The role of laparoscopic-assisted myomectomy (LAM).

Laparoscopic myomectomy has recently gained wide acceptance. However, this procedure remains technically highly demanding and concerns have been raised regarding the prolonged time of anesthesia, increased blood loss, and possibly a higher risk of postoperative adhesion formation. Laparoscopic-assisted myomectomy (LAM) is advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery, namely, short hospital stay, lower costs, and rapid recovery. By decreasing the technical demands, and thereby the operative time, LAM may be more widely offered to patients. In carefully selected cases, LAM is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy. These cases include patients with numerous large or deep intramural myomas. LAM allows easier repair of the uterus and rapid morcellation of the myomas. In women who desire a future pregnancy, LAM may be a better approach because it allows meticulous suturing of the uterine defect in layers and thereby eliminates excessive electrocoagulation.

Ovarian remnant syndrome after laparoscopic oophorectomy.

OBJECTIVE: To report the surgical history, clinical characteristics, and operative technique used in patients with ovarian remnant syndrome after laparoscopic oophorectomy. DESIGN: Observational study. SETTING: Teaching hospital and private practice office. PATIENT(S): Nineteen patients with documented history of unilateral or bilateral laparoscopic oophorectomies with histologic confirmation of ovarian remnants. INTERVENTION(S): Operative laparoscopy for resection of ovarian remnants. MAIN OUTCOME MEASURE(S): Risk factors and surgical technique contributing to ovarian remnant syndrome. RESULT(S): The patients underwent a mean of 4.7 previous surgical procedures (range, two to nine): 12 had bilateral oophorectomy, and seven had unilateral oophorectomy. The infundibulopelvic ligament had been secured with bipolar desiccation in 11 patients, pretied surgical loops in six, and a linear stapler in two. Cystic ovarian remnants were identified by pelvic sonography in 12 women and by computed tomography (CT) scan in one. Six women underwent reoperation, two for ovarian remnants in different sites. CONCLUSION(S): With laparoscopic oophorectomy there is risk of ovarian remnant due to improper tissue extraction or misapplication or improper use of pretied surgical loops, linear stapler, or bipolar electrodesiccation on the infundibulopelvic ligament, especially in women with a history of multiple pelvic surgeries, adhesions, or endometriosis.

Laparoscopic adhesiolysis and relief of chronic pelvic pain.

OBJECTIVE: To evaluate the short- and long-term results of laparoscopic enterolysis in patients with chronic pelvic pain following hysterectomy. METHODS: Forty-eight patients were evaluated at time intervals from 2 weeks to 5 years after laparoscopic enterolysis. Patients were asked to rate postoperative relief of their pelvic pain as complete/near complete relief (80-100% pain relief), significant relief (50-80% pain relief), or less than 50% or no pain relief. RESULTS: We found that after 2 to 8 weeks, 39% of patients reported complete/near complete pain relief, 33% reported significant pain relief, and 28% reported less than 50% or no pain relief. Six months to one year postlaparoscopy, 49% of patients reported complete/near complete pain relief, 15% reported significant pain relief, and 36% reported less than 50% or no pain relief. Two to five years after laparoscopic enterolysis, 37% of patients reported complete/near complete pain relief, 30% reported significant pain relief, and 33% reported less than 50% or no pain relief. Some patients required between 1 and 3 subsequent laparoscopic adhesiolysis. A total of 3 enterotomies and 2 cystotomies occurred, all of which were repaired laparoscopically. CONCLUSION: We conclude that laparoscopic enterolysis may offer significant long-term relief of chronic pelvic pain in some patients.

Laparoscopic management of ovarian dermoid cysts: ten years' experience.

OBJECTIVE: To determine the safety and efficacy of laparoscopic management of ovarian dermoid cysts based upon our ten years' experience. METHODS: Charts of 81 patients who underwent laparoscopic removal of dermoid cysts since March 1988 at Stanford University Medical Center or the Center for Special Pelvic Surgery in Atlanta were reviewed retrospectively. RESULTS: Ninety-three dermoid cysts with a mean diameter of 4.5 cm were removed in 81 patients. Operative techniques used were cystectomy for 70 cysts, salpingooophorectomy for 14, and 9 salpingo-oophorectomy with hysterectomy. Fifty-three cysts were treated via enucleation followed by cystectomy or salpingo-oophorectomy and removal through a trocar sleeve. Twenty-two were treated via enucleation and removal within an impermeable sack. Nine were treated via enucleation and removal by posterior colpotomy. Nine were removed via colpotomy following hysterectomy. We had a total of 39 spillages. Spillage rates varied with removal method: 32 (62%) for trocar removal without an endobag, 3 (13.6%) for removal within an endobag, and 4 (40%) with colpotomy removal. No spillage occurred for the nine patients who had a colpotomy done for hysterectomy. Mean hospital stay after surgery was 0.98 days, and there were no intraoperative complications. In one case, there was a postoperative complication of an incisional infection in the umbilicus. CONCLUSION: Including this and 13 other studies, review of the literature reveals a 0.2% incidence of chemical peritonitis following laparoscopic removal of dermoid cysts. Thus, we conclude that laparoscopic management of dermoid cysts is a safe and beneficial method in selected patients when performed by an experienced laparoscopic surgeon.

