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PubMed1998

Delayed recognition of major vascular injury during laparoscopy.

We report an unusual case of left common iliac artery and vein injury during laparoscopy. The injury was recognized 3 h after the completion of the laparoscopy. The patient was promptly treated by explorative laparotomy and repair of the lacerated vessels. Major vascular injury during laparoscopy is usually caused by the Verres needle or the first laparoscopic trocar. Failure to recognize the injury during the laparoscopic procedure itself can be attributed to the intraperitoneal CO2 pressure compressing the bleeding vessels and to the decreased venous return caused by the steep Trendelenburg position. Major vascular injury should be recognized as early as possible since it is a life threatening condition that necessitates immediate and prompt treatment.

Adult↗
PubMed1998

Hemodynamic changes induced by laparoscopy and their endocrine correlates: effects of clonidine.

OBJECTIVES: We investigated endocrine correlates of the hemodynamic changes induced by carbon dioxide pneumoperitoneum (PNO). We then studied whether clonidine might modulate the hemodynamic changes induced by PNO by reducing release of catecholamines and vasopressin. BACKGROUND: Both mechanical and neurohumoral factors contribute to the hemodynamic changes induced by carbon dioxide PNO. Several mediators have been proposed, but no study has correlated hemodynamic changes with changes in levels of these potential mediators. METHODS: We conducted two studies, each including 20 healthy patients scheduled for elective laparoscopic cholecystectomy. In the first study serial measurements of hemodynamics (thermodilution technique) were done during laparoscopy and after exsufflation. Plasma concentrations of cortisol, catecholamines, vasopressin, renin, endothelin and prostaglandins were measured at the same time points. In the second study patients were randomly allocated to receive 8 microg/kg clonidine infused over 1 h or placebo before PNO. Hemodynamics and plasma levels of cortisol, catecholamines and vasopressin were measured during PNO and after exsufflation. RESULTS: Peritoneal insufflation resulted in a significant reduction of cardiac output (18+/-4%) and increases in mean arterial pressure (39+/-8%) and systemic (70+/-12%) and pulmonary (98+/-18%) vascular resistances. Laparoscopy resulted in progressive and significant increases in plasma concentrations of cortisol, epinephrine, norepinephrine and renin. Vasopressin plasma concentrations markedly increased immediately after the beginning of PNO (before PNO 6+/-4 pg/ml; during PNO 129+/-42 pg/ml; p < 0.05). The profile of vasopressin release paralleled the time course of changes in systemic vascular resistance. Prostaglandins and endothelin did not change significantly. Clonidine significantly reduced mean arterial pressure, heart rate and the increase in systemic vascular resistance. Clonidine also significantly reduced catecholamine concentrations but did not alter vasopressin and cortisol plasma concentrations. CONCLUSIONS: Vasopressin and catecholamines probably mediate the increase in systemic vascular resistance observed during PNO. Clonidine before PNO reduces catecholamine release and attenuates hemodynamic changes during laparoscopy.

Adrenergic alpha-Agonists↗
PubMed1999

Gynecologic cancer and laparoscopy.

Numerous technologic and surgical advances have led to the application of operative laparoscopic techniques to gynecologic cancers. Operative laparoscopy has been described in the surgical staging and treatment of patients with ovarian, cervical, and endometrial cancers. it seems to be a very promising approach with the potential to revolutionize numerous aspects of the management of gynecologic malignancies. Since 1996, the SGO has offered an operative laparoscopy course to all gynecologic oncology fellowship programs. Boike and colleagues report that faculty and fellows from 25 different fellowship programs have attended the 2-day course. In questionnaires filled out at the completion of the course, more than 85% of respondents believed that operative laparoscopic procedures were equivalent to open techniques and should be taught in fellowship programs. Despite the enthusiasm for the use of endoscopy in patients with gynecologic malignancies, its potential is unconfirmed and its hazards unknown. Reports regarding complications and long-term results are just now beginning to be published. More clinical data must be collected before the minimally invasive techniques can be accepted as new surgical standards. Ongoing prospective clinical trials will help to answer many of the questions regarding safety and efficacy. Pending the completion of additional trials, operative laparoscopy will remain a promising but unproven tool in the management of patients with gynecologic cancer.

