Laparoscopic findings in patients with pelvic pain.

We have reviewed 1,194 charts of consecutive patients who had a diagnostic laparoscopy for pelvic pain from January 1, 1972, to December 31, 1980, at the Deaconess Division of the Buffalo General Hospital. A total of 749 of these patients had normal pelvic examinations prior to the diagnostic laparoscopy; 479 (63%) had abnormal findings on diagnostic laparoscopy. Of the 445 patients with abnormal pelvic examinations, 78 (17.5%) had normal findings on diagnostic laparoscopy. The laparoscopic findings and ovarian pathology are reviewed. These results are substantiated by other reports in the literature and certainly justify the increasing use of the laparoscope as a diagnostic tool in the gynecologist's armamentarium.

Choriocarcinoma of the ovary with coexisting normal pregnancy.

A rare case of ovarian choriocarcinoma coexistent with a normal term pregnancy is presented. In this case, the third documented report of ovarian choriocarcinoma with a term pregnancy, illustrates the difficulty of making the correct diagnosis.

Complications of laparoscopic tubal sterilization.

The experience of laparoscopic sterilization in 5018 cases at the Deaconess Division of Buffalo General Hospital over a period of 8.5 years is presented. The procedure was completed in 4992 cases, with a complication rate of less than 1% and with no operative mortality. One half of the patients with complications required a laparotomy. Bleeding was the most common complication; it accounted for exactly one half the complications. The laparotomy rate for all complications was 4.6 per 1000 cases. Seven ectopic and 4 intrauterine pregnancies occurred after this procedure, for a method failure rate of 2.2 per 1000 cases. Recommendations for prevention and management of complications are presented.

PIP: 5018 cases of laparoscopic tubal sterilization were attempted by the gynecologic staff of the Deaconess Hospital, Buffalo, from February 1970-August 1978. The procedure was completed in 4992 cases. A 2-puncture technique was employed with tubal coagulation with or without resection of the tube. A single or double-burn technique was use to coagulate a 1.5-2 cm segment of the tube. The CSV Bovie Generator was the electrocoagulation unit, and the unipolar Palmer-Jacobs biopsy forceps were the coagulating forceps. Abortion was performed on 861 (17%) patients at time of sterilization. The complication rate was less than 1%, with no mortalities. Bleeding was the most common complication. Half the patients with complications required a laparotomy. The laparotomy rate for all complications was 4.6/1000. After this procedure, 7 ectopic and 4 intrauterine pregnancies occurred, for a method failure rate of 2.2/1000. Preoperative preparation consisted of a sleeping medication at the patient's request, nothing taken after midnight; and parenteral administration of atropine, .4 mg, or Robinul, .2 mg, .5 to 1 hour prior to surgery. A general anesthetic was given through a cuffed endotracheal tube and a muscle relaxant administered during the procedure to reduce unnecessary movement by the patient.

[Pregnancy following laparoscopic tubal electro-coagulation and division (author's transl)].

PIP: Between 1970-1975 the authors performed 3160 laparoscopic tubal electrocoagulations and divisions on women desiring permanent sterilization. While the literature reports a failure rate of 0.2% on sterilizations performed with such a procedure, in the series considered there were 16 pregnancies, i.e., a failure rate of 0.51%. However, 7 patients were already pregnant at the time of tubal sterilization, bringing the failure rate down to 0.28%. Of these 9 unwanted pregnancies 6 were ectopic. The result of this investigation induced the authors to modify their sterilization procedure, and to use only wide electrocoagulation with the bipolar forceps.^ieng

Pregnancy following laparoscopic tubal electrocoagulation and division.

PIP: In a series of 3160 sterilization procedures performed by laparoscopic electrocoagulation and division, 16 pregnancies were reported. 9 of these failures were attributable to surgical error, for a surgical failure rate of .28%. It is suggested that these patients had microscopic tuboperitoneal fistulas in the cut ends of the tubes, and that fertilization occurred on the ovarian surfaces rather than in the oviduct ampullae. 5 of the pregnancies were ectopic, and all were found in the distal ends of the tube. The authors have modified the surgical technique by eliminiating division and using only wide electrocoagulation, with the triple-burn technique of Wheeless, and the Kleppinger bipolar forceps, in hopes of improving the success rate. The modifications also eliminate the risk of burns from unipolar current and of hemorrahage from biopsy.^ieng

Failed prostaglandin F2alpha-induced abortion: a case report.

A case of an attempted prostaglandin- and oxytocin-induced abortion which failed when the pregnancy continued to term is presented.

Combined laparoscopic sterilization and pregnancy termination.

PIP: This is a report of 306 dilation and suction curettage abortions combined with laparoscopic tubal ligations over a 2 1/2 year period. Patients' ages ranged from 21 to 44 years. All were multigravida and in the first trimester of their current pregnancy. 61 had undergone previous abdominal surgery. Average hospital stay was 1 day. Patients are preferably admitted the night before so a laminaria digitata tent can be placed to dilate the cervix. General anesthesia is used and occasionally the patient is intubated if conditions indicate. Insulated instruments are sterilized for 30 minutes in a solution of aqueous cidex or activated dialdehyde. After the area is prepared with Betadine, Hegar cervical dilators are used to dilate the cervix 1 size larger than the suction curette. Care needs to be exercised in making traction on the cervix at the time the dilator is introduced. Berkley suction apparatus is used with negative pressure of 60-70 mm of mercury. Manipulation of the suction curette to reach all areas is required. Blood loss is usually 50-200 ml. This may be minimized by adding Pitocin or Syntocinon to the anesthetic solution. A single-tooth tenaculum and a tubal insufflation cannula control the uterus during the subsequent sterilization procedure. The Verres cannula is inserted paraumbilically and 2.5-3 liters of carbon dioxide injected into the peritoneal cavity. Over distention is to be avoided. A second smaller cannula is inserted. The Palmer biopsy tong is inserted. Each tube is manipulated, grasped, coagulated, severed, and a biopsy taken. Care must be taken not to touch the tip of the tongs to the trocar sleeve. After checking the area the instruments are withdrawn and the carbon dioxide allowed to escape. Incisions are approximated with adhesive bandages. The patient may be discharged 3 to 6 hours after operation. Postoperative hysterosalpingograms on 14 of the 306 women showed no tubal potency in 13 at 8 months after surgery. Tubal peritoneal fistulas were shown in 1. 1 patient became pregnant 6 months after surgery but spontaneously aborted. The uterus was perforated once but immediately repaired. Procedures as used are recommended because of ease, safety, and economy.^ieng