Per Lundorff

Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy*

OBJECTIVE Women with ectopic pregnancy (EP) who have been operated on by laparoscopy are thought to have improved subsequent fertility, probably because of less adhesion formation. We aimed to evaluate the adhesion formation after laparoscopy as compared with laparotomy in a randomized trial. DESIGN One hundred five patients with tubal pregnancy were stratified with regard to age and risk factors and randomized to surgery by laparoscopy or laparotomy. To evaluate adhesion formation and tubal status, 73 patients with strong desire of pregnancy underwent a second-look laparoscopy. The adhesion status at the ipsilateral and contralateral side at primary surgery was compared with the status at second-look laparoscopy. RESULTS Patients operated on by laparotomy developed significantly more adhesions at the operated side than patients operated on by laparoscopy (P less than 0.001). Substantially more patients in the laparotomy group underwent adhesiolysis at second-look laparoscopy than did patients in the laparoscopy group. Tubal patency did not differ between the groups. CONCLUSIONS Laparoscopic treatment of EP results in less impairment of the pelvic status compared with conventional conservative surgery.

Laparoscopic surgery in ectopic pregnancy : a randomized trial versus laparotomy

A randomized, prospective clinical trial was conducted to compare the efficacy of laparoscopic treatment with conventional conservative abdominal surgery for tubal pregnancy. Entry criteria were: size of the ectopic gestation < 4 cm, hemodynamic stability, accessibility for laparoscopic treatment and a trained laparoscopist on duty. There was no difference between the groups regarding gestational duration, size and location of the ectopic gestation, or the mean preoperative hCG values. The groups differed with respect to total operation time (73 min for the laparoscopy group vs. 88 min for the laparotomy group), hospital stay (2.2 vs. 5.4 days) and convalescence period (11 vs. 24 days). The rates of elimination of hCG was similar in the groups, and there were no statistical difference in the rate of second intervention.

A cost-effectiveness study of a randomised trial of laparoscopy versus laparotomy for ectopic pregnancy

We compared the cost-effectiveness of therapeutic laparoscopy and open laparotomy for treatment of laparoscopically diagnosed ectopic pregnancy. Clinical outcomes of ectopic pregnancy treatment were based on results of a randomised trial done between 1987 and 1989 at Sahlgrenska University Hospital (Göteborg, Sweden). We estimated costs for inpatient and follow-up care of ectopic pregnancy by the two methods. Observed resource use (eg, procedure duration) was multiplied by 1992 estimates of resource unit cost (eg, cost per minute of laparoscopy time), based on detailed internal cost accounting data from Huddinge University Hospital. By specified criteria, the initial procedure eliminated trophoblastic activity without major complications in 81% (95% CI: 68-90) of 52 laparoscopy patients, versus 95% (85-99) of 57 laparotomy patients. Residual trophoblast or complications were successfully treated in all remaining patients. Mean simulated costs (standard error) for the overall laparoscopy strategy were 28,058 (1780) Swedish kronor versus 32,699 (1080) kronor for laparotomy (p = 0.03). In the baseline simulation and most sensitivity analyses, laparoscopy produced final outcomes equivalent to those of laparotomy at lower costs. As laparoscopic outcomes improve, this newer approach should become increasingly preferable.

Fertility outcome after conservative surgical treatment of ectopic pregnancy evaluated in a randomized trial

OBJECTIVE To evaluate the fertility outcome after laparoscopic surgery for ectopic pregnancy. DESIGN A randomized trial versus laparotomy was performed between May 1987 and June 1989. SETTING The study was conducted in a clinical university center, the Sahlgrens Hospital. PATIENTS A group of 105 patients with tubal pregnancy were stratified with regard to risk determinants and age and randomized to laparoscopy or laparotomy. Eighty-seven patients who desired pregnancy were evaluated for subsequent fertility outcome. INTERVENTIONS Linear salpingotomy was performed in both surgical groups. MAIN OUTCOME MEASURE We evaluated the fertility outcome after laparoscopic salpingotomy for comparison with the outcome after laparotomy. RESULTS There was no difference between the groups in the overall fertility outcome. A substantially higher proportion of patients in the laparotomy group were subjected to adhesiolysis performed at a second-look laparoscopy. CONCLUSIONS The fertility prospects are not impaired by laparoscopic surgery. Adhesiolysis at a second-look laparoscopy, especially after laparotomy, might be beneficial in selected cases and may serve to improve subsequent fertility.

Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2α*

Twenty-six cases of unruptured tubal pregnancy were treated by laparoscope-guided injection of prostaglandin (PG) F2α into the affected tube and the ovary containing the corpus luteum. Preoperative serum human chorionic gonadotropin (hCG) levels were 22 to 2,050 IU/L (mean 328 IU/L). The procedure was successful in 24 patients (92%), as indicated by reduction of hCG values to

Second-look laparoscopy after ectopic pregnancy.

During the 4-year period of 1984 to 1987, 102 women with ectopic pregnancy (EP) underwent second-look laparoscopy 6 to 10 weeks after EP surgery. Benefits of this procedure, e.g., adhesiolysis and/or selection of women for further fertility interventions (in vitro fertilization [IVF], gamete intrafallopian transfer [GIFT], tubal microsurgery), were evaluated. On the basis of the second-look laparoscopy, 13% of the women were offered tubal microsurgery and 14% recommended for IVF. Patients without risk factors for EP developed adhesions as frequently as those with known risk factors and no specific surgical procedure was correlated to impairment of the pelvic status. Almost 40% of the patients presented with an impairment of adhesions on the affected side compared with the status at the time of EP surgery. Lysis of adhesions was performed during the second-look laparoscopy in 42 patients (41%). We conclude that second-look laparoscopy should be recommended to all EP patients with a desire for pregnancy.

Transvaginal hydrolaparoscopy: a new diagnostic tool in infertility investigation

Background.  To establish the value of a new technique called transvaginal hydrolaparoscopy for exploration of the tubo‐ovarian structures in the management of patients with unexplained infertility.

Coexistence of bilateral tubal and intrauterine pregnancy

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Modern management of ectopic pregnancy: Early recognition, laparoscopic treatment and fertility prospects

Ectopic pregnancy (EP) today constitutes about 2% of all pregnancies and is a menace to future female fertility. One purpose of this thesis was to analyze whether the identification of women with increased risk for ectopic pregnancy, such as previous ectopic pregnancy, infertility, previous laparotomy or pregnant with an IUD .q situ would lead to an earlier diagnosis and hopefully to a more atraumatic intervention. These patients could be identified by using a risk score model developed by Thorburn et al. (1). Hospital records from 1986 and 1987 of 178 patients with EP were scrutinized and the risk score model was applied to this material. Patients with increased risk for ectopic pregnancy were diagnosed one week earlier than patients without risk factors. The frequency of tubal rupture was significantly reduced, the patients presented with less clinical symptoms than did the patients from the low risk group, and they were significantly older. There was no difference in the plasma levels of hCG or in the findings at endovaginal sonography. The overall aim of this study was to evaluate whether laparoscopic surgery in ectopic pregnancy would be advantageous compared with traditional laparotomy. Of 105 patients with laparoscopically diagnosed ectopic pregnancy, about half of the patients were randomized to laparoscopy and the rest to laparotomy. The entrance criteria to this trial was a tubal pregnancy < 4 cm in diameter, a hemodynamically stable patient, plasma hCG levels < 10.000 IU/I and a trained laparoscopist on duty. To reduce bleeding, 5 IU of Vasopressin diluted in 10 ml of NaCl was injected into the mesosalpinx of all patients in the