Compliance and complications of culdotomy.

BACKGROUND: Culdotomy is a practically exclusive appanage of gynaecological surgeons. Today the transvaginal access to pelvis and abdominal cavity is also utilized for non-gynecological surgery. METHODS: The authors report the complications and compliance of 326 culdotomies performed in the Simple Maternity Unit of Asiago Hospital (Asiago, Vicenza, Italy). The casuistry includes 18 adnexetomies, 90 ovarian cysts and fibroids enucleations and/or resections, 23 paraovarian cysts removals, 59 myomectomies, 120 sterilizations, 11 salpingectomies, 1 adesiolysis, 2 ovarian biopsies and 1 abscess drainage. RESULTS: Couldtomy showed to be a procedure with good results in terms of 18 grade 1 and 1 grade IV (5.8%) of Clavien-Dindo grading system for classification of surgical complications, the incidence of conversions in laparotomies, laparoscopies and vaginal hysterectomy (3.1%), the average hospital postoperatory admission (25 hours), low cost of culdotomy compared to laparotomic and laparoscopic surgery; absence of dispareunia and/or other discomforts at long term. CONCLUSIONS: Culdotomy is a simple, proper and alternative route, especially when morcellation is unavoidable.

Transvaginal hydrolaparoscopy.

Transvaginal hydrolaparoscopy (THL) is a modification of culdoscopy that can be used to evaluate the posterior uterus, pelvic sidewalls, and adnexae. Diagnostic THL can be done in the office under local anesthesia. Combined with diagnostic hysteroscopy and chromotubation, it can replace hysterosalpingography (HSG) as the first-line diagnostic test for the infertile woman. Studies have shown high patient tolerability with less pain reported postprocedure than with HSG. THL has been shown to have a high concordance with HSG for tubal patency, but THL diagnosed more intrauterine abnormalities as well as finding adhesions and endometriosis not visible with HSG. In addition, salpingoscopy may be performed during THL to assess the tubal lumen. THL also has a high concordance rate with laparoscopy when a complete evaluation is accomplished during THL. Complications of THL are uncommon and minor. Finally, operative procedures such as ovarian drilling, coagulation of endometriosis, lysis of adhesions, treatment of ovarian cysts, and salpingostomy may be performed via THL.

"People sometimes react funny if they're not told enough": women's views about the risks of diagnostic laparoscopy.

OBJECTIVES: To explore women's views about the risks and benefits of diagnostic laparoscopy in the investigation of chronic pelvic pain, including how much information it is thought appropriate to give about three specific risks: death, major complications and the chance that the procedure would have an inconclusive result. DESIGN: A qualitative analysis of semi-structured, audio-taped interviews with 20 women about their experiences of undergoing a diagnostic laparoscopy in a day surgery unit. Interviews were conducted 3-6 months after the procedure. RESULTS: All the women who were interviewed were aware that diagnostic laparoscopy carried risks, including the small risk of death associated with general anaesthesia. One-third of respondents said that they had initially been reluctant to discuss the risks of the procedure in general terms. However, when specific examples of complications and risks were introduced all but one of the respondents reported that they would have liked to discuss these at the time that the decision to have the operation was made. Women maintained that the information was needed to make an informed decision about whether to have the operation, to help them understand and cope should things go wrong and in order to make appropriate plans to cover contingencies. Most were surprised to hear that the procedure is frequently inconclusive and thought that this information should be made clear to women contemplating a laparoscopy. CONCLUSIONS: Women undergoing diagnostic laparoscopy for the investigation of chronic pelvic pain wish to be given full and accurate information about complication rates such as bowel perforation, what to expect during their recovery, and the chances of finding a cause for their pain. Although they may not want to dwell on the risk of death, they do need to be informed about the specific risks associated with the procedure in order to make a balanced decision.

Sonographic demonstration of air in the myometrium. A complication of culdocentesis.

Six cases are presented in which air was seen in the myometrium in the distribution of the arcuate vessels during sonography performed after culdocentesis to exclude ectopic pregnancy. Three of these patients had viable intrauterine pregnancies; the others had an incomplete abortion, a complete abortion, and a right ectopic pregnancy. This relatively rare complication of culdocentesis should be kept in mind, especially when scanning patients with suspected inflammatory process of the uterus, so as not to confuse air in the arcuate vessels with a uterine abscess.

Culdoscopy--useful or useless?

With the increased use of laparoscopy as a diagnostic method in gynecologic practice, the continued usefulness of culdoscopy has been questioned. The author presents his experience with 402 culdoscopies, listing indications, anesthesia used, results and complications. There was a 4.7% failure rate and a 1.7% complication rate. No permanent damage or death occurred.

Current status of hysteroscopy in gynecologic practice.

