Laparoscopic management of 641 adnexal tumors in Kiel, Germany.

STUDY OBJECTIVE: To evaluate the effectiveness and safety of laparoscopic and laparotomic management of ovarian tumors. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Six hundred forty-one women with benign and malignant ovarian tumors. INTERVENTIONS: Laparoscopy and laparotomy. MEASUREMENTS AND MAIN RESULTS: Between January 1997 and December 1998, 493 (76.9%) ovarian tumors were treated laparoscopically and 138 (21.5%) by laparotomy. Criteria for laparotomy were high suspicion of malignancy and tumors larger than 10 cm that were technically too difficult for the laparoscopic approach. The mean size of tumors treated laparoscopically was 4.5 cm (range 1.1-11 cm) and by laparotomy 8.2 cm (range 3-20 cm). Mean operating times were 75.7 minutes (range 30-200 min) and 126 minutes (range 30-235 min), respectively, and mean blood loss was 193 ml (range 50-1200 ml) and 431 ml (range 50-2500 ml), respectively. Twelve laparoscopies were converted to laparotomy, six because of technical reasons such as severe adhesions, bleeding, or tumor size, and six for intraoperative suspicion of malignancy. Of the latter, four (66.7%) turned out to be ovarian carcinoma and two (33.3%) borderline tumors. Histologic evaluation clearly revealed predominance of functional ovarian cysts, endometriomas, and dermoid cysts in the group treated by laparoscopy, whereas ovarian carcinomas, large endometriomas, and serous cysts prevailed in the laparotomy group. CONCLUSION: With careful preoperative screening, the rate of laparoscopies for treatment of benign ovarian cysts can be increased. (J Am Assoc Gynecol Laparosc 8(1):74-82, 2001)

Maintenance of body temperature at laparoscopic surgery.

Reducing the loss of energy by a patient during laparoscopic surgery supports better quality of life. Homo sapiens are homeothermic and are thus only able to effectively tolerate temperature changes ranging from 37+/ -O.5°C. Maintenance of body temperature both intra- and post-operatively is essential. Variations in temperature may bring about changes in enzyme reactions and metabolic processes in the body. Maintenance of body temperature in the central core, including the brain, thoracic and abdominal organs, is most vital.

Endoscopic management of adnexal masses.

BACKGROUND: The laparoscopic management of suspicious adnexal masses and early ovarian malignancies is discussed with the aim of maintaining accepted oncologic treatment principles. Comparative survival data of patients with gynecological malignancies managed by laparoscopy or laparotomy are still very scarce and the survival of cancer patients must not be compromised by new techniques. It is time to closely analyze laparoscopy and determine if it has a positive impact on the diagnosis and treatment of ovarian malignancies. In this paper we will address the following points: 1) Which ovarian cysts can be surgically treated by laparoscopy (pelviscopy)? 2) Is staging laparoscopy an accepted technique? 3) Is laparoscopy, as a second-look procedure, of benefit? 4) Is laparoscopic staging, together with histologic tissue sampling, adequate surgical technique in inoperable ovarian cancer with ascites and peritoneal carcinomatosis? 5) Does endoscopic biopsy of ovarian cancer stage Ia change the destiny of a patient into ovarian cancer Ic? DATA BASE: The above questions are analyzed based on our experience with the laparoscopic treatment of 1,225 patients with ovarian cysts and 165 ovarian cancer patients stage I to IV treated immediately by laparotomy during the years 1992-1995. CONCLUSIONS: Ovarian cystic tumors with no signs of malignancy can be dealt with by laparoscopic means with the option of immediate conversion to laparotomy or within one week if an ovarian malignancy is diagnosed. Today sampling laparoscopic lymphadenectomy of both pelvic and para-aortic is feasible and adequate. On a curative level, the number of lymph nodes to be resected has yet to be determined. The adnexa can be extracted from the abdominal cavity with bag extraction without the danger of spillage. The uterus can be removed transvaginally with laparoscopic assisted vaginal hysterectomy (LAVH). We must be cautious to advocate laparoscopy for ovarian cancer. However, it is an excellent tool when used as a staging procedure. A careful preoperative screening of the patient and an exact definition of existing cysts with imaging techniques allows us to frequently apply laparoscopic surgery for ovarian cysts, leaving only readily detectable cancer cases for laparotomy. Many gynecological oncologists employing staging and second-look procedures for ovarian cancer agree that initiating a case with laparoscopy may preclude laparotomy for many patients. Tumor propagation by performing a biopsy in FIGO stage Ia ovarian cancer patients does not occur if the patient receives adequate radical surgical treatment within one week. According to the reports of Sevelda et al. and Dembo et al., the degree of differentiation and the existence of ascites are more relevant to decreasing the five-year survival rate of patients with ovarian cancer stage I than the rupture of capsule or penetration of the tumor. A dependency on the first two parameters was found in these two large statistical studies. As the question of endoscopic operations for adnexal mass is predominantly put for the sanitation of small ovarian tumors (ovarian tumors with solid particles in the cysts can be put into the section of primary laparotomies) there remains a wide field of indications for the laparoscopic treatment of adnexal mass and ovarian cysts with benign indications. For many young patients with non-malignant ovarian lesions such as endometriosis, benign cysts, benign cystic proliferations and fibromas, a laparotomy can be avoided and these lesions treated by laparoscopy.

