Minilaparoscopy-assisted natural orifice surgery.

BACKGROUND AND OBJECTIVES: New technology has allowed us to perform major abdominal and pelvic surgeries with increasingly smaller instruments. The ultimate goal is surgery with no visible scars. Until current technical limitations are overcome, minilaparoscopy-assisted natural orifice surgery (MANOS) provides a solution. The aim of this study was to examine our clinical and experimental experience with MANOS. METHOD: Minilaparoscopic abdominal instruments were used together with a large vaginal port, which was used for insufflation, visual purposes, introduction of operative instruments, and specimen extraction. Minilaparoscopy-assisted intraperitoneal transgastric appendectomy was done in simulators (Lap trainer with SimuVision, Simulab Corp., Seattle, WA). RESULTS: Since 1998, we have used this technique in 100 cases including ovarian cystectomies, oophorectomies, salpingo-oophorectomies, myomectomies, appendectomies, and cholecystectomies. Some oophorectomies were performed after vaginal hysterectomy in cases where vaginal extraction was not possible. In this case series, we had only one complication, a case of postoperative fever after an ovarian cystectomy, which was diagnosed as drug-related fever. Our limited simulator experience showed that MANOS is a feasible technique for performing transgastric appendectomies. CONCLUSION: It may take several years for natural orifice surgery to become standard care. Meanwhile, MANOS could encourage and expedite this process.

Does ICSI require acrosomal disruption? An ultrastructural study.

BACKGROUND: Aggressive immobilization of sperm prior to ICSI significantly improves fertilization rates, but the mechanism of this effect is not yet clear. This study was performed in order to assess the characteristics of mechanically immobilized human sperm by transmission electron microscope (TEM). METHODS: Sperm obtained from ejaculated semen samples from three different donors were immobilized in a standard manner for ICSI. They were then injected into the perivitelline space of mouse oocytes in order to be able to locate them by TEM. Intact motile sperm injected subzonally served as controls (n=160). Finally, the 'carrier' oocytes were fixed and processed for TEM. RESULTS: A total of 300 sperm were mechanically immobilized and inserted into the perivitelline space of mouse oocytes. Ultrathin sections revealed consistent alterations in the acrosomal region including disruption of the plasma membrane, and disruption, vesiculation or even loss of the acrosome. Thus, all of the sperm assessed had undergone some disorganization of the head, in contrast to a majority of control sperm. CONCLUSIONS: Immobilization of sperm for ICSI by compressing and rolling the sperm tails induces a variable disruption and sometimes loss of the acrosome. This could well be a reason for the higher success rates when ICSI is performed using immobilized sperm.

Culdolaparoscopic oophorectomy with vaginal hysterectomy: an optional minimal-access surgical technique.

BACKGROUND AND PURPOSE: Oophorectomy during vaginal hysterectomy may be difficult or impossible when the ovaries lie high in the pelvis or when adhesions are present. A new technique of culdolaparoscopic oophorectomy during vaginal hysterectomy is described. PATIENTS AND METHODS: After the uterus is removed, a 12-mm cannula is introduced into the culde-sac, and a pneumoperitoneum is created. A 10-mm telescope is inserted through the vaginal port, and, under culdoscopic surveillance, two or three 3-mm abdominal ports are placed. The 10-mm telescope is removed, and a minilaparoscope is introduced through one of the abdominal cannulas. Oophorectomy is performed with a coagulator and scissors introduced via the vaginal port, and the ovaries are extracted through the vaginal cannula. Eight patients with pelvic adhesions found at the time of vaginal hysterectomy underwent culdolaparoscopic oophorectomy. RESULTS: The procedure lasted between 28 minutes and 45 minutes, including adhesiolysis, removal of an enlarged ovary, and a liver biopsy. No complications occurred in any of the patients. CONCLUSION: Culdolaparoscopic oophorectomy is a simple minimal-access surgical technique for removing the ovaries when these are not easily accessible at vaginal hysterectomy.

Chromosome analysis of epididymal and testicular sperm in azoospermic patients undergoing ICSI.

BACKGROUND: Although ICSI provides a way of treating azoospermic men, concern has been raised about the potential risk for transmission of genetic abnormalities to the offspring. We quantified the incidence of chromosomal abnormalities in epididymal and testicular sperm retrieved from azoospermic patients undergoing ICSI. METHODS: Individual testicular sperm were collected from testicular biopsies with an ICSI pipette, and epididymal sperm were retrieved by microsurgical epididymal sperm aspiration. Samples were processed by fluorescent in-situ hybridization (FISH) for chromosomes 18, 21, X and Y and the results compared with those from normal ejaculated samples. RESULTS: The overall aneuploidy rate of 11.4% in men with non-obstructive azoospermia was significantly higher (P = 0.0001) than the 1.8% detected in epididymal sperm from men with obstructive azoospermia and also the 1.5% found in ejaculated sperm. No significant difference was found between the epididymal and ejaculated samples. When the chromosomal abnormalities were analysed, gonosomal disomy was the most recurrent abnormality in both obstructive and non-obstructive azoospermic patients, while autosomal disomy was the most frequent in ejaculated sperm. CONCLUSIONS: Sperm of non-obstructive azoospermic men had a higher incidence of chromosomal abnormalities, of which sex chromosome aneuploidy was the most predominant. Genetic counselling should be offered to all couples considering infertility treatment by ICSI with testicular sperm.