Howard T. Sharp

The acute abdomen during pregnancy.

The term acute abdomen designates symptoms and signs of intraperitoneal disease usually treated best by surgical operation. The most common cause of the acute abdomen in pregnancy is appendicitis; however, over the past decade there have been case reports of new and bizarre causes of the acute abdomen, unique to pregnancy, which should also be considered in the differential diagnosis (Table 1). The greatest changes concerning the acute abdomen during pregnancy have been technologic. These advances present new opportunity and controversy. One such example is the use of laparoscopy. Several series are now available documenting the use of laparoscopy in pregnant women with an acute abdomen in over 500 cases, yet long-term follow-up data are scarce. With this in mind, the objectives of this chapter are to provide a contemporary overview of the acute abdomen during pregnancy, to review the literature regarding fetal and maternal morbidity and mortality, and to provide recommendations for clinical management. The vast majority of data regarding the acute abdomen in pregnancy are based on case reports and case series and are, therefore, considered level III data as outlined by the United States Preventive Services Task Force.

Complications associated with optical-access laparoscopic trocars

OBJECTIVE To investigate the number and type of serious complications associated with optical‐access trocars reported by sources other than the medical literature. METHODS Optical‐access trocars, first introduced in 1994, were designed to decrease the risk of injury to intra‐abdominal structures by allowing the surgeon to visualize abdominal wall layers during placement. To date, very few complications with their use have been reported in the medical literature. MEDLINE, the Food and Drug Administrations Medical Device Reporting, and the Manufacturer and User Facility Device Experience databases were searched for reports of complications occurring during the use of optical‐access trocars for laparoscopic access. RESULTS Only two serious complications resulting from the use of optical‐access trocars (vena cava injuries) have been reported in the medical literature. However, 79 serious complications using these techniques have been cited in the Medical Device Reporting and Manufacturer and User Facility Device Experience databases since 1994. These include 37 major vascular injuries involving aorta, vena cava, or iliac vessels, 18 bowel perforations, 20 cases of significant bleeding from other sites, three liver lacerations, and one stomach perforation. Four of these complications resulted in patient deaths. CONCLUSION Optical‐access trocars may be associated with significant injuries despite having the ability to visualize tissue layers during insertion.

Subtotal hysterectomy in modern gynecology: A decision analysis

OBJECTIVE Our purpose was to compare the risks and benefits of subtotal (supracervical) hysterectomy with those of total hysterectomy in women at low risk for cervical cancer. STUDY DESIGN A decision analysis was performed. Baseline probabilities for operative and postoperative morbidity, mortality, and long-term quality of life were established for subtotal and total hysterectomy. RESULTS Operative complication rates and ranges for total abdominal hysterectomy were infection 3.0% (3.0% to 20.0%), hemorrhage 2.0% (2.0% to 15.4%), and adjacent organ injury 1.0% (0.7% to 2.0%). Those for subtotal hysterectomy were infection 1.4% (1.0% to 5.0%), hemorrhage 2.0% (0.7% to 4.0%), and adjacent organ injury 0.7% (0.6% to 1.0%). Operative mortality, the risk for development of cervicovaginal cancer, and long-term adverse effects on sexual or vesicourethral function were low in both groups. CONCLUSIONS Recently proposed benefits from subtotal hysterectomy are not well proven. Total hysterectomy remains the procedure of choice for most women.

Assessment of new technology in the treatment of idiopathic menorrhagia and uterine leiomyomata.

