Philippe Y. Laberge

Laparoscopic Entry: A Review of Techniques, Technologies, and Complications

OBJECTIVE To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. OPTIONS The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. OUTCOMES Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. EVIDENCE English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. RECOMMENDATIONS AND SUMMARY STATEMENT: 1. Left upper quadrant (LUQ, Palmers) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. (II-2 A) Other sites of insertion, such as transuterine Veress CO(2) insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option. (I-A) 2. The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels. (II-1 A) 3. The Veress intraperitoneal (VIP-pressure </= 10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO(2) source to the Veress needle on entry. (II-1 A) 4. Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury. (II-2 B) 5. The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45 degrees in non-obese women to 90 degrees in obese women. (II-2 B) 6. The volume of CO(2) inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO(2) volume. (II-1 A) 7. In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women. (II-1 A) 8. The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available. (II-2 C) 9. Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique. (II-2) 10. Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique. (I) 11. Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access. (II-B) 12. Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars. (I-A) 13. The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury. (2 B).

Regional differences in adipose tissue metabolism in women : Minor effect of obesity and body fat distribution

Studies comparing adipose tissue metabolism in central versus peripheral fat depots have generated equivocal data. We examined whether regional differences in abdominal subcutaneous and omental adipose tissue metabolism in women exist and whether they persist across the spectrum of body fatness and abdominal adiposity values. We measured adipocyte size; lipoprotein lipase (LPL) activity; and basal, isoproterenol-, forskolin-, and dibutyryl cAMP–stimulated lipolysis in adipose tissue or mature adipocytes isolated from the omental and subcutaneous fat depots in a sample of 55 healthy women undergoing elective gynecological surgery. Measures of body fat mass and body fat distribution were also obtained by dual-energy X-ray absorptiometry and computed tomography. Subcutaneous adipocytes were significantly larger than omental adipocytes (P < 0.0001). LPL activity expressed as a function of cell number was significantly higher in subcutaneous versus omental adipose tissue (P < 0.0001). Basal, isoproterenol-stimulated, dibutyryl cAMP–stimulated (10−3 mol/l) and forskolin-stimulated (10−5 mol/l) lipolysis (expressed as a function of cell number) were all significantly higher in subcutaneous versus omental adipocytes (P < 0.05 to P < 0.0001). However, the response of omental adipocytes to lipolytic stimuli tested (fold increase over basal level) was significantly greater in magnitude compared with subcutaneous adipocytes (P < 0.01). These differences were relatively constant across total body fat mass and visceral adipose tissue area tertiles. In conclusion, compared with adipocytes from the omental fat compartment, subcutaneous adipocytes are larger, have higher LPL activity, and are more lipolytic on an absolute basis, which may reflect a higher fat storage capacity in this depot in women. In contrast, omental adipocytes display greater relative responsiveness to both adrenergic receptor–and postreceptor-acting agents compared with subcutaneous adipocytes. Overall and visceral obesity have only minor effects on regional differences in adipose tissue metabolism.

A Randomized, Multicenter Trial of Safety and Efficacy of the NovaSure System in the Treatment of Menorrhagia

STUDY OBJECTIVE To compare the safety and effectiveness of the NovaSure impedance-controlled endometrial ablation system with hysteroscopic wire loop resection plus rollerball ablation for treatment of excessive uterine bleeding in premenopausal women. DESIGN Randomized, multicenter, double-arm study (Canadian Task Force classification I). SETTING Nine academic medical centers and private offices. PATIENTS Two hundred sixty-five premenopausal women with symptomatic menorrhagia. INTERVENTION Ablation performed with the NovaSure system or wire loop resection and rollerball. MEASUREMENTS AND MAIN RESULTS Success [pictorial blood loss-assessment chart (PBLAC) score < or =75] was achieved in 88.3% of NovaSure-treated and 81.7% of rollerball-treated patients. One year after treatment 90.9% and 87.8%, respectively, reported normal bleeding or less (PBLAC < or =100) and 41% and 35%, respectively, experienced amenorrhea (PBLAC = 0). Mean procedure time was 4.2 minutes (average 84 sec) in the NovaSure group and 24.2 minutes in the rollerball group. Local and/or intravenous sedation was administered in 73% of NovaSure patients and 18% of rollerball patients. Intraoperative adverse events occurred less frequently with NovaSure (0.6%) than with rollerball (6.7%). Postoperative adverse events occurred in 13% and 25.3% of patients, respectively. CONCLUSION The NovaSure system was safe and effective in treatment of women with menorrhagia. The procedure is both quick and effective, and eliminates the expense and side effects of endometrial pretreatment.

