Natural orifice transluminal endoscopic surgery (NOTES) subtotal hysterectomy: A feasibility study.

OBJECTIVE: Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES) has been carried out for benign uterine diseases and nonprolapsed uteri in recent years. Subtotal hysterectomy was performed to remove the uterus with preservation of the cervix by abdominal, laparoscopic, or vaginal routes. The aim of this retrospective study is to gain insight into the feasibility and safety of subtotal hysterectomy through transvaginal NOTES. MATERIALS AND METHODS: This is the first case series study to describe the technique and to evaluate the feasibility of this innovative surgical procedure. 10 patients were recruited and underwent NOTES subtotal hysterectomy within one-year duration. RESULTS: The mean operative time was 106.7 ± 40.0 min with a mean blood loss of 250.0 ± 120.2 mL. The mean weight of specimen retrieved was 452.2 ± 227.8 g (range 195 g-905 g). None of these patients sustained injury to surrounding structures or major blood vessels during the surgery. Five patients required analgesia during the first 24 h post-surgery. Post-operative hospital stay ranged from 2 to 3 days. No patients complained of surgical complications at 1, 3, and 6 months follow-up. All patients recovered uneventfully and carried on daily activities without difficulty. CONCLUSION: This study confirms the feasibility and safety of NOTES subtotal hysterectomy.

The Power Law of Learning in Transumbilical Single-Port Laparoscopic Subtotal Hysterectomy.

STUDY OBJECTIVE: To analyze the surgical outcomes and learning curve of transumbilical single-port laparoscopic subtotal hysterectomy, which requires sutures of the cervical stump. DESIGN: A prospective observational study (Canadian Task Force classification II-2). SETTING: A university-affiliated center. PATIENTS: From the first (July 2012) and consecutive patients of benign uterine disease scheduled for subtotal hysterectomy until October 2013. INTERVENTIONS: All single-port laparoscopies were performed using straight instruments by 1 gynecologist. An ancillary port was added whenever technical difficulties could endanger surgical quality. MEASUREMENT AND MAIN RESULTS: Seventy-five patients were recruited for intention-to-treat analysis with a mean (±SD) age of 44.7 ± 3.8 years and a body mass index of 24.2 ± 3.7 kg/m2. No major complication was noted. The mean uterine weight was 432.5 ± 344.0 g with 24 (32%) uteri ≧500 g. The patients' sequential order, or gradually increasing experience, was the determining factor in progressively decreasing operative time. Furthermore, most cases that required an additional ancillary port (67%) were clustered in the first 20 cases, whereas 4 were scattered after the 47th patient because of severe pelvic adhesion. The mean operative time decreased in the power law function of the patients' sequential order with a plateau achieved at the 20th patient. CONCLUSION: The patients' sequential order was identified as an independent factor of achieving purely single-port access, and the trend of decreasing operative time delineated the existence of a learning curve. Approximately 20 patients were needed for an experienced multiport laparoscopist to reach technical competency in the current series.

Massively parallel sequencing and genome-wide copy number analysis revealed a clonal relationship in benign metastasizing leiomyoma.

Benign metastasizing leiomyoma (BML) is a rare disease entity typically presenting as multiple extrauterine leiomyomas associated with a uterine leiomyoma. It has been hypothesized that the extrauterine leiomyomata represent distant metastasis of the uterine leiomyoma. To date, the only molecular evidence supporting this hypothesis was derived from clonality analyses based on X-chromosome inactivation assays. Here, we sought to address this issue by examining paired specimens of synchronous pulmonary and uterine leiomyomata from three patients using targeted massively parallel sequencing and molecular inversion probe array analysis for detecting somatic mutations and copy number aberrations. We detected identical non-hot-spot somatic mutations and similar patterns of copy number aberrations (CNAs) in paired pulmonary and uterine leiomyomata from two patients, indicating the clonal relationship between pulmonary and uterine leiomyomata. In addition to loss of chromosome 22q found in the literature, we identified additional recurrent CNAs including losses of chromosome 3q and 11q. In conclusion, our findings of the clonal relationship between synchronous pulmonary and uterine leiomyomas support the hypothesis that BML represents a condition wherein a uterine leiomyoma disseminates to distant extrauterine locations.

Subtotal hysterectomy by natural orifice transluminal endoscopic surgery.