Clinical Trials as Topic↗
PubMed1989

Double-optic laparoscopy. Salpingoscopy, ovarian cystoscopy and endo-ovarian surgery with the argon laser.

Salpingoscopy gives detailed visual information on the mucosal pattern of the tubal ampulla as far as the isthmoampullary junction. With experience it takes 10 minutes to perform salpingoscopy on both sides and with an additional dye test a most complete evaluation of tubal morphology and patency can be obtained during routine diagnostic laparoscopy. Comparative studies proved the technique to be superior to HSG and the laparoscopic inspection of the tubal serosa and of the fimbriae. In some instances, like a tubocornual block, only salpingoscopy can provide additional information. Eventually, with the current techniques of operative laparoscopy salpingoscopic inspection of a phimosis or even a hydrosalpinx can be performed quite easily and these findings help us in the clinical management of patients requiring either microsurgical cuff-salpingostomy (giving a more realistic chance of a spontaneous pregnancy every month) or in vitro fertilization (avoiding laparotomy). Salpingoscopy also guides us in the selection of patients for a GIFT procedure and probably provides a better estimation of the risk of ectopic pregnancy. Ovarian cystoscopy can be applied for accurate diagnosis of non-malignant ovarian cysts at the time of laparoscopy. The wall of the cyst is inspected in detail and selective biopsies are obtained. Unnecessary surgery for non-neoplastic tumours can be avoided and endometrial and cystic tumours can be treated in situ using an argon laser with minimal surgical damage to the ovarian capsule. This laser technique is under further investigation to evaluate its place in the diagnosis and conservative surgical treatment of benign ovarian cysts occurring during reproductive life.

Fallopian Tube Diseases↗
PubMed2000

Spleen laceration, a rare complication of laparoscopy.

A 31-year-old woman had secondary infertility of 4 years' duration. Hysterosalpingography revealed bilateral distal tubal occlusion with bilateral hydrosalpinx-like appearance. At laparoscopy, both oviducts were occluded with marked hydropic change. Salpingoplasty was performed to correct bilateral hydrosalpinges and reform the fimbriated tubal ends. The procedure was performed uneventfully by an experienced surgeon in 45 minutes. Nine hours after the operation an emergency exploratory laparotomy was performed due to massive intraabdominal bleeding. The cause was a small tear, 3 cm long and 1 cm deep, with active bleeding in the inferior splenic tail. The laceration was repaired successfully with 1-0 chromic suture. The etiology of splenic laceration during laparoscopic surgery is uncertain. Many complications of laparoscopy are physiologic, and this one might have occurred while establishing pneumoperitoneum. Distortion and stretching of small vascular adhesions of the spleen with the abdominal wall also may have played a role. Gynecologists must be aware of the physiologic insult to patients during laparoscopy.

Adult↗
PubMed2003

Comparison of laparoscopy and laparotomy in managing hemodynamically stable patients with ruptured corpus luteum with hemoperitoneum.

STUDY OBJECTIVE: To compare differences between laparoscopy and laparotomy in managing women ruptured corpus luteum with hemoperitoneum. DESIGN: Three-year, prospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: University-affiliated regional hospital. PATIENTS: Sixty hemodynamically stable women. INTERVENTION: Laparoscopic surgery (30 women) and laparotomy (30). MEASUREMENTS AND MAIN RESULTS: Laparoscopic surgery had significant advantages over laparotomy, including shorter hospital stay (55.33 +/- 7.67 vs 97.77 +/- 14.45 hrs, p < 0.001) without increased adverse events. Laparoscopic surgery also showed trends of shorter operating time, improved wound care, and less postoperative pain. CONCLUSION: Laparoscopy surgery for diagnosis and treatment of women with ruptured hemorrhagic corpus luteum appears superior to laparotomy. We suggest that surgeons try laparoscopy first as a diagnostic and probably therapeutic procedure.