Normal variations of abdominal and pelvic anatomy evaluated at laparoscopy.

OBJECTIVE: To describe certain anatomic relationships in the pelvis and abdominal wall at laparoscopy and the effect of body mass index (BMI) on those parameters. METHODS: In 103 patients we determined the following: distances from the midline to each medial umbilical ligament and the respective inferior epigastric vessels; distances between each ureter and the ipsilateral uterosacral and the infundibulopelvic ligament; relative visibility of the ureters, umbilical and uterosacral ligaments, and the sacral promontory; and the presence and location of congenital bowel attachments to the pelvic walls. RESULTS: The right ureter ran significantly closer to the infundibulopelvic and uterosacral ligaments than the left ureter. The right inferior epigastric vessels and umbilical ligament coursed more laterally than did those on the left. Both sets of inferior epigastric vessels, and the left umbilical ligament and ureter were significantly more difficult to identify in overweight women. In 69% of the subjects, the uterosacral ligaments were found to be thick or moderately thick. In two thirds, the sacral promontory was more than 75% visualized. Congenital bowel attachments were observed in 74.8% of subjects on the left pelvic sidewall, and 48.5% on the right. CONCLUSION: Left and right pelvic anatomy are not necessarily mirror images laparoscopically. The course of the inferior epigastric vessels can be more difficult to identify in overweight patients. Despite marked obesity or congenital bowel attachments to the pelvic side walls, both ureters can usually be identified. The proximity of the ureter to the uterosacral and infundibulopelvic ligaments reaffirms the need to identify them before dissection.

Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.

Laparoscopic vesicopsoas hitch for infiltrative ureteral endometriosis.

OBJECTIVE: To report the technique and outcome of a laparoscopic vesicopsoas hitch used for the treatment of infiltrative ureteral endometriosis. DESIGN: Case report. SETTING: A tertiary care center. PATIENT(S): A 36-year-old woman with infiltrative endometriosis of the ureter. INTERVENTION(S): A laparoscopic vesicopsoas hitch. MAIN OUTCOME MEASURE(S): The return of normal ureteral function as measured by IV pyelography and ultrasonography. RESULT(S): After partial ureteral resection, it was noted that a tension-free anastomosis to the bladder was not possible. Thus, a laparoscopic vesicopsoas hitch was performed. CONCLUSION(S): A vesicopsoas hitch can be performed successfully by laparoscopy.

Recurrence rate after laparoscopic myomectomy.

STUDY OBJECTIVE: To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION: Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

Laparoscopic treatment of type IV rectovaginal fistula.

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon's experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

Long-term outcome of laparoscopic presacral neurectomy for the treatment of central pelvic pain attributed to endometriosis.

OBJECTIVE: To evaluate the long-term pain reduction achieved by laparoscopic presacral neurectomy. METHODS: One hundred seventy-six women with median (range) age 30 (18-45) years underwent presacral neurectomy combined with excision and vaporization of endometriotic lesions and were observed, using structured questionnaires, for up to 72 months postoperatively. The study included a convenience sample of the first 100 questionnaires returned. Forty of the women were studied for 12-23 months, and 60 for 24-72 months. The main outcome measures were reduction of pelvic pain, dysmenorrhea, and dyspareunia after surgery. RESULTS: Pelvic pain, dysmenorrhea, and dyspareunia were reportedly reduced by more than 50% in 74, 61, and 55 patients, respectively, more than 12 months after laparoscopic presacral neurectomy. More than 50% reduction in pelvic pain was reported by 69.8%, 77.3%, 71.4%, and 84.6% of the patients, respectively, with endometriosis stages I-IV, using the revised classification of the American Fertility Society. Comparatively, more than 50% reduction in dysmenorrhea was reported by 52.8% of the patients with stage I endometriosis, 68.2% with stage II, 71.4% with stage III, and 69.2% with stage IV. Reduction of dyspareunia by more than 50% was reported by 54.7% of the patients with stage I endometriosis, 50.0% with stage II, 28.6% with stage III, and 61.5% with stage IV. CONCLUSION: Long-term outcome of laparoscopic presacral neurectomy is satisfactory in the majority of patients. The stage of endometriosis is not related directly to the degree of pain improvement achieved.

