Major Vessel Injury During Advanced Laparoscopic Surgery

Eight cases of large vessel laceration occurred during operative laparoscopy, but were not related to cannula or Veress needle injury. Four injuries were managed at laparoscopy. One patient was operated on by us. We reviewed four cases for colleagues, and the remainder were subject to litigation. Four women were undergoing lymph node dissection and three others had endometriosis or adhesions that obliterated the normal anatomy. The injury involved the inferior vena cava in two women, the right external iliac artery in four, and the left hypogastric and inferior mesenteric artery in one woman each. Vascular lacerations were caused by unipolar electrosurgery in two patients and by the carbon dioxide laser in two. In the remaining four women the injury to the artery or vein occurred during sharp dissection. The vessel injury was repaired by the conventional open technique in four women. The other four were managed laparoscopically, two by applying metal clips on the vessel wall and one with bipolar electrocoagulation. The outcome in all patients was good except for one, who died.

Long-Term Outcome of Laparoscopic Adhesiolysis in Women with Chronic Pelvic Pain after Hysterectomy

The management of severe small and large bowel adhesions in patients suffering from chronic pelvic pain after undergoing hysterectomy remains highly challenging. A cohort of 48 women (median age 41 yrs, range 26-59 yrs) with chronic pelvic pain had severe bowel adhesions. Forty-two had undergone a total abdominal hysterectomy (27 with bilateral, 7 with unilateral salpingo-oophorectomy), five a vaginal hysterectomy (4 with bilateral salpingo-oophorectomy), and one a laparoscopic hysterectomy. After laparoscopic adhesiolysis, 23 patients were followed for up to 24 months, 23 for 48 to 60 months, and 2 were lost to follow-up. Three intraoperative complications (6.2%) were one ileus, which required a 2-day hospital admission, one pelvic abscess requiring readmission and second-look laparoscopy, and one episode of urinary retention requiring a 1-day readmission. Of the 23 women followed for more than 24 months, 11 (47.8%) required from one to three subsequent surgeries. Complete pain relief was reported by 10 (43.5%) women, 8 of whom did not require further surgery. Twelve (57.1%) of the 21 patients followed for 6 to 12 months reported complete pain relief. Laparoscopic adhesiolysis achieved complete pain relief in approximately half of the women.

Is Carbon Monoxide Poisoning a Risk During Prolonged Laparoscopic Surgery?

We evaluated whether prolonged laparoscopic procedures performed with high-flow carbon dioxide (CO2) insufflation, intensive evacuation of intraabdominal smoke, and controlled hyperventilation with 50% to 90% oxygen results in significant elevation in blood carboxyhemoglobin levels. Twenty-seven healthy, nonsmoking women (mean ± SD age 39.1 ± 8.0 yrs, range 22-56 yrs) undergoing laparoscopic procedures in which smoke was generated participated. In all cases both the CO2 laser and bipolar electrosurgery were used extensively. The mean ± SD duration of surgery was 141 ± 72 minutes (range 45-300 min). Blood samples were drawn before and after surgery. Carboxyhemoglobin concentrations were measured using a highly accurate gas chromatography method. The mean ± SD carboxyhemoglobin levels were 0.70% ± 0.15% (range 0.44-1.20%) before and 0.58% ± 0.20% (range 0.30-1.33%) after surgery. The concentrations decreased significantly during surgery (mean ± SD 20% ± 11%, range 3-46%, p <0.001). In only one woman the level increased at the end of surgery. This also occurred when levels exceeded 1% (1.33%). The correlation coefficient (r) between carboxyhemoglobin concentrations and duration of surgery was 0.324. We concluded that carbon monoxide poisoning is not associated with prolonged laparoscopic surgical procedures. This may be attributed to aggressive smoke evacuation that minimized exposure and to elimination of CO2 through hyperventilation.