Adult↗
PubMed2003

Comparative, double-blind, randomized, placebo-controlled trial of intraperitoneal of bupivacaine and lidocaine for pain control after diagnostic laparoscopy.

STUDY OBJECTIVE: To compare the effect of intraperitoneal bupivacaine and lidocaine on reducing pain after diagnostic laparoscopy. DESIGN: Randomized, double-blind, placebo-controlled study (Canadian Task Force classification I). SETTING: University teaching hospital. PATIENTS: One hundred thirty-four women with unexplained infertility. INTERVENTION: Diagnostic laparoscopy with intraperitoneal administration of bupivacaine or lidocaine. MEASUREMENTS AND MAIN RESULTS: Patients were randomized into one of four groups. In group A, at the end of laparoscopy 0.125% bupivacaine 30 ml was instilled into the pelvic cavity and the same dose was instilled over the diaphragmatic vault. Groups B and C received the same volume of 5% lidocaine and normal saline, respectively. Group D received no intraperitoneal agent. The verbal pain scale questionnaire was used to assess postoperative pain. Pain scores 2 and 24 hours postoperatively were significantly lower for group A than for groups B and C (p = 0.0001). Scores in group B were also significantly lower than those in groups C and D (p = 0.0001). Women in group A required less additional analgesia than those in the other groups. CONCLUSION: Compared with lidocaine and placebo, intraperitoneal bupivacaine significantly decreased postoperative pain, and this effect was long lasting.

Adult↗
PubMed2003

Chance of adhesion formation after laparoscopic salpingo-ovariolysis: is there a place for second-look laparoscopy?

STUDY OBJECTIVE: To evaluate the chance of adhesion formation after laparoscopic salpingo-ovariolysis and determine the efficacy of early second-look laparoscopy (SLL). DESIGN: Prospective, randomized study (Canadian Task Force classification I). SETTING: Shiraz University hospitals. SUBJECT: Ninety women with mean duration of infertility of 7.2 years. INTERVENTIONS: Operative laparoscopy, with early SLL with adhesiolysis in 46 (group 1) and no SLL in 44 women (group 2). MEASUREMENTS AND MAIN RESULTS: Adnexal adhesions were evaluated according to American Society for Reproductive Medicine adhesion classification. Separation of newly reformed adhesions was performed at the time of SLL. Patients were followed for a year after operation without other infertility treatment. At the time of operation in group 1, adnexal adhesions were graded as severe (class D) in 19 women, moderate (class C) in 31, mild (class B) in 28, and minimal (class A) in 14. Respective figures in group 2 were 10, 30, 34, and 14. After salpingo-ovariolysis these figures were 12, 10, 20, and 50 in group 1 and 6, 14, 17, and 51 in group 2. In group 1 in whom early second-look laparoscopy was performed, at the start of the operation these figures were 17, 20, 21, and 34, and after operation 12, 8, 20, and 52, respectively. There were 11 term pregnancies in group 1 and 15 in group 2. No women with severe adhesions in either group conceived. In group 1, chances of term pregnancy were 18.75% for those with moderate adhesions, 35.71% for women with mild adhesions, and 42.86% in patients with minimal adhesions. Respective figures in group 2 were 26.67%, 41.18%, and 57.14%. CONCLUSION: The chance of moderate and severe adhesion reformation after laparoscopic salpingo-ovariolysis was 40.2%. Although separation of these adhesions could be performed more easily at the time of early SLL, the chance of pregnancy did not increase compared with that in patients who did not undergo SLL.

Adult↗
PubMed2001

Major complications of operative gynecologic laparoscopy in southern Taiwan.

