Marco A. Pelosi

Laparoscopically assisted hysterectomy for uteri weighing 500 g or more

We attempted to determine the feasibility and results of laparoscopically assisted vaginal hysterectomy (LAVH) for removing symptomatic fibroid uteri not suitable for vaginal hysterectomy. We retrospectively reviewed cases in which the uterus weighed 500 g or more and was considered not suitable for traditional vaginal hysterectomy after examination under anesthesia. Laparoscopically assisted hysterectomy with or without unilateral or bilateral adnexectomy was successfully completed in 20 (91%) of 22 cases. Thirteen patients had concurrent laparoscopic lysis of adhesions, and one a laparoscopic bladder neck suspension. Mean uterine weight was 837 g, mean operating time 167 +/- 42 minutes, mean blood loss 390 +/- 107 ml, and mean hospital stay 2.6 days. No febrile morbidity or surgical complications occurred among these patients. The only significant intraoperative complication was bleeding requiring blood transfusions, which occurred in one of the two women who required abdominal hysterectomy. Our results suggest that LAVH is a safe and effective alternative to total abdominal hysterectomy of the very large fibroid uterus, and that conversion to total abdominal hysterectomy could be expected to occur in less than 10% of cases.

Fetal risk in hyperextension of the fetal head in breech presentation

An evaluation of the possible etiologic factors in hyperextension of the fetal head in breech presentation and a discussion of management are presented. Our seven cases plus a review of the literature led to the conclusion that hyperextension of the aftercoming head is a dangerous malpresentation that should not be underestimated. For this reason, we strongly suggest an x-ray of all breech presentations in early labor, not only to evaluate pelvic adequacy but also to determine the attitude of the head. In persistent hyperextension, cesarean section is the management of choice.

Laparoscopic-assisted transvaginal myomectomy.

We conducted a retrospective review of 21 combined laparovaginal myomectomies to treat extensive and deeply infiltrating fundal and posterior wall leiomyomata. Laparoscopy confirmed the size, number, and position of leiomyomata, permitted intramyometrial vasopressin infiltration, and allowed partial enucleation of large and deep myomata. Posterior colpotomy permitted delivery of myomata and uteri, and uterine reconstruction by conventional suturing performed transvaginally. The uteri were then placed in their anatomic position, the colpotomies were repaired, and a final laparoscopic survey and lavage were performed. All surgeries were successfully completed without intraoperative or postoperative complications. This approach allows a layered traditional uterine reconstruction of deep myometrial defects and may enhance the ability to repair extensive uterine defects in a minimally invasive fashion.

Routine use of ureteric catheters at laparoscopic hysterectomy may cause unnecessary complications

STUDY OBJECTIVE To test the use of ureteric catheters in preventing ureteric trauma during laparoscopic hysterectomy. DESIGN Prospective study of 492 consecutive women. SETTING Pelosi Womens Medical Center, New Jersey, and Cliveden Hill Private Hospital, Melbourne, Australia. PATIENTS Four hundred ninety-two consecutive women. INTERVENTIONS Laparoscopic hysterectomy was performed in all women. Because of the reported increased risk of ureteric trauma during laparoscopic hysterectomy, we passed ureteric catheters in 92 such procedures and ceased the practice with the last 400 when further reports suggested lack of increased risk. MEASUREMENTS AND MAIN RESULTS Oliguria and anuria occurred in 7 of 92 patients having ureteric catheterization. No ureteric trauma occurred in 400 patients without ureteric catheterization. The injury rate in this series was significantly lower than in three other series of abdominal hysterectomy. CONCLUSIONS As long as surgical techniques incorporate various procedures to avoid ureteric injury, routine ureteric catheterization during laparoscopic hysterectomy is not indicated and may result in unnecessary complications.

Galactorrhea-amenorrhea syndrome associated with heroin addiction

Abstract Three patients with galactorrhea and amenorrhea associated with the long-term use of heroin are reported, introducing a possible etiologic factor for the amenorrhea-galactorrhea symptom complex. The patients, heroin addicts, had copious galactorrhea and amenorrhea and demonstrated low gonadotropin values, hypoestrogenism, and normal thyroid and adrenal function. The possibility of a pituitary tumor was excluded in all the cases. The clinical picture, the laboratory, radiologic, and laparoscopic findings, and the results of the biopsies are described. The mechanism of action of heroin is probably pharmacologic blockage of the hypothalamus or the hypothalamic-pituitary axis. As a consequence, the hypophysis is not stimulated by the gonadotropin-releasing factors and is not inhibited by the prolactin-inhibiting factor, producing hypoestrogenism and secretion of prolactin, clinically manifested by amenorrhea and galactorrhea. This symptom complex is probably a temporary syndrome which will disappear or improve after cessation of heroin use.

