[Rectovaginal endometriosis--analysis of 160 cases]. / Endometrioza przestrzeni odbytniczo-pochwowej--analiza 160 przypadków.

OBJECTIVES: The aim of the study was a retrospective analysis of the medical records of patients who underwent surgery due to deep infiltrating rectovaginal endometriosis (mainly with the use of the 'shaving' technique). MATERIAL AND METHODS: We analysed 160 cases of patients who underwent surgery due to the deep infiltrating rectovaginal endometriosis in our ward between 2003-2014. Depending on lesion localization, disease severity and clinical characteristics, three possible ways of operation were proposed: laparoscopic, vaginal or a combined vagino-laparoscopic approach. RESULTS: A total of 120 patients underwent laparoscopic removal of the endometrial lesions, whereas 17 were operated vaginally and 23 with the use of the combined approach. Nodule resection was successfully performed in all cases. The combined vagino-laparoscopic operations were characterized by the longest operating time. The rate of perioperative complications was low in the group of patients who underwent laparoscopic or combined operations. The necessity of bowel wall suturing occurred in 15 cases. This procedure was performed in order to strengthen the bowel wall (in cases when no perforation occurred) or due to bowel resection during surgery. Unexpected bowel perforation occurred in only 5 cases. Conclusions: Vaginal, laparoscopic and the combined vagino-laparoscopic surgeries can be safely performed in cases of deep rectovaginal endometriosis.

Evaluation of total laparoscopic hysterectomy with lymphadenectomy in surgical treatment of endometrial cancers.

OBJECTIVES: The study was conducted to evaluate the efficacy feasibility and safety of total laparoscopic hysterectomy (TLH) with lymphadenectomy in the treatment of endometrial cancer MATERIAL AND METHODS: The retrospective study included 31 patients with endometrial cancer who underwent TLH with lymphadenectomy and 42 patients with endometrial cancer who were operated by laparotomy. In both groups the following parameters were analyzed: age, BMI, accompanying diseases, previous surgeries, parity duration of the surgery blood loss (complete blood count before and after the operation was compared), necessity of blood transfusion, length of hospital stay uterine volume, grade, stage of endometrial cancer (FIGO), and intra/ postoperative complications. RESULTS: Mean age of patients was lower in the laparoscopic group than in women operated by laparotomy: 54 and 64, respectively (p = 0.0001). There were no significant differences between both groups in BMI, uterine volume, grade, staging (FIGO), and parity The percentage of patients with accompanying chronic diseases in the TLH group was lower than in the laparotomy group: 48.39% and 83.34%, respectively (p = 0,032). There were no significant differences between both group in the history of previous laparotomies (p = 0.704). Mean duration of surgery was shorter in the case of laparotomy than in case of laparoscopy: 130.6 and 151.77, respectively (p = 0.003). Laparotomy was associated with greater blood loss during surgery Statistically significantly higher decrease in the Hb concentration and Hct values was noted in the group operated by laparotomy when compared to laparoscopy (mean values.: Hb-1.1 7 g/dl, Hct-3.49% for the TLH technique and Hb-7.8 g/dl Hct-5.47% for laparotomy; p = 0.011-Hb; p = 0.003-Hct). Mean hospital stay after laparoscopy was shorter than after laparotomy--4 and 9 days, respectively (p = 0,0001). The influence of the operational technique on the number of pelvic lymph nodes taken for histopathological examination was evaluated. No statistically significant correlation between the number of lymph nodes taken for histopathological examination during the surgery and the operational technique was noted (p = 0.083). Mean number of nodes taken for examination was 15 during the TLH surgery and 19 during laparotomy Postoperative complications were observed in 2 patients from the TLH and in 12 patients from the laparotomy groups (p = 0.038). The most statistically significantly frequent complication in the laparotomy group was postoperative wound infection: 8 (19.05%) patients. CONCLUSIONS: Total laparoscopic hysterectomy with lymphadenectomy in endometrial cancer therapy is a safe and feasible procedure. It is characterized by significantly smaller percentage of complications and shorter hospital stay This technique offers an alternative for laparotomy when it is performed by a highly experienced surgeon.

[Uterine cervix agenesis--uterovaginal anastomosis]. / Wrodzony brak szyjki macicy--wytworzenie polaczenia maciczno-pochwowego.