Subtotal versus total laparoscopic hysterectomy.

Between 1993 and 1994, 368 women underwent hysterectomy for benign disorders at the University of Kiel. Of these operations, 58.7% were performed either by pelviscopic or by laparotomic Classic Intrafascial Supracervical Hysterectomy, subtotal hysterectomy with coring of the inner cervix. Of the remainder, 14.8% were performed by total abdominal hysterectomy, 13.6% by Intrafascial Vaginal Hysterectomy, 12.2% by vaginal hysterectomy, and only 0.05% by Laparoscopic Assisted Vaginal Hysterectomy. Comparative data of these six surgical techniques concerning patients' characteristics, indications for operation, histological features, blood loss, operating time, hospital stay, uterine weights and postoperatively used analgesics are described.

Endoscopic subtotal hysterectomy without colpotomy: classic intrafascial SEMM hysterectomy. A new method of hysterectomy by pelviscopy, laparotomy, per vaginam or functionally by total uterine mucosal ablation.

The CISH-technique per laparotomiam, vaginam, or pelviscopiam which sometimes may be limited to a TUMA procedure should replace classic total hysterectomy is approximately 80% of the cases. Where hysterectomy is indicated CISH and TUMA reduce the feeling of disfiguration many women feel after total hysterectomy. The uterine artery is not ligated as is routinely performed at total hysterectomy where, thereafter, the vagina is supplied by collateral branches only. Atrophic tissue in the pelvic floor results. The CISH-technique preserves the full blood supply to the lower pelvis, and this is particularly important for older patients. Perhaps this is the first step in the prophylaxis against prolapse. With TUMA not only the sexual function of the vagina remains intact but through the preservation of the genital blood supply the endocrinological function of the ovaries remains unchanged. We are at the beginning of a new era of minimal invasive operative techniques in gynecology. This new era of surgery limits itself to removing only the diseased part of the affected organ. Radical operations such as oophorectomy, salpingectomy, hysterectomy etc. are reduced to a minimum and indicated only in cases of malignant disease in these organs. Experience will show whether IVH is the least physically traumatic hysterectomy technique or not. At the present IVH is the most minimally invasive hysterectomy technique.

[Psychiatric and sexual sequelae of hysterectomy--a comparison of different surgical methods]. / Psychische und sexuelle Folgen der Gebärmutterentfernung--ein Vergleich unterschiedlicher Operationsmethoden.