Laparoscopic appraisal of the anatomic relationship of the umbilicus to the aortic bifurcation.

STUDY OBJECTIVE: To determine the cephalocaudal relationship among the umbilicus, aortic bifurcation, and iliac vessels by direct measurement during laparoscopy. DESIGN: Prospective, consecutive study (Canadian Task Force classification II-1). SETTING: Tertiary referral center. PATIENTS: Ninety-seven women undergoing operative laparoscopy. INTERVENTIONS: The distance from the aortic bifurcation relative to the umbilicus was measured in both the supine and Trendelenburg positions with a marked suction-irrigator probe. Patients were stratified into three groups based on body mass index (kg/m2). The anatomic location of the common iliac vessels and course of the left common iliac vein were identified in 68 women. MEASUREMENTS AND MAIN RESULTS: The position of the aortic bifurcation ranged from 5 cm cephalad to 3 cm caudal to the umbilicus in the supine position, and from 3 cm cephalad to 3 cm caudal in the Trendelenburg position. In the supine position, the aortic bifurcation was located caudal to the umbilicus in only 11% of patients compared with 33% in the Trendelenburg position. This difference was statistically significant for the total study population (p <0.0001) and for the nonoverweight group (p <0.01). In both positions no significant correlation was found between the distance from the aortic bifurcation to the umbilicus and body mass index. Mean +/- SD distance of the aortic bifurcation from the umbilicus in the supine position was 0.1 +/- 1.2 cm for the nonoverweight group, 0.7 +/- 1.5 cm for the overweight group, and 1. 2 +/- 1.5 cm for the very overweight group. Respective values in Trendelenburg position were 1.0 +/- 1.1, -0.4 +/- 1.2, and -0.2 +/- 1.3 cm. The common iliac artery was caudal to the umbilicus in four women. The space between common iliac arteries was always at least partly occupied by the left common iliac vein, and was completely filled in 19 women (28%). CONCLUSIONS: The cephalocaudal relationship between the aortic bifurcation and umbilicus varies widely and is not related to body mass index in anesthetized patients. Regardless of body mass index, the aortic bifurcation is more likely to be located caudal to the umbilicus in the Trendelenburg compared with the supine position. Its presumed location can be misleading during Veress needle or primary cannula insertion, and a more reliable guide is necessary for this procedure to avoid major retroperitoneal vascular injury.

Laparoscopic management of pelvic pathology during pregnancy.

Advanced operative laparoscopy is being performed increasingly for various indications and in diverse patient populations, including gravid women. In the United States approximately 1.6% to 2.2% of pregnant women require nonobstetric surgery for abdominal and pelvic pathology. Increasing numbers of case reports suggest the feasibility and safety of operative laparoscopy during pregnancy. We identified certain management issues specific to these procedures based on our experience with nine cases of operative laparoscopy in women with gestations up to 22 weeks.

Major retroperitoneal vascular injury during laparoscopic surgery.

We sought to assess the outcome of large retroperitoneal vascular injury that occurred during operative laparoscopy but was not related to trocar or Veress needle injury. We conducted a retrospective review of cases operated and reviewed by our centres. Eight cases were identified. Four women were undergoing lymphadenectomy, where vascular injury is a recognized risk. Distorted anatomy was a compounding factor in three of the remaining four patients who were undergoing intraperitoneal procedures. The injuries involved the inferior vena cava (n = 2), the right external iliac artery (n = 2), the left external iliac artery (n = 1), the right external iliac vein (n = 1), the hypogastric artery (n = 1) and the inferior mesenteric artery (n = 1). Injuries were caused by unipolar electrode (n = 1), electrosurgical scissors (n = 3), sharp scissors (n = 2) and CO(2) laser (n = 2). The vessel injury was repaired at laparotomy in four women. The other four cases were managed laparoscopically. Transfusion attributable to the vascular injury occurred in two cases. The outcome in all cases was good, except for one in which the patient died. These cases demonstrate that all energy sources used without proper understanding and caution can cause significant vascular injury. The adequacy and safety of laparoscopic control of major vessel bleeding should be investigated further and consultation with a vascular surgeon should be considered in all cases.

