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PubMed2005

[Risk factors for prosthesis exposure in treatment of genital prolapse via the vaginal approach].

OBJECTIVES: Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is currently on the increase. However, this technique is not without tolerance-related problems. The most frequently described complication is prosthesis exposure, including erosion and delayed healing. It is independent of a granuloma and a major infection as pelvic cellulitis. Its mechanism is associated with defective vaginal healing. The purpose of our study is to define the risk factors for exposure of the prosthetic material. PATIENTS AND METHODS: Two hundred and seventy-seven medical records relating to patients undergoing surgery due to pelvic prolapse were included in our study. The treatment of genital prolapse was managed via the vaginal approach with polypropylene mesh. This is a continuous, retrospective study conducted over a period of 24 months. RESULTS: Thirty-four cases of prosthesis exposure were observed in the 2 months following surgery, which represents an incidence of 12.27%. The risk factors are concomitant hysterectomy [odds ratio 5.17 (P = 0.001)] and inverted T colpotomy [odds ratio 6.06 (P = 0.01)]. The protective factors are preservation of the uterus and the performance of a minor colpotomy in patients who had already undergone a hysterectomy or in those whose uterus had been preserved [odds ratio 5.16 (P = 0.0001)]. DISCUSSION AND CONCLUSION: In our study, we have only found risk factors of operative protocol. In fact, other information as age, menopause status or medical history of the patient is not significant. The uterus must be preserved and the number and extent of colpotomies needed to insert the prosthesis must be limited.

Adult↗
PubMed2003

Laparoscopic appendectomy: a gynecological approach.

The removal of surgical specimen at operative laparoscopy through an incision of the posterior fornix is frequently performed for the removal of pelvic masses of the internal genital tract. We present a technique for the removal of the appendix through a laparoscopic colpotomy. Eight patients who underwent laparoscopy for a suspected pelvic or adnexal disease and intraoperatively found to be affected by an appendicular disease were included in the present series. After intrabdominal dissection, the appendix was removed from the abdomen transvaginally through a laparoscopic colpotomy. The median range of the operation was 45 minutes (range 25-95). There were no intraoperative complications. The postoperative hospitalization period ranged from 2 to 7 days. Vaginal spotting was present in one case and lasted 24 hours. At follow-up visit, no patients complained of pelvic pain or dyspareunia. Vaginal wall induration was not found in any of the patients at pelvic examination. The removal of the appendix through a posterior colpotomy after laparoscopic appendectomy is simple, safe, feasible, well tolerated, and can be considered a valid alternative to other methods.

Adnexal Diseases↗
PubMed2005

Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors.

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR = 5.17 (p = 10(-3))] and inverted T colpotomy [OR = 6.06 (p = 10(-2))]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.

Adult↗
PubMed2004

[Surgical and conservative methods for removing mummified fetuses in cattle].

The purpose of this study was to describe the findings and therapy in 4 cows and 1 heifer with mummified fetus. All animals were admitted at the clinic after several unsuccessful therapies with prostaglandin F2alpha and local uterine infusions. All animals were in good condition. In case 1, diagnosis of mummified fetus could not be confirmed after manual rectal palpation and ultrasonography whereas cases 2, 4, 5 all had mummified fetus. In case 3, the fetus was in maceration. Initial therapy consisted of administration of prostaglandin F2alpha and prostaglandin E2 followed by repeated administration of prostaglandin E2. Mummies (length from apex to rump 13-32 cm) could be taken out within 3 to 6 days per vias naturales in cases 2, 4, 5 and in case 3, bones (maximal length 4 cm) could be unhinged. The structure in the uterus of case 1 could not be mobilised and was consequently removed under sight control using colpotomy followed by hysterotomy. Animals 2, 3, 4 and 5 were pregnant on the occasion of telephone inquiry. On the basis of our results, we recommend the conservative medical therapy with PGE2 for cases of mummified fetus. Colpotomy and hysterotomy are reserved as therapy feasible if the use of prostaglandin E2 is not successful.

Abortion, Veterinary↗
PubMed2002

Vaginal extraction of the intact specimen following laparoscopic radical nephrectomy.