STUDY OBJECTIVE: To introduce the innovative surgical procedure of treating benign uterine pathology with subtotal hysterectomy by natural orifice transluminal endoscopic surgery (NOTES). DESIGN: Prospective observational study. SETTING: Tertiary referral medical center. METHODS: From June 2014 to May 2016, three patients with benign uterine diseases who were eligible for laparoscopic subtotal hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. RESULTS: Subtotal hysterectomy by transvaginal NOTES was successfully completed in all patients without any conversion to conventional laparoscopy. The operative time was 144 ± 4.5 (138-149) minutes with an average estimated blood loss of 133 ± 62 (50-200) mL. None of the patients required an intraoperative blood transfusion. The mean specimen weight was 140 ± 59 (56-188) g. The final histology reports were uterine leiomyoma and adenomyosis in these three cases. There were no intraoperative or postoperative complications. No case required intraoperative or postoperative blood transfusion. No cases were converted to traditional laparoscopy or laparotomy. CONCLUSION: Our preliminary results showed the safety and feasibility of subtotal hysterectomy by transvaginal NOTES in selected patients. It is one of the most minimally invasive surgeries and results in invisible scars.

Accuracy of hysteroscopic biopsy, compared to dilation and curettage, as a predictor of final pathology in patients with endometrial cancer.

OBJECTIVE: To compare the methods of transcervical resectoscopy versus dilation and curettage (D&C) for endometrial biopsy and to compare these methods for the percentage of histological upgrades at the final posthysterectomy pathology findings in endometrial cancer. MATERIALS AND METHODS: We retrospectively reviewed 253 cases of uterine cancer diagnosed from May 1995 to January 2014. Included in the study were patients who received transcervical resectoscopy (TCR) or D&C biopsy as the diagnostic method and underwent laparoscopic staging at our institution. The International Federation of Gynecologists and Obstetricians (FIGO) grade in the pathological report of the biopsy and final hysterectomy were recorded. The extrauterine risk was stratified using the initial FIGO grade and depth of myometrium invasion. It was compared to the actual risk using final pathological findings. RESULTS: We identified 203 cases of endometrial cancer; 18 (8.9%) patients had a higher histological grade at the final hysterectomy. Among the 203 patients, 76 patients underwent TCR biopsy and 127 underwent D&C biopsy. The histological grade was upgraded in two (2.6%) patients in the TCR group. Three (3.9%) patients had positive peritoneal washings. In the D&C group, 16 (12.6%) patients with three (2.4%) positive peritoneal washings were upgraded. CONCLUSION: Transcervical resectoscopy could provide more precise grading information, compared to D&C (2.6% vs. 12.6%). Doctors could therefore make a more accurate staging plan, based on the preoperative risk evaluation.

Robot-assisted natural orifice transluminal endoscopic surgery for hysterectomy.

OBJECTIVE: To describe the surgical procedures of robot-assisted natural orifice transluminal endoscopic surgery (NOTES) for hysterectomy and to evaluate its feasibility. MATERIALS AND METHODS: From December 2014 to February 2015, four patients with benign diseases who were eligible for robot-assisted NOTES at Chang Gung Memorial Hospital were recruited to this study. Intraoperative and postoperative surgical outcomes were evaluated. RESULTS: Robot-assisted NOTES hysterectomy was successfully performed in all these patients. None of the patients had vaginal delivery, with two being nulliparous. The mean ± standard error of the mean uterine weight was 365.5 ± 69.2 g, the mean operative time was 198.8 ± 39.0 minutes, the mean docking time was 38.3 ± 2.4 minutes, the mean blood loss was 180.0 ± 56.1 mL, and the mean postoperative hospital stay was 2.5 ± 0.3 days. The final pathologic diagnoses were adenomyosis and/or leiomyomas. CONCLUSION: The novel robot-assisted NOTES technology created scarless skin wounds. More importantly, the device allows the surgeon to reach deeper places to achieve hemostasis, and perform surgery on larger tumors using the curved cannulae-wristed instrument. However, its implementation is limited by the lack of appropriate instrumentation, which requires further development and break through. At this stage, robot-assisted NOTES is only useful for limited applications in highly selected patients.

Accessibility and surgical outcomes of transumbilical single-port laparoscopy using straight instruments for hysterectomy in difficult conditions.