STUDY OBJECTIVE: To describe our experience with major complications in gynecologic laparoscopy compared with literature reports. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Two regional teaching hospitals in southern Taiwan. Patients. One thousand five hundred seven women. INTERVENTION: Gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The overall number of major complications in 1507 laparoscopies was 24 (1.6%): 6 bladder injuries, 5 bowel injuries, 4 ureteral injuries, 3 cases of delayed vaginal stump bleeding, 2 cases of postoperative ileus, 2 abscesses, 1 vessel injury, and 1 umbilical hernia. Complication rates were analyzed by type of surgery-laparoscopic-assisted vaginal hysterectomy (LAVH) versus non-LAVH. We correlated clinical outcome with time of recognition and treatment of complications. Our complication rates were similar to those reported in the literature and were not significantly different between LAVH and non-LAVH. CONCLUSION: Early recognition of injuries, preferably intraoperatively, with immediate appropriate treatment is crucial. It is also important to be alert to early manifestations of complications in the postoperative observation period. (J Am Assoc Gynecol Laparosc 8(1):61-67, 2001)

Adolescent↗
PubMed2001

Effect of heating and humidifying gas on patients undergoing awake laparoscopy.

STUDY OBJECTIVE: To determine the effect of heating and humidifying CO2 on the tolerance of awake laparoscopy and frequency of shoulder pain and patient recovery. DESIGN: Randomized, controlled study (Canadian Task Force classification I). SETTING: University-affiliated hospital. PATIENTS: Forty consecutive women. INTERVENTION: Awake laparoscopy with and without heating and humidifying CO2. MEASUREMENTS AND MAIN RESULTS: Heating and humidifying CO2 decreased the frequency of shoulder pain and increased tolerance of the procedure. Thirty percent of patients required no intravenous sedation and did not experience shoulder pain when 3 L of gas or 15 mm Hg pressure was achieved. When shoulder pain did occur with heated and humidified gas, it was brief. CONCLUSION: Heating and humidifying CO2 increases tolerance of awake laparoscopy and decreases the frequency and duration of shoulder pain.

Carbon Dioxide↗
PubMed1997

Anterior abdominal wall adhesions after laparotomy or laparoscopy.

STUDY OBJECTIVE: To determine the frequency of postoperative adhesions to the anterior abdominal wall peritoneum that could affect safe placement of the initial laparoscopic umbilical cannula at subsequent procedures. DESIGN: Prospective cohort study. SETTING: Reproductive endocrinology and infertility service of a tertiary care referral hospital. PATIENTS: Two hundred fifteen women, 124 with prior abdominal surgery and 91 with no prior surgery. INTERVENTIONS: Surgical histories were reviewed, abdominal skin scars noted, and extent of anterior abdominal wall adhesions prospectively recorded. Statistical analysis was performed with the chi2 test. MEASUREMENTS AND MAIN RESULTS: No anterior abdominal wall adhesions were present in 91 patients with no previous surgery or 45 patients with previous laparoscopy (12 had more than 1 laparoscopy; p <0.001 vs laparotomy). Seventeen (59%) of 29 patients with a midline vertical incision had anterior wall adhesions (p <0.05 vs suprapubic transverse incision). Eleven (28%) of 39 with a suprapubic transverse incision had anterior wall adhesions (p <0.001 vs no surgery or laparoscopy). Ninety-six percent of adhesions involved omentum and 29% included bowel. CONCLUSION: Prior laparotomy, whether through a midline vertical or suprapubic transverse incision, significantly increased the frequency of anterior abdominal wall adhesions, and these adhesions may complicate the placement of the laparoscopic cannula through the umbilicus.

Abdominal Muscles↗
PubMed1994

Management of benign ovarian cystic teratomas: laparoscopy compared with laparotomy.

STUDY OBJECTIVE: To determine the outcomes of laparoscopic management of benign ovarian cystic teratomas (dermoids) compared with traditional laparotomy and excision. DESIGN: A retrospective analysis of patients treated from October 1988 to May 1993. SETTING: University of Connecticut Health Center-affiliated hospitals. PATIENTS: Thirty-eight women with dermoid cysts that were managed either by laparotomy or laparoscopy, 19 matched patients in each group. The majority of lesions in both groups were diagnosed at routine pelvic examination. INTERVENTIONS: The two groups were assessed with respect to age, gravidy, parity, size of lesions, and estimated blood loss at surgery. MEASUREMENTS AND MAIN RESULTS: Two values were significantly different in the group treated by laparoscopy: more dermoids ruptured intraoperatively, and the mean hospital stay was significantly shorter (p</=0.01). In most cases cystectomy was performed with preservation of the involved ovary. After a mean follow-up of 11 months no complications such as severe chemical granulomatous peritonitis or persistent pelvic pain have been encountered in the laparoscopy group. CONCLUSIONS: Laparoscopic management of dermoids is safe and cost effective, and provides patients the benefit of a shorter hospital stay and recovery time.

