Mark A. Carlton

METHODS OF CREATING PNEUMOPERITONEUM : A REVIEW OF TECHNIQUES AND COMPLICATIONS

The existence of numerous techniques for the creation of pneumoperitoneum at laparoscopy indicates that none have been proven totally efficacious or complication free. These methods include the standard technique of insufflation after insertion of the Veress needle via the umbilicus or less commonly via the transfundal or transforniceal routes, open laparoscopy involving dissection through the linea alba and opening of the peritoneum under direct vision, and direct trocar insertion as well as variations on these techniques. After reviewing the methods available and surveying the existing data concerning the rates of failure and complications, we conclude that no single technique can claim to be overwhelmingly superior, and that laparoscopists should, therefore, acquaint themselves with at least two of these techniques. Finally, we recommend a large-scale combined survey by the colleges of obstetricians and gynecologists and surgeons on rates of failure and complications of the varied approaches of abdominal entry for laparoscopy.

Home Within 24 Hours of Laparoscopic Hysterectomy

We assessed the feasibility of safe discharge home within 24 hours following laparoscopic hysterectomy in 30 patients who met the inclusion criteria and consented to be enrolled in the study group. Patients were admitted on the day of their surgery with the expectation of discharge within 24 hours. Appropriate home nursing follow‐up and phone contact by the surgical team were organized preoperatively. Inclusion criteria were: age 30–65 years, absence of any major medical history that would require prolonged hospitalization, availability of home support for the first 48 hours after discharge and presence of a working telephone line and an address within the area of the Community Home Nursing service. All 30 operative procedures were completed without incident. Six patients underwent total laparoscopic hysterectomy (TLH) (all the procedures of hysterectomy being performed laparoscopically including the suturing of uterine arteries, colpotomy and closure of the vaginal vault. The uterus was removed vaginally) and 24 patients underwent laparoscopic hysterectomy (LH) (this techniques differs from TLH in that the colpotomy was performed laparoscopically but the uterosacral ligaments were divided vaginally and the vault also was closed vaginally after the uterus was removed vaginally). The average operating time was 115 minutes (range 85–150 minutes) and the average blood loss was 97 mL (20–250 mL). There were no intraoperative complications, no requirement for transfusion and no readmission to hospital for any of the patients in the study. Postoperative complications were minor (umbilical cellulitis (1), intestinal colic (1)) and both were treated with resolution of the symptoms. Ninety per cent of patients in the study were discharged within 24 hours of their surgery, the average duration of stay being 22.9 hours (20–24 hours). Three patients were not fit for discharge at 24 hours postoperatively due to general lethargy, migraine and nausea; their average discharge time was 53.5 hours. The study showed that laparoscopic hysterectomy can be associated with a reduction in length of in‐patient stay compared to traditional laparotomy. Furthermore this reduction could be safely reduced to 24 hours following laparoscopic hysterectomy. There was also an associated cost saving in terms of inpatient bed days. Patient satisfaction with this protocol was high in this selected and motivated group.

A Review of Results in a Series of 113 Laparoscopic Colposuspensions

The case records of 113 women having laparoscopic retropubic colposuspensions (Burch procedure) performed for the treatment of genuine urinary stress incontinence between December, 1992 and April, 1995 were retrospectively reviewed. The mean age of the group was 49.4 (30–80) years, mean weight 72.1 (44.5–114) kg, and mean parity 2.7 (0–8). All patients had preoperative urodynamic study to confirm genuine stress incontinence (GSI). Sixteen patients (14%) had dual pathology (GSI and detrusor instability).

Is Hysterectomy Necessary for Laparoscopic Pelvic Floor Repair? A Prospective Study

