A comparative study of laparoscopy and colpotomy for the removal of ovarian dermoid cysts.

OBJECTIVE: To compare laparoscope-assisted transvaginal removal of dermoid cysts to more standard laparoscopic cystectomy techniques. METHODS: We conducted a retrospective review of 44 laparoscopic dermoid removals performed at Olive View-UCLA Medical Center between 1992 and 1995. Cases were divided into three groups based on surgical approach: 1) conventional laparoscopic ovarian cystectomy, 2) laparoscopic ovarian cystectomy and removal of the freed mass via colpotomy, and 3) laparoscopic inspection, then transvaginal cystectomy via colpotomy. Surgical time, estimated blood loss, cyst spillage, and complications were compared. RESULTS: There were 11-19 patients in each group. The groups were similar in patient age, parity, and weight. Larger cysts tended to be removed by the laparoscopy-colpotomy techniques (mean diameter 10 cm) rather than by the purely laparoscopic approach (mean diameter 7 cm, P < .05). Cyst spillage occurred less often (43%, P < .05) and surgical time was shortest (mean 81 minutes, P < .05) with laparoscope-assisted transvaginal ovarian cystectomy compared with conventional laparoscopic techniques. Disposable laparoscopic instruments were used less often with transvaginal cystectomy (7%) than with conventional laparoscopic cystectomy (77%, P < .01). The difference in mean estimated blood loss in the cases using colpotomy (89 mL) compared with cases that did not (65 mL) was not statistically significant. Among the three groups, there were four major operative complications related to blood loss and infection. CONCLUSION: Laparoscope-assisted transvaginal ovarian cystectomy allows the removal of larger dermoid cysts, with less cyst spillage and savings in operative time and equipment compared with conventional laparoscopic cystectomy.

Commonly used diagnostic criteria for pelvic inflammatory disease have poor sensitivity for plasma cell endometritis.

BACKGROUND: The majority of women with tubal damage do not have a history of acute pelvic inflammatory disease. The prevalence of upper genital tract inflammation was evaluated in women deemed not to have pelvic inflammatory disease by common diagnostic criteria. GOAL OF THIS STUDY: To compare clinical signs and laboratory tests used to diagnose pelvic inflammatory disease with endometrial biopsy histopathology. STUDY DESIGN: Endometrial biopsy and commonly used physical and laboratory tests were performed on 52 women with pelvic tenderness, 51 with vaginosis or cervicitis, and 22 control subjects who had no evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis and who tested negative for bacterial vaginosis using vaginal swab Gram's stain. RESULTS: Thirty-six of 52 patients (69%) with pelvic tenderness, compared with 22 of 51 patients (43%) with vaginosis or cervicitis and two of 22 control subjects (9%), had plasma cell endometritis. The Centers for Disease Control and Prevention minimal diagnostic criteria for pelvic inflammatory disease had a sensitivity of 33% for plasma cell endometritis. CONCLUSIONS: The clinical diagnosis of pelvic inflammatory disease using published criteria correlates poorly with plasma cell endometritis.

Retropubic vaginopexy for correction of urinary stress incontinence.

One of the most important principles of surgical correction of urinary stress incontinence is the restoration of the urethrovesical angle to its original anatomic position. A new variant of urethropexy, suspending the vaginal wall from the anterior rectus fascia, is presented. To accomplish this goal, a special ligature carrier needle was designed. The ligatures are carried with this needle from the vaginal wall, through the space of Retzius, and upward above the rectus fascia where they are tied across the midline, one side to the other. This report describes the new method in detail. Using this technique, urethropexy was performed on 98 patients at the UCLA Olive View Medical Center. The overall cure rate for urinary stress incontinence was over 95% at 6-months to 3-year follow-up. The most common complications were postoperative urinary retention and urinary tract infection. The average length of hospitalization was 5 days.

A new technique for female sterilization.

The normal mobility and inherent length of the fallopian tube make possible its exteriorization from the abdominal cavity to perform tubal sterilization. The authors offer a new laparoscopic technique using exteriorization of the tube, performance of either tubal ligation (modified Pomeroy technique) or unipolar cauterization, and intra-abdominal in-sleeve cauterization in case of failure to exteriorize the tube. This approach averts laparotomy, preserves the advantages of tubal ligation, and precludes bowel injury that may result from using electric cauterization. To ensure safety an uninsulated trocar sleeve and grasping forceps were designed and used through the second puncture site. With this technique, 364 patients have had voluntary interval sterilization at the UCLA-Olive View Medical Center between 1977 and 1980, including tubal ligation (181 patients), cauterization (161), and intra-abdominal in-sleeve cauterization (22). No bowel burn was occurred and no laparotomies have been necessary. Complications were minor and compared favorably with other laparoscopic sterilization techniques.