PURPOSE: We report the detailed technique and results of transvaginal extraction of the intact laparoscopic radical nephrectomy specimen. MATERIALS AND METHODS: Since June 2000, 10 select female patients with a median age of 67 years underwent transvaginal extraction of the intact specimen after laparoscopic radical nephrectomy. In 5 patients open surgery had previously been performed on the uterus, including transabdominal hysterectomy in 2 and cesarean section in 3. Laparoscopic nephrectomy was performed via the transperitoneal and retroperitoneal approach in 5 cases each. After completion of the primary laparoscopic procedure a sponge stick was externally inserted into the sterile prepared vagina and tautly positioned in the posterior fornix. Laparoscopically a transverse posterior colpotomy was created at the apex of the tented up posterior fornix and the drawstring of the entrapped specimen was delivered into the vagina. After laparoscopic exit was completed the patient was placed in the supine lithotomy position. The specimen was extracted intact via the vagina and the posterior colpotomy incision was repaired transvaginally. Patients were mailed a linear scale analog questionnaire to assess various aspects of recovery with responses graded from 0--no pain and/or change to 10--severe pain and/or change. RESULTS: Vaginal extraction was successful in all 10 patients. Median operative time for the vaginal extraction procedure was 35 minutes. Blood loss was minimal. Median tumor size was 3.6 cm. (range 2.4 to 7.4) and median specimen weight was 327 gm. (range 152 to 484). No intraoperative complications occurred. Postoperatively blood spotting via the vagina in 1 patient resolved spontaneously. Postoperative questionnaires revealed excellent patient satisfaction and convalescence. CONCLUSIONS: Vaginal extraction is an efficacious and minimally morbid technique for removing the intact entrapped specimen after laparoscopic radical nephrectomy. It has now become our preferred technique of intact specimen extraction in appropriate female patients.

Adult↗
PubMed1975

Female sterilization. II. A comparison of methods.

An analysis was made of 1757 female sterilization procedures performed over a 5 1/2-year period. The majority of these were accomplished by one of 8 technics: puerperal abdominal tubal ligation (TL), cesarean section plus TL, hysterotomy plus TL, interval abdominal TL, colpotomy TL, laparoscopic TL, vaginal hysterectomy, and abdominal hysterectomy. The various technics have been compared with respect to 55 variables. The procedures having the shortest hospital stay, lowest morbidity, lowest blood loss, and shortest operating time were interval laparoscopic TL, colpotomy TO, and puerperal abdominal TL. The more major procedures were attended by significantly more morbidity and longer hospitalization and should be used only when specific indications justify the increased cost and risk.

Adolescent↗
PubMed1995

Menstrual disorders and pelvic pain after sterilization.

Changes in menstrual cycle length, menstrual duration, number of pads, dysmenorrhea and non-cyclic pelvic pain were studied in 43 women following tubal sterilization with three different techniques. One group consisted of 17 women undergoing laparotomy by Pomeroy technique; the second group consisted of 11 women undergoing laparoscopy by Fallope rings; and the third group consisted of 15 women undergoing colpotomy by fimbriectomy. The differences before and after sterilization in cycle length were non-significant in all groups (p > 0.05). After sterilization, menstrual duration and number of pads were significantly increased in the laparotomy (p < 0.001) and laparoscopy (p < 0.01) groups but non-significantly in the colpotomy group (p > 0.05). Comparison of these parameters between the groups did not show any significant differences (p > 0.05). After sterilization, increases in the severity of dysmenorrhea and non-cyclic pelvic pain were non-significant in all groups (p > 0.05). We concluded that there were no significant differences in menstrual disorders after sterilization among these three different techniques.

Adult↗
PubMed1980

Vaginal tubal ligation--is infection a significant risk?

Previous reports from the United States have shown that the morbidity and complication rates for vaginal sterilization are more than twice those for laparoscopic sterilization. Infection is usually reported to be the most frequent complication. This study reviews 329 cases from three private practitioners' offices to determine whether infection is, in fact, a significant risk in sterilization via colpotomy. Only six patients (1.8%) showed any evidence of pelvic infection, and all responded to antibiotics without requiring hospitalization. Hence, the risk of pelvic infection does not appear to be a deterrent to vaginal sterilization. Postoperative bleeding at the site of incision was reported in eight patients (2.4%), all of whom were treated as outpatients. Other complications that are reported and discussed do not negate the suitability of colpotomy sterilization as an outpatient procedure. An unsuspected and disturbing finding was a high subsequent pregnancy rate of 2.4%, which rose to 4.2% when the vaginal sterilization was combined with suction curettage. Since these rates are considerably higher than those reported for laparoscopic or laparotomy sterilizations, the selection of patients and the techniques employed for vaginal sterilization must be critically reviewed.

