Peter Maher

Transeervieal Endometrial Resection for Abnormal Uterine Bleeding - Report of 100 Cases and Review of the Literature

Summary: Many Australian women suffer from unacceptable uterine bleeding and up to 40% may undergo hysterectomy for benign conditions which may be better treated by a less radical procedure ‐ endometrial resection. The preliminary results of 100 patients treated in this way are presented.

Rectal Surgery for Endometriosis—Should We Be Aggressive?

STUDY OBJECTIVE To assess the outcome of aggressive but conservative laparoscopic surgery in the treatment of severe endometriosis involving the rectum. DESIGN Retrospective study (Canadian Task Force classification III). SETTING Endosurgery unit of a tertiary referral center. PATIENTS One hundred sixty-nine women. INTERVENTION Laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS The procedure was completed successfully laparoscopically in 145 (86%) and by laparotomy in 24 women (14%). The rate of preoperative symptoms was higher in 25 women who underwent bowel resection compared with those who had other bowel surgery. In addition to bowel surgery, excision of uterosacral ligaments, adhesiolysis, excision of endometrioma, and oophorectomy were the four most commonly performed procedures. At 35-month follow-up 61 patients (36%) required further surgery for pain. The average time between primary and repeat surgery was 16 months. This second operation was performed by laparoscopy in over three-fourths of the women. Overall recurrent endometriosis was found in 26 patients (15%). Overall morbidity associated with all surgery was 12.4%. CONCLUSION Surgery for endometriosis of the cul-de-sac and bowel involves some of the most difficult dissections encountered, but it can be accomplished successfully with the low postoperative morbidity typical of laparoscopy.

Ten-year review of hysterectomy morbidity and mortality: can we change direction?

Summary: The medical records of all women who underwent hysterectomy for benign disease performed between 1986 and 1995 were reviewed to ascertain the incidence of morbidity and mortality of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy at a university teaching hospital. A total of 1940 hysterectomies were performed during this period; 74% of hysterectomies were performed abdominally, 24% vaginally and 2% were laparoscopically assisted. In 80% of the patients uterine leiomyomas, adenomyosis, dysfunctional uterine bleeding or uterine prolapse were the indications for hysterectomy. The overall complication rate was 44% for abdominal hysterectomy (AH) and 27.3% for vaginal hysterectomy (VH). An unintended major surgical procedure was required in 3% and 1% of women undergoing AH and VH respectively. The rate of return to the operating room for haemostasis was 0.6% for AH and 0.2% for VH. The AH group was four times more likely than the VH group to require surgical intervention (36% versus 9%) at readmission. Vaginal hysterectomy was associated with a lower febrile morbidity and minor complication rate. Prophylactic antibiotics reduced the febrile morbidity for VH and AH by 50% (Students t‐test, p = 0.02) and 40% (Students t‐test, p < 0.001) respectively The overall mortality rate was 1.5 per 1000.

Pain Relief and Outpatient Hysteroscopy: A Literature Review

Our early experience in setting up an ambulatory hysteroscopy service provoked a review of the literature, due to an unacceptably high failure rate. A literature review has been undertaken to establish the accepted success rates and reasons for failure, and to assess evidence for various analgesic protocols through randomized controlled trials. The data suggest the procedure is acceptable to most patients, with a completion success rate over 90%, and the use of analgesia may enhance the success rate. Analgesic protocols studied were nonsteroidal anti-inflammatory drugs, intracervical block, paracervical block, transcervical block, and topical analgesia. Failures are due predominantly to pain, stenosis, and poor view.

Routine use of ureteric catheters at laparoscopic hysterectomy may cause unnecessary complications

STUDY OBJECTIVE To test the use of ureteric catheters in preventing ureteric trauma during laparoscopic hysterectomy. DESIGN Prospective study of 492 consecutive women. SETTING Pelosi Womens Medical Center, New Jersey, and Cliveden Hill Private Hospital, Melbourne, Australia. PATIENTS Four hundred ninety-two consecutive women. INTERVENTIONS Laparoscopic hysterectomy was performed in all women. Because of the reported increased risk of ureteric trauma during laparoscopic hysterectomy, we passed ureteric catheters in 92 such procedures and ceased the practice with the last 400 when further reports suggested lack of increased risk. MEASUREMENTS AND MAIN RESULTS Oliguria and anuria occurred in 7 of 92 patients having ureteric catheterization. No ureteric trauma occurred in 400 patients without ureteric catheterization. The injury rate in this series was significantly lower than in three other series of abdominal hysterectomy. CONCLUSIONS As long as surgical techniques incorporate various procedures to avoid ureteric injury, routine ureteric catheterization during laparoscopic hysterectomy is not indicated and may result in unnecessary complications.

Use of the CEEA Stapler to Avoid Ultra-Low Segmental Resection of a Full-Thickness Rectal Endometriotic Nodule

A woman with a history of numerous surgical episodes for treatment of aggressive endometriosis experienced rectal symptoms. She was prepared for the possibility of laparotomy with or without colostomy to relieve her symptoms. After extensive laparoscopic dissection of the rectovaginal septum, a circular stapling device (Premium Plus CEEA; Autosuture, Melbourne, Victoria, Australia) was used to excise completely an anterior rectal lesion that otherwise would have resulted in ultra-low rectal resection and anastomosis. Morbidity associated with the latter procedure was avoided; the patient was discharged within 72 hours and experienced no early or late complications. Postoperative barium enema was obviated by rapid return to normal bowel habits and complete resolution of dyschezia and dyspareunia.

Complications of laparoscopic hysterectomy

Although laparoscopic hysterectomy is now being performed worldwide, few reported data are available on the associated morbidity and mortality. Between December 1990 and September 1993, 220 women underwent laparoscopic hysterectomy at the Melbourne Gynoscopy Centre. Complications occurred in 35 (15.9%). Among these were anterior abdominal wall vessel injury in 5 patients, bladder injury in 5, febrile illness in 13, secondary hemorrhage in 4, temporary ureteral obstruction in 4, and Richter hernia in 1.

Direct Cannula Entry for Laparoscopy

The common blind puncture technique for inserting a cannula to establish pneumoperitoneum was first described by Veress in 1938 and carries several significant and specific complications such as gas embolism, subcutaneous inflation, failed pneumoperitoneum, and bowel or visceral insufflation. Direct cannula insertion is both safe and effective. No major complications using this technique occurred in a series of 550 consecutive laparoscopies. It would seem that the patient who is served safely by a Veress needle approach is equally served by direct cannula entry.

A prospective randomised double-blind placebo controlled trial to assess whether gas drains reduce shoulder pain following gynaecological laparoscopy

To assess the effects on patient discomfort of an intraabdominal passive gas drain left for four hours postoperatively following gynaecologic laparoscopic surgery.

Can anyone screen for deep infiltrating endometriosis with transvaginal ultrasound

Surgical treatment of deep infiltrating endometriosis (DIE) is complex, and preoperative diagnosis benefits both surgeon and patient. Studies in expert centres have reported high accuracy for transvaginal ultrasound (TVUS) diagnosis of DIE. External validation of these findings has been limited, and no information is available on how quickly these skills can be acquired. The aim of this study was to measure the learning curve of DIE‐TVUS and to identify the causes for inaccuracies in the diagnosis of bowel lesions and Pouch of Douglas (POD) obliteration.