Laparoscopic segmental resection for infiltrating endometriosis of rectosigmoid colon: a preliminary report.
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Adult↗
Biomedical subjects
F Nezhat
Publications and source records attributed to F Nezhat.
Laparoscopic management of adnexal masses the opportunities and the risks.
Suspected ovarian neoplasm is a common clinical problem affecting women of all ages. Although the majority of adnexal masses are benign, the primary goal of diagnostic evaluation is the exclusion of malignancy. It has been estimated that approximately 5-10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. Despite the magnitude of the problem, there is still considerable disagreement regarding the optimal surgical management of these lesions. Traditional management has relied on laparotomy to avoid undertreatment of a potentially malignant process. Advances in detection, diagnosis, and minimally invasive surgical techniques make it necessary now to review this practice in an effort to avoid unnecessary morbidity among patients. Here, we review the literature on the laparosopic approach to the treatment of the adnexal mass without sacrificing the principles of oncologic surgery. We highlight potentials of minimally invasive surgery and address the risks associated with the laparoscopic approach.
Biomarkers, Tumor↗
Arterial occlusion after surgery for ovarian malignancy. A case report.
BACKGROUND: Inherent in the risks of pelvic surgery is the postoperative morbidity and mortality associated with the procedure. The gynecologic oncology patient presents further risks for several reasons, including a relative state of hypercoagulability. Anticipation of the problem and early recognition are the keys to decreasing the long-term sequelae of a complication. A well-recognized complication of gynecologic oncology surgery is venous thromboembolism. Advances allow the prophylaxis, recognition and treatment of this problem. Acute arterial occlusion is a much less common but potentially devastating complication. CASE: A woman underwent surgery for ovarian malignancy and developed bilateral arterial occlusion of the lower extremities postoperatively. CONCLUSION: Understanding the various genetic defects that predispose certain individuals to hypercoagulability will help identify patients with a particularly high risk of developing acute arterial occlusive disease.
Aged↗
Approaching the adnexal mass in the new millennium.
Adnexal masses are common dilemmas faced by practicing gynecologists. They affect women from before birth throughout life, yet considerable disagreement exists regarding their optimal management. Traditional management focused on avoiding undertreatment of a potentially malignant process. Advances in detection, diagnosis, and minimally invasive management make it necessary to review this practice to avoid unnecessary morbidity and mortality. The literature emphasizes a minimally invasive approach to the treatment of benign lesions without sacrificing the principles of oncologic surgery.
Adnexa Uteri↗
Normal variations of abdominal and pelvic anatomy evaluated at laparoscopy.
OBJECTIVE: To describe certain anatomic relationships in the pelvis and abdominal wall at laparoscopy and the effect of body mass index (BMI) on those parameters. METHODS: In 103 patients we determined the following: distances from the midline to each medial umbilical ligament and the respective inferior epigastric vessels; distances between each ureter and the ipsilateral uterosacral and the infundibulopelvic ligament; relative visibility of the ureters, umbilical and uterosacral ligaments, and the sacral promontory; and the presence and location of congenital bowel attachments to the pelvic walls. RESULTS: The right ureter ran significantly closer to the infundibulopelvic and uterosacral ligaments than the left ureter. The right inferior epigastric vessels and umbilical ligament coursed more laterally than did those on the left. Both sets of inferior epigastric vessels, and the left umbilical ligament and ureter were significantly more difficult to identify in overweight women. In 69% of the subjects, the uterosacral ligaments were found to be thick or moderately thick. In two thirds, the sacral promontory was more than 75% visualized. Congenital bowel attachments were observed in 74.8% of subjects on the left pelvic sidewall, and 48.5% on the right. CONCLUSION: Left and right pelvic anatomy are not necessarily mirror images laparoscopically. The course of the inferior epigastric vessels can be more difficult to identify in overweight patients. Despite marked obesity or congenital bowel attachments to the pelvic side walls, both ureters can usually be identified. The proximity of the ureter to the uterosacral and infundibulopelvic ligaments reaffirms the need to identify them before dissection.
Abdominal Muscles↗
Pregnancy following laparoscopic myomectomy: preliminary results.
The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.
Adult↗
Are the long-term adverse effects of laparoscopic presacral neurectomy for the management of central pain associated with endometriosis acceptable?