During the past century hysteroscopy has developed into a highly sophisticated and effective technique with increasing applicability. Hysteroscopic instruments have been refined with fiberoptics, allowing light to be introduced into the uterine cavity with high intensity but without danger of thermal injury. Safe methods for uterine distention provide an undistorted panoramic view of the uterine cavity. As a diagnostic technique, hysteroscopy affords accuracy in detecting intrauterine conditions which may not be revealed by traditional methods of exploration. As an operative technique, hysteroscopy increases the precision of surgery and minimizes trauma to the endometrial lining, and may, on some occasions, preclude major surgical intervention. In addition, hysterscopy is potentially useful for female sterilization and offers promise as an investigative tool for studies of the intratubal milieu.

Culdoscopic ligation as an outpatient procedure.

The increasing demand for abortion and sexual sterilization has caused the need to perform such operations on an outpatient basis. The University Department of Obstetrics and Gynaecology, Singapore, started a prospective study of culdoscopic ligation as an outpatient procedure in November, 1972. To date, over 600 operations have been performed. Analysis of the first 405 cases showed a low complication rate of 2.4 per cent. This study showed that culdoscopic ligation performed in the hospital outpatient is safe and feasible.

PIP: A prospective study of 116 inpatient and 289 outpatient culdoscopic tubal ligation sterilzations is presented. Visualization of the Fallopian tubes was hindered by bowel obstruction in 18 cases and by adhesions in 13 cases. The procedure could not be completed in 6 cases, 2 of which were due to anesthetic complications and 1 due to faulty technique. Postoperative complications involved 3 cases of salpingo-oophoritis. The operation is considered safe on an outpatient basis.

Operative culdoscopy.

A study of 257 operative culdoscopies done without general anaesthesia is presented and the advantages and limitations of the technique are detailed.

Female sterilization in current clinical practice.

PIP: The sterilization procedures most widely employed in the U.S. and newer methods which hold promise are reviewed. Abdominal Pomeroy tubal ligation, the most commonly used method, is usually done within 48 hours after delivery. A small incision ate. A knuckle of each fallopian tube is ligated and then resected. The cut ends of the tubes retract from each other when the suture absorbs and become sealed by a peritoneal covering. Local or general anesthesia may be used. nimally prolonged. Postoperative morbidity is 2-4% and a reported failure rate of less than 1%. Following Caesarean section, the Irving procedure is used most often. In this method the tubes are double ligated and bedded in the uterine musculature and the distal ends are buried beneath the broad ligament. As an interval procedure, the Pomeroy method or fimbriectomy may be done using the vaginal approach. Pelvic erus prevent this method from being used. igation is combined with first trimester abortion the morbidity is increased. Laparoscopy, culdoscopy, and hysteroscopy are recent advances. To use these methods, special training is needed and the required equipment is 2-puncture method and general anesthesia are preferred. An alternative to coagulation of the tubes is the application of clips. The new spring-loaded clips appear to be most promising. With culdoscopy each tube ligated, cut, and returned to its normal position. Tantalum clips may be used to occlude the tubes. This operation requires a good deal of time to learn but can be done as an outpatient procedure. Pelvic cult. Postoperative infection may follow in 2-10% of cases. In using the hysteroscopic technique, after dilatation of the cervix the hysteroscopic sleeve is introduced and the uterine cavity A cautery probe is introduced into each uterotubal junction and electrocoagulation done. Scar tissue later blocks the tubes. The equipment is expensive and special training is re are numerous contraindications to this method. Hysterectomy for sterilization is a drastic measure. Quinacrine hydrochloride instilled into the uterine cavity is 90% effective in preventing pregnancy. Other sclerosing agents cements, as gelatin-resorcinol-formilin have been used to promote tissue ingrowth to seal fallopian tubes. The choice of procedure for each woman varies according to her life situation and specific needs. seem to offer any advantages over the postpartum Pomeroy tubal ligation. Hysterotomy and tubal ligation are a combination which sometimes seems favorable. Counseling for sterilization is important and complications. problems.^ieng

Tubal pregnancy following application of tantalum clips at culdoscopy for sterilization.

PIP: In 1971, a 30-year-old woman underwent a culdoscopic tubal ligation with the application of tantalum clips. She was healthy on first examination and 3 weeks after the operation. Procedure included local anesthesia, meperidine and diazepam analgesia, Weck-Gutierrez clamp for delivering the fallopian tubes, and Weck Hemo-clips applied to the mid ampullae. The patient failed to appear for hysterosalpingogram after her first menses, but returned for abdominal complaint 7 months later. Eleven months after the operation she reported with 5 weeks of amenorrhea, followed 3 days later by cramps and bleeding. Pelvic exam, culdocentesis, and laparoscopy showed a mass in the left fimbria. Pathology revealed a slit lumen on the left, and flat epithelium, attenuated muscle layer bilaterally. The failure to obtain hysterosalpingography and to reveal incomplete occlusion of the tube in this case suggest a need for meticulous follow-up care. The role of epithelium and of muscularis in pregnancy is unclear.^ieng