Michael S. Baggish

Endometrial ablation : A series of 568 patients treated over an 11-year period

OBJECTIVE Our purpose was to retrospectively review the intraoperative and long-term outcomes of 568 patients with abnormal uterine bleeding who were treated by endometrial ablation over an 11-year period. STUDY DESIGN From 1893 to 1994, 401 endometrial ablations were performed with the neodymium-yttrium-aluminum-garnet laser and another 167 patients were treated by electrosurgery. The majority of the patients were treated for irregular, heavy menses. Fifty-seven had ablation because of abnormal bleeding associated with a serious medical disorder, 12 with a bleeding diathesis, and 50 with morbid obesity. All patients had preoperative endometrial sampling that demonstrated benign histology. Nineteen patients had submucous myomas that were resected at the time of hysteroscopic ablation. All patients received preoperative and postoperative suppression. The minimum follow-up period was 1 year. RESULTS The average operative time was 32.5 minutes. The mean hospital stay was 8 hours. Four patients who received 32% dextran 70 in dextrose (Hyskon) as the distending medium had pulmonary edema postoperatively. One case of endometritis was also detected. No uterine perforations were observed. Amenorrhea developed in 58% of the patients, 34% reported light or normal menstrual flow, and 8% did not respond (continued heavy flow). CONCLUSION This study represents one of the largest published series of endometrial ablation, with a mean follow-up of 4.5 years. It demonstrates that hysteroscopic endometrial ablation is a reliable, safe alternative to hysterectomy for the surgical management of abnormal uterine bleeding.

Endometrial carcinoma after endometrial ablation: High-risk factors predicting its occurrence

Our purpose was to review reported cases of endometrial carcinoma after endometrial ablation and to evaluate high-risk factors predicting its occurrence. We present guidelines for the treatment of abnormal uterine bleeding unresponsive to medical therapy in this high-risk group of patients. Eight detailed reports on endometrial carcinoma after endometrial ablation were reviewed. The indications, methods of treatment, follow-up, and associated high-risk factors for endometrial carcinoma were analyzed. A focused list of high-risk factors for endometrial carcinoma was developed on the basis of the data collected. Guidelines were established to enable surgeons to minimize the risks of subsequent uterine cancer in women with abnormal uterine bleeding that is unresponsive to medical therapy (ie, candidates for ablation). Women who had endometrial carcinoma develop after ablation had predictive high-risk factors for subsequent neoplasia, and all eventually underwent a hysterectomy. Women with abnormal uterine bleeding and high-risk factors for endometrial carcinoma who did not respond to medical treatment may safely undergo endometrial ablation but must have a preablation biopsy indicating normal endometrium. Persistent hyperplasia unresponsive to hormonal therapy should influence the selection of a hysterectomy. Careful screening of patients before undergoing endometrial destructive procedures is prescient because minimally invasive, nonhysteroscopic ablative techniques are now emerging.

Complications of Laparoscopic Sterilization: Comparison of 2 Methods

A retrospective study of 5346 cases of laparoscopic sterilization with special reference to early and late complications was undertaken. In the 6-year period from 1972 to 1978, 846 patients were sterilized by the elasticized silicone-ring technique and 4500 patients were sterilized by the electrocautery method. The electrocautery method was complicated by electrical burns in 13 cases (0.29%); 3 of these patients required bowel resections. Mechanical complications occurred in 1.6% of the Silastic-ring cases, but none of the patients required additional surgery. The Silastic-ring patients had greater postoperative abdominal pain than the electrocautery patients, but it usually abated within 48 hours. There were 15 cases of postoperative pelvic infection in the electrocautery group, and none in the Silastic-ring group. Bleeding from the mesosalpinx occurred in both groups and occurred more often with coincident suction D&C. Technical failure to perform the sterilization procedure was principally related to previous abdominal surgery. A substantial number of patients complained of menstrual irregularity and/or dysmenorrhea following these sterilization procedures. The majority of women reported unchanged or improved sexual relations. Improvement in sexual relations was reported by significantly more patients in the Silastic-ring group than in the electrocautery group.