Hand-assisted laparoscopy for complex hysterectomy.

In rare cases of extreme uterine enlargement, hysterectomy by vaginal and laparoscopic-assisted techniques is not feasible and requires a large abdominal incision. Hand-assisted laparoscopy permits the performance of such cases through a much smaller, glove-size abdominal incision while preserving pneumoperitoneum. In a 45-year-old nullipara with a grossly enlarged, impacted uterus and total vaginal obliteration, hysterectomy was safely performed by hand-assisted laparoscopy using the Pneumo Sleeve system through a 7. 5-cm transverse suprapubic incision, and a 1-cm laparoscopic incision. The operation lasted 150 minutes, blood loss was 220 ml, and the specimen weighed 3050 g. The patient was discharged in excellent condition on the second postoperative day and had an uneventful recovery. (J Am Assoc Gynecol Laparosc 6(2):183-188, 1999)

Laparoscopic removal of a 1500-g symptomatic myoma during the second trimester of pregnancy

A successful myomectomy was performed in the second trimester of pregnancy to remove a 1500-g, symptomatic myoma that was refractory to conservative therapy. A laparoscopic single umbilical puncture technique was used. We suggest that laparoscopic myomectomy can be performed safely and effectively during pregnancy. If further studies confirm our experience, for selected patients, it should be considered a minimally invasive alternative to traditional laparotomy when myomectomy during pregnancy becomes inevitable for the removal of symptomatic pedunculated tumors.

Laparoscopic electrosurgical furrowing technique for the treatment of polycystic ovaries.

A retrospective analysis of reproductive outcomes was conducted in 30 anovulatory women treated with a new laparoscopic electrosurgical furrowing technique. All patients had polycystic ovary syndrome refractory to ovulation induction with clomiphene citrate and gonadotropin therapy. Bilateral ovarian furrowing was successfully accomplished in all 30 patients without technical difficulty or surgical complications. Average furrowing time was 5 minutes per ovary and all patients were discharged by 12 hours postoperatively. Regular ovulatory function resumed in 25 women (83.3%); the 5 refractory patients were administered clomiphene citrate. Spontaneous conception occurred in 21 ovulatory patients (70.0%) and clomiphene-assisted conception occurred in 3 of the 5 refractory women, for an overall pregnancy rate of 80% (24/30). Twenty-three pregnancies resulted in viable term deliveries; one (4.2%) ended in a first-trimester abortion. These results suggest that the laparoscopic electrosurgical furrowing technique for the treatment of anovulatory infertility in women with polycystic ovary syndrome refractory to clomiphene citrate and gonadotropin therapy is effective, safe, and easily performed. Further evaluation is warranted to confirm the appropriateness of this procedure.

Hand-assisted laparoscopic cholecystectomy at cesarean section

Laparoscopic cholecystectomy at the time of elective cesarean delivery eliminates the need for separate operations. Hand-assisted laparoscopy takes technical advantage of the cesarean abdominal incision to facilitate laparoscopic maneuvers with retention of pneumoperitoneum. A 39-year-old woman with two previous cesarean sections and recurrent cholecystitis throughout her third pregnancy underwent full-term, elective cesarean section, tubal sterilization, and hand-assisted laparoscopic cholecystectomy under general anesthesia. Total operating time was 53 minutes, estimated blood loss was 550 ml, and postoperative hospital stay was 72 hours. The operation and recovery were uneventful.

Laparoscopic removal of a 103-pound ovarian tumor

Abstract The surgical removal of extremely large abdominopelvic masses is associated with a high perioperative complication rate related to massive physiologic and anatomic distortions. The judicious use of minimally invasive techniques in carefully selected patients may diminish the convalescent stresses inherent to laparotomy. We removed a 103-pound benign, ovarian mucinous cystadenoma from a 22-year-old woman by laparoscopy. We believe this is the largest such tumor removed by this method, and it raises several issues relevant to the intraoperative and perioperative management of such neoplasms. Systematic laparoscopic drainage and excision of extremely large, benign, abdominopelvic tumors is not only feasible, but is a reproducible, safe, low-morbidity alternative to initial laparotomy in the treatment of these rare lesions.