Objective: To assess the long-term genitourinary and gastrointestinal complaints following presacral neurectomy.Design: A prospective postoperative follow-up of patients who underwent laparoscopic presacral neurectomy and treatment of endometriosis.Materials and Methods: The mean follow-up of the 67 women (mean age 27.5 years, range 16-58 years) was an average of 36.8 months with a range of 6-69 years. Main outcome variables include diarrhea, constipation, bladder and urinary complaints, vaginal dryness, dyspareunia, and orgasm. The degree of pain and dysmenorrhea after surgery was also elevated.Results: Diarrhea was reported to have improved after surgery in 39.1% of the patients and none reported any worsening. Constipation improved in 28.6% and worsened in 12.5%. Only one patient suffered from debilitating constipation. Bladder and urinary problems were improved on 25.0% and worsened in 19.2%. A similar proportion of women (19.6%) reported improvement and worsening vaginal dryness. Pain during intercourse improved in 58.9% and worsened in 8.9%. The ability to achieve orgasm improved in 21.6% and worsened in 2.7%. Postoperatively, pain was improved by 80-100% in 46.6% of the women, by 50-80% in 36.5%, by less than 50% in 6.4%, and did not improve in 9.5%. Dysmenorrhea was improved by 80-100% in 35.2% of the women, by 50-80% in 38.8%, by less than 50% in 14.9%, and did not improve in 11.1%. Twelve of 16 patients trying to become pregnant were successful following surgery, two with the aid of in vitro fertilization.Conclusion: After laparoscopic presacral neurectomy, constipation and bladder and urinary problems were reported to have worsened in only a minority of patients. However, diarrhea and dyspareunia improved in a large proportion of patients. Since pelvic pain was relieved by more than 50% in 83.1%, the procedure seems to be associated with an acceptable rate of long-term side effects.
Journal Article↗
Laparoscopic ureteroureterostomy: a prospective follow-up of 9 patients.
Objective: To report the technique and long-term outcome of laparoscopic ureteroureterostomy of injured ureter.Design: A prospective follow-up study.Materials and Methods: Follow-up of nine patients, aged 30-43 years, who acquired intentional ureteral injury during operative laparoscopy for treatment of endometriosis. They were treated between September 1991 and September 1997 by ureteral transection or resection with primary laparoscopic repair by ureteroureterostomy (8 procedures) and ureteroneocystostomy (2 procedures).Results: All operations were successfully completed by operative laparoscopy without need to convert to laparotomy. Estimated blood loss related to the ureteral portion of the procedure was less than 100 mL. Duration of follow-up was between 2 months and 6 years. Follow-up intravenous pyelogram revealed complete healing in seven patients. One patient had mild ureteral stricture, which resolved with transvesical ureteral dilatation, and she is doing well 4 years postoperatively. Another patient with severe endometriosis had recurrent ureteral stricture due to fibrosis distal to the anastomosis site. She underwent laparoscopic ureteroneocystostomy psoas hitch and is doing well 3 months postoperatively.Conclusions: This is the first series of laparoscopic ureter reanastomosis reported to date. The outcome was excellent with low postoperative morbidity typically associated with laparoscopy.
Journal Article↗
Laparoscopic surgical management of diaphragmatic endometriosis.
OBJECTIVE: To review the clinical presentations of and management options for diaphragmatic endometriosis. DESIGN: Retrospective review. SETTING: Referral center. PATIENT(S): Twenty-four women with endometriosis of the diaphragm. INTERVENTION(S): Surgical management. MAIN OUTCOME MEASURE(S): Diagnostic accuracy and therapeutic feasibility of operative laparoscopy. RESULT(S): Operative findings in 17 patients included 2-5 spots of endometriosis on the diaphragm measuring <1 cm. Seven women had numerous lesions scattered across the diaphragm. Lesions were bilateral in 8 patients, limited to the right hemidiaphragm in 14 patients, and limited to the left hemidiaphragm in 2 patients. In 7 patients, six endometriosis lesions were directly in the line of the left ventricle and three lesions were adjacent to the phrenic nerve. Endometriosis was infiltrating into the muscular layer of the diaphragm in 7 patients. The symptoms in all 7 symptomatic patients decreased significantly after treatment, with a minimum follow-up period of 12 months. No postoperative complications occurred. CONCLUSION(S): The abdominal diaphragm can be involved with endometriosis and can be diagnosed and treated effectively with the use of videolaparoscopy.
Adolescent↗
Laparoscopic appraisal of the anatomic relationship of the umbilicus to the aortic bifurcation.
STUDY OBJECTIVE: To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy. DESIGN: Prospective, consecutive study (Canadian Task Force classification II-1). SETTING: Tertiary referral center. PATIENTS: Ninety-seven women undergoing operative laparoscopy. INTERVENTIONS: The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women. MEASUREMENTS AND MAIN RESULTS: The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). CONCLUSIONS: The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.
Adolescent↗
Pelvic endometriosis--the same or different entities in disguise?
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Diagnosis, Differential↗
Surgery for endometriosis of the bowel, bladder, ureter, and diaphragm.
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Diaphragm↗
Incisional hernias after operative laparoscopy.
The objective of this study was to determine the possible risk factors of incisional hernias after operative laparoscopy. A retrospective case review was performed in a single referral obstetrics/gynecology clinic and center for special pelvic surgery considering the last 5300 surgeries. Of the approximately 5300 patients who underwent laparoscopy from January 1988 through June 1996, 10 women were evaluated for incisional hernias. A total of 11 hernias occurred, which is an incidence of approximately 0.2%. Omentum herniated in seven cases and bowel herniated in four cases. In one case, the sigmoid epiploica irreducibly herniated through the peritoneum and not the fascia. The hernia occurred through a 5-mm trocar incision site in five cases. The median duration of the laparoscopic surgeries was 192 minutes (range, 25-375 minutes). Six women required laparoscopic surgery in order to retract the entrapped omentum or bowel. In one case, laparoscopically assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using trocars of 10 mm and larger as previously suggested but also when extensive manipulation is performed through a 5-mm trocar port, causing extension of the incision.