Endometriosis: Diagnosis and Management

OBJECTIVE To improve the understanding of endometriosis and to provide evidence-based guidelines for the diagnosis and management of endometriosis. OUTCOMES OUTCOMES evaluated include the impact of the medical and surgical management of endometriosis on womens experience of morbidity and infertility. METHODS Members of the guideline committee were selected on the basis of individual expertise to represent a range of practical and academic experience in terms of both location in Canada and type of practice, as well as subspecialty expertise along with general gynaecology background. The committee reviewed all available evidence in the English and French medical literature and available data from a survey of Canadian women. Recommendations were established as consensus statements. The final document was reviewed and approved by the Executive and Council of the SOGC. RESULTS This document provides a summary of up-to-date evidence regarding diagnosis, investigations, and medical and surgical management of endometriosis. The resulting recommendations may be adapted by individual health care workers when serving women with this condition. CONCLUSIONS Endometriosis is a common and sometimes debilitating condition for women of reproductive age. A multidisciplinary approach involving a combination of lifestyle modifications, medications, and allied health services should be used to limit the impact of this condition on activities of daily living and fertility. In some circumstances surgery is required to confirm the diagnosis and provide therapy to achieve the desired goal of pain relief or improved fecundity. Women who find an acceptable management strategy for this condition may have an improved quality of life or attain their goal of successful pregnancy. EVIDENCE Medline and Cochrane databases were searched for articles in English and French on subjects related to endometriosis, pelvic pain, and infertility from January 1999 to October 2009 in order to prepare a Canadian consensus guideline on the management of endometriosis. VALUES The quality of evidence was rated with use of the criteria described by the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described by the Task Force. See Table 1. BENEFITS, HARMS, AND COSTS Implementation of the guideline recommendations will improve the care of women with pain and infertility associated with endometriosis.

Visceral Adipocyte Hypertrophy is Associated With Dyslipidemia Independent of Body Composition and Fat Distribution in Women

OBJECTIVE We assessed whether subcutaneous and omental adipocyte hypertrophy are related to metabolic alterations independent of body composition and fat distribution in women. RESEARCH DESIGN AND METHODS Mean adipocyte diameter of paired subcutaneous and omental adipose tissue samples was obtained in lean to obese women. Linear regression models predicting adipocyte size in both adipose tissue depots were computed using body composition and fat distribution measures (n = 150). In a given depot, women with larger adipocytes than predicted by the regression were considered as having adipocyte hypertrophy, whereas women with smaller adipocytes than predicted were considered as having adipocyte hyperplasia. RESULTS Women characterized by omental adipocyte hypertrophy had higher plasma and VLDL triglyceride levels as well as a higher total-to-HDL cholesterol ratio compared with women characterized by omental adipocyte hyperplasia (P < 0.05). Conversely, women characterized by subcutaneous adipocyte hypertrophy or hyperplasia showed a similar lipid profile. In logistic regression analyses, a 10% enlargement of omental adipocytes increased the risk of hypertriglyceridemia (adjusted odds ratio [OR] 4.06, P < 0.001) independent of body composition and fat distribution measures. A 10% increase in visceral adipocyte number also raised the risk of hypertriglyceridemia (adjusted OR 1.55, P < 0.02). Associations between adipocyte size and homeostasis model assessment of insulin resistance were not significant once adjusted for adiposity and body fat distribution. CONCLUSIONS These results suggest that omental, but not subcutaneous, adipocyte hypertrophy is associated with an altered lipid profile independent of body composition and fat distribution in women.

Short-Term Morbidity and Long-TermRecurrence Rate of Ovarian Dermoid CystsTreated by Laparoscopy Versus Laparotomy

OBJECTIVE To compare the short-term morbidity and the long-term recurrence rate of ovarian dermoid cysts in women treated conservatively by laparoscopy with the outcomes in women treated by laparotomy. METHODS This retrospective multicentre cohort study compared the outcomes of removal of dermoid cysts by laparoscopy with removal by laparotomy. All specimens were confirmed histologically as dermoid cysts. We reviewed all medical records and identified all surgical interventions for dermoid cysts over a 10-year period (1993-2003) in two academic centres in Quebec City. Of the 299 women treated for ovarian dermoid cysts, 167 were treated by laparotomy and 132 were treated by laparoscopy. To compare short-term morbidity, we excluded those who had undergone ophorectomy or any concomitant surgery, and we consequently reviewed the records of 98 patients in the laparotomy group and 100 patients in the laparoscopy group. To compare long-term recurrence rates we excluded only those patients who had had oophorectomy. In total, 245 women with available follow-up were identified as having ovarian cystectomy (95 in the laparoscopy group and 150 in the laparotomy group). Two-tailed Fisher exact test was used for analysis of categorical variables, and Student t test or Wilcoxon rank test were used for analysis of continuous variables comparing the two groups. Life table analysis using the Kaplan-Meier method was performed to assess the risk of long-term recurrence. RESULTS The mean diameter of the cyst in women who had a laparotomy was significantly larger than in women who had laparoscopy (8.27 cm vs. 5.94 cm), and significantly more women in the laparotomy group had bilateral cysts (16% vs. 5% in the laparoscopy group). In women who had laparoscopy, operating time was greater (P = 0.0363), but blood loss was less (P < 0.0001) and duration of hospital stay (P < 0.0001) was shorter. Spillage of the cysts contents occurred in 18% of cases in the laparoscopy group and in 1% in the laparotomy group. Conversions of laparoscopy to laparotomy occurred in 11% of cases, mainly because of cyst size. Postoperative complication rates were similar in the two groups. Reintervention rate was 4.2% in the laparoscopy group and 0% in the laparotomy group (P = 0.0217). Using life table analysis, the probability of recurrence at two years was 7.6% (95% confidence intervals 2.9, 19.2) in the laparoscopy group and 0% in the laparotomy group. CONCLUSION Ovarian cystectomy performed by laparoscopy is associated with a higher incidence of intra-abdominal spillage than laparotomy, but this not associated with any increase in morbidity. Laparoscopic treatment results in a shorter hospital stay and less intraoperative blood loss than laparotomy, but it is associated with a significantly higher risk of recurrence.