Laparoscopy during pregnancy: a literature review.

OBJECTIVE: To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. MATERIALS AND METHODS: A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. RESULTS: The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes. CONCLUSIONS: Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.

Urinary tract endometriosis treated by laparoscopy.

OBJECTIVE: To evaluate the efficacy of the laparoscopic approach for the diagnosis and treatment of severe urinary tract endometriosis. DESIGN: Retrospective review of 28 cases of severe urinary tract endometriosis. SETTING: Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S): Between October 1989 and September 1994, we treated 28 women who had deeply infiltrating urinary tract endometriosis (bladder, 7, ureter, 21). INTERVENTION(S): All procedures were performed laparoscopically. MAIN OUTCOME MEASURE(S): Postoperative urinary function, pain relief, and complications. RESULT(S): Those who had vesical endometriosis underwent partial cystectomy and primary repair. Partial ureteral obstruction was found in 17 women; 10 underwent ureterolysis and excision of endometriosis, and 7 had partial wall resection. Four patients with ureter involvement had complete obstruction. Three underwent partial resection and ureteroureterostomy, and one had ureteroneocystostomy. The rate of ureteral endometriosis in the present series is higher than that reported previously. CONCLUSION(S): Severe infiltrative endometriosis of the bladder and the ureter can present without specific symptoms and can cause silent compromise of renal function. We demonstrated that the laparoscopic approach is safe and effective in the diagnosis and treatment of this entity.

Laparoscopic trachelectomy for persistent pelvic pain and endometriosis after supracervical hysterectomy.

OBJECTIVES: To discuss the safety of laparoscopic removal of the cervical stump after supracervical hysterectomy. DESIGN: Retrospective review of six cases. SETTING: Center for Special Pelvic Surgery, a tertiary referral center. PATIENT(S): Between August 1993 and December 1995, six patients underwent laparoscopic removal of the cervical stump. Their mean age was 43.1 years (range 32 to 56 years). All women had pelvic pain, and one had abnormal bleeding. Three patients had histories of severe endometriosis only, one had extensive endometriosis with adhesions, one had severe adhesions and leiomyomas, and one had all three conditions at hysterectomy. INTERVENTION(S): Laparoscopic trachelectomy. MAIN OUTCOME MEASURE(S): Laparoscopic findings and intraoperative and postoperative complications. RESULT(S): The mean blood loss was 100 mL (range 50 to 200 mL). There were no major intraoperative or postoperative complications. CONCLUSION(S): Cervical stump removal can be accomplished laparoscopically by an experienced surgeon.

Laparoscopic management of intentional and unintentional cystotomy.

PURPOSE: We assessed the laparoscopic closure of intentional or unintentional bladder lacerations during operative laparoscopy. MATERIALS AND METHODS: Retrospective review of operative reports revealed 19 women who required bladder repair. The defect was repaired laparoscopically in 1 layer using interrupted absorbable polyglycolic suture (17 patients) or polydioxanone suture (2) and followed by 7 to 14 days of transurethral drainage. RESULTS: Complications were limited to 1 vesicovaginal fistula that required reoperation. After 6 to 48 months of followup all patients were well with a good outcome. CONCLUSIONS: In select cases the bladder can be repaired safely and effectively during operative laparoscopy by an experienced laparoscopic surgeon.

A new method for laparoscopic access to the space of Retzius during retropubic cystourethropexy.

PURPOSE: We assessed the feasibility of a new technique for laparoscopic dissection of the space of Retzius. MATERIALS AND METHODS: In 10 women 40 to 70 years old (median age 45) undergoing laparoscopic retropubic cystourethropexy for stress urinary incontinence hydrodissection was used to create a pneumo-subperitoneal space. A suction irrigator probe was inserted into a mid peritoneal incision created with a 5 mm. trocar above the symphysis pubis between the 2 umbilical ligaments. The subperitoneal space was developed and insufflated with carbon dioxide without incising the peritoneum. RESULTS: All procedures were completed laparoscopically without intraoperative or postoperative complications. Operative time for cystourethropexy ranged from 30 to 70 minutes (median 40). Estimated blood loss ranged from less than 50 to 300 ml. (median 100). Patients were discharged from the hospital within 24 to 48 hours. All patients reported satisfactory relief of symptoms at 3 to 6 months of followup. CONCLUSIONS: The new technique is not difficult and may minimize tissue injury. Pneumosubperitoneal pressure provides clear exposure of the space of Retzius with minimal bleeding.