James F. Daniell

Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery

At second-look laparoscopy, 82 of 161 women (51%) were noted to have adhesions at at least one new location. Such adhesions occurred at 31% of available sites. Among 121 women with adhesions at the initial operative procedure, the rate and type of recurrence assessed on the ovaries, fimbriae, and other sites were independent of the initial type. Additionally, neither the rate nor the type of adhesion recurrence observed at the time of second-look laparotomy was determined by the variable amount of time between the initial and second-look operative procedures. We conclude that reproductive pelvic surgical procedures are frequently complicated not only by adhesion reformation but by de novo adhesion formation as well.

Tubal patency and pelvic adhesions at early second-look laparoscopy following intraabdominal use of the carbon dioxide laser: initial report of the intraabdominal laser study group

It has been suggested that the carbon dioxide (CO2) laser, by virtue of its hypothetical capabilities for precise incisions, minimization of tissue handling and bleeding, and shortened operating time, may improve the success rate of gynecologic infertility surgery. To assess this hypothesis, a multicenter prospective study was performed to assess tubal patency and adhesion formation at early second-look laparoscopy after intraabdominal laser surgery. Procedures performed included salpingoneostomy, fimbrioplasty, lysis of adhesions, vaporization of endometriosis, and ovarian wedge resection. The results were compared with those of another multicenter prospective study that utilized nonlaser reconstructive pelvic surgery. Use of the CO2 laser was found to result in a greater tubal patency rate at the time of the second-look procedure. Adhesions present at the time of the second-look procedure were reduced from initial presentation at most sites; however, nonlaser infertility surgery appeared to have equal or greater efficacy in the prevention of adhesion formation at most sites. Thus, the CO2 laser does not appear to be a panacea for the treatment of tuboperitoneal causes of infertility. Pregnancy rates following intraabdominal use of the CO2 laser remain to be established.

Early Complications of Laparoscopic Hysterectomy

Since Reich first described laparoscopic hysterectomy (LH) in 1989, a number of series have appeared in the literature detailing complications of this procedure. This review included all series obtained through a MEDLINE search from April 1989 through October 1994. Also included were series from the Journal of Gynecologic Surgery, Gynaecological Endoscopy, and the Journal of the American Association of Gynecologic Laparoscopists. Rates of various complications were calculated and compared with existing standards for abdominal and vaginal hysterectomy. Hemorrhage and injury to adjacent organs were fairly similar between traditional hysterectomy methods and LH. Infectious morbidity, however, was decreased in LH. Caution should be used in interpreting these data, as these initial reports come predominantly from leading experts in the field of endoscopic surgery. Whether these rates can be duplicated in a community hospital is debatable.

Structural anomalies of the X chromosome: personal observation and review of non-mosaic cases.

We describe a new case of partial deletion of the long arm of the X chromosome, found in a 24‐year‐old female with secondary amenorrhea; the karyotype of the proposita is 46, X, del(X)(q22). We take this opportunity to review the previously published descriptions of non‐mosaic structural anomalies of the X chromosome (X isochromosomes excepted), with the goal of “testing” the recent hypotheses formulated about: (a) the existence of an X inactivation center (Therman et al. 1974b); (b) the presence of a “b” segment remaining active on Xp (Therman et al. 1976); (c) the potential importance of a critical area on Xq linked to gonadal function (Sarto et al. 1973); and (d) the presence of normal gonadal function despite an Xp terminal deletion (Fraccaro et al. 1977). We conclude that the above‐mentioned theories, as well as those concerning phylogenetic evolution of sex chromosome morphology presented by Lyon (1974) and Hoo (1975), receive support from practically all of the 149 cases we compared. Regarding the features of the Turner syndrome, we propose “mapping” of the X chromosome as follows: the genes involved in gonadal function seem to be located on the proximal part of Xp and on the distal part of Xq, whereas the genes whose absence is responsible for somatic features of the syndrome may be distributed along the length of Xp and the middle section of Xq(q21‐q26). Furthermore, we note some interesting analogies between the evolutionary model proposed by Hoo (1975) and the map we visualize.

A comparison of the CO2 laser and electrocautery on postoperative intraperitoneal adhesion formation in rabbits

The effect of the CO2 laser and microelectrocautery on postoperative intraperitoneal adhesions was examined in 31 female rabbits. Standard injuries were performed and/or repaired with each technique on the uterine peritoneum, the right uterine horn, and the left ovary. The animals were sacrificed 5 weeks later, and the adhesions were graded at each site. No significant differences were found between the two techniques for each site or all sites collectively (P greater than 0.05). The ovary had more extensive adhesions than the other soft tissue site (P less than 0.01) with both techniques. The present study suggests that there is no apparent difference between CO2 laser and conventional microelectrocautery on adhesion formation, and that the ovary seems particularly prone to adhesion formation with either technique.