STUDY OBJECTIVE To evaluate whether the addition of hysterectomy to laparoscopic pelvic floor repair has any impact on the short-term (perioperative) or long-term (prolapse outcome) effects of the surgery. DESIGN A controlled prospective trial (Canadian Task Force classification II-1). SETTING Private and public hospitals affiliated with a single institution. PATIENTS A total of 64 patients with uterovaginal prolapse pelvic organ prolapse quantification system stage 2 to 4 had consent for laparoscopic pelvic floor repair from January 2005 through January 2006 (32 patients in each treatment arm). Patients self-selected to undergo hysterectomy in addition to their surgery. INTERVENTIONS Patients were divided into group A (laparoscopic pelvic floor repair with hysterectomy) or group B (laparoscopic pelvic floor repair alone). All patients had laparoscopic pelvic floor repair in at least 1 compartment, whereas 52 patients had global pelvic floor prolapse requiring multicompartment repair. Burch colposuspension and/or additional vaginal procedures were performed at the discretion of the surgeon in each case. MEASUREMENTS AND MAIN RESULTS Symptoms of prolapse and pelvic organ prolapse quantification system assessments were collected preoperatively, perioperatively, and at 6 weeks, 12 months, and 24 months postoperatively. Validated mental and physical health questionnaires (Short-Form Health Survey) were also completed at baseline, 6 weeks, and 12 months. No demographic differences occurred between the groups. Time of surgery was greater in group A (+35 minutes), as was estimated blood loss and inpatient stay, although the latter 2 results had no clinically significant impact. No difference between groups was detected in the rate of de novo postoperative symptoms. At 12 months, 4 (12.9%) patients in group A had recurrent prolapse as did 6 (21.4%) patients in group B. At 24 months these figures were 6 (22.2%) and 6 (21.4%), respectively. These differences were not statistically significant (p=.500 at 12 months and .746 at 24 months). In the group not having hysterectomy, 4 (14.3%) of 28 patients had cervical elongation or level-1 prolapse by the 12-month assessment. CONCLUSION The addition of total laparoscopic hysterectomy to laparoscopic pelvic floor repair adds approximately 35 minutes to surgical time with no difference in the rate of perioperative or postoperative complications or prolapse outcome. Leaving the uterus in situ, however, is associated with a risk of cervical elongation potentially requiring further surgery. Laparoscopic pelvic floor repair is successful in 80% of patients at 2 years.

Nitric Oxide Excretion in Normal and Hypertensive Pregnancies

Objective: To determine whether nitric oxide (NO) excretion, assessed by the measurement of NO breakdown products, was increased in normal pregnancy but reduced in preeclampsia (PE).Methods: The study was conducted in a university teaching hospital and in the antenatal wards of a private community cooperative hospital. Measurements of urinary NO breakdown products were made on 24-h urines collected from 31 nonpregnant age-matched women, 56 normal pregnant women in their third trimester. 18 women with mild preeclampsia (equivalent to “gestational” or “transient” hypertension in pregnancy in other classifications), 30 women with severe preeclampsia (87′/r with proteinuria), and 13 women with essential hypertension. All women were eating a free diet.Main Outcome Measure: Twenty-four-hour urinary nitrite/nitrate excretion.Results: Urinary nitrate/nitrite excretion was similar among groups– micromoles per day. median (interquartile range): nonpregnant, 982 (763, 1534); normal pregnant. 980 (673. 1274); mild pr...

Skin closure at laparoscopy

STUDY OBJECTIVE To discern the best method of wound closure after laparoscopy based on patient acceptability of pain, complications, and cosmetic result. DESIGN Randomized, prospective study. SETTING A university-affiliated hospital. PATIENTS Fifty-four women. Interventions. The women received interrupted 3-0 nylon sutures, subcuticular 3-0 polyglactin 910 sutures, or adhesive strips for skin closure. At the umbilical port site the rectus sheath was closed with a single 0 polyglactin suture and then one of the three materials for skin closure. The lateral ports were closed with a combination of these materials, allowing each patient to act as her own control. MEASUREMENTS AND MAIN RESULTS Pain was significantly less in wounds closed by subcuticular technique than in those closed by either transcutaneous suture or adhesive strips. This was seen for the 5-mm, 10-mm, and umbilical port sites. There was no statistically significant difference in the rate of reported complications or patient satisfaction between subcuticular and transcutaneous wound sites. CONCLUSION We believe these results support subcuticular methods of wound closure after laparoscopic procedures.