Expression of genes related to glucocorticoid action in human subcutaneous and omental adipose tissue.

Adipose tissue glucocorticoid action relies on local enzymatic interconversion and glucocorticoid receptor (GR) availability. 11β-Hydroxysteroid dehydrogenase type 1 (11β-HSD1), 2 (11β-HSD2) and hexose-6-phosphate dehydrogenase (H6PDH) are likely involved in glucocorticoid activation/inactivation within adipose tissue. We examined adipose tissue mRNA expression of genes related to glucocorticoid action and their association with total and visceral adiposity. Messenger RNA was measured in paired subcutaneous and omental fat samples obtained from 56 women (age: 47.3 ± 4.8 years, BMI: 27.1 ± 5.2 kg/m(2)) undergoing gynaecological surgery. Expression levels of 11β-HSD2, H6PDH and GRα were higher in omental adipose tissue while 11β-HSD1 expression was similar between fat compartments. Subcutaneous and omental 11β-HSD1 mRNA abundances were positively associated with total and visceral adiposity whereas omental H6PDH mRNA abundance was negatively associated with these measures. Only omental 11β-HSD1 mRNA expression remained significantly associated with visceral adipose tissue area following statistical adjustment for fat mass, age and menopausal status. Omental 11β-HSD1 mRNA expression explained 19.1% of the variance in visceral adipose tissue area. Omental fat tissue 11β-HSD-1 protein and cortisol levels were higher in visceral obese women, supporting findings obtained with 11β-HSD-1 mRNA. These results suggest that among the transcripts examined only omental 11β-HSD1 is independently associated with visceral obesity in women.

Assessment and comparison of intraoperative and postoperative pain associated with NovaSure and ThermaChoice endometrial ablation systems.

STUDY OBJECTIVE To assess and compare intraoperative and postoperative pain associated with NovaSure impedance-controlled endometrial ablation system and ThermaChoice system. DESIGN Prospective, international, multicenter, double-arm study (Canadian Task Force classification II-1). Setting. Academic medical centers and private offices. PATIENTS Sixty-seven premenopausal women with menorrhagia. INTERVENTION Endometrial ablation with either the NovaSure (37 women) or ThermaChoice (30) system. NovaSure-treated patients received no endometrial pretreatment; those treated with ThermaChoice received the recommended 3-minute suction dilatation and curettage. MEASUREMENTS AND MAIN RESULTS Standard pain measurement instruments (visual analog scale, numeric rating scale) were used to assess intraoperative and postoperative pain. Serum levels of prostaglandin-F(2alpha) were measured before and 5, 30, and 60 minutes after the procedure. Patients treated with the NovaSure system reported statistically significantly lower intraoperative and postoperative pain than those treated with the ThermaChoice system (p <0.0001). Procedure time was statistically significantly shorter with the NovaSure system (p <0.0001). Prostaglandin-F(2alpha) values did not differ statistically between groups. CONCLUSION The NovaSure system is associated with statistically significantly lower intraoperative and postoperative pain than ThermaChoice system, and endometrial ablation with NovaSure could become an office-based procedure.