OBJECTIVES: To evaluate the accessibility of transumbilical single-port laparoscopy for hysterectomy in difficult conditions. MATERIALS AND METHODS: This prospective observational study recruited patients with benign diseases who were scheduled for laparoscopic hysterectomy between March 2010 and October 2011 to undergo the transumbilical single-port approach with straight instruments and a laparoscope. RESULTS: In total, 109 patients were included with a mean [± standard error of the mean (SEM)] age of 45.9 ± 0.4 years and mean body mass index of 23.9 ± 0.3 kg/m(2). The yielded mean uterine weight was 403.4 ± 25.3 g, with 28 (25.7%) weighing ≥500 g, including four specimens >1000 g, and 44 (40.4%) needed concurrent adhesiolysis. The operative time was 117.2 ± 4.2 minutes, estimated blood loss was 270.3 ± 22.9 mL, and the postoperative hospital stay was 2.8 ± 0.1 days. Patients with a uterus weighing ≥500 g had a higher intraoperative blood loss in comparison with those with a uterus weighing <500 g (375.4 ± 55.3 mL vs. 234.0 ± 23.0 mL; p < 0.05) and a higher incidence of blood transfusion (17.9% and 6.2%, respectively). The single-port approach was abandoned in four (3.7%) patients with severe pelvic adhesion--an additional port was opened for extensive adhesiolysis. None of the patients with a voluminous uterus needed an additional port. There were no major intraoperative or postoperative complications. CONCLUSION: The single-port approach using straight, conventional laparoscopic instruments was feasible and safe in the majority of the patients undergoing hysterectomy, and was found to be accessible even in cases with a large uterus. The patients benefitted from this approach and had less abdominal wounds. However, patients with a voluminous uterus tended to have more intraoperative blood loss, and in some cases with severe adhesions, additional port(s) were required for surgical effectiveness.

Laparoendoscopic single-site herniorrhaphy after gynecologic surgery.

BACKGROUND AND OBJECTIVES: Increased interest in laparoendoscopic single-site surgery has instigated research into trials of novel techniques. The procedure we propose may potentially improve patient satisfaction and cosmetic results while diminishing the incidence of trocar-site herniation. We report our initial experience with laparoendoscopic single-site totally extraperitoneal herniorrhaphy for postoperative incisional hernia to determine the procedure's feasibility and safety. METHODS: Three patients with incisional hernias after gynecologic surgery underwent laparoendoscopic single-site totally extraperitoneal procedures. We evaluated the patients' preoperative and postoperative condition, as well as the details of their original surgery. We performed the procedure through a 2-cm umbilical incision followed by mesh insertion and transabdominal suture placement in all patients. RESULTS: Laparoendoscopic single-site totally extraperitoneal herniorrhaphy was completed in 80 to 120 minutes. No intraoperative complications were encountered, and surgical blood loss was minimal. The duration of hospital stay ranged from 2 to 4 days. One patient had a postoperative wound infection. The patients have shown no sign of recurrence at 9 months' follow-up. CONCLUSION: Laparoendoscopic single-site totally extraperitoneal herniorrhaphy appears to be feasible and safe. It may be performed with readily available instruments, although further experience and practice are warranted for a more efficient repair. The procedure has similar advantages to a multiport laparoscopic totally extraperitoneal procedure but yields better cosmetic results. More studies are needed to assess the long-term benefits and complications of this procedure.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery (NOTES): a series of 137 patients.

