Laparoscopy versus laparotomy in conservative surgical treatment for severe endometriosis.

OBJECTIVE: To determine the outcome of laparoscopy compared with laparotomy in conservative surgical treatment for severe endometriosis. DESIGN: Comparison of nonrandomized historical surgical series. SETTING: Two teaching hospitals and referral centers specializing in reparative and reconstructive surgery. PATIENT(S): A total of 216 patients operated for severe endometriosis during a 5-year period. INTERVENTION(S): Conservative surgical treatment at laparoscopy (n = 67) or laparotomy (n = 149) with median follow-up of 24 months. MAIN OUTCOME MEASURE(S): Cumulative probability of pregnancy in previously infertile patients (22 in the laparoscopy group and 70 in the laparotomy group) and cumulative probability of pain recurrence in subjects with moderate or severe symptoms before surgery (47 in the laparoscopy group and 108 in the laparotomy group). RESULT(S): The 24-month cumulative probability of pregnancy according to the Kaplan-Meier method was 44.9% after laparoscopy and 62.7% after laparotomy. The 24-month cumulative probability of symptoms recurrence evaluated with a 0 to 3 point verbal rating scale was, respectively, 16.4% versus 20.3% for dysmenorrhea, 33.3% versus 15.4% for deep dyspareunia, and 25.0% versus 15.9% for nonmenstrual pain. The corresponding figures obtained with a 10-point linear analogue scale were 20.3% versus 24.7%, 28.6% versus 10.4%, and 17.5% versus 20.1%. No difference is statistically significant. CONCLUSION(S): Laparoscopy and laparotomy seem equally effective in the treatment of infertility and chronic pelvic pain associated with severe endometriosis. However, a trend was observed toward a higher pregnancy rate and lower dyspareunia recurrence rate after surgery for severe endometriosis performed at laparotomy compared with laparoscopy.

[Infusion pre-hydration and a humid room in the prevention of postoperative adhesions]. / Preidratazione infusionale e camera umida nella profilassi delle aderenze postchirurgiche.

The Authors after an overview on the most important causes of postsurgical adhesions, drove their attention to the tissue injury determined, during abdominal surgery, by exposure of pelvic serosa to the humidity of operating area. The AA tested body temperature in the Douglas pouch and under the liver on 30 patients who were operated by conservative surgery (myomectomy) and on 8 patient who underwent laparoscopy. A decrease of one degree in the Douglas pouch after one hour on the patient who had a Pfannestiel incision has been detected. While on the patients with longitudinal laparotomy no difference was evidenced. Serosal biopsies done at the beginning of surgery after pelvis exposure to the external conditions (temperature, humidity) showed a marked phlogosis in the tissue of the patients not treated at all. These tissue injuries were almost absent in the group treated with saline tissue irrigation and absent in the group that had parenteral prehydration, too. The AA suggested the use of the two techniques in conservative surgery in order to obtain in the open abdomen surgery results similar to those of the endoscopic one.

Hypogastric vein ligation during oncologic surgery as thromboembolic disease prevention.

Pulmonary embolism and vein thrombosis are frequent and dangerous complications in pelvic surgery. They can be the cause of death in 0.01%-0.87%. The Authors have used, since 1973, as vein thrombosis prophilaxis (VTP): early mobilization, physiotherapy, elastic compressive stocking plus pharmacologic therapy. Since 1975, according to Heidrich and Thomas researches, they have also adopted hypogastric vein ligation (HVL) in high risk patients, because those Authors underlined a primitive responsibility of the hypogastric district (mainly the left one). The Authors mortality rate after the introduction of HVL seemed very low. However, since Jan. '86, they have divided the high risk patients in 3 group (R), in order to collect statistically significant data in the usefulness of the proposed technique.

Pathology of the uterine tubal junction.

First the Author reviews briefly the anatomy and the physiology of the Uterine-Tubal Junction (UTJ) with a main concern for the muscular pattern and the secretory activity of this part of the tube, in relation with the hormonal and nervous control. Speaking about the pathology of the UTJ that can impair fertility, different are the causes: chronic infections and their sequelae, salpingitis isthmica nodosa, polyps, iatrogenic lesions (mainly following sterilization procedures), congenital malformations. Other pathologies might be: ectopic pregnancies - 2.5% of all tubal pregnancies - and neoplasms even if not related to infertility. The therapy in most cases for restoring the continuity and hopefully the function of the tube is surgery through a microsurgical approach.