K. Semm

Macrophage‐ and lymphocyte‐subtypes in the endometrium during different phases of the ovarian cycle

The presence of immunocompetetive cells in the endometrium during the proliferative and secretory phase of the ovarian cycle is demonstrated on the light and electron microscopic level using monoclonal antibodies (MoAb). Subtypes of monocytes, macrophages and T‐lymphocytes appear during the different phases in variable extent and different localization. Some subpopulations of the monocyte/ macrophage system and T‐helper lymphocytes increase in number on day 21/22. Our observations indicate that cells with bone marrow origin take part in functional events of the endometrium during the ovarian cycle.

Treatment of female infertility due to tubal obstruction by operative laparoscopy.

The advent in recent years of safe endocoagulation (thermocoagulation within the abdomen) has permitted operative laparoscopic treatment of the tubal factor in infertility in selected cases. This paper reviews the results of operative laparoscopy in 223 cases treated for infertility between 1971 and 1976. Tubal occlusion was present in 133 patients before surgical intervention. Following operative laparoscopy, tubal patency was demonstrated in 67% on testing at the time of operation and in 12% at the first postoperative hydrotubation. In only 21% of cases was tubal patency not achieved by these methods. Those cases requiring isthmic salpingostomy, ampullary or isthmic-tubal implantation, or end-to-end anastomosis were further treated by laparotomy and microsurgery. Ninety cases of pelvic endometriosis were treated by a combination treatment of thermocoagulation, ovarian cyst resection, and the antigonadotropin agent, danazol. Ovariolysis, salpingolysis, fimbrioplasty, and salpingostomy can easily be performed using operative laparoscopy as the method of choice with a minimum of complications, shortened hospitalization time (2 days), and the potential for a repeat procedure or a follow-up laparotomy should this be necessary. The pregnancy rate following laparoscopic treatment for the correction of distal tubal occlusion was 30.5% and for endometriosis genitalis externa, 40%. These rates compare favorably with the rates following procedures involving laparotomy and microsurgery for correction of similar lesions.

Laparoscopic Management of 641 Adnexal Tumors in Kiel, Germany

STUDY OBJECTIVE To evaluate the effectiveness and safety of laparoscopic and laparotomic management of ovarian tumors. DESIGN Retrospective analysis (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Six hundred forty-one women with benign and malignant ovarian tumors. INTERVENTIONS Laparoscopy and laparotomy. MEASUREMENTS AND MAIN RESULTS Between January 1997 and December 1998, 493 (76.9%) ovarian tumors were treated laparoscopically and 138 (21.5%) by laparotomy. Criteria for laparotomy were high suspicion of malignancy and tumors larger than 10 cm that were technically too difficult for the laparoscopic approach. The mean size of tumors treated laparoscopically was 4.5 cm (range 1.1-11 cm) and by laparotomy 8.2 cm (range 3-20 cm). Mean operating times were 75.7 minutes (range 30-200 min) and 126 minutes (range 30-235 min), respectively, and mean blood loss was 193 ml (range 50-1200 ml) and 431 ml (range 50-2500 ml), respectively. Twelve laparoscopies were converted to laparotomy, six because of technical reasons such as severe adhesions, bleeding, or tumor size, and six for intraoperative suspicion of malignancy. Of the latter, four (66.7%) turned out to be ovarian carcinoma and two (33.3%) borderline tumors. Histologic evaluation clearly revealed predominance of functional ovarian cysts, endometriomas, and dermoid cysts in the group treated by laparoscopy, whereas ovarian carcinomas, large endometriomas, and serous cysts prevailed in the laparotomy group. CONCLUSION With careful preoperative screening, the rate of laparoscopies for treatment of benign ovarian cysts can be increased. (J Am Assoc Gynecol Laparosc 8(1):74-82, 2001)

