Comparative anti-Pseudomonas aeruginosa activity of chemically modified and native immunoglobulin G (human), and potentiation of antibiotic protection against Pseudomonas aeruginosa and group B Streptococcus in vivo.

Immunoglobulin G intravenous is prepared by controlled reduction and alkylation of approximately four interheavy chain disulfide bonds per molecule. To determine if the protective activity of antibody modified by this process is diminished, mice were treated with identical doses of reduced and alkylated IgG and native IgG prepared from the same plasma pool. Three hours later mice were given a 10 percent body surface burn followed by challenge with the seven Fisher-Devlin-Gnabasik immunotypes of Pseudomonas aeruginosa. Against five of the seven immunotypes, the 50 percent protective doses were approximately 100 mg or less per kg body weight. Overall there was no significant difference in protection afforded to the mice by the two immunoglobulin preparations indicating that in vivo the activity of IgG against P. aeruginosa remains unimpaired by reduction and alkylation. In the second part of this study, immunoglobulin G intravenous significantly enhanced the activity of tobramycin and carbenicillin in the treatment of P. aeruginosa infection in burned mice and of penicillin G in the treatment of group B Streptococcus 1C infection in normal mice.

The 4-S modification of the Roeder knot: how to tie it.

BACKGROUND: The 4-S modification of the Roeder knot may be tied laparoscopically as a single-throw knot. TECHNIQUE: It is tied by adding a fourth wrap around the suture loop and securing the loop in place with a square knot rather than a single half-hitch. EXPERIENCE: We have used this knot in laparoscopic surgeries for more than 2 years and have not observed knot slippage. CONCLUSION: This modification results in a knot comparable in strength to the strongest laparoscopic multiple-throw square knots.

CO2 laser for the treatment of vulvar carcinoma in situ.

A new conservative method for treating carcinoma in situ of the vulva is presented. The carbon dioxide laser offers the advantage of a microsurgical technique combined with the benefits of sharp local excision. As one third of the 35 patients treated in this series are under 30 years of age, preservation of the anatomic and functional integrity of the vulva is of paramount importance. Laser therapy has proved to be precise and has resulted in rapid healing without scar formation. The laser regimen conveniently unifies the therapeutic program directed against multicentric squamous neoplasia of the lower genital canal.

Contact hysteroscopic evaluation of the endocervix as an adjunct to colposcopy.

A total of 66 women with cervical intraepithelial neoplasia extending into the endocervical canal were investigated by endocervical curettage, contact endoscopy, and conization biopsy of the cervix. Although atypical epithelium was obtained in only 8 women by blind endocervical curettage, contact endoscopy identified 42 instances of disease of equal or greater magnitude than determined by the original ectocervical colposcopic evaluation. These findings were subsequently confirmed by conization biopsy. As the 6-mm contact hysteroscope may easily be inserted into the pregnant cervix, sufficient reassurance may be gained to avoid endocervical curettage or cone biopsy and thus to avoid the hazard of major hemorrhage and/or pregnancy interruption.

Microsurgical conization of the cervix by carbon dioxide laser.

The carbon dioxide (CO2) laser has been used to treat cervical intraepithelial neoplasis (CIN) by vaporization of colposcopically visible lesions. Recently, several investigators have reported a series of laser-treated CIN with very promising cure rates. The use of the laser to excise cervical tissue surgically has been neglected. A series of patients who have undergone cervical cone biopsies taken by the CO2 laser is presented. The tissue sections obtained from these cone biopsies are suitable for pathologic interpretation and study. The complication rate for cervical conization by laser is very low. Other advantages of this method of cervical conization are discussed.

Gracilis myocutaneous flap in reconstruction of the vulva and female perineum.

For the past 2 decades there has been a definite trend among pelvic surgeons to immediately reconstruct the large defects created by deforming radical cancer surgery in the female pelvis and perineum. Extensive en bloc removal of more tissue has enhanced the probabilities of increased 5-year survival. At the same time, however, the quality of life following radical surgery has been of great concern to both patient and surgeon. Recent advances have been made in techniques for reconstruction. It is the purpose of this paper to present our experience using the gracilis myocutaneous flap for reconstruction of the vulva after radical excision of perineal tissue. The technique of the procedure is presented with the clinical results in 5 cases, and the complications noted therein.

