Michael Cooper

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).

Laparoscopic‐assisted Vecchietti procedure for creation of a neovagina: an analysis of five cases

The aim of this study was to review the functional and psychological outcomes of subjects with vaginal aplasia undergoing a laparoscopic creation of a neovagina (Vecchietti procedure). A semi‐structured telephone interview was undertaken of five consecutive subjects who underwent the procedure in the preceding three years. Information was obtained with regard to the operation, immediate post‐operative period, complications experienced, sexual function and improvements in general and psychological well‐being.

Laparoscopic Excision of Endocervicosis of the Urinary Bladder

Endocervicosis is a benign lesion in which endocervical mucosa develops in anatomic locations distant from the endocervical canal. Two cases of infiltrating endocervicosis of the urinary bladder were managed by laparoscopic partial cystectomy. This avoided the morbidity of laparotomy and provided improved visualization of the extent of bladder resection required to remove the lesion completely.

Hepatic endometriosis: A case report and review of the literature

A 46-year-old nulliparous woman presented in October 2001complaining of right upper quadrant pain. Pelvic endometriosishad been diagnosed at laparoscopy in 1987. An endome-triotic bladder nodule was removed in 1988 and a subtotalhysterectomy for endometriosis was carried out in 1990. Abilateral oopherectomy and resection of an endometrioticbowel lesion (requiring temporary colostomy) was under-taken in 1992, and oestradiol implants were used from 1992to 1996.In 1997, an upper abdominal ultrasound showed a 10-cmlesion within the right lobe of the liver, with echogenicmargins and internal debris. Computed tomography (CT)scanning showed a low-density lesion, a small subphrenic fluidcollection and a right pleural effusion. At laparotomy, thelesion was marsupialised. Pathological examination of thecyst wall confirmed an endometrioma.The patient was treated with Goserelin 3.6 mg monthlyfor a year following surgery. A further CT scan in August2000 showed reformation of a 6-cm cyst within the liverparenchyma. Repeat CT scanning carried out in August2001 revealed that this lesion had grown to 11 cm. It alsodemonstrated attachment to the inferior surface of the righthemi-diaphram (Fig. 1). She had experienced minimalmenopausal symptoms since cessation of Goserelin in 1998,although serum assays at her last presentation showed afollicle-stimulating hormone level of 48 IU/L, an oestradiollevel of 105 IU/L and a CA125 >1000 IU/L.A further laparotomy was undertaken in November 2001.The patient had a large multiloculated endometrioma occu-pying the right lobe of the liver that was attached to theinferior surface of the right hemi-diaphram. There was full-thickness invasion of endometriosis through the diaphram.A right hemi-hepatectomy, cholecystectomy and diaphrag-matic resection were undertaken. Fibrotic obliteration of thepleural cavity at the base of the right lung was noted, so noattempt was made to close the diaphragmatic defect.The specimen of hemi-liver contained an endometrioma(Fig. 2) showing moderately atypical complex hyperplasia(Fig. 3).Figure 1 Intrahepatic endometrioma demonstrated by computedtomography scanning.

Implications for Port Placement of Deep Circumflex Iliac Artery Damage at Laparoscopy

A cannula injury to the deep circumflex iliac vessels led to substantial morbidity and required surgical repair. Surgeons must increase their awareness of the anatomy of these vessels and place laparoscopic ports to minimize the risk of injury. (J Am Assoc Gynecol Laparosc 6(2):221-223, 1999)

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.

Re: Endometrial Resection - A Comparison of Techniques

Summary: To assess the long-term effectiveness and safety of endometrial resection, an ongoing prospective study of 927 patients, followed for 1 to 5 years, was carried out. The patients met criteria previously adopted, for vaginal hysterectomy. Three techniques were used, modified over time with experience gained and failures encountered: Technique 1: Resection alone; Technique 2: Resection, followed by roller-ball cautery of the whole endometrium; Technique 3: Laparoscopic control, resection, roller-ball cautery, further resection especially in the comua and fundus and finally laparoscopic cautery of the cornual region of the uterus. Various parameters were measured including preparation of the endometrium, pathology present, complications and outcomes. There was a marked improvement in the success of the procedure with changes from Technique I to 2 to 3. There was a fall in the failure rate from 22% to 5%. These results were statistically highly significant (p<0.0001). The best results obtained were in women with endometrial polyps and pure dysfunctional bleeding with good results in cases of intramural fibroids and adenomyosis. There were no deaths and no cases of long-term adverse sequelae resulting from complications, but the following were encountered: perforation of the uterus, hyponatraemia, pregnancy, infection, unanticipated malignancy and cervical stenosis. It is concluded that in view of the high success rate and relative lack of serious complications, endometrial ablation should be considered the treatment of choice in cases of dysfunctional bleeding in women who have completed their families.

Dangerous injury associated with bipolar diathermy

A 34-year-old woman underwent laparoscopic surgery for endometriosis. During the procedure she sustained a partial thickness burn injury to her sigmoid colon. The operating suite staff became aware of unintended diathermy activation when an audible alarm on the generator sounded spontaneously. It was noted that the bipolar lead had been inadvertently placed into the monopolar sockets, and the paddles of the Lyons bipolar forceps became active when approximated within the abdominal cavity. The injury was immediately identified and repaired laparoscopically with 2/0 vicryl sutures. Endometriosis involving the pelvic sidewall, uterosacral ligaments and muscularis layer of the sigmoid colon was excised. The patient was discharged from hospital on day 2 with no postoperative sequelae.

Electrosurgical Principles and Problems

EDITORIAL COMMENT: We have not previously published information concerning electrosurgical principles applicable to the instrumentation now widely used in gynaecological practice. This is our beginning. The information presented should, at the very least, warn surgeons, especially those using electrosurgery in combination with laparoscopy, that a thorough understanding of these principles should be mastered before surgical training in these techniques is commenced.