Adult↗
Major retroperitoneal vascular injury during laparoscopic surgery.
We sought to assess the outcome of large retroperitoneal vascular injury that occurred during operative laparoscopy but was not related to trocar or Veress needle injury. We conducted a retrospective review of cases operated and reviewed by our centres. Eight cases were identified. Four women were undergoing lymphadenectomy, where vascular injury is a recognized risk. Distorted anatomy was a compounding factor in three of the remaining four patients who were undergoing intraperitoneal procedures. The injuries involved the inferior vena cava (n = 2), the right external iliac artery (n = 2), the left external iliac artery (n = 1), the right external iliac vein (n = 1), the hypogastric artery (n = 1) and the inferior mesenteric artery (n = 1). Injuries were caused by unipolar electrode (n = 1), electrosurgical scissors (n = 3), sharp scissors (n = 2) and CO(2) laser (n = 2). The vessel injury was repaired at laparotomy in four women. The other four cases were managed laparoscopically. Transfusion attributable to the vascular injury occurred in two cases. The outcome in all cases was good, except for one in which the patient died. These cases demonstrate that all energy sources used without proper understanding and caution can cause significant vascular injury. The adequacy and safety of laparoscopic control of major vessel bleeding should be investigated further and consultation with a vascular surgeon should be considered in all cases.
Adult↗
Gynecologic operative laparoscopy: new training programs are needed.
The revolution in laparoscopic surgery demands implementation of adequate training programs preferably in an academic setting. The most dramatic progress over the last decade in the field of gynecology was undoubtedly the development of advanced operative laparoscopy. This has been initiated by an unprecedented technological revolution.
Journal Article↗
Laparoscopic management of a noncommunicating uterine horn in a patient with an acute abdomen.
A 13-year-old girl with a history of cloacal anomalies presented with acute abdominal pain. Abdominal ultrasound was not definitive, and vaginal probe ultrasound was precluded by the patient's stenotic vagina. Magnetic resonance imaging delineated a left hematometra and hematosalpinx as well as a more normal-appearing right hemiuterus. Operative laparoscopy was used to lyse the extensive pelvic adhesions in a patient with a history of an imperforate anus and to resect a left rudimentary uterine horn with outflow obstruction. A review of cases in the world literature reveals that operative laparoscopy can be used to treat these patients successfully.
Abdomen, Acute↗
Delayed recognition of iliac artery injury during laparoscopic surgery.
Vascular injury is one of the major complications of laparoscopic surgery. Prompt diagnosis is crucial for proper management of this potentially life-threatening complication. Two cases of iliac artery puncture occurred during operative laparoscopy. The injuries were not diagnosed immediately, probably due to the initial accumulation of blood in the retroperitoneum. Significant damage to large blood vessels may not be readily apparent during laparoscopic surgery.
Adult↗
The risk of carbon monoxide poisoning after prolonged laparoscopic surgery.
OBJECTIVE: To evaluate whether thermal energy produced by laser and bipolar electrosurgery during laparoscopic procedures significantly elevates blood carboxyhemoglobin levels. METHODS: We prospectively studied 27 healthy nonsmoking patients, mean +/- standard deviation (SD) age 39.1 +/- 8.0 years (range 22-56), scheduled for laparoscopic procedures in which smoke was generated. Prolonged operative laparoscopy involved high-flow carbon dioxide insufflation, intensive evacuation of intra-abdominal smoke, and controlled hyperventilation with 50-100% oxygen. Laser and bipolar electrosurgery were used in all cases. Blood samples were drawn before and after surgery. Carboxyhemoglobin concentrations were measured using a highly accurate gas chromatography method. RESULTS: The mean +/- SD duration of surgery was 141 +/- 72 minutes (range 45-300). The mean +/- SD carboxyhemoglobin levels were 0.70 +/- 0.15% (range 0.44-1.20%) before surgery and 0.58 +/- 0.20% (range 0.30-1.33%) after surgery. A significant decrease (P < .001) in carboxyhemoglobin concentrations occurred during surgery (mean +/- SD, 20 +/- 11%; range 3-46%). The carboxyhemoglobin level was increased at the end of surgery in only one woman. In only one patient did the levels exceed 1% (1.33%), still well below the human threshold tolerance level of 2%. The Spearman correlation coefficient between carboxyhemoglobin concentrations and duration of surgery was r = 0.308 (P = .12). CONCLUSION: Carbon monoxide (CO) poisoning is not associated with even prolonged laparoscopic surgical procedures. This may be attributed to aggressive smoke evacuation that minimizes exposure to CO, and to active elimination of CO by ventilation with high oxygen concentrations.
Adult↗