STUDY OBJECTIVE: To evaluate the feasibility and safety of hysterectomy in benign disease using transvaginal natural orifice transluminal endoscopic surgery (NOTES). DESIGN: Prospective observational study (Canadian Task Force classification II-3). SETTING: Tertiary referral medical center. PATIENTS: From May 2010 to August 2011, consecutive patients who were scheduled to undergo laparoscopic hysterectomy and without virginity or suspected pelvic inflammation or cul-de-sac obliteration were included. INTERVENTION: Total hysterectomy via transvaginal NOTES. MEASUREMENTS AND MAIN RESULTS: The study included 137 patients, with mean (SEM) age 46.0 (0.4) years and body mass index 24.7 (0.4). Transvaginal NOTES was successfully performed in 130 patients (94.9%). Fifteen patients underwent concurrent adhesiolysis, and 17 underwent adnexal procedures. Mean (SEM) uterine weight was 450.0 (24.1) g; in 45 patients (34.6%), uterine weight was >500 g, and in 7 (5.4%) it was >1000 g. Operative time was 88.2 (4.1) minutes, with blood loss of 257.7 (23.9) mL. In 2 patients there was intraoperative hemorrhage or unintended cystotomy, and in another 5 transvaginal colpotomy failed because of a narrow vagina, cul-de-sac obliteration by bowel adhesions, or mass obstruction. Complications in these 7 patients (5.1%) were successfully managed via transabdominal laparoscopy. Five patients (3.6%) experienced postoperative urinary retention or febrile morbidity, and recovered uneventfully with conservative treatment. CONCLUSION: Transvaginal NOTES is a feasible technique for performance of hysterectomy and can be used in procedures that are difficult to complete via conventional vaginal surgery because posterior colpotomy is achievable. This procedure was not impeded by uterine volume, and had the advantage of no abdominal incision.

Early detection and minimally invasive management of intramural pregnancy.

Intramural pregnancy is a rare form of ectopic pregnancy, wherein the fetus is implanted within the myometrium, separate from the endometrial cavity. In the early reported cases, a diagnosis was only possible after an operation for uterine rupture; however, recent developments in ultrasonography and magnetic resonance imaging assist in early diagnosis. Early diagnosis prevents potential life-threatening hemorrhage and preserves fertility. Both medical therapy and surgery are used to treat intramural pregnancy: surgery is often performed via laparotomy and includes hysterectomy. Here, we report the first case of successfully combining hysteroscopy and laparoscopy in the early diagnosis and management of intramural pregnancy. Our experience reveals that the minimally invasive procedure is safe and effective in select cases where advanced endoscopic expertise is available.

Single-port laparoscopic myomectomy: initial operative experience and comparative outcome.

OBJECTIVE: To present the initial operative outcome and comparative data among patients undergoing single-port laparoscopic myomectomy (SPLM). MATERIALS AND METHODS: A prospective, observational study of all patients who underwent SPLM was performed. The demographic and operative data, including age, body mass index, operative indications, operative time, estimated blood loss, complications, and postoperative hospital stay were recorded. A match cohort of patients undergoing traditional LM was also retrospectively compared. RESULTS: SPLM was successfully performed in all ten patients from April 2010 to October 2010. The two groups (SPLM and traditional LM) were matched by age, body mass index, size, and weight of fibroids. The median operating time (196.5 vs. 82.5 min, P < 0.001) and length of hospitalization (3 vs. 2 days, P = 0.042) were significantly longer in SPLM group than in traditional LM group. The median operative blood loss was not significantly different. No patients in either group had serious complications. CONCLUSION: Despite the increased operating time, SPLM is feasible and offers comparable surgical outcomes and superior cosmesis compared with traditional LM.

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (NOTES): feasibility of an innovative approach.

OBJECTIVE: To evaluate the feasibility and safety of performing a hysterectomy using the transvaginal natural orifice transluminal endoscopic surgery (NOTES). MATERIALS AND METHODS: From May through December 2010, 16 patients with benign uterine diseases who were eligible for laparoscopic hysterectomy were recruited to undergo transvaginal NOTES at a tertiary referral medical center. Intraoperative and postoperative surgical outcomes were measured. RESULTS: All of the included hysterectomies were completed via transvaginal NOTES without conversion to conventional laparoscopy. The mean (± standard error of mean (SEM)) uterine weight was 538.8±102.9 g, the mean operative time was 122.7±17.6 minutes, and the mean blood loss was 379.4±95.4 mL. The mean postoperative hospital stay was 2.8±0.2 days. No intraoperative or postoperative complications were noted in this series. CONCLUSION: Hysterectomy for the treatment of benign diseases can be feasibly carried out via transvaginal NOTES. However, prospective studies are needed to determine its full clinical applications.

Pierce and push: a simplified method to facilitate laparoscopic myomectomy.