New technologies available for the treatment of idiopathic menorrhagia include five global endometrial ablation devices that use differing ablative methods, including thermal balloon, circulated hot fluid, cryotherapy, radiofrequency electrosurgery, and microwave energy. All have been compared with rollerball endometrial ablation by way of randomized clinical trials and are associated with high patient satisfaction rates, regardless of method, but a wide range of amenorrhea rates (13.9-55.3%). They are associated with low complication rates when performed by well-trained physicians following protocols in Food and Drug Administration trials. Some serious complications have been reported subsequently. Strict adherence to patient selection criteria and manufacturer protocols is strongly recommended. New technologies for the treatment of uterine leiomyomata include uterine artery embolization, magnetic resonance-guided focused ultrasonography, laparoscopic uterine artery occlusion, and cryomyolysis. There is sound evidence for shorter hospital stay, quicker return to work, and a similar major complication rate compared with hysterectomy. Uterine artery embolization appears to be effective for up to 5 years in reducing bulk symptoms and menorrhagia associated with leiomyomata. The chance of reoperation for leiomyoma-related symptoms within 5 years is 20-29%. Women who wish to become pregnant should be cautioned about potential complications during pregnancy. There is insufficient evidence to recommend uterine artery embolization in postmenopausal women. With regard to magnetic resonance-guided focused ultrasonography, cryomyolysis, and laparoscopic uterine artery occlusion, although the initial symptom reduction outcomes have been reported as favorable, more data are needed to better understand the durability of these results.

Laparoscopic knot strength: a comparison with conventional knots.

Objective To compare the strength of laparoscopic knots with those used at laparotomy. Methods Three types of laparoscopic knots commonly used (Roeder, extracorporeal sliding square, and intracorporeal two-turn flat square) and three widely used conventional knots (flat square, surgeons square, and sliding square) were tied using seven suture materials. Each knot was tied five times in random order by a single surgeon in a pelvic training model. Knot strengths were scored by tensiometer readings. A two-way analysis of variance was performed to uncover differences in mean knot strength. Tukey multiple-comparisons test was performed to determine the variability in strength of different knot geometries. Knot strength was measured in newtons. Results Significant main effects for knot geometry (P < .05) and material (P < .05) as they contribute to differences in knot strength were identified, as well as an interaction for knot geometry with material (P < .05). The laparoscopic Roeder knot was significantly weaker than all other laparoscopic and conventional knots tested. The laparoscopic extracorporeal sliding square knot was significantly weaker than the conventional surgeons square knot, and the conventional sliding square knot was significantly weaker than the conventional flat square knot and the surgeons knot. The laparoscopic intracorporeal two-turn flat square knot was as strong as the strongest conventional knot. A significant main effect was discovered for knots with eight throws. Conclusion When performing laparoscopic procedures that result in significant tension on suture lines, consideration should be given to using the stronger laparoscopic knots, such as the intracorporeal two-turn flat square knot and the extracorporeal sliding square knot, instead of the weaker Roeder knot.

Endometrial ablation: postoperative complications

Endometrial ablation as a treatment for abnormal uterine bleeding has evolved considerably over the past several decades. Postoperative complications include the following: (1) pregnancy after endometrial ablation; (2) pain-related obstructed menses (hematometra, postablation tubal sterilization syndrome); (3) failure to control menses (repeat ablation, hysterectomy); (4) risk from preexisting conditions (endometrial neoplasia, cesarean section); and (5) infection. Physicians performing endometrial ablation should be aware of postoperative complications and be able to diagnose and provide treatment for these conditions.

The 4-S Modification of the Roeder Knot: How to Tie It☆

Background The 4-S modification of the Roeder knot may be tied laparoscopically as a single-throw knot. Technique It is tied by adding a fourth wrap around the suture loop and securing the loop in place with a square knot rather than a single half-hitch. Experience We have used this knot in laparoscopic surgeries for more than 2 years and have not observed knot slippage. Conclusion This modification results in a knot comparable in strength to the strongest laparoscopic multiple-throw square knots.

Cervical ripening before induction of labor: A randomized trial of prostaglandin E2gel versus low-dose oxytocin