Cystourethroscopy with the direct view contact endoscope.

A new instrument originally designed for hysteroscopy can also be used for cystourethroscopy. The advantages of the instrument are: 1) it uses available room light; 2) it does not require any viewing medium such as water or gas; 3) it gives an excellent direct view of the urethra, bladder neck, and trigone; 4) it is easily included on the instrument table to be used as an adjunct to surgery; and 5) cystourethroscopy with the contact endoscope is an easy office procedure. Although this instrument does not give a panoramic view, limitations are readily recognized by the experienced operator; thus, errors resulting from its use can be avoided.

Laparoscopic knot strength: a comparison with conventional knots.

OBJECTIVE: To compare the strength of laparoscopic knots with those used at laparotomy. METHODS: Three types of laparoscopic knots commonly used (Roeder, extracorporeal sliding square, and intracorporeal two-turn flat square) and three widely used conventional knots (flat square, surgeon's square, and sliding square) were tied using seven suture materials. Each knot was tied five times in random order by a single surgeon in a pelvic training model. Knot strengths were scored by tensiometer readings. A two-way analysis of variance was performed to uncover differences in mean knot strength. Turkey multiple-comparisons test was performed to determine the variability in strength of different knot geometries. Knot strength was measured in newtons. RESULTS: Significant main effects for knot geometry (P < .05) and material (P < .05) as they contribute to differences in knot strength were identified, as well as an interaction for knot geometry with material (P < .05). The laparoscopic Roeder knot was significantly weaker than all other laparoscopic and conventional knots tested. The laparoscopic extracoporeal sliding square knot was significantly weaker than the conventional surgeon's square knot, and the conventional sliding square knot was significantly weaker than the conventional flat square knot and the surgeon's knot. The laparoscopic intracorporeal two-turn flat square knot was as strong as the strongest conventional knot. A significant main effect was discovered for knots with eight throws. CONCLUSION: When performing laparoscopic procedures that result in significant tension on suture lines, consideration should be given to using the stronger laparoscopic knots, such as the intracorporeal two-turn flat square knot and the extracorporeal sliding square knot, instead of the weaker Roeder knot.

The effect of knot geometry on the strength of laparoscopic slip knots.

OBJECTIVE: To evaluate and compare the strength of six different knot geometries used in laparoscopic slip knots. METHODS: The strength of six extracorporeal slip knots used in laparoscopic surgery was measured using a tensiometer. Two multiple-throw laparoscopic square knots (the intracorporeal two-turn flat square knot and the extracorporeal sliding square knot) were used as controls. Each knot type was tied five times, and each type was tied in random order by the same primary and assisting surgeons using a laparoscopic pelvic surgery training model. One-way analysis of variance was performed to detect significant differences in knot strengths, and the variability in knot strength for each knot type was determined by Tukey's multiple comparison test. RESULTS: A statistically significant effect for knot geometry was identified. The mean knot strengths +/- standard deviation (SD), measured in newtons, from strongest to weakest, were: 4S knot (28.01 +/- 11.45), fisherman's knot (22.45 +/- 6.89), modified Roeder knot (19.86 +/- 9.30), Roeder knot (15.77 +/- 7.02), Weston knot (7.28 +/- 7.96), and Duncan knot (6.55 +/- 0.95). The mean knot strengths for the multiple-throw control square knots were as follows: intracorporeal two-turn flat square knot (41.21 +/- 2.69) and extracorporeal sliding square knot (27.81 +/- 16.27). The intracorporeal two-turn flat square knot (control) was significantly stronger (P < .05) than all slip knots except the 4S and fisherman's knot. CONCLUSION: The 4S and fisherman's knots are the strongest laparoscopic slip knots and are the only slip knots similar in strength to multiple-throw square knots.

Replacement estrogen therapy for menopausal vasomotor flushes. Comparison of quinestrol and conjugated estrogens.