Pelviscopic Treatment of Ovarian Cysts in Premenopausal Women

Between 1984 and 1989, 773 patients less than or equal to 45 years of age, presenting with a total of 809 ovarian cysts, underwent pelviscopy at the Department of Obstetrics and Gynecology of Kiel University. In 36 cases, cysts were bilateral. 678 cysts (84%) were treated by pelviscopy alone. Organ-preserving treatment was performed in 83%, oophorectomy or adnexectomy in only 17% of cases. Two stage Ia ovarian carcinomas (0.26% of all cysts) were operated on by pelviscopy before laparotomy. Sonography is particularly important in determining whether a pelviscopic approach is appropriate. Pelviscopic procedures are unacceptable in multilocular cysts measuring greater than or equal to 7 cm in diameter with echo-dense components. Special caution is required for any cyst measuring greater than 9 cm in diameter. The risk of opening a malignant cyst must be weighed against the advantages of pelviscopic surgery: minimal physical strain, better postoperative quality of life, and organ conservation. In doubtful cases, laparotomy is recommended.

Human ovum recovery via operative laparoscopy and in vitro fertilization

Between January 1979 and December 1980, 142 laparoscopies were performed on 114 patients with long-standing tubal factor infertility. Twenty-eight were performed during spontaneous menstrual cycles, 20 following continuous human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG) therapy, and 94 following intermittent hMG/hCG stimulation. Follicular ripeness was judged by multiple criteria, which were also used to time the laparoscopy. Operative procedures were performed in all cases and follicular puncture was attempted in all but 16 subjects, where adhesions prevented access to the ovaries. In 28 spontaneous cycles, 28 follicles were punctured and 17 ova recovered; whereas in the 98 patients where ovulation was stimulated, 217 follicles were punctured and 43 ova collected. Following in vitro fertilization with the husbands spermatozoa and embryo culture, pronucleus formation, 2-cell, 4-cell, 8-cell, and 16-cell stages were observed in 18 oocytes obtained from 17 patients. Embryo transfer has, however, not yet been performed.

Management of patients with persistent β-hCG values following laparoscopic surgical and local drug treatment for ectopic pregnancy

Objectives: To show that the β‐human chorionic gonadotropin (hCG) decline following tubal‐preserving techniques for ectopic pregnancy (EP) can take a longer course than currently believed, indicating expectant management; and to define the indications for a second‐look laparoscopy if β‐hCG persists. Methods: Three hundred thirty‐seven patients treated for EP were retrospectively reviewed. In order to define the ‘normal’ β‐hCG decline following tubal‐preserving techniques we acquired a Kaplan‐Meier curve for 98 patients treated by laparoscopic linear salpingotomy, the main method performed for EP (253 patients). The Mann‐Whitney U‐test served as a statistical test. The patient population requiring a second‐look laparoscopy for proliferating trophoblastic remnants is described. Results: Twenty‐eight patients (8.3%) required a second‐look laparoscopy (acute abdominal pain and sonographically suspect findings combined with increasing β‐hCG values). The majority (15 patients) underwent a preceding laparoscopic linear salpingotomy (6.5% unresolved cases). The relative β‐hCG values differed significantly from the unresolved group compared to the group with resolved EP starting at postoperative day 2 (P < 0.01). A maximal β‐hCG decline period of 77 days postoperatively was observed. Conclusions: Patients with slowly declining β‐hCG levels following tubal‐preserving techniques for EP can be managed expectantly. Increasing β‐hCG values combined with abdominal pain and sonographically suspect observations indicate a second‐look laparoscopy.

Width of thermal damage after using the YAG contact laser for cutting biological tissue : animal experimental investigation

SummaryAt the University Womens Clinic in Kiel, the YAG contact laser has been used as a cutting instrument in pelviscopic operations since 1987. When the laser cuts, it produces only a scant amount of mechanical trauma. The determining factor is the amount of thermal damage produced along the wound margins and in direct neighboring tissue. The extent of the tissue change seen in the uterus and liver parenchyma of rats and the striated muscle of rabbits after application of the YAG contact laser was demonstrated using various staining techniques and stains. Liver parenchyma proved to be the most sensitive to thermal damage. In the uterine horn, enzyme-histochemical ATPase and alkaline phosphatase demonstrations showed a significantly wider zone of thermal damage after laser incision than did hematoxylin-eosin and Goldner staining techniques. A good understanding of the extent of thermal damage is essential for atraumatic pelviscopic operations using the YAG contact laser and also for the preventing of complications.

