Site-specific fascial defects in the diagnosis and surgical management of enterocele.

OBJECTIVE: The aim of this study was to assess the surgical feasibility and clinical outcomes of a vaginal enterocele repair that was based on the theory of site-specific defects in the vaginal fascia. STUDY DESIGN: Seventeen patients during a 2-year period with a diagnosis of enterocele and vaginal vault descensus with or without coexisting rectocele underwent surgical correction with a site-specific fascial defect repair. An enterocele was defined as vaginal wall prolapse seen during the operation in which the peritoneum was found to be in direct contact with the vaginal epithelium, with no intervening fascia. Patients were examined at 4 weeks after the operation and then at 6-month intervals, with site-specific analysis of pelvic prolapse at the vaginal apex and posterior vaginal segment. RESULTS: Identification and site-specific fascial defect repair of the enterocele were successfully performed in all 17 cases. All patients also underwent a uterosacral ligament vaginal vault suspension, and 15 patients (88%) underwent concurrent posterior colporrhaphy. There were no intraoperative complications. At a mean follow-up of 6.3 months (range 1-17 months), 2 patients (12%) had mild, asymptomatic vaginal vault descensus but no patients (0/17) had evidence of a recurrent enterocele or rectocele. CONCLUSION: Enterocele correction through a fascial defect repair is easily performed through the vaginal route and is associated with excellent surgical outcomes on short-term follow-up.

Sciatic hernia as a cause of chronic pelvic pain in women.

OBJECTIVE: To review experience with 20 women treated for sciatic hernia between 1993 and 1997. METHODS: Patients with chronic pelvic pain and sciatic hernias, identified retrospectively from chart review, were seen during a 46-month period that covered the surgical experience at our institution and included approximately 1100 cases. The median length of follow-up was 13 months (range 3-36). RESULTS: Sciatic hernia was diagnosed in 20 white women with chronic pelvic pain and was treated using laparoscopy. In 14 cases the hernias were right sided, in five they were left sided, and in one they were bilateral. All sciatic hernias contained the ipsilateral ovary alone or with its fallopian tube. All 20 patients reported symptomatic relief at follow-up. CONCLUSION: Sciatic hernia is a cause of chronic pelvic pain and should be considered in the differential diagnosis.

Percutaneous suprapubic teloscopy: a minimally invasive cystoscopic technique.

We describe a percutaneous approach to suprapubic teloscopy that may be used to assess bladder-ureteral integrity during laparoscopic surgery. After access is gained to the hollow of the bladder using a percutaneous suprapubic catheter introducer, a telescope is inserted via the access sheath, and bladder integrity and ureteral patency are confirmed. We describe this technique as a viable alternative to traditional cystoscopy at laparoscopic surgery.

Technique of hand-assisted laparoscopic surgery.

Advanced laparoscopic techniques can be challenging to perform because tactile sensation is limited with available laparoscopic instrumentation. Described is a technique of placing the surgeon's hand into the peritoneal cavity while maintaining pneumoperitoneum. Use of the hand allows for easy exposure, complete exploration, meticulous dissection, and immediate hemostasis. Our experience reveals patients have a short hospital stay and recuperation time.

Laparoscopic posterior partial fundoplication: analysis of 100 consecutive cases.

Performance of a laparoscopic posterior partial fundoplication (LPPF) for severe gastroesophageal reflux disease may have significant advantages. These include a low incidence of postop dysphagia, maintenance of the ability to belch, excellent antireflux effects, and the ease of performance of the surgery. The purpose of this study was to evaluate this antireflux procedure for these advantages to determine both its safety and effectiveness. Over 200 LPPFs have been performed by the authors in a community setting. One hundred consecutive cases are evaluated for indications, preop, and postop studies (EGD, manometry, 24 h pH), time of operation, hospital stay, complications, and conversions to an open procedure. Our technique of LPPF is presented in detail. All patients maintained the ability to belch. Postop dysphagia resolved totally in 4 patients by 7 days. Four pneumothoraces occurred; 1 patient required bilateral chest tube placement. There were no esophageal, stomach, or splenic injuries. The average hospital stay was 1.6 days. Postop 24 h pH studies revealed resolution of the esophageal reflux. Postop manometric studies show a median increase of 9.2 mm Hg for the LES pressure. No patients have resumed antireflux medication. No short gastric vessels were divided and no esophageal sutures were placed. There were no conversions to a laparotomy. Laparoscopic posterior partial fundoplication is a safe and effective antireflux procedure.

Laparoscopic Doderlein hysterectomy: a rational alternative to traditional abdominal hysterectomy.

Nearly three of four hysterectomies are performed by abdominal incision. When laparoscopically directed dissection of the uterus adnexae and development of the bladder flap are coupled with a Doderlein vaginal hysterectomy, most of these abdominal procedures can be converted to vaginal procedures. Experience with 167 procedures has demonstrated that this new procedure can be performed safely, effectively, and efficiently. The benefits of less postoperative discomfort, resulting in shorter hospital stays and quicker return to normal activity, coupled with a reduced cosmetic defect, have been clearly demonstrated.

Electrosurgery thermal injury. Myth or misconception?

Two sets of experiments were conducted to determine whether the potential hazards of secondary sparking and distal tissue burns are a serious risk for surgeons using monopolar electrosurgery during laparoscopy. The results indicate that secondary sparking poses little threat, whereas distal burns are very likely, given certain tissue parameters that force the entire electric current through narrow structures.

Laparoscopic appendectomy: three years' experience.

Laparoscopic appendectomy was performed on 109 patients over a 3-year-period--1988 to 1991. All procedures were uneventful and all patients resumed normal activity within a shorter period than had been experienced with open appendectomy. Patients had a superior cosmetic result and experienced significantly less postoperative discomfort.

Laparoscopic techniques in appendectomy with argon laser.

We used laparoscopic techniques to do appendectomies with the argon laser on 32 patients. The first two patients were hospitalized overnight, and the other 30 patients were treated as outpatients. All patients resumed normal activity within 7 days. All recoveries were uneventful and no complications developed. Diagnostic laparoscopy enables the surgeon to diagnose and treat abdominal pain more definitively and much earlier.