Quinestrol, conjugated estrogens, or placebo was used to treat 156 patients with pernicious vasomotor instability in a prospective, double-blind, randomized, multiinvestigator trial. Vasomotor flushes were severe in approximately 80% of the cases and moderate in 20%, relatively equally distributed among the various drug groups. Both qinestrol and conjugated estrogens were significantly more effective than placebo in relieving vasomotor symptoms (by chi2 analysis, P less than or equal to 0.05). Greatest improvement was seen in the group receiving the higher once weekly quinestrol dosage of 0.2 mg followed by the group on the lower quinestrol dosage of 0.1 mg once weekly and the group on conjugated estrogens, 1.25 mg daily for 21 days on and 7 days off. No significant difference in relief of vasomotor flushes was shown between the active drug groups. No drug-related complications or side reactions of significance occurred. The results indicate that once weekly quinestrol is effective in relieving the vasomotor symptoms of the menopause. Either of two once weekly quinestrol regimens is an effective as conjugated estrogens given daily in a cyclic manner and therefore offers an alternative form of exogenous estrogen therapy.

Flap reconstruction of the stenotic vagina.

Reconstruction of the congenital or acquired stenotic vagina has traditionally been accomplished by skin grafting or reverse perineorrhaphy in addition to other less successful methods. The advent of musculocutaneous flaps has provided an excellent means of reconstructing the vagina after exenterative surgical treatment; however, the bulk associated with these flaps has precluded their use in reconstruction of the stenotic vagina. Thin, supple, axial pattern fasciocutaneous flaps based on the terminal branches of the internal pudendal artery provide a reliable and durable vaginal lining after surgical enlargement. Seven flaps have been used in four patients without complications. A follow-up period of greater than three years has yielded excellent results.

Operating room organization. Lasers and advanced operative laparoscopy.

Advanced operative laparoscopy and laser surgery require a trained team of physicians, nurses and technicians to be properly carried out. The institution, surgeons, and nursing department must understand this concept if the laparoscopic program is to be successful.

Laser surgery for cervical intraepithelial neoplasia.

The laser has provided a relatively easy and safe method for treating all types of CIN. The advantages of lasers include great conservatism due to tissue sparing, great precision because of microsurgical method, combination of excisions and vaporization possible, suitable for therapy of multifocal disease, uncluttered field, and good hemostasis. Although other modalities have also been used successfully in the therapy of this disease, it appears that none are so versatile as CO2 laser or possess its ability to accurately treat the multifocal disease that may involve large surface areas of the lower reproductive tract. It seems unlikely that any of the cervical ablation methods--chemical destruction, hot cautery, diathermy electrode, cryoprobe, laser, and diathermy loop--will completely disappear from use in the near future. Ablation is an attractive alternative to cold-knife excision in properly triaged patients, since it is almost always an outpatient procedure done without anesthesia or with only local anesthesia. Most importantly, a large number of patients have completely visible lesions of a severity less than that of in situ cancer; they really do not need excisional conization by any technique and benefit by quick ablation of the transformation zone. A conization, to be diagnostic and therapeutic, must remove the entire transformation zone to the proper depth. This procedure is almost always attended by a higher morbidity rate than is simple ablation. Laser excisional conization and the large loop excision of the transformation zone procedure are similar in a number of respects, because the operator must have certain capabilities and a through understanding of the disease to be treated to perform the operation correctly.

Endometrial ablation.

Both YAG ablation and resectoscopic ablation of the endometrial cavity produce good results in most patients. Most hysteroscopic surgeons choose the resectoscope because it is much faster and easier and the results are comparable or better. Newer, larger YAG fibers may make a great difference in technical ease and speed. These new series are just beginning.

Education and credentialing of the gynecologic laser surgeon.

Gynecologic laser surgery involves the use and understanding of a number of different wavelengths (lasers) and their delivery systems. The educated laser surgeon understands the pros and cons of all the practical wavelengths, their tissue reactions, and their safety features. The laser surgeon may use a colposcope, hysteroscope, laparoscope, or laser handpiece in surgery. Few gynecologists have acquired the necessary expertise to perform laser surgery during residency training. For this reason, attendance at courses that include hands-on laboratory experience has been mandatory. Hospitals, not course directors, credential surgeons to perform laser operations in their operating rooms. The credentialing committee of the hospital must decide which surgeons have been properly trained for laser surgery. Objective criteria have been offered in this chapter in the effort to make the task easier and more fair. As the number of laser surgeons grows, the need for training courses may decrease, because if laser surgery is learned during the residency years, the demand for postgraduate training will decrease. On the other hand, since surgical laser evolution continues, the training center will continue to offer a valuable educational experience.