Urinary oxalate excretion and its role in vulvar pain syndrome

OBJECTIVE This study was undertaken to determine the urinary oxalate excretion patterns in patients with vulvodynia compared with controls and to evaluate antioxalate therapy in women with vulvar pain syndrome (vulvodynia). STUDY DESIGN A total of 130 consecutive patients with vulvar pain syndrome and 23 volunteers without symptoms collected urine specimens for 24 hours; each voiding was saved in individual labeled containers and refrigerated. The specimens were analyzed individually for oxalate and calculated according to 24-hour concentration, volume, and peak oxalate by hour. A total of 59 patients were treated with low-oxalate diets and calcium citrate for 3 months and evaluated for objective relief of vulvar pain. RESULTS The 24-hour excretion of oxalate was almost identical in controls and vulvodynia patients. The total 24-hour excretion was directly proportional to the volume of urine excreted (p < 0.001). No significant differences were found in peak oxalate excretion (95% confidence intervals). The number of voidings was higher in the vulvodynia cohort (p < 0.02). The 59 women with elevated oxalate concentrations (> 1 mg/40 dl) were treated with an antioxalate regimen. Fourteen (24%) demonstrated an objective response, but only 6 (10%) could have pain-free sexual intercourse. CONCLUSIONS Urinary oxalates may be nonspecific irritants that aggravate vulvodynia; however, the role of oxalates as instigators is doubtful.

Effects of an educational workshop on performance of fourth-degree perineal laceration repair.

OBJECTIVE: To develop a valid and reliable tool to objectively measure surgical skill necessary for repair of fourth-degree perineal lacerations and then to use this tool to measure improvement after a workshop. METHODS: We measured baseline surgical ability and clinical knowledge of 26 residents (postgraduate year [PGY]-1 to PGY-4) using the Objective Structured Assessment of Technical Skills (OSATS) and a written examination. The OSATS consists of a global surgical skills assessment (OSATS-G), a procedure checklist (OSAT-C), and pass/fail grade. Five weeks after our baseline evaluation, a 1.5-hour workshop was administered to approximately half of the 26 residents (n=14). One week after this intervention, the residents were re-examined using the same assessment tools. RESULTS: The OSATS demonstrated construct validity as scores on the examination increased on both the OSATS-G and the OSATS-C from PGY-1 through PGY-4 (P=.001 and P=.041, respectively). Reliability indices for the OSATS were high. Eighty-one percent of the residents failed the OSATS before intervention because of failure to identify and repair the internal anal sphincter. After educational intervention, senior residents improved on all assessments (OSATS-G, P=.041; OSATS-C, P=.004; written examination, P=.008), and all residents passed the OSATS. CONCLUSION: A valid and reliable OSATS and written examination were developed to assess surgical skills, knowledge, and judgment necessary to properly manage fourth-degree perineal lacerations. Residents improved on the OSATS and the written examination after undergoing a structured educational workshop. LEVEL OF EVIDENCE: II

Assessment of the safety of intrauterine instillation of heated saline for endometrial ablation

OBJECTIVE To evaluate the safety of pressure, temperature-controlled, continuously circulating hot saline (EnAbl system, InnerDyne Medical, Sunnyvale, CA) for endometrial ablation using the in vivo human uterus. DESIGN Clinical safety study. SETTING An academic research environment. PATIENTS Eleven women undergoing abdominal hysterectomy because of abnormal uterine bleeding. INTERVENTION Before uterine removal, endometrial cavities were exposed to 15 minutes of recirculatory normal saline heated to 70-85 degrees C. MAIN OUTCOME MEASURE(S) The uteri were analyzed for extent of thermal damage using standard histopathological techniques and tissue viability histochemical staining. Intrauterine pressures and serosal and subserosal temperatures were continuously monitored by computer. RESULT(S) In each treated specimen, histochemical staining demonstrated a depth of necrosis that extended through the entire endometrium and approximately 1-2 mm into the myometrium. The control specimen showed no thermal or mechanical damage. There were no observed negative effects or related complications with this system. CONCLUSION(S) The computer-controlled system employing continuously circulating hot saline is an effective method to destroy the endometrium. In four cases with clearly patent tubes, no spill was observed. In all 11 patients, serosal and subserosal temperatures were within safe levels (mean temperature, 37 degrees C).

Vaginal uterine artery ligation avoids high blood loss and puerperal hysterectomy in postpartum hemorrhage.