BACKGROUND: The aim of this study was to present our experience with a novel approach called the pierce and push (PP) method which uses a stainless steel centimeter probe instead of a 5 mm claw forceps to enucleate fibroids in a laparoscopic myomectomy (LM). METHODS: A retrospective chart review of 90 women with symptomatic uterine fibroids who underwent an LM was performed. Cases of LM with the PP method were compared with a matched control group of LM with a 5 mm claw forceps. The operative time, tumor separation time, specimen removal time, amount of blood loss, requirement for blood transfusion and length of hospital stay were compared between groups. RESULTS: The two groups were matched by age, body mass index, previous cesarean delivery, main fibroid size, and number and weight of fibroids. The tumor separation time was significantly shorter in the PP group than the claw forceps group (9.7 ± 3.1 minutes versus 17.1 ± 4.4 minutes, p < 0.001). The length of the operation, hospitalization time, specimen removal time, amount of blood loss, and requirement for blood transfusion were not significantly different between groups. CONCLUSION: A stainless steel centimeter probe has an advantage over a 5 mm claw forceps in pushing and pulling fibroids. Our findings indicate that the PP method was much more effective in excision of fibroids than a 5 mm claw grasper in LM.

Outcome of laparoscopic repair of ureteral injury: follow-up of twelve cases.

STUDY OBJECTIVE: To review the feasibility of laparoscopic repair in cases of ureteral injuries occurring during gynecologic laparoscopy. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Institution-specific retrospective review of data from a tertiary referral medical center. PATIENTS: Patients suffering from iatrogenic ureteral injuries diagnosed during or after surgery, and cases with deliberate ureteral resection and repair because of underlying disease. MEASUREMENTS AND MAIN RESULTS: We conducted a retrospective review of all (10 345) laparoscopic gynecologic surgeries performed in our institute between February 2004 and November 2008. Twelve cases (median: 45.5 years, range: 27-63) of ureter transections were diagnosed and repaired laparoscopically by endoscopists. Of these, 10 had previous surgeries, pelvic adhesions, or a large pelvic-abdominal mass. One patient had undergone a segmental resection and laparoscopic ureteroureterostomy for deep infiltrative endometriosis. Of the remaining 11 iatrogenic ureteral transections, 10 were repaired via laparoscopic ureteroureterostomy, whereas 1 had undergone a laparoscopic ureteroneocystostomy. One injury was recognized on the second postoperative day, but intraoperative recognition was attained in 11 cases. The median duration of double J stenting was 73 days. Three patients had development of strictures (between 42 and 79 days after surgery) treated with restenting, but 1 had to undergo an ureteroneocystostomy for ureter disruption when trying to restent. One patient had development of leakage of the anastomotic site but recovered with a change of the double J stent. Only 1 case required another laparotomy for ureteroneocystostomy. Laparoscopic primary repair of ureteral injury was successful for 11 of 12 patients. All the patients were well and symptom free at the conclusion of the study period. CONCLUSION: Early recognition and treatment of ureteral injuries are important to prevent morbidity. Laparoscopic ureteroureterostomy could be considered in transections of the ureter where technical expertise is available. To the best of our knowledge, this is the largest series, to date, of ureteral repairs via laparoscopy.

Comparison of the efficacy of the pulsed bipolar system and conventional electrosurgery in laparoscopic myomectomy - a retrospective matched control study.

OBJECTIVE: Comparing the safety and effectiveness of the pulsed bipolar (PK) system and conventional electrosurgery in laparoscopic myomectomy (LM). MATERIALS AND METHODS: Retrospective chart review of 194 women with symptomatic uterine fibroids undertaken LM was performed. Cases of LMs with PK cutting forceps were compared with a matched control group of standard LMs with conventional electrosurgery. Outcome measures for both groups were studied comparatively in terms of the length of operative time, amount of blood loss, requirement of blood transfusion and length of hospital stay. RESULTS: The two groups were matched by age, body mass index, parity, previous cesarean delivery, size, number, and weight of fibroids. Amount of blood loss was significantly greater in electrosurgery group than in PK group at 243.8 ± 150.4mL versus 190.4 ± 178.5mL (p=0.025). Length of operation, hospitalization time, hemoglobin decrease, and requirement of blood transfusion were not significantly different. CONCLUSION: Our findings indicate that PK system is more effective in LM when compared with conventional electrosurgery. PK system has advantage over conventional electrosurgery in less blood loss and may offer an alternative option for patients undergoing LM.

Robot-assisted laparoscopic staging surgery for endometrial cancer--a preliminary report.