PURPOSE: Atresia of the uterine cervix is an uncommon Mullerian anomaly. Until ten years ago many authors recommended hysterectomy as the first line treatment in case of uterine cervix atresia. Recent advances in reproductive technology and laparoscopic surgical techniques mean that conservative surgery is a possibility and should be considered as the first line treatment option. Surgical treatment of uterine cervical atresia appears to be a good choice of treatment with good functional result. MATERIALS AND METHOLOGY: We report a case of a 19-year-old woman who was admitted to our Department with amenorrhea and pelvic pain. Examination found no communication between vagina and uterus. The patient under general anesthesia was placed in a lithotomy position, allowing both abdominal (laparoscopy) and vaginal approach. A large dissection between the bladder and the uterus and later between the rectum and the uterus was performed. An incision was made on the uterine fundus and a probe to identify the upper limit of artretic tissue of the cervix was inserted. The atretic tissue was resected as for the cervical conisation until the uterine cavity was reached. Then the uterus was sutured to the high vaginal mucosa with separate stitches. A Foley catheter was inserted in the uterine cavity for 21 days. During the entire post-operative treatment the patient received antibiotics, oral contraceptives and vaginal douche. Four months after the surgery a hysteroscopic evaluation revealed that the communication between the uterus and the vagina was healed. CONCLUSIONS: The result of our surgery confirms that uterine atresia may be successfully treated by utero-vaginal anastomosis.

[Operative treatment of benign ovarian tumours in adolescent patients: laparotomy or laparoscopy?]. / Leczenie operacyjne lagodnych nowotworów jajnika u dziewczat: laparotomia czy laparoskopia?

THE AIM: The aim of the study was a retrospective analysis of operative procedures, laparoscopy or laparotomy, carried out in cases of benign adolescent ovarian tumours. MATERIAL AND METHODS: A retrospective review of 709 patient charts with ovarian tumours, who had undergone surgical interventions at The Department of Surgical Gynaecology and Endoscopy of The Polish Mother's Memorial Hospital--Research Institute in Lódz--has been conducted. Among groups of girls treated either with laparoscopy or laparotomy, the following parameters were analysed: age of the patients, character of the tumour (based on the pathological result), size of the lesion, type of the surgical procedure, duration of the hospitalisation and postoperative complications. RESULTS: 109 girls had ovarian tumours operated--54 times laparoscopy and 55 laparotomy times were performed. An average age of patients who underwent laparoscopy was 16.2 years, in case of laparotomy: 15.3 years (p > 0.05). An average size of tumours excised in laparotomy was 82 mm (60-190 mm), whereas in laparoscopy 64 mm (30-80 mm) (p > 0.05). The most common laparotomic procedure was the ovarian cystectomy (63%) and cystovariectomy (32%), while during laparoscopy the cystectomy was performed in 92% (p > 0.05). Duration of the laparoscopy was shorter, average was 46.7 min, whereas mean time of laparotomy was 49.2 min (p > 0.05). Also duration of postoperative hospitalisation was longer in case of laparotomy, its average time was 5.4 days in comparison with laparoscopy--2.8 days (p < 0.05). CONCLUSIONS: Laparoscopy performed in adolescents due to benign ovarian tumours seems to be a very safe way of the surgical treatment. Moreover, laparoscopy reduces duration of hospitalisation and convalescence, also giving a nice cosmetic effect.

[Why vaginal hysterectomy?]. / Dlaczego histerektomia pochwowa?

The article presents current view on vaginal hysterectomy. Arguments in favour of this miniinvasive, minimal access surgical technique are presented. In conclusion the authors underline that vaginal hysterectomy is a cheap, miniinvasive technique which doesn't require expensive, sophisticated equipment and, what is the most important, which is relatively easy to learn. Due to these advantages, if hysterectomy is necessary, vaginal route should be considered as a technique of choice. While taking a decision which technique to choose, a surgeon should rather look for contraindications for vaginal hysterectomy than indications for this technique.

[Operating time of laparoscopically assisted vaginal hysterectomy (LAVH)--the causative factors and the course of the postoperative period]. / Czas trwania LAVH--czynniki sprawcze i przebieg okresu pooperacyjnego.