Adult↗
PubMed1996

Evaluation of stress-related hormones after surgery by laparoscopy or laparotomy.

STUDY OBJECTIVE: To evaluate the stress hormone response after pelvic surgery performed by laparoscopy versus laparotomy. DESIGN: Prospective study. SETTING: A tertiary care university hospital. PATIENTS: Ten women were scheduled to undergo laparoscopic surgery and 10 laparotomy for either tubal disease or endometriosis. INTERVENTIONS: Surgical procedures were performed by laparoscopy or laparotomy for stage III-IV endometriosis, pelvic adhesions, or distal tubal occlusion. The following hormones were measured before the induction of anesthesia in the ward, 60 minutes after the beginning of surgery, at the end of surgery after extubation, and 2 hours and 6 hours after the end of the operation: norepinephrine (NE), epinephrine (E), dopamine (D), adrenocorticotropic hormone (ACTH), cortisol, prolactin (PRL), and GH. MEASUREMENTS AND MAIN RESULTS: The mean duration of surgery was not significantly different between the two groups. Surgery-related adrenergic activation (E, NE, D) appears more pronounced in the laparotomy group (p<0.005) during surgery and in the postoperative period. More elevated values for laparotomy were observed also for the other stress hormones (ACTH, cortisol, PRL, GH), even though statistical significance was not always reached. CONCLUSIONS: Compared with laparotomy, activation of stress-related factors during laparoscopy seems to be less intense and of shorter duration.

Adrenocorticotropic Hormone↗
PubMed1996

The prognostic significance of minimal intracystic vegetations during operative laparoscopy for adnexal masses in women of reproductive age.

STUDY OBJECTIVE: To evaluate the prognostic significance of minimal intracystic vegetations in ovarian cysts approached by laparoscopy. DESIGN: Prospective study. SETTING: A tertiary care university hospital. PATIENTS: Ten of 208 women with adnexal cysts and minimal intracystic vegetations, under 40 years of age, carefully selected for operative laparoscopy on the basis of a preoperative sonogram suggestive of a unilocular cyst, with no thick septa or solid components in the absence of ascites. INTERVENTIONS: Adnexal cyst excision at operative laparoscopy. MEASUREMENTS AND MAIN RESULTS: In all 208 women evaluation of the abdomen, pelvis, and external surface of the cyst was negative. In 10 patients minimal intracystic vegetations, not detected by preoperative sonography, were identified during endocystic evaluation. In all these cases frozen section examination was negative. Definitive histologic diagnosis confirmed the presence of benign cysts. CONCLUSION: The presence of minimal intracystic vegetations alone when diagnosed in highly selected patients under 40 years of age may not justify immediate midline laparotomy if frozen section is negative.

Adnexal Diseases↗
PubMed1999

Complications of gynecologic laparoscopy.

STUDY OBJECTIVE: To examine the frequency of gynecologic laparoscopy complications from January 1996 to June 1996. DESIGN: Prospective review (Canadian Task Force classification II-1). SETTING: Tertiary center teaching hospital with 607 beds. PATIENTS: Two hundred thirty-four patients (age 15-70 yrs). INTERVENTIONS: Gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The overall number of complications was 23 (9.8%). They were principally infection, extraperitoneal insufflation, and injury to blood vessels. Complication rates were examined by service (private, clinic, staff) and by type of laparoscopy (operative, diagnostic, laparoscopic-assisted vaginal hysterectomy). Of 11 (47.8%) complications that occurred during laparoscopic-assisted vaginal hysterectomy, 5 involved postoperative infection. CONCLUSION: The complication rate in this review was similar to that published in the literature, with the exception of ileus and infection, which occurred at higher rates in our institution. (J Am Assoc Gynecol Laparosc 6(3):317-321, 1999)

Adolescent↗
PubMed2001

[Management of adnexal tumors: role and risks of laparoscopy].

