L. Mettler

Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.

STUDY OBJECTIVE To evaluate SprayGel, a new sprayable adhesion barrier developed for laparoscopic and open pelvic and abdominal surgical procedures. DESIGN Prospective, randomized, controlled, multicenter trial (Canadian Task Force classification I). SETTING University clinic and private clinic. PATIENTS Forty-five women, 24 randomized to treatment and 21 to control group. INTERVENTIONS Open or laparoscopic myomectomy with and without application of SprayGel, followed by second-look laparoscopy (SLL) to evaluate postoperative adhesions. MEASUREMENTS AND MAIN RESULTS Application of SprayGel was fast and easy. On average, 10 weeks after surgery, 18 treated patients (75%) and 13 (61.9%) controls had SLL. That procedure showed 5 (27.8%) of 18 treatment patients to be adhesion free versus 1 (7.7%) of 13 controls (p = 0.163). Patients randomized to SprayGel were 3.6 times more likely to be adhesion free than controls. Mean tenacity scores were significantly lower than in controls (0.5 vs. 1.7), a difference of 0.9 (95% CI 0.3, 1.5, p = 0.003) or 47% (95% CI 17%, 77%) less. Mean adhesion area was reduced in the treatment group (4.1 vs. 5.6) but not significant (p = 0.6747, 95% CI-5.4, 8.4). No adverse events regarding application of SprayGel were seen. CONCLUSION SprayGel was effective in reducing postoperative adhesion severity, and showed a trend toward reducing frequency and extent of adhesions after laparoscopic and open myomectomy. Further studies are necessary to confirm the promising results of this interim analysis.

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)

Laparoscopic hysterectomy: challenges and limitations.

Twenty years after the first description of vaginal hysterectomy with laparoscopic assistance by Kurt Semm in 1984 (1), and 16 years after the publication of the so‐called laparoscopically assisted vaginal hysterectomy (LAVH) by Harry Reich in 1989 (2), it is time to review and evaluate the real benefits of laparoscopic hysterectomy. Although laparoscopic surgery is well accepted by gynaecologists worldwide for the treatment of certain gynaecological conditions, laparoscopic hysterectomy in Germany, and probably worldwide, is still only performed by a few specialists. Highly skilled surgical techniques, longer operating time and expensive technology are suggested to be the deterring factors. Laparoscopic hysterectomy, in its different forms, is an attractive and safe procedure for the management of benign gynaecological conditions and many authorities recommend its use on a larger extent. On the other hand, in our opinion, the use of laparoscopic hysterectomy for oncological indications is still controversial. Extensive experience of over 15 years, of the first author, in practising and teaching various forms laparoscopic hysterectomy, namely, laparoscopically assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), classic intrafascial supracervical hysterectomy (CISH) and laparoscopic supracervical hysterectomy (LSH), has led us to the firm conclusion that these techniques are advantageous to patients if performed for the appropriate indication. In particular, subtotal or supracervical hysterectomy, with the cervix remaining in its place, is associated with fewer complications and a very favourable outcome for the patient. Radical laparoscopic vaginal hysterectomy (RLVH), the last variant in our exposé, is only successful in an experts hands. The surgical techniques of these varieties of laparoscopic hysterectomies will be described and illustrated in detail in this paper.

Measurement of CO2 hypothermia during laparoscopy and pelviscopy: How cold it gets and how to prevent it

STUDY OBJECTIVE To evaluate intraabdominal CO(2) temperature during a variety of standard operative laparoscopy procedures with different insufflators (BEI Medical, Snowden & Pencer, Storz Laparoflator, Storz Endoflator, Wolf) and devices to maintain body temperature (Bair Hugger, fluid warmer, Blanketrol blankets). DESIGN Prospective, nonrandomized study (Canadian Task Force classification II-1). SETTING Community hospital in rural Alabama. PATIENTS Sixty-two consecutive patients (53 women, 9 men; average age 56.8 yrs, range 21-94 yrs). INTERVENTIONS Patients underwent standard laparoscopic and pelviscopic procedures during which intraoperative temperature changes in the insufflation system, abdomen, and rectum were measured. MEASUREMENTS AND MAIN RESULTS Carbon dioxide was at room temperature in the insufflation hose ( approximately 23 degrees C). During insufflation, intraabdominal gas temperature decreased to as much as 27.7 degrees C (average 32.7 degrees C) depending on length of operation (23 min-5 hrs 8 min), amount of gas used (12.8-801 L), gas flow (up to 20 L/min), and leakage rate. Preoperative and postoperative temperature comparisons showed no decline in rectal temperature (average +0.18 degrees C) because warming equipment was sufficient. CONCLUSION The decrease in intraoperative intraabdominal gas temperature is remarkable and can potentially harm the patient. It can be limited by restricting gas flow and leakage. In operations longer than 1 hour, substantial core body temperature drop should be prevented with appropriate heating and hydration devices. An insufflator with internal gas heating (Snowden & Pencer) had no significant clinical effect. (J Am Assoc Gynecol Laparosc 6(3):289-295, 1999)

Treatment of myomas by laparoscopic and laparotomic myomectomy and laparoscopic hysterectomy