Abortion, Therapeutic↗
PubMed1995

Endovaginal ultrasonographically guided transvaginal drainage for treatment of pelvic abscesses.

OBJECTIVE: This study assessed the ability of endovaginal ultrasonographically directed transvaginal drainage of pelvic abscesses to treat patients who failed intravenous antibiotic therapies and whose abscesses were not amenable to percutaneous or colpotomy drainage. STUDY DESIGN: Thirty-one women who would otherwise have required surgery to treat their pelvic abscesses underwent the procedure. Immediate clinical response and longer-term follow-up results were collected retrospectively. RESULTS: Thirty-four procedures were performed on 31 women. Purulent material (10 to 350 ml) was aspirated in every case. Twenty-six of the 31 women (84%) were successfully treated by drainage. In the 6- to 21-month follow-up period, 10 women remained without problems, eight had sequelae related to pelvic infection, and eight were lost to follow-up. CONCLUSION: Endovaginal ultrasonographically guided transvaginal drainage is a safe, effective procedure for treatment of pelvic abscesses and should be considered the route of choice for draining collections not amenable to percutaneous or colpotomy drainage.

Abscess↗
PubMed1996

Laparoscopic-assisted transvaginal metroplasty for the treatment of bicornuate uterus: a case study.

OBJECTIVE: To introduce a combined laparovaginal metroplasty approach to the treatment of bicornuate uterus. DESIGN: Case report. SETTING: Private community hospital. PATIENT: A nulliparous patient with three recurrent spontaneous midtrimester abortions and a double uterus on hysterosalpingogram was evaluated laparoscopically. INTERVENTIONS: A laparoscopic-assisted transvaginal wedge metroplasty for the surgical correction of a symptomatic bicornuate uterus was performed. Intraoperative hysteroscopy also was used. MAIN OUTCOME MEASURES: Term pregnancy, uterine integrity. RESULTS: Hysteroscopic transillumination of the uterine horns delineated the uterine cavities while a laparoscopic wedge incision was initiated with a unipolar needle. The uterus was delivered through a posterior colpotomy, the wedge excision and uterine unification were completed transvaginally, the uterus was replaced into the pelvis, and the colpotomy was closed. The patient subsequently became pregnant, carried to term without complications, and delivered a healthy infant by cesarean section. The metroplasty scar was noted to be intact. CONCLUSIONS: Laparoscopic-assisted transvaginal metroplasty is a logical and useful minimally invasive alternative to laparotomy for the treatment of symptomatic bicornuate uterus and has potential utility for the treatment of complicated septate uterus and the correction of uterine perforation not amenable to laparoscopic suturing occurring during hysteroscopic septal resection.

Adult↗
PubMed1994

Laparoscopic Radical Hysterectomy: A Preliminary Experience

From June 1993 through September 1993, we had performed four cases of laparoscopic radical hysterectomy. All these patients had early cervical squamous cell carcinoma of less than 4 cm in diameter. We first developed the left paravesical and pararectal space with the suction-irrigator probe and Endoretractor (Autosure, USA). Then we desiccated the left uterine artery at its origin. The left ureter was dissected from the point it enters the pelvis to the ureteric canal. The left cardinal ligament was completely divided twice by the EndoGIA (Autosuture, USA). The rectovaginal space was opened and the uterosacral ligament was transected by electrosurgery. The left ureter was dissected and unroofed to the point it enters the bladder with Endodissector and electrosurgery. The left paracolpos was divided by EndoGIA. The same procedures were repeated on the right side. The anterior and posterior colpotomy could be done by monopolar electrosurgery but they were deferred until the lymph node dissection was completed. Finally, we did pelvic lymph node dissection and colpotomy, after which we removed the uterus through the vagina. We closed the vaginal cuff from below. The operation time ranged from 5.5 to 8 hours. The blood loss ranged from 150 to 500 ml. The lymph nodes dissected ranged from seven to nine in number. The parametrium removed was 3.5 x 2.5 x 2 cm on average. The vaginal cuff removed was at least 2 cm in length. The patients recovered quickly and the hospital stay was shorter than that needed for those patients undergoing traditional abdominal radical hysterectomy. In conclusion, we think the preliminary results were satisfactory. More experience is needed to answer the question of whether laparoscopic radical hysterectomy can be an alternative to traditional abdominal radical hysterectomy in some selected cases.

