Biomedical subjects
Publications and source records attributed to B Bojahr.
Laparotomy and carbon dioxide laparoscopy are relatively traumatic and high-risk operations for patients. They may have negative effects on pregnancy, especially in advanced pregnancy. Gasless laparoscopy was performed on torqued hematosalpinx in a woman in the thirteenth week of pregnancy. After salpingectomy, the pregnancy proceeded normally.
As a part of a prospective study of 20 patients with previous pelvic surgery, the efficacy of using a 2/3 mm dilatable STEP device (InnerDyne, Inc., Sunnyvale, USA) for the first insertion in the area below the left costal border was tested, using 2 or 3.3 mm minilaparoscopes (Storz). Despite the high incidence of periumbilical omental and bowel adhesions (55%), no complications were observed in any of the 20 patients with previous pelvic surgery. Herewith could be confirmed that the use of a minilaparoscope in the area below the left costal border represents in high risk patients a safe and minimally invasive method for preventing or reducing the number of trocar-related injuries during first trocar insertion. In combination with the use of 2/3 mm disposable STEP-trocars if clinically required an atraumatic dilation and safe insertion of reusable 5 mm, 10 mm or 12 mm trocars is enabled.
A mobile, subserous, pedunculated myoma was located on the anterior surface of the uterus in a 45-year-old woman. Bipolar coagulation was performed on the pedicle, and the myoma was dissected with an electrical morcellator and removed through the umbilicus. This technique required placement of one 5- to 12-mm cannula in the umbilicus and two 2-mm miniports at the pubic hairline. This technique is easy to perform, and the patient benefits from minimal postoperative pain and excellent cosmetic results.
The postoperative course of a not recognized perforation of the small bowel will be reported. The patient underwent a control-laparoscopy because of ovarian cancer following radical surgery and postoperative chemotherapy. Prevention possibilities with the use of the Minioptik (Storz) and Visiport (Auto Suture) are described.
In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.
We performed gasless lymph node dissection in a woman with cervical carcinoma FIGO stage Ib. The dissection of the parametrium was done vaginally by hysterectomy including the Schuchardt incision and the removal of 2 cm of vagina. We removed 45 lymph nodes. For the laparoscopic procedures we used a Laparofan and Laparolift (Origin Medsystems). The estimated blood loss was 250 ml and operative time 330 minutes. An advantage of the gasless method is that one can use endoscopic and conventional instruments. We combined advantages of laparoscopy (good visibility, enlargement of blood and lymph vessels) and of the gasless method (use of the same instruments as in laparotomy, quick change of endoscopic and conventional instruments without gas loss). This technique achieves the same surgical results as radical laparotomy in selected women with cervical carcinoma.
The treatment of 3 non-ruptured tubal pregnancies by hysteroscopic intratubal injection of methotrexate was reported. In all 3 cases the beta-hCG serum levels decreased after injection during clinical, serological and sonographical control. In 2 patients the tubes were patent at a later control. In selected cases the intratubal administration of methotrexate via hysteroscopy is an alternative minimal invasive treatment.
A prospective study was conducted on the incidence of intrauterine pathology after abortions diagnosed by post-abortion hysteroscopy. In 80 patients outpatient hysteroscopy was performed 8-12 weeks after a dilatation and curettage for incomplete or missed abortions. Intrauterine pathological changes were found in 40 patients. There were 10 cases of uterus subseptus/ bicornis and 7 of uterus arcuatus, 2 submucous myoma and 1 corpus polyp. Intrauterine adhesions were diagnosed in 20 patients. The incidence of intrauterine adhesions was about the same after incomplete abortions and after missed abortions, but in patients with recurrent abortions the incidence was significantly higher than in patients after the first abortion (27.8% versus 14.9%). Post-abortion hysteroscopy is a simple and useful method for early diagnosis of congenital and acquired intrauterine pathology after abortions.
In a prospective study in 40 patients the pretreatment for endometrial ablation with a gestagen (Orgametril 10 mg/die), danazol (600 mg/die) and an injection of a GnRH-analogon (Decapeptyl-Depot) was compared with a control group without pretreatment. The subjective estimation of the surgeon (endometrial thickness and depth of coagulation) showed a sufficient pretreatment in 90 % of all cases following danazol- and GnRH-analogon-pretreatment. In 90 % of the danazol- and GnRH-analogon pretreated group the histological findings showed also an atrophic or little proliferative endometrium. In a follow up of 6 months after endometrial ablation the highest amenorrhoea-rates were reached following danazol- and GnRH-analogon pretreatment. These two regimes should be used for the pretreatment for endometrial ablation.