The objective of this study was to evaluate the benefits, feasibility and limitations of laparoscopic myomectomy. It was a retrospective review (Canadian Task Force Classification II‐2) at a university‐based primary treatment centre for endoscopic surgery. The 216 evaluated patients were treated at the Department of Obstetrics and Gynaecology, University of Kiel, between January 1998 and November 2000. Of 216 patients with myomas, 178 (83%) underwent laparoscopic myomectomy, 27 (12%) laparoscopic hysterectomy and 11 (5%) laparotomic myomectomy. The study reviewed the indications and surgical techniques and evaluated the benefits and limitations of laparoscopic myomectomy. Nine patients were selected for Classic Intrafascial Supracervical Hysterectomy (CISH) and 18 for Laparoscopic Assisted Vaginal Hysterectomy (LAVH), i.e. 12% of the patients were selected for laparoscopic hysterectomy. In an additional 11 (5%) patients the laparoscopic approach was difficult because of the location of the myoma and the procedure converted to a laparotomic myomectomy. A total of 178 patients (83%) was treated by laparoscopic myomectomy. The mean hospital stay was three days. No serious complications occurred. Two patients suffered a uterine wound bleeding which was corrected and one patient an abdominal hematoma. Since this study mainly focuses on laparoscopic myomectomies (83%), hysteroscopic myomectomies were evaluated in a separate study. At our institution laparoscopic myomectomy is the first‐step treatment for patients with myomatous uteri. Only a small percentage of patients had to undergo a laparotomy (5%) and for 27 patients (12%) hysterectomy proved to be the treatment of choice.

Investigation of the Effectiveness of the Radially-Expanding Needle System, in Contrast to the Cutting Trocar in Enhancing Patient Recovery

Conventional cutting trocars used in laparoscopic surgery occasionally produce serious intra-operative complications and increased postoperative pain. In previous randomised prospective studies comparing the newer radially-expanding needle system (Step) with the cutting trocar, pain scores were significantly lower in the Step group. In this prospective, randomised, multicentre study conducted at three institutions, 100 patients were assigned to treatment with either cutting trocars or the blunt Step system. A total of 49 patients were randomly assigned to the Step system and 51 patients were randomly assigned to trocars. Patients were asked to rate their pain using a 101 -Visual Analogue Scale at 4, 8, 12, 24 and 72 h after surgery. There was a statistically-significant pain reduction with the Step system. The mean postoperative pain scores were consistently lower in the Step group; this was most apparent at 4, 8 and 12 h (p = 0.05). Differences in operative time and adverse events were not statistically significant. In contrast to the conventional cutting trocar, the Step radially-expanding needle system leads to a statistically-significant improvement of patient postoperative comfort.

Specific resistance of Veress needles, disposable and reusable trocars is limiting CO2 gas flow performance in pelviscopy and laparoscopy

SummaryAn efficient insufflation technique is essential for laparoscopy. Up to now physicians have had to rely on their experience and intuition when putting together an insufflation system. Comparable, objective data about the insufflation properties of all insufflation components used has not been available. In this study, details of the insufflation properties of disposable and reusable Veress needles and trocars and Luer lock connectors and the particular meaning of flow resistance for function and efficiency of the entire insufflation system have been measured and compared. In an independent laboratory study, a computer-based data acquisition measurement model was developed. Specific pressure dependent flow and resistance curves of insufflation components from manufacturers such as Auto Suture, Dexide, Ethicon, HiTec, Olympus, Origin, Richard-Allan, Volzer, Wiest, Wolf and Storz were evaluated by measurement of physical parameters pressure, CO2 gas flow and resistance. Through the introduction of ref...

Pelviscopic Reversal of Tubal Sterilization with the One- to Two-Stitch Technique

STUDY OBJECTIVE To describe 28 pelviscopic proximal reversals of tubal sterilization. DESIGN Cohort study (Canadian Task Force classification II-2). SETTING University-affiliated hospital. PATIENTS Twenty-eight women. INTERVENTIONS Twenty-two women underwent bilateral and six unilateral tubal end-to-end anastomosis through a catheter introduced through the working channel of a hysteroscope for a combined hysteroscopic-laparoscopic operation. MEASUREMENTS AND MAIN RESULTS In the two-stitch technique the first stitch adapted the mesosalpinx and the second (4-0 or 6-0 material) to unite the tube muscularis. In some cases a third stitch was applied to either the muscularis or mesosalpinx. In all cases the wound was sealed with tissue col at the end of the procedure. Tubal patency was achieved in 95% of bilateral anastomoses and 100% of unilateral ones. Seventeen pregnancies (61%) were achieved within a minimum of 6 months and a maximum of 4 years. Fifteen patients (54%) had an intrauterine pregnancy with normal delivery and two (7%) had a tubal pregnancy. No abortions occurred. CONCLUSION Laparoscopic end-to-end anastomosis is a suitable surgical alternative to tubal end-to-end anastomosis by laparotomy and has all the advantages of a laparoscopic procedure.

Ectopic pregnancy treatment by laparoscopy, a short glimpse.

Ectopic pregnancy is a life‐threatening emergency, the incidence of which is increasing globally. There are a number of factors predisposing to this condition; today, the most common of these is salpingitis. Due to advancements in diagnostic technology it is possible to diagnose this condition early and thus try to achieve a favourable outcome for the patient. Treatment options in the form of medical and surgical modalities are widely available. As minimally invasive therapy techniques are rapidly advancing, laparoscopic treatment has become the most popular and preferred method for treating ectopic pregnancy. Both salpingotomy as well as salpingectomy can be performed through the laparoscope. This paper gives a short glimpse at the predisposing factors and the diagnostic investigations available for ectopic pregnancy and an insight into its laparoscopic treatment. It also reviews the pregnancy outcome and laparoscopic treatment of cases at the Department of Obstetrics and Gynaecology, Campus Kiel, University Hospitals Schleswig‐Holstein.