The Human Aldose Reductase AKR1B1 Qualifies as the Primary Prostaglandin F Synthase in the Endometrium

CONTEXT Prostaglandins (PGs) E2 and PGF2α are produced in the endometrium and are important for menstruation and fertility. Dysmenorrhea is associated with increased production of PGF2α relative to PGE2, and the opposite is true for menorrhagia. The pathways leading to PGE2 biosynthesis are well described, but little is known for PGF2α. Aldoketoreductase (AKR)-1C3, the only PGF synthase identified in the human, cannot explain the production of PGF2α by endometrial cells. AKR1B1 appears to be an alternate candidate with promising therapeutic value. OBJECTIVE The objective of the study was to address whether AKR1B1 (gene ID 231) is a functional PGF2α synthase in the human endometrium and a valid therapeutic target for menstrual pain. DESIGN The design of the study was basic laboratory analyses to identify gene expression and protein levels associated with PGF2α production in endometrial tissues and endometrial cells from cycling women aged between 23 and 52 yr undergoing biopsies or hysterectomy for diverse gynecological disorders. RESULTS AKR1B1 is expressed at a high level during the menstrual cycle during the secretory phase and in both epithelial and stromal cells, whereas AKR1C3 was found only in epithelial cells. Purified recombinant AKR1B1 protein, gene silencing, and transient transfection experiments all concur to demonstrate that this enzyme is a functional PGF synthase. Ponalrestat, a specific inhibitor developed to block AKR1B1 activity, reduced PGF2α production in response to IL-1β in both cultured endometrial cells and endometrial explants. CONCLUSIONS The human aldose reductase AKR1B1 currently associated with diabetes complications is also a highly functional PGF synthase responsible for PGF2α production in the human endometrium and a potential target for treatment of menstrual disorders.

Hysterosalpingosonography for diagnosing tubal occlusion in subfertile women: a systematic review with meta-analysis

STUDY QUESTION Is hysterosalpingosonography (sono-HSG) an accurate test for diagnosing tubal occlusion in subfertile women and how does it perform compared with hysterosalpingography (HSG)? SUMMARY ANSWER sono-HSG is an accurate test for diagnosing tubal occlusion and performs similarly to HSG. WHAT IS KNOWN ALREADY sono-HSG and HSG are both short, well-tolerated outpatient procedures. However, sono-HSG has the advantage over HSG of obviating ionizing radiation and the risk of iodine allergy, being associated with a greater sensitivity and specificity in detecting anomalies of the uterine cavity and permitting concomitant visualization of the ovaries and myometrium. STUDY DESIGN, SIZE, DURATION A systematic review and meta-analysis of studies published in any language before 14 November 2012 were performed. All studies assessing the accuracy of sono-HSG for diagnosing tubal occlusion in a subfertile female population were considered. PARTICIPANTS/MATERIALS, SETTING, METHODS We searched Medline, Embase, Cochrane Library, Web of Science and Biosis as well as related articles, citations and reference lists. Diagnostic studies were eligible if they compared sono-HSG (±HSG) to laparoscopy with chromotubation in women suffering from subfertility. Two authors independently screened for eligibility, extracted data and assessed the quality of included studies. Risk of bias and applicability concerns were investigated according to the Quality Assessment of Diagnostic Accuracy Study (QUADAS-2). Bivariate random-effects models were used to estimate pooled sensitivity and specificity with their 95% confidence intervals (95% CIs), to generate summary receiver operating characteristic curves and to evaluate sources of heterogeneity. MAIN RESULTS AND THE ROLE OF CHANCE Of the 4221 citations identified, 30 studies were eligible. Of the latter, 28 reported results per individual tube and were included in the meta-analysis, representing a total of 1551 women and 2740 tubes. In nine studies, all participants underwent HSG in addition to sono-HSG and laparoscopy, allowing direct comparison of the accuracy of sono-HSG and HSG. Pooled estimates of sensitivity and specificity of sono-HSG were 0.92 (95% CI: 0.82-0.96) and 0.95 (95% CI: 0.90-0.97), respectively. In nine studies (582 women, 1055 tubes), sono-HSG and HSG were both compared with laparoscopy, giving pooled estimates of sensitivity and specificity of 0.95 (95% CI: 0.78-0.99) and 0.93 (95% CI: 0.89-0.96) for sono-HSG, and 0.94 (95% CI: 0.74-0.99) and 0.92 (95% CI: 0.87-0.95) for HSG, respectively. Doppler sonography was associated with significantly greater sensitivity and specificity of sono-HSG compared with its non-use (0.93 and 0.95 versus 0.86 and 0.89, respectively, P = 0.0497). Sensitivity analysis regarding methodological quality of studies was consistent with these findings. We also found no benefit of the commercially available contrast media over saline solution in regard to the diagnostic accuracy of sono-HSG. LIMITATIONS, REASONS FOR CAUTION Methodological quality varied greatly between studies. However, sensitivity analysis, taking methodological quality of studies into account, did not modify the results. This systematic review did not allow the distinction between distal and proximal occlusion. This could be interesting to take into account in further studies, as the performance of the test may differ for each localization. WIDER IMPLICATIONS OF THE FINDINGS Given our findings and the known benefits of sono-HSG over HSG in the context of subfertility, sono-HSG should replace HSG in the initial workup of subfertile couples. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by personal funds. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER This review has been registered at PROSPERO: Registration number #CRD42013003829.