Increased morbidity in combined abdominal sacrocolpopexy and abdominoplasty procedures.

INTRODUCTION AND HYPOTHESIS: This study was performed to determine whether abdominoplasty combined with abdominal sacrocolpopexy (ASC + A) increases perioperative morbidity compared with ASC alone. We hypothesized that patients undergoing combined procedures would have increased complications. METHODS: This was a multicenter, retrospective cohort study of all women undergoing ASC + A from 2002 to 2010 at Washington Hospital Center and Johns Hopkins University. We selected two women undergoing ASC alone for comparison with each ASC + A patient. Baseline demographics, surgical data, length of hospitalization, and perioperative complications were recorded. The primary outcome was any major complication within 6 weeks of surgery, including intraoperative complications, pulmonary embolism (PE), deep venous thrombosis (DVT), cardiac compromise, intensive care unit (ICU) admission, reoperation, and readmission. Surgical data and minor complications were also compared. RESULTS: Twenty-six ASC + A patients and 52 ASC patients were identified. There were no significant differences in baseline characteristics between groups. Patients with ASC + A had longer operating times (337 vs 261 min, p < 0.01), more intravenous fluid administration intraoperatively (4,665 vs 3181 ml, p < 0.01), and longer hospital stays (3.7 vs 2.7 days, p < 0.01). Major complications occurred in 23 % of the ASC + A group compared with 12 % of the ASC group (p = 0.20). The ASC + A group had greater declines in hematocrit levels and higher rates of PE, ICU admission, and blood transfusion, all of which were statistically significant. CONCLUSIONS: ASC + A increases length of stay and perioperative complications, such as PE, ICU admission, and blood transfusion, compared with ASC alone. Surgeons should consider recommending interval abdominoplasty due to increased morbidity risk with a combined procedure.

Endoscopic management of endometriosis.

Randomized clinical trials in the effectiveness of laparoscopic surgery in the management of endometriosis associated with chronic pelvic pain show a 66% to 80% response rate. There is a 20% to 30% ''placebo'' response rate. The value of surgery for infertile patients with minimal and mild disease is still debated but is most likely small. In advanced disease, surgery clearly improves outcome, although the surgery is more challenging. After an initial unsuccessful surgery for restoration of fertility in patients with advanced endometriosis, in vitro fertilization rather than repeat surgery is more effective. Laparoscopic treatment of endometriomas should be performed by excisional surgery. Drainage and/or medical therapy is associated with a very high recurrence rate. The main concern with excision of endometriomas is the potential to decrease ovarian reserve. Most experts would agree that if there is an endometrioma of 4 cm or greater that a laparoscopic excision be performed before an anticipated in vitro fertilization cycle to decrease the potential risk of infection and improve access to follicle. Surgery for pelvic extragenital disease is challenging. Excision of rectal endometriosis may require disc excision of the nodular lesion or segmental resection. Morbidity of a laparoscopic procedure is similar to laparotomy. Relief of symptoms after laparoscopic bowel surgery is excellent but there are potential complications such as rectovaginal fistula and pelvic abscess. Endo-metriosis of the bladder or ureter typically only involves the overlying peritoneum and can be easily excised by laparoscopy. Excision of deeper lesions of the bladder and ureter require resection. This can be accomplished laparoscopically but requires experience with laparoscopic suturing.

Laparoscopic surgery for pelvic organ prolapse.

There is growing interest in laparoscopic procedures for the correction of pelvic organ prolapse. The goals of prolapse surgery are to correct symptomatic pelvic floor defects and reestablish vaginal support resulting in the maintenance or restoration of normal visceral and sexual function. A thorough understanding of pelvic floor support as well as anterior abdominal wall and intra-abdominal, pelvic, and retropubic anatomy must be ascertained before attempting laparoscopic prolapse procedures. As many of these procedures require advanced laparoscopic skills and experienced surgeons, most of the literatures are comprised of case series by expert surgeons, with many of the studies centered on sacral colpopexies. However, the principles of laparoscopic prolapse surgery are based on open procedures and the only difference in the technique should be related to the route of operation; therefore, the efficacy of laparoscopic prolapse procedures should theoretically be comparable to their open abdominal counterparts.