Journal Article↗
PubMed1996

Total Laparoscopic Hysterectomy

The benefits of total laparoscopic hysterectomy (TLH) over total abdominal hysterectomy (TAH) and laparoscopic-assisted vaginal hysterectomy (LAVH) include significantly reduced blood loss, reduced risk of surgical injuries, shorter recuperation than TAH, less pain and earlier ambulating, and lower cost. In TLH the round and infundibulopelvic ligaments were divided, the bladder reflection was created, and the uterine vessels were isolated and secured. A circumferential colpotomy was performed, and it and the peritoneal reflection were closed laparoscopically after vaginal delivery of the uterus. A special uterine manipulator used in all procedures aided in anatomic definition and performing the circumferential colpotomy. In over 250 TLH procedures the estimated blood loss and operating room time decreased due to the technique and increased surgeon experience.

Journal Article↗
PubMed1997

Laparoscopic-assisted transvaginal myomectomy.

We conducted a retrospective review of 21 combined laparovaginal myomectomies to treat extensive and deeply infiltrating fundal and posterior wall leiomyomata. Laparoscopy confirmed the size, number, and position of leiomyomata, permitted intramyometrial vasopressin infiltration, and allowed partial enucleation of large and deep myomata. Posterior colpotomy permitted delivery of myomata and uteri, and uterine reconstruction by conventional suturing performed transvaginally. The uteri were then placed in their anatomic position, the colpotomies were repaired, and a final laparoscopic survey and lavage were performed. All surgeries were successfully completed without intraoperative or postoperative complications. This approach allows a layered traditional uterine reconstruction of deep myometrial defects and may enhance the ability to repair extensive uterine defects in a minimally invasive fashion.

Adult↗
PubMed2003

Microbiological pattern of the contents of pelvic abscess at the University College Hospital, Ibadan, Nigeria.

A retrospective analysis of 49 cases of pelvic abscess over a 10-year study period spanning 1 January 1989 to 31 December 1998 was undertaken. Forty-one patients had laparotomy to drain the pelvic abscess, while eight had colpotomy. The volume of pus drained at surgery ranged between 10 ml and 3.5 l for laparotomy, with a median value of 500 ml and 100 ml to 1 l with a median of 200 ml for colpotomy. There was no significant difference in these values. Swabs for bacteriological cultures were taken at surgery and results available in 18 patients. In two patients (11%) the cultures were sterile. In the positive cultures, Escherichia coli was isolated in seven patients. Klebsiella species and Staphylococcus aureus were isolated in four patients each. It is important to know the causative organisms for this infection in our environment because pelvic abscess is the end stage in the progression of a treatable genital tract infection and is frequently an unnecessary complication that is very expensive to treat.

Abscess↗
PubMed1999

Home within 24 hours of laparoscopic hysterectomy.

We assessed the feasibility of safe discharge home within 24 hours following laparoscopic hysterectomy in 30 patients who met the inclusion criteria and consented to be enrolled in the study group. Patients were admitted on the day of their surgery with the expectation of discharge within 24 hours. Appropriate home nursing follow-up and phone contact by the surgical team were organized preoperatively. Inclusion criteria were: age 30-65 years, absence of any major medical history that would require prolonged hospitalization, availability of home support for the first 48 hours after discharge and presence of a working telephone line and an address within the area of the Community Home Nursing service. All 30 operative procedures were completed without incident. Six patients underwent total laparoscopic hysterectomy (TLH) (all the procedures of hysterectomy being performed laparoscopically including the suturing of uterine arteries, colpotomy and closure of the vaginal vault. The uterus was removed vaginally) and 24 patients underwent laparoscopic hysterectomy (LH) (this techniques differs from TLH in that the colpotomy was performed laparoscopically but the uterosacral ligaments were divided vaginally and the vault also was closed vaginally after the uterus was removed vaginally). The average operating time was 115 minutes (range 85-150 minutes) and the average blood loss was 97 mL (20-250 mL). There were no intraoperative complications, no requirement for transfusion and no readmission to hospital for any of the patients in the study. Postoperative complications were minor (umbilical cellulitis (1), intestinal colic (1)) and both were treated with resolution of the symptoms. Ninety per cent of patients in the study were discharged within 24 hours of their surgery, the average duration of stay being 22.9 hours (20-24 hours). Three patients were not fit for discharge at 24 hours postoperatively due to general lethargy, migraine and nausea; their average discharge time was 53.5 hours. The study showed that laparoscopic hysterectomy can be associated with a reduction in length of in-patient stay compared to traditional laparotomy. Furthermore this reduction could be safely reduced to 24 hours following laparoscopic hysterectomy. There was also an associated cost saving in terms of inpatient bed days. Patient satisfaction with this protocol was high in this selected and motivated group.