OBJECTIVES: The aim of the study was to find the causative factors of prolongation of the operating time of laparoscopically assisted vaginal hysterectomy (LAVH) and to analyse the influence of the operating time on the course of the postoperative period. MATERIAL AND METHODS: Retrospective analysis of 103 LAVH procedures performed from June 2002 to April 2006 for benign conditions. All the cases have been divided in two groups, depending on the operating time: 45 procedures up to 90 minutes (average 76, range 50-90) and 58--over 90 minutes (average 126, range 95-210). In both groups we have analysed patient characteristics, indications, uterine size, intra- and postoperative complications, blood loss, hospital stay, the day of the return to the general diet, anaesthetic and antibiotic demand in postoperative period. RESULTS: There were 42.2% of postmenopausal patients in the "short-time" LAVH group and 17.2% in the "long-time" LAVH group (p < 0.05). 8.9% women in the short LAVH group and 31.0% in the long LAVH group had had no vaginal deliveries (p < 0.05). There was no significant difference in previous surgery history between the groups. Significant correlation of operating time of LAVH with patient weight (r = 0.26, p < 0.01) and BMI (Body Mass Index) (r = 0.21, p < 0.05) was noted. Uterine size was bigger in the long LAVH group (p < 0.01). There was one intraoperative complication (bowel injury) and three postoperative ones (two cases of bleeding to abdominal cavity demanding reoperation and one to the abdominal wall from injured superficial epigastric artery), all occurred in the long LAVH group. The average perioperative decrease in haemoglobin concentration was insignificantly higher in the long LAVH group (2.0 g% vs 1.4%). There was 4.4% rate of antibiotic demand after the short LAVH procedures and 24.1% after the long ones (p < 0.05). There was no significant difference in anaesthetic demand. The average day of introducing the general diet was 1,0 (range 1-2) in the short LAVH group and 1,4 (range 1-5) in the long LAVH group (p < 0.05). The average hospital stay was 2,6 days after the short LAVH procedures and 3,3 days after the long ones (p < 0.05). CONCLUSIONS: The operating time of LAVH depends on operator experience, obstetric history, presence or absence of the menstrual cycles, uterine size and, probably, patient weight and BMI. After the long LAVH procedure antibiotic use is more common, return to the general diet takes place later and hospital stay is prolonged.

[Anterior approach sacrospinous colpopexy in a patient with vaginal vault prolapse, stress urinary incontinence and cystocoele with lateral defect]. / Kolpopeksja krzyzowo-kolcowa z dostepu przedniego u pacjentki z wypadaniem kikuta pochwy wysilkowym nietrzymaniem moczu oraz cystocoele z defektem bocznym.

We present a case of vaginal vault prolapse after hysterectomy associated with cystocoele with central and lateral defect and stress urinary incontinence, that was treated surgically with employment of sacrospinous colpopexy through anterior approach (from paravesical space), combined with anterior colporrhaphy by double TOT approach method (that is a butterfly-shaped polipropylen mesh, which arms were carried through upper and lower parts of obturator foramens by tension-free method). There were no postoperative complications. A control examination at 1 and 3 months after the operation showed maintenance of normal anatomic relations, which were obtained as a result of repair, total control of urinary continence and full patient's satisfaction from the operation.

[The modification in surgical technique of incision and closure vault of the vagina during vaginal hysterectomy on the incidence of vault haematoma]. / Modyfikacja techniki naciecia i zamkniecia pochwy podczas histerektomii pochwowej, a czestosc wystepowania krwiaków powyzej szczytu pochwy.

OBJECTIVES: Vault haematoma is one of the most common complication of vaginal hysterectomy. The aim of this work was to analyse the effects of a modification of incision and closure technique of the vaginal vault on the incidence of vault haematoma after vaginal hysterectomy. MATERIAL AND METHODS: The study group consisted of 333 women of whom 49 (group A) underwent vaginal hysterectomy traditional technique of incision and closure of the vaginal vault, an 284 (group B) modified technique. Following parameters were evaluated: number of vault haematomas, blood loss, postoperative fever, required antibiotics, length of hospital stay. RESULTS: The risk of vault haematoma was significantly lower in the group B (1,06% vs 12,4%). Loss of blood was higher in group A (310 ml vs 206 ml). Incidence of postoperative fever was in 12,2% patients from group A, and 1,4% from group B. The length of hospitalization was lower for women in group B (4,3 days compared with 7,3 days). CONCLUSIONS: The modification of incision and closure technique of the vaginal vault during vaginal hysterectomy is recommended to minimise intra- and postoperative complications.

[Bilateral adnexal masses in a pregnant woman--laparoscopic management]. / Obustronne guzy jajników u ciezarnej-- wyluszczenie na drodze laparoskopii.

A case of a 30 years old pregnant woman suffering from bilateral ovary tumour was presented. When she was sixteen weeks pregnant she had both tumours enucleated using the method of laparoscopy. Diagnostic and therapeutic process have been described. Authors are convinced that laparoscopy as a method of treatment can be safely applied to pregnant women provided, that specific rules are obeyed and elaborate precautions during the surgery are taken.

[Influence of increased carbon dioxide pressure used to establish pneumoperitoneum in laparoscopy on safety of the operation]. / Wplyw zwikszonego cisnienia CO2 przy wytwarzaniu odmy otrzewnqwej w laparoskopii na bezpieczenstwo operacji.

