgical site after the surgery is completed. The device consists of a moveable laparoscopic cannula cone fitted with suture holders. The cone contains tunnels terminating at its distal end that serve as passages for sutures loaded on a special needle to traverse the abdominal wall. When sutures are pulled into suture holders they stabilize the cannula and seal the puncture site. When sutures are tied at the end of the procedure, they achieve full-thickness closure of the operative site. The laparoscopic cannula cone stabilizes the cannula on the abdominal wall, maintains an air-tight seal, controls potential hemorrhage from the cannula puncture site, and achieves satisfactory closure of the surgical defect. Preliminary experience with the instrument and method has been most satisfactory.

Experience with laparoscopic hysterectomy

We conducted laparoscopic hysterectomy on 62 consecutive patients; 12 had laparoscopically assisted vaginal hysterectomy (LAVH), 16 had total laparoscopic hysterectomy (TLH), and 34 had supracervical laparoscopic hysterectomy (SLH). The groups were comparable with regard to age, weight, history of abdominal surgery, number of additional procedures performed, and weight of specimens; 74% had previous abdominal surgery, and 69% had additional procedures at hysterectomy. The mean estimated blood loss associated with LAVH was 2.5 times greater than that with TLH and 3 times greater than with SLH. The length of surgery was influenced by patient selection, surgeons experience, and equipment malfunction, with a mean of 213 minutes for LAVH, 244 for TLH, and 212 for SLH. The mean hospital stay for LAVH was 1.9 days and less than 1 day for TLH and SLH. There were nine total complications in the series (15%). Twelve (19%) of the specimens showed no abnormalities on pathologic examination. Total and supracervical laparoscopic hysterectomy and LAVH are appropriate operations for selected patients and compare favorably with standard abdominal or vaginal hysterectomy. The procedures demand sophisticated instrumentation and a dedicated endoscopy team to ensure safe and efficient performance.

Ovarian remnant syndrome after laparoscopic hysterectomy and bilateral salpingo-oophorectomy for severe pelvic endometriosis

Ovarian remnant syndrome is a rare complication of total abdominal hysterectomy and bilateral salpingo-oophorectomy (BSO). Ovarian enlargement and dense periovarian adhesions are the predisposing factors. Recurrent ovarian remnant syndrome was associated with recurrence of symptomatic endometriosis in a woman who underwent laparoscopic supracervical hysterectomy and BSO for severe endometriosis and extensive pelvic adhesions. After primary surgery she required five additional procedures for complete resection of all ovarian remnants. Definitive surgery for advanced endometriosis with extensive periovarian adhesions may be complicated by ovarian remnant syndrome and reactivation of the disease. Careful retroperitoneal resection of all ovarian tissue is of paramount importance in preventing the syndrome. This, however, may be a limitation of laparoscopic surgery. The choice between laparoscopy and laparotomy in such cases should be individualized and based on the degree of surgical difficulty and the surgeons level of experience.

Endoscopic surgery, cost effectiveness, and the quality of life

One measure of mitigating escalating costs of health care is to create an economic market-based system that connects value to cost. Cost-effectiveness analysis compares treatments that produce different benefits and require different costs, and ranks them by the amount of net treatment benefit divided by cost. Evaluation of the impact of illness and treatment on the medical condition, quality of life, and productivity of individual patients is essential for capturing all dimensions of treatment outcome. When performed by efficient teams, laparoscopic surgery, compared with conventional open surgery, adds value through reduced operative morbidity, earlier return to work, and improved quality of life. These advantages have to be confirmed by cost-effectiveness analysis, however. Endoscopic surgery will be consistently more cost effective than conventional surgery only when performed by a dedicated team of surgeons, nurses, and technicians. The need for a specialized team arises from the fact that endoscopic surgery requires different skills, including the ability to develop a two-dimensional concept for tissue manipulation, perform major surgery through small incisions using a different type of hand-eye coordination, and operate and maintain highly sophisticated and sensitive equipment and instrumentation. Reusable instruments will contribute to lower costs.

Interrupted Laparoscopic Suture Secured with the Needle-Through-the-Sliding-Loop Knot

A special needle holder with a step and knot-forming stand was designed to permit wrapping sutures into distinctive sliding loops around the needle holder, outside the abdomen. The loaded instrument was introduced into the abdomen and the appropriate stitch was made. The suture next to the needle was grasped with the needle holder and pulled through the sliding loops(s) to establish a knot. When the needle was passed through a simple noose the needle-through-the-noose knot was created. This knot maintained tension on captured tissues, but it required additional half-hitches to secure. When the needle was passed through rolling hitch loops it established a knot that was secure in simple applications, but required one additional half-hitch to secure in vulnerable applications involving slippery sutures or tissue purchases subjected to disruptive tension. The procedures were first practiced on inanimate models using a laparoscopy training simulator and then performed successfully over 20 times in 11 patients who had laparoscopic myomectomy or hysterectomy.

Laparoscopic complications in Finland

edema may occur with isotonic hyponatremia, but the mortality rate remained significant. These data suggest that exact control of fluid movement into and out of the brain is very complex, and this is supported by data showing women to be at higher risk for cerebral complications due to estrogens effect on the sodium pump across the blood-brain barrier. Animal data suggest that cerebral edema can certainly occur in a hyponatremic, isotonic state. As a result, it is unclear how much safer dilutional hyponatremia is when created by 5% mannitol versus glycine or sorbitol. Until more definitive data are available, the operative hysteroscopist should err on the side of caution and adhere to strict guidelines for stopping the procedure when an absorption limit is reached for any electrolyte-free medium. We believe it would be dangerous at this point to conclude that as long as plasma remains isotonic the patient is not a risk for cerebral edema, brain damage, and death.

The distalCAMTM video camera

Abstract A new endoscopic camera that does not require a viewing rod lens endoscope has been developed. It consists of a 10-mm metal tube and handle containing a distally placed camera chip. The distal chip endoscope is attached to a combined camera light source and processor by a well-protected cable. Due to the distally placed chip and the fact that no glass rod lenses are used, a full-screen image of improved quality and constant lighting is achieved. Elimination of rod lenses and all but one interface in the system minimizes image distortion, color degradation, and interface-related loss of illumination. A bright light is provided across the entire screen uniformly, without variation in intensity or color regardless of temporal proximity to target tissues. The system does not require white balancing or focusing since the color and focus range are set, and it uses a cool 40-W light to achieve the same intensity of existing 300-W lamps. The camera system was used successfully in 30 operative laparoscopy procedures.