OBJECTIVE The purpose of this study was to compare prostaglandin E2 gel and a low-dose infusion of oxytocin for cervical ripening before labor induction. STUDY DESIGN A total of 158 women were randomized to receive either two intracervical doses of 0.5 mg prostaglandin E2 gel 6 hours apart or 12 hours of intravenous oxytocin up to 4 mlU/min. After cervical ripening labor was induced with high-dose oxytocin infusion and amniotomy. RESULTS There was no difference between the prostaglandin E2 and low-dose oxytocin groups in the likelihood of being in labor or having a Bishop score favorable for induction after ripening (64.2% vs 52.0%, p = 0.12) or in the incidence of vaginal delivery (75.9% vs 74.7%). Prostaglandin E2-treated patients were delivered sooner (20.2 +/- 8.1 hours vs 25.0 +/- 10.5 hours, p = 0.002). Among delivered patients the likelihood of vaginal delivery within 24 hours was greater with prostaglandin E2 ripening (63.7% vs 47.2%, p = 0.04), but there was no difference at 36 hours (76.2% vs 75.0%). Uterine hyperstimulation and fetal distress during ripening occurred only in the prostaglandin E2 group, at a rate of 4.8%. CONCLUSIONS After cervical ripening with prostaglandin E2 gel or low-dose oxytocin vaginal delivery can be expected in three fourths of patients within 24 to 36 hours. We recommend that patients with an unfavorable cervix who require delivery undergo cervical ripening and induction of labor rather than automatic delivery by cesarean section.

Myofascial pain syndrome of the abdominal wall for the busy clinician.

Introduction Myofascial pain syndrome (MFPS) represents the largest group of unrecognized and undertreated acute and chronic medical problems in clinical practice. Its prevalence is estimated to be approximately 30% in patients seen in general medical clinics and as high as 85% to 93% in pain specialty clinics. In gynecologic circles, pelvic pain has been cited as the most common indication for performing diagnostic laparoscopy. Unfortunately, most obstetrician/gynecologists do not gain access to training in the evaluation and management of musculoskeletal pain. Therefore, it is possible that some patients who undergo surgery for chronic pelvic pain (CPP) may not have had an adequate evaluation to exclude musculoskeletal causes for pain that are amenable to nonsurgical treatment. An example of such is work published by Slocomb, who, in a pelvic pain clinic, found 131 of 177 patients (74%) to have MFPS. Of these, 89% had a successful response to nonsurgical therapy. Furthermore, the American College of Obstetrics and Gynecology, in their Quality Assessment and Improvement publication, recommends an assessment of the musculoskeletal system prior to laparoscopy or hysterectomy for CPP. To give full credence to musculoskeletal pain or MFPS in a brief chapter is not possible. However, there are basic concepts that can be learned quickly and used in the evaluation of patients with CPP involving the abdominal wall. The chapter by Pendergast and Weiss is an excellent resource and example of the importance of screening for several musculoskeletal causes for pelvic pain and involving physical therapists or physiatrists in the care of such patients. In this chapter, though the mechanics of myofascial trigger point (MTrP) injections will be demonstrated, it should be emphasized that treating MFPS with MTrP injections alone will not result in long-lasting pain reCorrespondence: Howard T. Sharp, MD, Suite 2B200, Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, 50 North Medical Drive, Salt Lake City, UT 84132. E-mail: howard.sharp@hsc. utah.edu CLINICAL OBSTETRICS AND GYNECOLOGY Volume 46, Number 4, 783–788

8 Laparoscopic sacral colpopexy and other procedures for prolapse

The repair of pelvic support defects is a demanding task. Irrespective of the route or repair chosen by the surgeon, sound surgical judgement, complete understanding of pelvic anatomy and the mechanisms involved in pelvic organ prolapse, and expertise in pelvic surgery are required if successful outcomes are to be expected. Laparoscopic surgery offers a substitute for conventional open abdominal surgery which, in our hospital, now has a record of low complication rates, speedy discharge and recovery times with outcomes that are equal to those achieved by conventional abdominal surgery. This type of surgery is no more difficult to perform than open abdominal surgery. However, it demands the same rigorous training and a very significant amount of time and dedicated effort to learn. The pelvic surgeon who desires to practise this form of advanced laparoscopic surgery must accept these facts. Obviously, more cases and long-term follow-up are needed for meaningful statistical analysis. Randomized prospective trials are greatly preferred, however, it is difficult for the laparoscopic surgeon to carry out such studies when the majority of patients are referred specifically for the laparoscopic route. Good sound statistical data are now becoming available concerning some essential components of the procedure such as laparoscopic knot and suture strengths. It seems very reasonable to conclude that, based on early experience with laparoscopic pelvic reconstruction, the future of this approach is bright.