Prevention of acute pelvic inflammatory disease after hysterosalpingography: Efficacy of doxycycline prophylaxis

In an attempt to minimize the infectious morbidity of hysterosalpingography, the efficacy of oral doxycycline prophylaxis was examined. The records and hysterosalpingograms of 278 consecutive women (group 1) were reviewed to correlate the radiologic findings and the development of acute pelvic inflammatory disease (PID) after hysterosalpingography. Four women (1.4%) developed PID and all four had tubal dilatation. The overall frequency of PID in women with dilated tubes was 4/35 (11%). Subsequently, 56 of 326 women (group 2) with tubal dilatation received oral doxycycline prophylaxis. No cases of PID were observed in the 56 women who had antibiotic prophylaxis (p less than 0.02) or in group 2 as a whole. The study suggests that the risk of infection after hysterosalpingography is very low when nondilated tubes are present (0/398 women of groups 1 and 2). The relative risk of PID in women with peritubal disease or proximal tubal occlusion, although apparently low, remains to be determined. Furthermore, in the highest-risk group of women with dilated tubes, doxycycline prophylaxis was effective in reducing infection after hysterosalpingography.

Initial evaluation of the use of the potassium-titanyl-phosphate (KTP/532)* laser in gynecologic laparoscopy

A new surgical laser, the potassium-titanyl-phosphate 532 nm laser (Laserscope, Santa Clara, CA) has recently become available for investigative procedures in gynecology. This article reports initial investigation of this laser energy at laparoscopy with the use of a flexible fiberoptic delivery system in rabbits and patients with endometriosis. Tissue effects on peritoneal structures of rabbits with laparoscopic firing of this new laser demonstrated the ability to accomplish surface vaporization without bowel perforation or penetration greater than 2 mm. In ten patients with pelvic endometriosis and pain, effective laparoscopic vaporization of implants has been safely accomplished with ease. Early follow-up revealed symptomatic improvement in all patients. This new laser is easy to use laparoscopically, appears safe in early investigations, and effectively reduces early postoperative pain associated with pelvic endometriosis.

One ovary or two: differences in ovulation induction, estradiol levels, and follicular development in a program for in vitro fertilization.

The choice of clomiphene citrate (CC) and human menopausal gonadotropin (hMG) protocols for stimulation of ovarian follicular maturation has traditionally not been made with regard to the anatomic status of the pelvis. To evaluate whether hormone production and/or follicular development vary based on the number of ovaries and/or the method of stimulation, 117 cycles were reviewed. Forty-five women received CC, 29 with two ovaries and 16 with one ovary. Seventy-two women received hMG, 50 with two ovaries and 22 with one ovary. Among women receiving CC, those with two ovaries tended to have higher initial estradiol levels and a greater number of large (greater than or equal to 15 mm) follicles. Among women receiving hMG, those with two ovaries tended to have higher estradiol levels, but the number of large follicles (greater than or equal to 15 mm) was similar. With either stimulation protocol, women with two ovaries developed a higher total number of follicles than women with one ovary. The total number of follicles in women with one ovary was similar for hMG and CC stimulations. The number of oocytes recovered at laparoscopy was greater in women with two ovaries who received hMG in comparison with CC, but did not significantly vary between women with one or two ovaries who received CC nor between women with one or two ovaries who received hMG. The number of oocytes was also similar for the women with one ovary regardless of stimulation protocol.

Early outcomes of laparoscopic-assisted vaginal hysterectomy versus laparoscopic supracervical hysterectomy

STUDY OBJECTIVE To compare two different laparoscopic techniques for hysterectomy: laparoscopic-assisted vaginal hysterectomy (LAVH) and laparoscopic supracervical hysterectomy (LSH). DESIGN A retrospective review of office and hospital charts, and a postoperative questionnaire completed by patients. SETTING A private gynecology practice and private hospital in Nashville, Tennessee. PATIENTS Forty women requiring laparoscopic hysterectomy between January 1993 and December 1994. Interventions. Twenty patients underwent LAVH and 20 LSH. Minimum follow-up was 3 months (range 3-27 mo). MEASUREMENTS AND MAIN RESULTS The chart review focused on operating times, blood loss, length of hospital stay, complications, and total hospital costs to the patients. The operating times were shorter and the blood loss was less in the LSH group than in the LAVH group, but the difference did not reach statistical significance. Hospital stay was shorter (p = 0.0005) and hospital costs were less (p = 0.01) in the LSH group. Of women who were sexually active, those in the LSH group resumed intercourse earlier than those in the LAVH group (3.5 vs 5.9 wks), and reported better overall improvement in sexual function and ability to achieve orgasm. CONCLUSION In certain patients, LSH is effective and associated with few complications.

Hysteroscopic correction of cornual occlusion with resultant term pregnancy

Hysteroscopic correction of proximal cornual occlusion is possible in some cases using a simple ureteral stent. This allows re-establishment of tubal patency in selected cases with the possibility for occurrence of intrauterine pregnancy without the need for major surgery. The case presented represents the first reported term pregnancy in a well-documented case of this type.