Comparison of Different Surgical Methods: The cardinal question of this prospective longitudinal study was whether different surgical methods of hysterectomy correlate with differences in adaptation and in respect of psychological as well as sexual consequences. A total of 83 patients were investigated immediately prior to surgery as well as 6 weeks later. 61 resp. 58 patients participated in follow-up investigations 6 months and 1 year following surgery. Total hysterectomy was performed vaginally in 16 females, abdominally in 22 patients. 23 patients underwent subtotal C.I.S.H. hysterectomy. 23 females indicated for myoma enucleation formed another group of this study. Besides several psychological variables of potential influence such as personality characteristics, coping, sexual attitudes and partner satisfaction, the study covered psychological as well as physical complaints, life satisfaction and differential characteristics of sexual experiences and behaviour longitudinally. The results indicate that single subgroups differ from each other in several respects. There were no indications of different psychological as well as sexual consequences depending on the surgical method. These findings support the view that consequences of hysterectomies are more likely to be predicted on the basis of psychological traits that existed before the operation, rather than from a medico-technical point of view.

Enucleation of 482 Myomectomies

Of more than 800 women with uterine myomas, 60% underwent endoscopic myomectomy with uterine preservation and 40% conventional hysterectomy. Before endoscopic myomectomy, 3% of women were treated with gonadotropin-releasing hormone analogs for 3 to 6 months. Operating time was 30 to 60 minutes. No complications occurred. Histologically, the majority of myomas were fibromyomas.

Tissue morcellation in endoscopic surgery.

In many surgical centers the intra-abdominal morcellation of IS-cm myomas' or freely dissected organs such as krdrieys" has become routine. A prerequisite is the availability of a macro-morcellator which re- duces the tissue bulk to a small enough size that it may be removed through the standard abdominal tro- cars in a reasonable amount of time.

[Value of pulsatile Doppler ultrasound in diagnosis of suspected placental insufficiency in comparison with other examination parameters]. / Stellenwert der pulsatilen Dopplersonographie zur Diagnostik bei Verdacht auf Plazentainsuffizienz im Vergleich zu anderen Untersuchungsparametern.

In order to determine the diagnostic value of various methods for placental insufficiency, the following parameters were obtained from 108 patients with intrauterine growth retardation (IUGR) as the only risk factor: A/B-ratio, resistence index (RI), pulsatility index (PI) of the umbilical artery (UA) and descending fetal aorta (FA), maternal serum estriol, grading of the placental maturity according to Grannum, amount of amniotic fluid, and fetal heart rate tracings. All Doppler indices showed the same efficacy as regards prediction of neonatal growth retardation. With a value of 8.0 for the A/B ratio of the FA and 4.5 for the UA neonatal dystrophy may be recognized with a precision of 72.2% (sensitivity 65.2%, specificity 77.4%). Maternal serum estriol has an accuracy of 64% (sensitivity 50%, specificity 74%), fetal heart rate tracings are able to predict neonatal growth retardation with a precision of 63% (sensitivity 43.5%, specificity 77.4%) determination of the amount of amniotic fluid has an accuracy of 58% (sensitivity 69%, specificity 50%) and grading of placental maturity 61% (sensitivity 17%, specificity 95%). The parameters combined yield in an accuracy of 75% (sensitivity 72%, specificity 74%). The fetal outcome of neonates with preceeding pathologic Doppler indices differed significantly from those with normal Doppler indices as regards indication for cesarean section, necessity of therapy in the intensive care unit, and preterm labor rate (chi square test, p < 0.05). This result could be improved to 2-4% by obtaining additional parameters. Pulsed Doppler sonography of fetal vessels is an additional tool in diagnosing intrauterine growth retardation.

[The aspiration pneumoperitoneum]. / Das Aspirations-Pneumoperitoneum.

To date the pneumoperitoneum has been passively created by instrumentally monitored introduction of a gas, such as carbon dioxide gas. The abdominal cavity expander ACE developed already in 1991 produces an active pneumoperitoneum by suctioning air into the abdominal cavity; this is achieved by a modified and automated form of the ACE. A modified myoma drill elevates the abdominal wall for primary aspiration of air into the abdominal cavity by means of a Veress needle.

Comparative evaluation of classical intrafascial-supracervical hysterectomy (CISH) with transuterine mucosal resection as performed by pelviscopy and laparotomy--our first 200 cases.