New laparoscopic sterilization with exteriorization of tubes (cauterization, ligation): a preliminary report.

The fallopian tube's remarkable mobility and inherent length makes possible its exteriorization from the abdominal cavity to perform any kind of tubal sterilization. We offer a new laparoscopic technique utilizing (1) exteriorization of the tube and the performance of either (a) tubal ligation (Pomeroy technique); or (b) unipolar cauterization, or (2) intraabdominal in-sleeve cauterization in case of failure to exteriorize the tube. Our approach, on the one hand, was to avoid laparotomy but still preserve the advantages of tubal ligation, and on the other hand, to avoid possible bowel burn but still retain the beneficiary effect of electrical cauterization. To accomplish this, a simple second puncture uninsulated trocar-sleeve and grasping forceps were designed. With this technique, 325 patients have had voluntary interval sterilization at Olive View Medical Center-UCLA Campus (1977-1980). No bowel burn or pregnancies have occurred. No laparotomies have been necessary. Complications were minor and compared favorably with those cases in which other techniques were used.

Primary abdominal pregnancy associated with the IUD (2 case reports).

Two patients with early abdominal pregnancy associated with intrauterine device (IUD) are reported. The role of the IUD in the genesis of ectopic pregnancy is discussed.

Use of prostaglandin, hypertonic saline and oxytocin for second-trimester abortion.

The management of second-trimester abortion is still not satisfactory with respect to safety and side-effects; it is considered to be in a state of evolution. The goal of this investigation has been to combine, in reduced quantity, prostaglandin and hypertonic saline in order to minimize the complications and side-effects associated with the separate administration of each component. This study documents the results of a random sample of 385 abortions performed in the second trimester, induced by intra-amniotic instillation of prostaglandin (20 mg) and NaCl 5 and 10 g in different volumes and concentrations augmented with oxytocin. In a series of 20 patients, the coagulation profile is presented and the clinical characteristics of 4 groups are compared. This study demonstrated no coagulation defects. The gastrointestinal side-effects were reduced. In spite of the reduced dosage of each component, the instillation abortion interval still remained 17.08 h on the average. Incomplete abortion ranged from 32% to 48.78%. The data presented in this report suggests that combination of prostaglandin, hypertonic saline and oxytocin is feasible for midtrimester abortion.

PIP: This study was conducted to determine whether combining prostaglandin (PG) and hypertonic saline augmented with oxytocin solution can be used in the management of second-trimester abortion to minimize the complications and side effects associated with the separate administration of each component. A total of 385 2nd-trimester pregnant patients (from the Montefiore Morrissania affiliated hospital and Mount Sinai Hospital of New York City) with gestational age 16 to 24 weeks were assigned randomly to 4 groups: Group 1 (PFG2a 20 mg + 100 ml 5% NaCl injected intraamniotically with no amniotic fluid removed); Group 2 (PGF2a 20 mg + 100 ml 10% NaCL (10g) injected intraamniotically and with no amniotic fluid removed; Group 3 (PGF2a 20 mg + 25 ml 20% NaCl injected intraamniotically and with no amniotic fluid removed; and Group 4 (PGF2a 20 mg + 100 ml 10% NaCL injected intraamniotically and with 100 ml amniotic fluid removed. The standard aseptic transabdominal amniocentesis with an 18-gauge needle and polyethylene catheter was used to administer the abortifacients. Success rate of the procedure was 98.97%. Instillation abortion interval ranged from 15.33 to 20.67 hours (Table 2). Of the 4 dosage schedules, Group 3 exhibited the most satisfactory results, with 15.33 hours as the average instillation abortion interval. Side effects were minimal. This study shows that the combination PG + NaCL augmented by oxytocin is one of the best available approaches to the management of 2nd-trimester abortions. The more amniotic fluid removed, the shorter the instillation abortion interval. Incomplete abortions were between 32 to 48.78%; the incidence was higher in cases where more amniotic fluids were removed.

Volume and sodium concentration studies in 300 saline-induced abortions.

In an attempt to clarify the role of volume changes and Na concentration in saline-induced midtrimester abortions, 800 amniotic fluid samples were studied in 300 cases. The immediate postinfusion values of Na ranged as high as 3,000 mEg. per liter and as low as 1,200 mEg. per liter, still resulting in abortion. In earlier gestation, higher Na concentration and greater volume increase was needed for successful induction of abortion. Volume increase, within limits, compensated for Na concentration decrease. Osmotically induced volume changes were proportionatenate to the advancing stage of gestation.