I read with great interest the article by Hebisch and Huch. It should be pointed out, however, that this is not a new procedure. Transvaginal uterine artery ligation to control postpartum hemorrhage has already been described by Philippe. The study performed at Zurich University Hospital was started 8 months later, a fact apparently overlooked by reviewers. In this study, patient population is not defined, and specific causes of bleeding are not stated. Because of the rather extended therapeutic time lag (1 hour to 22 days) and inaccurate assessment of blood loss, it is very difficult to determine the procedure’s effectiveness. Though the authors affirm embolization requires 60–90 minutes and is thus unacceptable, 11 of 13 women were treated within 24 hours postpartum. The risk of ureter ligation in such a limited operation field is never mentioned. Finally, the authors erroneously assert that to verify ligation results a laparoscopy is needed, ignoring transvaginal Doppler. Although their technique seems promising, to increase its safety a detailed anatomic description is required. Moreover, Dr. Philippe should be acknowledged as the mastermind of this interesting procedure.

Analysis of 31 Cases of Major-Vessel Injury Associated with Gynecologic Laparoscopy Operations

Thirty-one (31) cases with 49 major-vessel injuries associated with laparoscopic surgery are reported. Women with body mass indices ≥ 25-30 kg/M2 accounted for 22 of 31 cases. Ninety percent (90%) of vascular injuries in this study were associated with the use of disposable trocar devices. Although injuries to arteries and veins were approximately equal, the 7/31 (23%) fatalities all involved predominantly venous damage. Three (3) of the seven (7) deaths related to the use of extra-long trocar insertion. Collateral injuries happened at the time of the initial vascular injury or occurred as a complication during the repair of the primary vascular problem in 16 cases. The latter included urinary, gastrointestinal, neurologic, hematologic, and circulatory complications. Several inappropriate actions taken by the gynecologist are quantified. Large-vessel penetration during gynecologic laparoscopy is a bona fide emergency and requires timely diagnosis and proper remedial measures leading to precise restoration.

Mean Distance Between Primary Trocar Insertion Site and Major Retroperitoneal Vessels During Routine Laparoscopy

Major vascular injuries complicating laparoscopic operations are a source of significant morbidity and mortality. The goal of this study was to measure the distances between the anterior abdominal wall subumbilical trocar entry site and the retroperitoneal location(s) of the aorta, iliac vessels, and urinary bladder directly. Patients were measured during actual laparoscopic surgery in the lithotomy, or modified lithotomy position, level, and Trendelenburg positions. Patients were all divided according to body-mass index (BMI) and height. Significant differences between distances from the primary trocar insertion site to the aorta and the iliac vessels were observed. Similarly, significant differences in the thickness of the anterior abdominal wall were observed between three BMI groups. The use of reasonable precautions will enable the surgeon to avoid trocar damage to the great vessels located in the abdominal retroperitoneum.

Resident Duty-Hour Restrictions and Their Effect on Operative Experience in Obstetrics and Gynecology

Background/Aims: To determine the effect of duty-hour restrictions on the operative experience of obstetrics and gynecology residents. Methods: Operative numbers were obtained from graduates of Mayo Clinic (Rochester, Minn., USA) and Good Samaritan Hospital (Cincinnati, Ohio, USA). Mean operative numbers between graduates in 2007 and 2003 were compared. The following procedures were evaluated: spontaneous vaginal delivery, forceps-assisted vaginal delivery, vacuum-assisted vaginal delivery, cesarean delivery, surgery on antenatal patients, amniocentesis, total abdominal hysterectomy, total vaginal hysterectomy, laparotomy, incontinence or pelvic floor surgery, operative laparoscopy, hysteroscopy, cervical conization, and surgical sterilization. The number of procedures performed (total and as the primary surgeon) were evaluated. We analyzed each institution’s residents separately. Results: At Mayo Clinic, the 2007 graduates performed significantly fewer conizations than the 2003 graduates (p = 0.006). At Good Samaritan Hospital, the 2007 graduates performed significantly more vacuum-assisted vaginal deliveries (p = 0.002), cesarean deliveries (p = 0.002), and sterilizations (p < 0.001) than the 2003 graduates. The above findings were unchanged when evaluating procedures for which the resident was the primary surgeon. Conclusion: Duty-hour restrictions have not adversely affected the operative experience of obstetrics and gynecology residents. No significant differences in the number of the spontaneous vaginal deliveries, abdominal hysterectomies, or vaginal hysterectomies performed were observed.