A novel way of performing endoscopic intrafascial supracervical hysterectomy is presented. By using the endoscopic approach for dissection as well as uterine extraction using the serrated-edged macro-morcellator, we avoid giving the patient a colpotomy incision and its inherent post-operative discomfort. A further modification involves nearly complete excision (95%) of uterocervical mucosa using a calibrated resection tool, thus eliminating the possible subsequent development of cervical stump neoplasia. Sparing of the cardinal ligament insertion provides support to the cervical stump. Hemorrhage and genitourinary complications are prevented by avoiding dissection of the parametrium at the level of endocervix. Comparison of data of the pelviscopic CISH procedure with the laparotomy approach in our preliminary series (n = 190) confirms our claims as to its safety. Data on long-term postoperative evaluation are ongoing, but the initial reports deny any postoperative discomfort. Larger randomized studies are required to prove its value compared with the existing techniques. We believe that with its multitude of benefits, the classic intrafascial serrated-edged macro-morcellated (SEMM) hysterectomy (= CISH) may emerge as an attractive alternative to conventional hysterectomy.

Cutting versus conical tip designs.

The history of development in laparoscopy shows that the dilemma involving blind insertion of the trocar has not changed in over 100 years. Perforation of the abdominal wall with the cutting trocar is no longer necessary with today's anatomical and technical possibilities. The cutting trocar with its four cutting surfaces has a great disadvantage compared to the conical trocar with regard to safety. The linea alba should not be disrupted, and perforation of the abdominal wall should be performed in an area where the fascia is weaker and muscle is more abundant. The "z"-track method of trocar insertion prevents intestinal or omental herniation. For perforation and stretching of the muscle, a conical trocar with a blunt tip is recommended. After inserting the conical trocar down to the layer of subcutaneous fat or muscle, further advancement is performed under visual control using a normal straight endoscope and by rotating the bevelled end of the trocar sheath. Perforation of the abdominal wall with a conical trocar using the "z"-track incision under endoscopic control prevents incisional herniation of intestine or omentum.

[Development of gynecologic endoscopy in Germany--a statistical overview 1989 to 1993]. / Die Entwicklung der gynäkologischen Endoskopie in Deutschland--eine statistische Erhebung der Jahre 1989 bis 1993.

The first statistical report on pelvioscopy/laparoscopy of total Germany covers a five years period from 1989, 01.01 to 1993 31.12. It includes a total of 461,568 pelvioscopies/laparoscopies from 374 hospitals and 52,861 pelvioscopies/laparoscopies from 116 medical practitioners. Hospitals' response rate was 43% with 99.2% reporting pelvioscopy/laparoscopy. The response rate of medical practitioners was 41% with 97.4% performing same methods. During the five year period of survey, hospitals reported a total of 2095 serious complications requiring laparotomy or control laparoscopy (complication rate = 4.5/1000). Medical practitioners reported a total of 197 serious complications (complication rate = 3.7/1000). Compared with the data of the fourth statistical survey of laparoscopy (1986 to 1988) there is a remarkable increase in serious complications. Most of them are mechanical lesions of blood vessels in the abdominal wall or in the mesosalpinx, followed by mechanical lesions of the intestine. Also remarkable is the observation that pelvioscopy/laparoscopy as surgical method is continuously increasing. As shown in previous statistics on pelvioscopy for tubal sterilization the bipolar technique is the most popular one for both hospitals and medical practitioners. It is followed by endocoagulation after Semm whereas mechanical techniques are of little importance. The monopolar high frequency current is still used in 9.6% by hospitals and 8.8% by medical practitioners, with and without transsection. Sterilization failure rate remains nearly at the same levels as it was reported previously: 1.6/1000 in hospitals and 3.7/1000 in private practices. The highest failure rate was observed after the use of monopolar HF-techniques. 82.5% of the hospitals and 65% of the medical practitioners reported tendency in performing endoscopy by surgery is continuously increasing.

[Pelviscopic salpingostomy with everted suture]. / Pelviskopische Salpingostomie mit evertierender Naht.

