Laparoscopic Pomeroy tubal ligation as a teaching model for residents.

We reviewed our preliminary experience with laparoscopically directed bilateral midtubal resection for tubal ligation (endoscopic Pomeroy) as a potential teaching tool for the acquisition of endoscopic skills during residency training. Thirty-five laparoscopic Pomeroy and 206 banding procedures were reviewed. Age, parity and weight were similar in the two groups. The operative time for banding was reduced slightly after experience with > 10 procedures. In contrast, the operative time for laparoscopic Pomeroy procedures decreased dramatically after individual experience with only a few (< or = 5) procedures. The mean operative time for the Pomeroy group approached that of the more traditional banding technique at five procedures. Our data indicate that laparoscopic Pomeroy sterilization can be an effective teaching tool for operative laparoscopy, allowing residents to repeatedly perform an easy and safe procedure that incorporates basic techniques. Advanced operative endoscopic procedures could then be taught more efficiently after the acquisition of basic skills.

PIP: 25 gynecology residents performed laparoscopic banding (tubal rings) sterilization on 206 women and laparoscopic Pomeroy sterilization on 35 women, all of whom underwent tubal sterilization at the University of Mississippi Medical Center between September 1988 and October 1990. Three faculty members and a fourth year resident retrospectively analyzed the data of both groups to determine the effect of the Pomeroy method on operative laparoscopic skills acquired by the residents during training. Both groups were similar in age, parity, and weight. Each of the 23 residents performed 1-22 laparoscopic banding procedures. As residents gained experience, the time to perform both banding and Pomeroy methods decreased significantly (p = 0.026). After a resident had conducted 5 Pomeroy procedures, the surgery time had approached that of laparoscopic banding. These findings show that gynecology faculty can use laparoscopic Pomeroy tubal ligation as an effective teaching tool for laparoscopy by providing residents an opportunity to repeatedly perform an easy and safe procedure that includes basic techniques. After developing the basic skills, the residents can then learn more efficiently advanced operative endoscopic techniques.

Abnormal bleeding in the climacteric.

In the perimenopausal years, we encounter a situation where the normal diminution in reproductive capacity, with its resulting disruption of the normal menstrual hormonal pattern, coincides with a very real risk of pelvic pathology. Limitation in the ability to diagnose and to treat these patients conservatively has in the past resulted in a high rate of hysterectomy. With increased understanding of the normal physiology of this stage of transition and with improved diagnostic tools, we are now able to come to a definitive diagnosis in most patients. This ability to assure the diagnosis has made it much easier to counsel the patient confidently about the appropriate course of action. We will continue to encounter the problem of hysterectomy for bleeding with no histologic lesion being found. Although reviewers' letters may be considered an unnecessary thorn in the side, the improved practice that has resulted from these efforts gives strong support to their continued activities. We can have confidence that our treatment plan evolved in a logical manner and offers our patients a high probability of benefit at justifiable risk.