Paul K. Tulikangas

Gross and histologic characteristics of laparoscopic injuries with four different energy sources.

OBJECTIVE To compare the gross and histologic effects of bipolar and monopolar cautery, ultrasonic scalpel, and CO(2) laser on porcine ureter, bladder, and rectum. DESIGN Experimental prospective study. SETTING Cleveland Clinic Foundation Animal Research Laboratory, Cleveland, Ohio. ANIMAL(S) Nonpregnant adult female pigs. INTERVENTION(S) The rectum, bladder, and ureters of 12 female pigs were injured with four different laparoscopic energy sources. MAIN OUTCOME MEASURE(S) Gross measurements of injured tissue and histologic analysis of the depth of the tissue injury. RESULT(S) Gross assessment results were that monopolar injuries of the bowel and bladder were significantly longer than ultrasonic injuries (P<0.01). Injuries were generally manifest as coagulative denaturation of collagen bundles. This resulted in an eosinophilic homogenization of tissue. Nuclei were retained in the injured tissue, although in most cases they had a pyknotic, streamed appearance. The CO(2) laser caused no deep-tissue injury. CONCLUSION(S) Laparoscopic energy sources injure tissue differently. Monopolar cautery appears to have the most lateral spread of thermal energy. The CO(2) laser appears to cause the least deep-tissue injury.

Laparoscopy for Adnexal Masses in the Second Trimester of Pregnancy

STUDY OBJECTIVE To assess the safety of laparoscopic treatment of adnexal masses in the second trimester of pregnancy. DESIGN Retrospective chart review (Canadian Task Force classification II-3. SETTING Large tertiary care medical center. PATIENTS Eleven women. INTERVENTION Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS All masses were identified by ultrasound. The average gestational age at the time of surgery was 17 weeks, 4 days. In seven women the primary cannula was inserted in the left upper quadrant of the abdomen. Procedures were eight ovarian cystectomies, two oophorectomies, and one exploratory laparoscopy. Average operating time was 135 minutes (range 95-195 min). Average time exposed to carbon dioxide was 78 minutes (range 59-135 min). None of the masses was malignant. There were no fetal complications or malformations. No patients had preterm labor and all delivered at term. CONCLUSIONS The increasing number of reported cases and our experience suggest that laparoscopic treatment of adnexal masses in the second trimester is safe and effective, but the surgeon must be skilled in advanced techniques of laparoscopic surgery.

Laparoscopic repair of ureteral injuries.

STUDY OBJECTIVES To evaluate the laparoscopic approach for repairing ureteral injuries, and assess the effect of ureteral dissection (ureterolysis) on tissue healing. DESIGN Randomized animal study (Canadian Task Force classification I). SETTING Biological Resources Unit, Cleveland Clinic Foundation. SUBJECTS Ten pigs. INTERVENTION In all animals, the pelvic segment of the right ureter was completely dissected off the pelvic sidewall and peritoneum. In group A, both pelvic ureters were divided with scissors and repaired over a stent; in group B the ureters were coagulated and anastomosis was performed after resection of the necrotic segment. Laparoscopic intracorporeal suturing techniques were used for end-to-end ureteral anastomosis. MEASUREMENTS AND MAIN RESULTS All animals survived without complications. Ureteral stents were removed 4 weeks after repair. Creatinine level and retrograde pyelogram performed before injury and 12 weeks after repair were compared. At necropsy anastomoses were evaluated for leak, pressure flow studies, and histopathology. All anastomoses were patent with no leak. Although serum creatinine level increased significantly after repair (p = 0.001), this increase never reached levels found in renal failure, and all animals continued to do well and have good appetite (mean increase in body weight 20.3 +/- 6.2 kg). Mild hydronephrosis was diagnosed in three kidneys, all on the right side. Mild ureteral dilatation occurred bilaterally; it was significant on the right side (3.8 +/- 3.8 mm, p = 0.05) but not on the left (1.7 +/- 2 mm, p = 0.3). Results of pressure flow studies did not reveal significant obstruction at anastomoses. Healing around the dissected right ureter was marked with dense fibrosis, adhesions, and scar formation. On histopathology the right ureter showed more urothelial abnormalities than the left, with marked fibrosis and sclerosis in the muscularis and adventitial layers. CONCLUSION Ureterolysis may interfere with the healing process of ureteral injuries by increasing fibrosis and adventitial scarring. Laparoscopic repair of these injuries is feasible and safe.