By means of laparoscopic supracervical and pelviscopic intrafascial hysterectomy (CISH) new minimally invasive hysterectomy methods for benign indications have been developed where the cervix or a portion of the cervix remain intact. The carcinoma risk is extremely small. Using the example of a large cervical myoma 25 years after a supracervical hysterectomy, the possibility of recurrent myomas is emphasized.
The use of a 1.2 mm microendoscope is compared to the conventional laparoscopy technique in this study. In 22 sterility patients and 23 patients suffering from chronic pelvic pain the high diagnostic value of the microendoscope is shown. Only in one case endometriosis (EEC I) is overseen. The diagnostic laparoscopy by the microendoscope is a new minimal invasive procedure which could be important as a screening method in future.
The anamnesis, the preoperative diagnostics, the laparoscopic findings, and the therapeutic management are reported of 303 patients who underwent laparoscopy because of chronic pelvic pain during the years of 1989 and 1993. The most common laparoscopic diagnosis were adhesions of the bowel and omentum (34.7%), adhesions of the genital organs (24.1%) and endometriosis (19.8%). In 31.4% there were normal pelvic findings. In patients with a history of surgical or other gynecological procedures we found significantly more adhesions as compared to nontreated controls; the adhesions were predominantly confined to the bowel and rather than the gynecologic pelvis. PID-Patients had significantly more genital adhesions. The high frequency of surgical laparoscopies and therapeutic recommendations following a diagnostic laparoscopy emphasize the importance of a laparoscopic investigation in patients with chronic pelvic pain.
First experiences after the introduction of LAVH with regard to intra- and postoperative parameters of quality in comparison with the classical abdominal and vaginal hysterectomies are shown. The main indications for LAVH were large myomas, previous pelvic surgery and adnexal mass. Intra- and postoperative complications, time of operation, uterine weight, estimated blood loss, the period of use of analgetics and discharge wishes of 40 patients after abdominal and 25 after vaginal hysterectomies were compared with the results of 30 patients after LAVH. Patients after abdominal hysterectomy need more and longer analgetics. The lowest perioperative morbidity we found in the LAVH group. In cases with enlarged uteri the high blood loss during the vaginal hysterectomy can be significantly reduced with LAVH. LAVH offers a new technique to convert a lot of abdominal hysterectomies with benign indications (large myomas, adhesions, adnexal mass) into vaginal hysterectomies.
In a prospective study of 68 infertile patients the findings of hysterosalpingography and hysteroscopy have been compared. Hysterosalpingography showed in 3 cases false-negative results and in 10 cases false-positive results. Hysterosalpingography is especially limited for diagnostics of intrauterine adhesions. Hysteroscopy should be a necessary component of diagnostics of sterility, also in case of normal hysterosalpingographical findings.
Two patients with a trophoblastic tumour (one with an invasive mole and one with a choriocarcinoma) had early pregnancy factor (EPF; detected by rosette inhibition test) in serum. In both cases the EPF already disappeared during surgery which suggests that EPF could be a useful and sensitive tumour marker if laboratory technology for its detection could be improved.
At three patients who have been operated on because of completely different tumours (trophoblast tumour, endodermalsinus tumour of the right ovary and rhabdomyosarcoma as well as adrenal cortex carcinoma) pre-operatively the Early Pregnancy Factor (EPF) could in each case be shown in the serum with the help of the rosette inhibition test. In two cases the EPF already intra-operatively disappeared from the serum. In the third case it could be found until the second day after operation. Since that patient suffered from two histogenetically non-related malignant tumours it was not possible to trace whether the adrenal cortex carcinoma or the rhabdomyosarcoma have been the reason for the EPF-synthesis. The already intra-operative disappearance and the also during further post-operative controls unsuccessful proof of EPF in serum can indicate an opportunity for the early assessment of efficiency of the surgical treatment of tumours which develop EPF or which induce the EPF-synthesis.
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From 1983 to 1990 15 metroplasties were carried out at the Department of Obstetrics and Gynecology Greifswald. 11 of these operations were combined with a microsurgical tubal operation. For the diagnostics of uterus malformation and tubal damage as many methods as possible (hysterosalpingography, laparoscopy with chromotubation, hysteroscopy and sonography) should be used. A postoperative life birth rate of 62.5% shows that an operative correction of uterus malformation and tubal damage in one session is justified. Metroplasty is also indicated at primary tubal sterility with simultaneous uterus malformation. A caesarean section is not primarily indicated after metroplasty.