Pelviscopic Surgery: A Key for Conserving Fertility

As a result of experience with more than 16,000 pelviscopic operative procedures performed at the Kiel University Womens Clinic from 1971 to 1988 which in this time had been adapted and used around the world, it may be said that the pelviscopic operative techniques, based completely on the laparotomy techniques which employ the microscissors, needles and suture material, is superior for many of the classical gynecological indications to operation. Minimally invasive surgery reduces hospitalization for even the most difficult cases to approximately 3 days. Convalescence is also reduced to approximately 1 week. Postoperative complaints are few, particularly when the primary exudate is removed through an abdominal drain. Late complications are practically unknown. It must be said that even the most minimal of operative procedures can produce late postoperative complaints or can be ascribed as the source of late postoperative complaints. Experiences gathered from around the world with endoscopically guided intraabdominal surgery have shown that for some gynecological procedures laparotomy is now indicated only in the rare case. The leading example of this switch can be seen in the operative treatment of the ectopic pregnancy. Following closely are operations to correct sterility such as salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. Finally pelviscopic treatment is increasing for all benign ovarian tumors, and the enucleation of myomas of up to 400 grams in weight. Endoscopically guided intraabdominal surgery also has a place in the field of general abdominal surgery--that of treatment of chronic abdominal adhesions. These procedures in the future should basically commence with endoscopic adhesiolysis, the patient having had the proper preoperative bowel preparation. Because of this minimally invasive technique the surgeon will only rarely be forced to perform laparotomy. In the case of abdominal adhesions a prerequisite for pelviscopic treatment is the visually controlled perforation of the peritoneum. Endoscopic surgery, in contrast to open laparoscopy, has a large periumbilical radius of action and produces no postoperative scars. In Kiel operative pelviscopy has replaced 80% of the classic gynecological laparotomies. The recurrence rate of adhesions is 84% with laparotomy compared with a recurrence rate of less than 40% with postendoscopic adhesiolysis. Forty to sixty percent of the patients who underwent pelviscopic adhesiolysis are complaint-free; this is a result not attained with classical abdominal surgery. Adhesiolysis per laparotomy is now limited to the emergency situation, as in the cases of ileus, for example. Endoscopically guided intraabdominal surgery has now improved the quality of life for surgical patients.

Histologic Features of the CISH Procedure

STUDY OBJECTIVE To evaluate the classic intrafascial SEMM (serrated-edge macromorcellated) hysterectomy (CISH) performed by pelviscopy and by laparotomy, and determine the histologic features of the procedures. DESIGN The first 253 women who required hysterectomy were assigned to undergo the procedure by pelviscopy or laparotomy based on uterine size. PATIENTS One hundred fifty-two women underwent CISH by pelviscopy and 101 by laparotomy. INTERVENTIONS Between September 1991 and December 1993, the patients underwent the two procedures. Uterine leiomyomas with menstrual disorders and pressure symptoms were the principal indications (61%). MEASUREMENTS AND MAIN RESULTS Histologic findings were in agreement with indications for the procedures. Leiomyomas and leiomyomas with adenomyosis were the most frequent findings. Histologic analysis revealed that the squamocolumnar transformation zone was totally removed in all cases, and all cervical glands were excised in 92%. CONCLUSION Cervical dysplasia is not a contraindication to CISH, but emphasizes the importance of adequate preoperative screening. This is a conservative operation that my protect against some cervical cancers.

Incidence of adhesions in the true pelvis after pelviscopic operative treatment of tubal pregnancy

33 patients with tubal pregnancies, who had been treated by pelviscopy with organ preservation between 1978 until the beginning of 1988 have had follow-up examinations from within 4 months to 2 years after their first operation. In 15 (45%) of these 33 patients we found adhesions in the true pelvis on initial pelviscopy; these adhesions were lysed in all cases. During a second inspection of the abdominal cavity-either by laparotomy (Cesarean section; 4 patients) or by repelviscopy (29 patients)-mainly avascular, filmy adhesions on one or both adnexae were found in 17 cases (52%). The pelviscopic treatment of ectopic pregnancy does not completely prevent the development of postoperative adhesions. The concomitant pelviscopic adhesiolysis during the treatment of ectopic pregnancy reduces the degree of severity of the recurring adhesions.