From 1987 to 1990 pelvioscopic distal salpingostomy was performed in 47 patients at the University Hospital of Kiel. The tubal mucosa was everted and fixed with 4/0 PDS sutures. 35 patients (74%) responded to a questionnaire 2-4 years after surgery. A bilateral salpingostomy had been performed in 16 of these 35 cases, while the contralateral tube was either absent or intramurally occluded in 19 cases. Eight patients (23%) postoperatively had an intrauterine pregnancy, five patients gave birth to a healthy child, one patient was pregnant at time of follow-up. Three patients had abortions and three experienced a tubal pregnancy of one or both sides. Compared to the endoscopic procedure with the CO2 laser pelvioscopic salpingostomy with an everted suture represents an equally suited alternative.

[Follow-up of beta-hCG after pelviscopic linear salpingotomy for therapy of tubal pregnancy]. / beta-hCG-Verlauf nach pelviskopisch durchgeführter linearer Salpingotomie zur Therapie der Tubargravidität.

From 1987 until 1993 a total of 337 patients underwent a therapy for tubal pregnancy at the Department of Gynaecology and Obstetrics of the University of Kiel. The percentage of cases treated by tubal-preserving pelviscopic linear salpingotomy and subsequent extraction of the conceptus, increased from 59% in 1987 to 88% in 1993. In 6.5% a second look pelviscopy was performed for suspected remnants of trophoblastic tissue. Remaining trophoblastic cells can be recognised by serial determination of serum beta-hCG titers postoperatively. However, the interval of the postoperative beta-hCG decline reveals considerable interindividual variation. A regression following the "Cox Proportional Hazard" model shows that the period of the beta-hCG decline depends on the initial titer. The Kaplan Meier curve obtained via beta-hCG determination in 98 patients following pelviscopic linear salpingotomy until values reached 20 mIU/ml or less, shows that 50% of the patients had to be controlled for more than 7 days, 10% for more than 28 days and individual patients even for more than 70 days. The relative beta-hCG titers differ significantly from the unresolved group compared to the group with resolved ectopic pregnancy starting at postoperative day 2 (p < 0.01). At postoperative day 3/4 10% of the initial beta-hCG value is attained in 50% of cases. Even then a serial beta-hCG follow-up should be obtained down to the detection limit to ensure complete resolution of viable trophoblastic cells.

[Vaginal supracervical vs. laparoscopic supracervical hysterectomy, with resection of transcervical and transuterine mucosa]. / Vaginale suprazervikale vs laparoskopische suprazervikale Hysterektomie, mit Resektion der transzervikalen und transuterinen Mukosa.

Indications for the 346 hysterectomies performed in the Department of Obstetrics and Gynecology University of Kiel in the years 1991 till 1994 were myomas with pain, hypermenorrhoea, menorrhagia, recurrent bleedings and endometriosis. The applied hysterectomy technique consisted of supercervical hysterectomy without colpotomy including the resection of the transcervical and transuterine mucosa by laparotomy and via laparoscopy (pelviscopy). Histologically results were divided between fibromas, leiomyomas, adenomyosis and adenomatous hyperplasia. 42 patients where pretreated with hormones and showed a significantly reduced blood loss compared to the non treated patients during surgery. Intra- and postoperative complications were very low. The CISH-technique is an alternate method for vaginal and abdominal total hysterectomy via laparotomy or via laparoscopy. Gynecological indications for hysterectomies presents the following advantages. 1. CISH via pelviscopy: Prophylaxis against the development of cervical cancer, preservation of the pelvic floor, preservation of the pericervical vascular and nerve tissue and especially, avoiding the danger zone of the uterine arteria and ureter, reduced physical stress, short hospitalisation and recovery time of the patients. 2. CISH via laparotomy: Prophylaxes against cervical cancer, preservation of the pelvic floor, reduction of the pelvic trauma, simple technique. 3. CISH via vagina: The advances of the intrafascial vaginal hysterectomy are the same as those for laparoscopic intrafascial hysterectomy without colpotomy, no separation of cardinalia and sacrouterina ligaments, no cervical amputation. No search for the uterine artery, no change in sexual life. Ideal conditions for the preservation of pelvic floor to regain stability. 4. During the resection of the transcervical and transuterine mucosa the technique of mucosa ablation emerged, indications are dysfunctional bleeding.