Adult↗
PubMed2000

Adrenalin versus terlipressin: blood loss and cardiovascular side-effects in the vaginal part of laparoscopically-assisted vaginal hysterectomy or vaginal hysterectomy.

The purpose of the study was to compare blood loss and cardiovascular side-effects in the course of the vaginal part of laparoscopically-assisted vaginal hysterectomy (LAVH) or single vaginal hysterectomy (VH) [1]. Blood loss was evaluated in relation to local application of two haemostatic agents, e.g. adrenalin as a gold standard versus terlipressin. The investigation was designed as a prospective randomised study. A prospective group of 40 patients selected for LAVH or VH was randomised into two groups, e.g. 20 patients in each group. In both of these groups, the blindly selected haemostatic agent was applied locally immediately before circular colpotomy, the surgeon not being aware which agent was being used. Because of the claimed delayed effect of terlipressin a third group of another 20 patients was randomly selected. For comparison in this group terlipressin was locally already applied before the laparoscopic part of LAVH, e.g. 20-25 minutes before performing circular colpotomy. Thus, this particular group could not be made blind to the surgeon. The study confirmed a significantly superior haemostatic effect of adrenalin. On the other hand after the adrenalin application a higher frequency of hypertensive reactions and mild arrythmias were observed but without any clinical seguelae.

Adult↗
PubMed1972

Tubal sterilization: methodology, postoperative management and follow-up of 2934 cases.

Both posterior colpotomy with associated fimbriectomy and laparoscopy offer rapid and effective methods for carrying out interim and post-abortion tubal sterilization. They can effectively be performed on an out-patient basis. Posterior colpotomy has the added advantage that it can be conveniently performed under a combination of intravenous neuroleptanalgesia and local vaginal anesthesia. This series exemplifies the manner in which the burden upon hospital facilities and medical and paramedical personnel can be minimized. In addition, utilization of the "home-care program" has improved patient acceptance and convenience.

Abortion, Legal↗
PubMed1995

[Vaginal supracervical vs. laparoscopic supracervical hysterectomy, with resection of transcervical and transuterine mucosa].

Indications for the 346 hysterectomies performed in the Department of Obstetrics and Gynecology University of Kiel in the years 1991 till 1994 were myomas with pain, hypermenorrhoea, menorrhagia, recurrent bleedings and endometriosis. The applied hysterectomy technique consisted of supercervical hysterectomy without colpotomy including the resection of the transcervical and transuterine mucosa by laparotomy and via laparoscopy (pelviscopy). Histologically results were divided between fibromas, leiomyomas, adenomyosis and adenomatous hyperplasia. 42 patients where pretreated with hormones and showed a significantly reduced blood loss compared to the non treated patients during surgery. Intra- and postoperative complications were very low. The CISH-technique is an alternate method for vaginal and abdominal total hysterectomy via laparotomy or via laparoscopy. Gynecological indications for hysterectomies presents the following advantages. 1. CISH via pelviscopy: Prophylaxis against the development of cervical cancer, preservation of the pelvic floor, preservation of the pericervical vascular and nerve tissue and especially, avoiding the danger zone of the uterine arteria and ureter, reduced physical stress, short hospitalisation and recovery time of the patients. 2. CISH via laparotomy: Prophylaxes against cervical cancer, preservation of the pelvic floor, reduction of the pelvic trauma, simple technique. 3. CISH via vagina: The advances of the intrafascial vaginal hysterectomy are the same as those for laparoscopic intrafascial hysterectomy without colpotomy, no separation of cardinalia and sacrouterina ligaments, no cervical amputation. No search for the uterine artery, no change in sexual life. Ideal conditions for the preservation of pelvic floor to regain stability. 4. During the resection of the transcervical and transuterine mucosa the technique of mucosa ablation emerged, indications are dysfunctional bleeding.

Adult↗