Enterocele: is there a histologic defect? ☆

OBJECTIVE To examine the histology of the vaginal wall in women with an enterocele confirmed by physical examination, cystoproctography, and intraoperative exploration. METHODS Thirteen women with posthysterectomy apical and posterior wall prolapse were evaluated with a detailed physical examination, cystoproctography, and intraoperative exploration. All women had enterocele repair. A specimen of full thickness vaginal wall from the leading edge of the enterocele was excised and examined histologically. The histology of these patients was compared with the histology of two comparison groups, five women undergoing hysterectomy without prolapse and 13 women undergoing radical hysterectomy. RESULTS One woman with an enterocele repaired intraoperatively did not have an enterocele by cystoproctography. One woman with an enterocele repaired intraoperatively did not have an enterocele detected by physical examination. All women with an enterocele repaired had an intact vaginal wall muscularis. No woman had vaginal wall epithelium in direct contact with the peritoneum. The average vaginal wall muscularis thickness in women with enteroceles was 3.5 ± 1.4 mm, in women with no prolapse 3.2 ± 0.8 mm, and in women undergoing radical hysterectomy 2.8 ± 0.9 mm. CONCLUSION Women with enteroceles have a well‐defined vaginal muscularis between the peritoneum and vaginal epithelium.

Anatomy of the left upper quadrant for cannula insertion

STUDY OBJECTIVE To determine the anatomy of the left upper quadrant (LUQ) of the abdomen in women with different body mass indexes. DESIGN Review of computed tomographic (CT) scans and medical records (Canadian Task Force classification II-2). SETTING Large tertiary care medical center. PATIENTS Sixty-three women over age 18 years who had scans performed for any indication. Nine women were excluded because of contraindication to LUQ laparoscopic cannula insertion and five because of incomplete records. Intervention. None. MEASUREMENTS AND MAIN RESULTS The closest organs to the LUQ insertion site were the liver and stomach. There was significantly more subcutaneous fat at the umbilicus than at the insertion site. A positive correlation was found between body mass index and distance between structures and the site. CONCLUSION Cannulas should not be inserted in the LUQ in women with hepatomegaly or splenomegaly. Because the stomach is so close to the insertion site, gastric drainage should be performed before cannula insertion. The site is likely safe in obese women whose abdominal organs are far away from it, and who have less subcutaneous fat there than at the umbilicus.

Intraoperative cystoscopy in conjunction with anti-incontinence surgery

Objective To determine the frequency of lower urinary tract injury detected by routine intraoperative cystoscopy after anti-incontinence surgery. Methods We reviewed charts from women who had anti-incontinence surgery and routine intraoperative cystoscopy done by a single surgeon from June 1, 1995, to June 1, 1998, and assessed preoperative and intraoperative variables. Results We reviewed 351 patient records. Four records were incomplete and there were nine injuries in the other 347 cases (2.6%, 95% confidence interval [CI] 1.2, 4.9). Four cystotomies occurred during laparoscopic Burch procedures and were detected before cystoscopy. Five injuries were detected at cystoscopy, a rate of 1.5% (95% CI 0.5, 3.4). Four injuries occurred during 161 pubovaginal sling procedures (2.5%, 95% CI 0.7, 6.2). One woman had sutures in her bladder from a prior procedure detected at cystoscopy. In 186 Burch procedures (48 laparoscopic, 138 open), there were no previously unrecognized injuries detected by cystoscopy. All injuries were repaired during original surgery. It was not possible to assess preoperative and intraoperative risk factors because of the low rate of injury. Conclusion The rate of injury to the lower urinary tract during anti-incontinence surgery in this series was 2.6% (95% CI 1.2, 4.9). Injuries during Burch procedures were all detected before cystoscopy.

Functional and anatomic follow-up of enterocele repairs

OBJECTIVE To identify the functional and anatomic outcomes in women who have surgery for pelvic organ prolapse with enterocele repair. METHODS Fifty‐four women had surgery for pelvic organ prolapse which included enterocele repair. Preoperative and postoperative examinations were done by a research nurse, including a pelvic examination using the International Continence Society staging system and standardized questionnaires about bowel function, sexual function, and prolapse symptoms. RESULTS Fifty‐four women had enterocele repairs as part of their surgery. Mean follow‐up time was 16 months (range 6–29 months). Postoperatively five women were excluded from the analysis because of fluctuation in stage of prolapse over time. At the apex and posterior wall of the vagina, 33 women had stage 0 or I prolapse, and 16 had stage II prolapse. None had stage III or IV prolapse. Fifty‐three percent of women had improvement in bowel function and 91% had improvement in vaginal prolapse symptoms. Functional outcomes were not significantly different in women with and without stage II prolapse at follow‐up. CONCLUSION Most women who had surgery for pelvic organ prolapse with enterocele repair reported improvement in vaginal prolapse symptoms. Functional outcomes did not differ significantly between women with stage 0 and I prolapse and women with stage II prolapse at the vaginal apex and posterior vaginal wall. This was an observational study and the lack of statistically significant findings could result from inadequate sample size; however, the observed differences were judged to be not clinically significant.

Laparoscopic Repair of Ureteral Transection

Injury to the ureter is a possible complication of laparoscopic surgery. Traditionally, it is repaired by laparotomy. During laparoscopic surgery for bilateral ovarian remnants in a 29-year-old woman, the left ureter was transected. The ureter was repaired by primary end-to-end anastomosis by laparoscopy. The patient recovered uneventfully, and postoperative intravenous puelogram confirmed the repair to be intact.