OBJECTIVE: To evaluate the influence of increased CO2 pneumoperitoneum pressure on the safety of laparoscopic operation and the patients' condition. DESIGN & METHODS: 326 patients were operated on with a constant 12 mmHg pressure of CO2 pneumoperitoneum (group A). 637 laparoscopies were performed (group B) with the pressure of 18 mmHg until the main trocar insertion. In both groups complications, early postoperative period and duration of analgesic therapy were assessed. In 30 patients from group A and 52 from group B, during the operation, we controlled: systolic, diastolic and mean arterial blood pressure, heart rate, saturation, peak and mean airway pressure, end-tidal CO2 (ETCO2) and minute lung capacity. The measurements were taken at the beginning of the operation, in the 1st, 2nd, 3rd and 5th min. for both groups, in 7th min. for group A and in 10th and 15th min. for group B. RESULTS: Neither surgical complications, nor harmful effects of pneumoperitoneum were observed. There were no differences in respiratory and circulatory functions, duration of hospitalization, time to mobilization, and amount of administered analgesics. CONCLUSIONS: Creation of pneumoperitoneum with the increased pressure of CO2 up to 18 mmHg until the insertion of the first trocar to the abdominal cavity is safe, well tolerated by the patients and more comfortable for the surgeon.

[Significance of laparoscopic assistance in vaginal hysterectomy]. / Znaczenie wspomagania laparoskopowego w operacji usuniecia macicy przez pochwe.

OBJECTIVE: The objective of this publication was the analysis of laparoscopically assisted vaginal hysterectomies (LAVH) performed in Department of Surgical and Endoscopic Gynecology of Polish Mother Health Centre Research Institute. MATERIALS AND METHODS: There was the analysis of 57 LAVHs performed from June 2002 to December 2003. Following parameters were evaluated: indications to LAVH, operating time, weight of the removed uterus, complications, blood loss, duration of postoperative hospitalisation, the day of introducing general diet, anesthetic and antibiotic demand in postoperative period. RESULTS: There were indications to LAVH: fibroid uterus, endometrial hyperplasia, endometrial cancer, adnexal mass, cervix dysplasia. Previous laparotomy and caesarean section, endometriosis, narrow vagina of non-parous women were additional indications to use of laparoscopy during the operation. Complications were found in two (3,5%) cases: bleeding to abdominal cavity from infundibulo-pelvic ligament demanding reoperation and superficial epigastric artery injury no demanding reoperation. There were no infection, conversion to laparotomy, abdominal cavity organs injury and other complications. It was observed short time of introducing general diet, low anesthetic consumption and short post-operation stay in hospital (mean 3,6 days). CONCLUSIONS: Laparoscopically assisted vaginal hysterectomy is an operation with a small risk of intra- and postoperative complications, quick return to general diet and full life activity, short post-operation stay in hospital, low anesthetic consumption and good cosmetic effect. Use of laparoscopic stage in vaginal hysterectomy make possible evasion of laparotomy in the situation of impossible performance of ordinary vaginal hysterectomy.

[Sacrospinous ligament vaginal vault fixation--method, results and a one-year follow up in 10 patients]. / Podwieszenie wypadajacego kikuta pochwy do wiezadla krzyzowo-kolcowego--technika, wyniki i roczna obserwacja 10 pacjentek.

OBJECTIVES: The aim of the study was to present the author's experience in sacrospinous ligament vaginal vault fixation--description of procedure and estimation of procedure efficacy at 2, 6, and 12 months after the operation. DESIGN: This study was a prospective analysis of a one-year follow up of ten women with vaginal vault prolapse, who underwent sacrospinous ligament vaginal vault fixation after previous hysterectomy. MATERIALS AND METHODS: Ten women with prolapsed vagina after previously preformed hysterectomy hospitalised since September 2001 until Jun 2002 at Department of Surgical and Endoscopical Gynaecology at the Polish Mother's Memorial Institute in Lódz, underwent successful SSLF. RESULTS: Good post operative effect was achieved in all treated patients. There were no significant intraoperative complications. The average procedure's time was 38 minutes. The time of hospitalisation after surgery was 4 days. At control examinations at 2, 6 and 12 months after the operation, normal anatomic relations were stable. None of the patients had recurrence of pelvic floor disorders. Narrowing or shortening of vagina was not detected in any case. In nine operated patients sexual activity was remaining. CONCLUSIONS: We suggest, based on presented data, that suspension of vagina to sacrospinosus ligament can be effective and safe method of surgery for women with vaginal vault prolapse after hysterectomy.

[Conservative treatment of 12-week cervical pregnancy]. / Zachowawcze leczenie 12-tygodniowej ciazy szyjkowej.