Complications of 174 Laparoscopic Hysterectomies

The case records of 174 patients who underwent laparoscopic hysterectomy between September, 1992 and April, 1995 were retrospectively reviewed. The mean age of the group was 45.4 (range 17.8–68.5) years, mean weight 70.2 (50–121) kg and mean parity 2.3 (0–4). Laparoscopic hysterectomy (i.e. uterine arteries secured laparoscopically) was performed in 98 patients, laparoscopically assisted vaginal hysterectomy in 70, and laparoscopic subtotal hysterectomy in 6. Bilateral or unilateral oophorectomy were performed in 40 cases. The mean operating time was 131 (45–285) minutes and mean hospitalization 2.6 (1–11) days. Endoscopic stapling devices were used in 135 cases, biopolar diathermy in 117, sutures and ties in 84, and the harmonic scalpel in 29. The overall complication rate was 16%. Seven cases (4%) required conversion to laparotomy. These included 2 inadvertent cystotomies (1 after 2 Caesarean sections), 3 cases of dense uterovesical adhesions following previous surgery and 2 instances of excessive uterine size (>16 weeks). The mean follow‐up period was 2.2 (1–18) months. One patient had a shortened vagina requiring dilatation and another had vault granulations requiring diathermy treatment. Overall 98.3% of patients were satisfied with their surgery.

Recurrent intravenous leiomyomatosis with extension up the inferior vena cava

A 53-year-old woman was referred with an enlarged right ovary and associated ‘thrombus’ in the pelvic vessels and inferior vena cava (IVC). She had undergone a total abdominal hysterectomy and left oophorectomy for a fibroid uterus and left ovarian cyst 7 years previously. The histology had shown intravenous leiomyomatosis but her surgeon had not arranged regular follow-up. Neither the patient nor the referral letter conferred this diagnosis. Pelvic ultrasound showed a 4.2 cm enlarged right ovary adherent to the pelvic sidewall, lying adjacent to the internal iliac vein. A serum carcinoembryonic antigen (CEA) and Ca125 level were both within the normal range (CEA 2 (0– 10 μg/L); Ca125 10 (0–35 kU/L)). A pelvic and abdominal CT scan showed ill-defined low-density areas within the IVC, strongly suspicious of thrombus. Repeat pelvic and abdominal ultrasound showed a large echogenic, free-floating thrombus within the inferior vena cava, extending almost to the level of hepatic veins. She underwent surgery with the presumptive diagnosis of a right ovarian cyst and venous thrombosis. After initial laparoscopic adhesiolyis, the operation was converted to a laparotomy as the right ovary was totally adherent to the right pelvic sidewall and the ureter embedded within it. The right ovary was removed with part of the ureter and the remainder reimplanted. A ureteric stent was introduced at the end of the procedure (and was removed 8 weeks postoperatively). The histology of the right adnexal mass was that of a benign leiomyoma. Postoperative CT scan showed that ‘thrombus’ was still present in the IVC. There was a danger that this could lead to a massive pulmonary embolus and therefore a cardiothoracic surgeon removed this under cardiopulmonary bypass. It was only at the time of this surgery that it became obvious that the ‘thrombus’ was in fact an intravascular tumour. The histology showed a 250 mm length of lobulated benign leiomyoma with a maximum diameter of 25 mm. The diagnosis was consistent with intravenous leiomyomatosis.

Total laparoscopic hysterectomy with laparosonic coagulating shears: a retrospective report of 200 consecutive cases.

Summary: Despite 10 years of intensive education and training in Australia only around 14% of hysterectomies are performed with laparoscopic assistance. In particular total laparoscopic hysterectomy (TLH) has a poor penetration rate because of perceived technical difficulties that include instrumentation, prolonged operating times and an increase in complications. We present a series of 200 consecutive cases of TLH with very good results and propose that because of the many advantages that this technique offers that it should become the standard procedure for benign uterine disease.

An Unusual Set of Triplets: Twin Intrauterine Pregnancy with Singleton Extrauterine Pregnancy

Heterotopic pregnancy (simultaneous intrauterine and extrauterine pregnancy) is an extremely rare clinical phenomenon occurring approximately 1 in 30,000 pregnancies (1) or 1 in 2,000,000 live births (2). There have been 435 cases reported in the world literature up to 1956 (3). Simultaneous viability in heterotopic pregnancy is an even rarer event occurring in only 10.6% of cases (3).