OBJECTIVE: The robotic surgical system is reported to overcome some technical difficulties in traditional laparoscopic hysterectomy. This study aimed to evaluate the feasibility and surgical outcomes of a robotic surgery program for endometrial cancer. MATERIALS AND METHODS: Patients with endometrial cancer with the intention to receive treatment using robot-assisted laparoscopic staging surgery were recruited in a university hospital from July 2007 to August 2008. All of these surgeries were performed with the da Vinci system. RESULTS: Six patients (mean age, 47.5 ±1.4 years; mean body mass index, 26.2 ±3.5 kg/m(2)) were enrolled and completed robot-assisted laparoscopic staging surgery. The robot docking time was 45.0 ±13.6 minutes and the robot-assisted operation time was 200.3 ±30.0 minutes. The mean estimated blood loss was 180.0 ±147.6 mL. The mean number of lymph nodes retrieved was 23.2 ±7.4. No laparoconversion and no intraoperative or postoperative complications occurred. All patients were alive and free of disease up to the date of this report, at a median follow-up of 6.5 months (range, 5-17 months). CONCLUSION: Robot-assisted laparoscopic staging surgery is a feasible treatment and helps overcome the technical limitations in conventional laparoscopy for endometrial cancer.

A transient blocking uterine perfusion procedure to decrease operative blood loss in laparoscopic myomectomy.

BACKGROUND: To evaluate the feasibility and effectiveness of reversible ligating clips to block uterine arteries and reduce operative blood loss during laparoscopic myomectomy (LM). METHODS: Twenty consecutive women with symptomatic uterine fibroids desiring to preserve the uteri underwent laparoscopic surgery with ligation of the uterine arteries with ligating clips, followed by myomectomy and removal of the clips. RESULT: Laparoscopic uterine artery ligation with reversible ligating clips was successfully performed in all patients. The median main fibroid diameter and fibroid weight were 7.3 cm (interquartile range [IQR] 7.0-9.0) and 210 g (IQR 150-295 g), respectively. The median operating time was 120 minutes (IQR 100-148 minutes) and blood loss was 100.0 mL (IQR 56.3-137.5 mL). The median number of fibroids removed was 1 (IQR 1-4.3). The median post-operative hospital stay was 3 days (IQR 2-3 days) and no patient developed complications. Menstrual bleeding problems and bulk-related symptoms were controlled in 90.0% and 100% of women, respectively after 6 months of follow-up. One woman conceived spontaneously 4 months after surgery and delivered a baby girl at 38 weeks gestation via cesarean section. CONCLUSIONS: Blocking uterine perfusion before LM is valuable and feasible for the management of women with symptomatic fibroids. The procedure controlled operative blood loss without affecting the uterine blood supply after surgery.

Diagnostic laparoscopy in ascites of unknown origin: Chang Gung Memorial Hospital 20-year experience.

BACKGROUND: Ascites may appear with well-recognized disease but, in some situations, ascites is of unknown cause in spite of comprehensive study. The aim of this study was to assess the diagnostic accuracy of laparoscopy in patients with ascites of unknown origin, and evaluate the role of laparoscopy in this population after the advent of ultrasonography and computed tomography. METHODS: We collected 20 years' data of diagnostic laparoscopy from retrospective chart review at Chang Gung Memorial Hospital in Linkou and Taipei. We compared the first 10 years' data with the latter 10 years, in respect of surgical technique evolution and the different contributions of ascites. RESULTS: One hundred and seventy six patients who underwent laparoscopy for ascites of unknown origin were enrolled. They included: (1) carcinomatosis peritonei in 99 cases (56.2%); (2) tuberculous peritonitis in 31 cases (17.6%); (3) cirrhosis in 19 cases (10.8%); and (4) miscellaneous diagnoses in 27 cases (15.4%). Comparing the first 10 years' data with the latter 10 years', the distribution was nearly the same. Carcinomatosis peritonei accounted for the majority of cases and, with the evolution of anti-tuberculosis medicine, the number of tuberculosis cases is decreasing. Liver cirrhosis cases increased during the latter 10 years. CONCLUSION: Laparoscopy in combination with biopsy can clarify the causes of unexplained ascites in the majority of cases: it failed to reveal any gross abnormality in only 15% of cases. Therefore, laparoscopy is a valuable tool for the detection of the cause of unexplained ascites.