The laparoscopic management of adnexal tumeurs remains controversial because of the potentials risks of cancer dissemination suggested by many case reports and national surveys. From experimental data, the laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages. The risk of dissemination appears high when a large number of malignant cells are present so that adnexal tumors with external vegetations, and bulky lymph nodes may be considered as contra-indications to CO2 laparoscopy. Laparoscopic surgery has become the gold standard in the treatment of benign adnexal tumeurs, whereas laparotomy remains the standard for the treatment of malignant tumors. The surgical diagnosis is the key to adequate management of adnexal tumeurs. In our experience, after a careful preoperative evaluation, the laparoscopic diagnosis of malignancy is reliable. Moreover in national surveys, many malignant tumeurs were considered as benign despite suspicious laparoscopic findings. Using strict guidelines, laparoscopic diagnosis can be proposed for both non suspicious and complex tumeurs, thus avoiding many unnecessary laparotomies for benign tumeurs suspicious at ultrasound. The more controversial limits of laparoscopic treatment are discussed. If a laparotomy was performed for all tumeurs suspicious at surgery, 80% of the cases would be treated by laparoscopy. The role of laparoscopy for restaging and second look operations for ovarian cancer requires further evaluation.

Adnexal Diseases↗
PubMed2001

[Value of ureteral catheterization in laparoscopy].

OBJECTIVE: Describe indications and procedures of ureteral retrograde catheter placement in operative laparoscopy. Assess the security that allows this technique to avoid or detect ureteral injury. STUDY DESIGN: A cohort study over a five year period was performed on 1722 patients who underwent an operative gynecologic laparoscopy. SURGICAL TECHNIQUE: When presumptive evidence of ureter adhesiolysis (dense adhesions from previous surgery, endometriosis), or suspicion of iatrogenic ureter transection, laparoscopic procedure was interrupted. A cystoscopy was performed and an internalized stent was inserted. RESULTS: In nine cases (preventive indications), patients required this procedure in adnexal surgery (dense adhesions from previous operations endometriosis), in oophorectomy for residual ovary syndrome and ovarian remnant syndrome and in hysterectomy with an intraligamentary leiomyomata. In one case (diagnostic indication), ureteral catheter placement was performed after use of an endoscopic linear stapler during a laparoscopically assisted vaginal hysterectomy. CONCLUSION: This intra-operative procedure can allow better ureter recognition and its safe dissection when complex operative laparoscopy is foreseen.

Adnexal Diseases↗
PubMed2001

[Laparoscopy and gynecologic cancer: is it still necessary to debate or only convince the incredulous?].

Many papers suggested that laparoscopic treatment of cancer could be achieved and taught safely. Although cases reports about trocar site metastasis and national survey about inadequate management of early ovarian cancer suggested that laparoscopic management of cancer may be dangerous. The current literature may be summarized as follows. An inadequate surgical management performed by laparoscopy as well as by laparotomy may worsen the prognosis of an early ovarian cancer. If the abdominal wall is protected with a bag and the tumour is not morcellated, the incidence of trocar site site metastasis is about 1%. Animal studies demonstrated that the laparoscopic management of cancer has both advantages and disadvantages. Preliminary results from prospective randomised trials in the treatment of colon cancer suggested that the survival rate is similar after laparoscopy and after laparotomy. The risk of dissemination appears high when a large number of malignant cells are present in patients operated using an increased abdominal pressure and a CO2 pneumoperitoneum. These data suggest that laparoscopic treatment of gynaecologic cancer is not dangerous if an adequate surgical technique is used. However morcellation of suspicious solid tumours, treatment of adnexal tumours with external vegetations but without peritoneal dissemination and of bulky lymph nodes should be considered as contra-indications to CO2 laparoscopy, puncture of an ovarian tumour with intracystic vegetations is a high risk situation which should be avoided whenever possible.

Female↗