Removal of Adnexal Masses by Operative Laparoscopy During Pregnancy

We evaluated the outcomes of pregnancies in nine women who underwent removal of an adnexal mass by operative laparoscopy during pregnancy. These patients, who would otherwise have undergone exploratory laparotomy, were treated by diagnostic and operative laparoscopy using the carbon dioxide laser and electrocoagulation. Gestational ages ranged from 12 to 22 weeks (mean 15 wks). Indications for the surgery were persistent complex or enlarged adnexal mass (7), painful adnexal mass (1), and acute abdomen and intraabdominal hemorrhage (1). Procedures performed were ovarian cystectomy (7), paratubal cyst removal (1), and evacuation of pelvic hematoma (1). Operating time ranged from 55 to 150 minutes (mean 101 min). Peritoneal washings were always obtained. No tocolytics were used during or after surgery. Normal fetal heart tones were auscultated postoperatively in the recovery room. There were no complications secondary to the surgery. Six women delivered at term with weight appropriate for gestational age (AGA). One patient had premature rupture of membranes at 31 weeks' with delivery of a viable AGA infant by emergency cesarean section. Two patients' pregnancies at 26 and 29 weeks are progressing normally. Operative laparoscopy for certain pelvic pathology may be performed safely with no complications to the pregnancy.

Laparoscopic Management of Genitourinary Endometriosis

We treated 17 patients with severe endometriosis involving the genitourinary tract. Eight women presented with persistent right or left flank pain, two presented with known ureteral obstruction, and five presented with urinary frequency and burning, and/or hematuria with their periods. Presented are the results of laparoscopic management in these patients. We performed segmental bladder resection in six patients and ureteral resection and reanastomosis in two. Nine additional patients underwent partial resection of the ureteral wall for complete removal of endometrial implants. The ureter was repaired with 4-0 PDS in seven patients and a stent was left in place for 4 to 6 weeks. Two required only a stent due to the small size of the ureterotomy. The postoperative course of these patients was uneventful. Following ureteral repair/reanastomosis, all women underwent an intravenous pyelogram at follow-up, and normal bilateral excretion was demonstrated. Cystoscopy revealed no abnormal findings in five patients who had undergone partial bladder resection. All patients reported significant pain relief or complete resolution of symptoms. Operative laparoscopy can be safely used to achieve relief from severe symptomatic endometriosis of the genitourinary tract.

Is Hormonal Suppression Efficacious in Treating Functional Ovarian Cysts?

We randomly assigned 95 women, age 17-55 (mean 36.5) with unilateral or bilateral ovarian cysts measuring 1.1 to 6.1 cm in greatest diameter, to four groups to determine the efficacy of hormonal suppression. Eleven did not complete the study, and 9 did not follow up, for a study population of 75. Of these 75, 29 women had a history of endometriosis and 12 were treated with ovulation induction within 6 months of inclusion. Group I (24), received no treatment and served as a control; Group II (15) took oral contraceptives (OCP) containing 35 &mgr;g ethinyl estradiol and 1 mg norethindrone; Group III (23) received OCP's with 50 &mgr;g ethinyl estradiol and 1 mg norethindrone; and Group IV (13) took danazol 800 mg/day. All medications were taken continuously for 6 weeks. Patients were then re-evaluated by pelvic examination and transvaginal ultrasound. If the cysts persisted, the patient was scheduled for diagnostic and possible operative laparoscopy. Complete resolution of cysts was found in: Group I - 14 (58%), Group II - 6 (40%), Group III - 15 (65%), and Group IV - 7 (54%). Of the 33 women with persistent cysts, 28 underwent videolaparoscopy. The results were as follows: Group I (42%) - five functional, two endometriomas, one hydrosalpinx, and one benign paraovarian serous cyst; Group II (60%) - three functional, one endometrioma, and one benign simple cyst; Group III (35%) - two functional, five endometriomas, and one loop of bowel; and Group IV (46%) - four functional and two endometriomas. The results, analyzed using the chi2 test, indicated that there is no significant difference between expectant management and hormonal suppression in treating functional ovarian cysts. A CA 125 was obtained on 48 women. Using the t-test, we compared values for cysts which persisted and those which did not. There was no correlation between CA 125 levels and persistence or resolution.