Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae.

The following statements summarize the material presented herein. 1. Although laparoscopic tubal ligation remains an effective and widely available form of birth control throughout the world, cumulative failure rates may be higher than previously reported, and patients should be appropriately counseled, with special attention to younger women. 2. Proper surgical technique is important in reducing failure rates, particularly with regard to applying clips or using bipolar cautery. Teaching institutions should employ strict guidelines for instructing residents in the most effective techniques. 3. Although overall rates of ectopic pregnancy are lower after tubal ligation (as is true with any form of birth control), should pregnancy ensure from a failed procedure, there is a 30% to 80% chance of ectopic pregnancy. Consideration should be given to earlier ultrasound and documentation of the location of the pregnancy. 4. There is little evidence to support PTLS from a biologic standpoint. The data on increased hysterectomies in post-tubal patients may be a result of multiple factors, particularly for women aged less than 30 years at the time of occlusion. 5. Although the majority of women report satisfaction with sterilization, thorough counseling for all women cannot be overemphasized. Women aged less than 30 years should be completely aware of all alternatives and possibly encouraged to try another method prior to permanent sterilization.

PIP: This article details laparoscopic techniques of tubal sterilization, with a review of current literature addressing their effectiveness and common sequelae. Throughout the world, tubal ligation accounts for about 10-40% of the contraceptive methods. A brief explanation is stated on the timing of sterilization. Some of the methods for laparoscopic sterilization include the following: 1) unipolar coagulation; 2) bipolar coagulation; 3) silastic band application; 4) spring clip application; 5) filshie clip; and 6) laparoscopic Pomeroy procedure. Recent advances were also given, such as microlaparoscopy for fiber-optic technology, and performance of office laparoscopy under local anesthesia. However, despite the fact that laparoscopic tubal ligation remains to be an effective form of birth control throughout the world, cumulative failure rates remain high and patients should be appropriately counseled. Furthermore, women aged less than 30 years should be aware of all alternatives prior to permanent sterilization.

Chronic pelvic pain.

Chronic pelvic pain in women may involve more than the gynecologic organ systems. Urologic, gastrointestinal, musculoskeletal and psychiatric disease processes may be contributing factors, the majority of which can be treated medically. A thorough history and physical examination are often all that is necessary to initiate effective treatment. A multidisciplinary approach to management will recognize the interactive process of the biopsychosocial model that may act to produce chronic pelvic pain.

An object-oriented, knowledge-based system for cardiovascular rehabilitation--phase II.

The Heart Monitor is an object-oriented, knowledge-based system designed to support the clinical activities of cardiovascular (CV) rehabilitation. The original concept was developed as part of graduate research completed in 1992. This paper describes the second generation system which is being implemented in collaboration with a local heart rehabilitation program. The PC UNIX-based system supports an extensive patient database organized by clinical areas. In addition, a knowledge base is employed to monitor patient status. Rule-based automated reasoning is employed to assess risk factors contraindicative to exercise therapy and to monitor administrative and statutory requirements.

Laparoscopic capacitance: a mystery measured. Experiments in pigs with confirmation in the engineering laboratory.

OBJECTIVES: Our purpose was to determine whether capacitive currents induced in operative laparoscopes during endoscopic electrosurgery can cause unintentional injury and to measure these currents in the laboratory. STUDY DESIGN: In five anesthetized live pigs we tested whether capacitive currents generated in operative laparoscopes by unipolar instruments cause serosal injury. These currents were then measured in the clinical engineering laboratory. RESULTS: In the setting examined by us serosal injury by capacitive currents occurred only with high generator output power. In the laboratory the maximum power of these capacitive currents measured 2.5 W. CONCLUSIONS: Capacitive coupling between unipolar instruments and 10 mm operating laparoscopes requires relatively high generator output to cause serosal injury. Lower generator output settings may cause injury with electrosurgical generators capable of higher voltages than the units used in this study (Valleylab SSE2L and Force 2).

Bladder and bowel injury after electrodesiccation with Kleppinger bipolar forceps. A clinicopathologic study.

To evaluate the extent of electrocoagulation damage in tissue undergoing bipolar desiccation, five mature female pigs were used as models of tissue and adjacent vital structures commonly encountered during operative laparoscopy. Electrocoagulation was performed on bowel mesentery, sidewall peritoneum, ureters, uterus, uterotubal junction and broad ligament; superficial bowel and bladder burns were treated. Kleppinger forceps were also used to coagulate various-sized arteries to determine hemostasis. Histopathologic analysis demonstrated no inflammation or tissue destruction beyond the desiccated area seen immediately after coagulation and no direct correlation between tissue thickness and spread of electrocoagulation. It also appears that blood vessel hemostasis can be achieved safely with Kleppinger forceps on vessels up to 3 mm in diameter.

A comparison of bed rest and immersion for treating the edema of pregnancy.

Bed rest and immersion both lead to a mobilization of extravascular fluid and thus reduce edema. This study compared three treatments for edema in healthy pregnant women in the third trimester: lateral supine bed rest at room temperature, sitting in a bathtub of waist-deep water at 32 +/- 0.5C with legs horizontal, and sitting immersed in shoulder-deep water at 32 +/- 0.5C with legs extended downward. Post-treatment diuresis was selected as the indicator of extravascular fluid mobilization. The mean (+/- SD) diuresis was 105 +/- 48, 161 +/- 155, or 242 +/- 161 mL/hour for bed rest, bathtub, and immersion tank, respectively (P less than .008, tank versus bed rest; P less than .05, tank versus bath). In all treatments, mean arterial pressure (MAP) declined from a baseline value of 88 +/- 9 to 77 +/- 10 mmHg 25 minutes into treatment and 77 +/- 11 mmHg at 50 minutes (both P less than .0001 compared with pre-treatment). Shoulder-deep immersion produced the greatest decline in MAP. Sodium clearance increased from 0.7 to 1.0 mEq/minute in all treatments (P less than .01). Serum sodium, potassium, creatinine, osmolarity, total protein, 6-keto prostaglandin F1 alpha, and plasma volume did not change significantly after the treatments. Serum prolactin declined significantly from 137.8 +/- 44 to 124 +/- 31 ng/mL after treatment; there was no difference among treatments. Immersion appears to be a safe and more rapid method than bed rest to mobilize extravascular fluid during pregnancy.