A cervical pregnancy is very rare form of ectopic pregnancy. Usually it is associated with unexpected occurrence hemorrhage from the cervix. For this reason the treatment for a cervical pregnancy very often requires an abdominal hysterectomy. To avoid hysterectomy several conservative methods of termination have been used. In this paper has been reported the case of 29 years old woman with a 12-week cervical pregnancy. She had been treated (methotrexate and potassium chloride application, ligation of the uterine arteries, local haemostatic sutures) before evacuation products of conception from the cervix. Post-operative period was uneventful. After a 9 day of postoperative stay the woman was discharged. These behaviour allowed for save of uterus and preserve future fertility.

[Treatment outcome in women suffering from recurrent miscarriages and antiphospholipid syndrome]. / Wyniki leczenia kobiet z nawracajacymi samoistnymi poronieniami i zespolem antyfosfolipidowym.

OBJECTIVE: To evaluate the outcomes of treatment in patients suffering from recurrent spontaneous abortion and antiphospholipid syndrome. MATERIALS AND METHODS: 148 observed women suffering from recurrent abortion with presence of lupus anticoagulant antibodies (LA) and/or high moderate concentration of anticardiolipin antibodies (ACA) have been divided randomly into followed three treated groups: I--56 patients treated by low-dose of acetylsalicylic acid (LDA, 75 mg daily); II--39 patients treated by low molecular weight heparin (applied in dose of 20 g daily); III--53 patients treated by LDA and low molecular weight heparin simultaneously. RESULTS: It has been affirmed that coincidental application of low-dose of acetylsalicylic acid and low molecular weight heparin statistically more often increase the percentage of successful pregnancy in comparison with application of low molecular weight heparin or acetylsalicylic acid alone. In the group where only low-dose of acetylsalicylic acid was applied the success of pregnancy equaled 89.3%, in the group where only low molecular weight heparin was applied the successful pregnancy equaled 81.1% and in the group with acetylsalicylic acid and low molecular weight heparin being applied together the successful pregnancy equaled 92.5%. In has simultaneously been affirmed that the percentage of pregnancy loss is statistically higher in the women suffering from isolated occurrence of lupus anticoagulant antibodies (21.2%) in comparison with the women suffering from occurrence of anticardiolipin antibodies (6.7%) and anticardiolipin antibodies with lupus anticoagulant antibodies simultaneously. CONCLUSION: 1. Simultaneous application of low-doses of acetylsalicylic acid and low molecular weight heparin seems to be the best solution in patients suffering from recurrent spontaneous abortion and antiphospholipid syndrome. 2. The occurrence of anticardiolipin antibodies in the serum of blood in patients suffering from antiphospholipid syndrome is a better foretelling factor for the future pregnancy outcome than the occurrence of lupus anticoagulant antibodies.

[Ovarian tumors in the reproductive age group]. / Guzy jajników u kobiet w okresie rozrodczym.

OBJECTIVES: Analysis of the type and localization of the ovarian tumors in the reproductive age group of women. MATERIALS AND METHODS: The study group consisted of all women operated on Gynecologic Surgery Department of Polish Mothers's Memorial Hospital-Research Institute due to ovarian tumors in 1996-99. As the reproductive age we defined 18-39 year, when the majority of deliveries occurs. RESULTS: We analyzed 326 patients operated on the ovarian tumors. In 60 cases (18.4%) we noticed ovarian malignant tumors, in 7 (2.1%) borderline tumors and in 259 (79.5%) benign cysts. In the reproductive age (130 women) the incidence of ovarian malignancies was significantly lower (4.6%), higher for benign tumors (93.1%) and constant for borderline malignancy (2.3%), p < 0.005. The most common malignancy among all patients was epithelial cancer--83.4% (germ cell and metastatic--8.3%, both), but in the reproductive age group (6 cases) germ cell tumors were the majority--66.8% (epithelial and metastatic--16.6%, both), p < 0.005. In women aged 18-39 yr. with ovarian malignancies 4 of them had I stage of the disease and 2 were in the stage III. 121 women in the reproductive age were operated on the benign ovarian tumors; 107 (88.4%) had unilateral cysts and 14 (11.6%) had tumors in both ovaries. On histology we revealed 31.1% of endometrioid cysts, 28.9%--teratomas, 19.3%--serous, 3.7%--mucinous and others (hemorrhagic, functional, sex cord, inflammatory) in the remaining 17%. CONCLUSION: In the reproductive age ovarian tumors are mainly unilateral benign cysts. Only a few of ovarian tumors were malignant but the majority of them were in the early stage of the disease.