The role of lasers in advanced operative laparoscopy.

Lasers, electrosurgery, and conventional pelviscopic techniques all provide the accomplished endoscopic surgeon with a sophisticated approach to advanced operative laparoscopy. The different lasers, as well as other energy delivery systems and conventional techniques, offer a wide choice of pathways through which a desired end result may be achieved. The sophisticated laparoscopic surgeon is able to choose the best instrument and technique to fit the purpose of the operation and skills of the surgeon. As in conventional surgery, different surgeons prefer different instruments and use different techniques. These various instruments and operative techniques should be considered synergistic rather than competitive, because they have greatly increased the scope and safety of laparoscopic surgery.

Indications and general techniques for lasers in advanced operative laparoscopy.

Lasers are but one of the several energy delivery systems used by the operative laparoscopist in the performance of advanced operative laparoscopy. Safety is a key factor in the selection of a laser because the tissue damage produced by this instrument is absolutely predictable. The surgeon must be totally familiar with the chosen wavelength and its tissue reaction if this safety factor is to be realized. Other instruments complement the use of lasers in advanced operative laparoscopy, and without thorough knowledge of all available techniques and instruments, the operative laparoscopist will not achieve the full potential of this specialty. It is beyond the scope of this issue on gynecologic laser surgery to present all of the useful nonlaser techniques. Suffice it to say that we often use laser, loop ligature, sutures, hemoclips, bipolar electricity, hydrodissection, and endocoagulation during the course of a day in the operating room and sometimes during one case. As enthusiasm for advanced operative laparoscopy grows and endoscopic capability increases, more complicated and prolonged surgical feats are reported. Radical hysterectomy and lymphadenectomy have been performed by the laparoscopic route, and endoscopic management of ovarian tumors also has been reported. At this moment, these must be viewed as "show and tell" procedures unsupported by statistics to demonstrate any advantage (or disadvantage) when compared with conventional surgical methods. The time required of advanced operative laparoscopy for any given procedure is certainly an important factor. Prolonged operative and anesthesia time certainly can negate the supposed benefit of small incisions and minimally invasive surgery. What goes on inside the abdomen is certainly the most important part of advanced operative laparoscopy. Good surgeons must recognize their own limitations and the limitations of available technology. The operative laparoscopist must know when to quit and institute a laparotomy. In general, when the magnitude of the operative laparoscopy greatly increases the time required to perform the surgery or exceeds the capability of the surgeon, laparotomy is necessary. Patients should never be promised that an operation will be done by laparoscopy. In advanced operative laparoscopy, informed consent means that the patient has had a reasonable explanation of the method, its benefits and its dangers, and has also been told that laparotomy is always a possibility. In our large series, the laparotomy rate is about 3%. It is also wise not to promise the patient that advanced operative laparoscopy will be done by the laser.(ABSTRACT TRUNCATED AT 400 WORDS)

Mini-laparoscopy and fiber-optic lasers.

The use of the Adair Verres needle and an optical catheter system has enabled us to perform both diagnostic and laser mini-laparoscopy. The prefix mini refers to the fact that the three incisions placed in the abdomen were 3 mm in diameter. There were no complications in our pilot series. Because initial inspections of the abdomen may localize abnormalities such as intestinal adhesions and may show the surgeon a safer approach to subsequent trocar placement, nothing is lost and much may be gained by routinely performing mini-laparoscopy. The picture produced on the video monitor is now of excellent quality and seems likely to improve. In the near future, a three-chip camera, which is able to produce even better resolution, will become available. The further development of 3-mm instrumentation promises additional expansion in operative capability. Although mini-laparoscopy will not replace conventional operative laparoscopy with the 10-mm telescope in the near future, a significant proportion of diagnostic and minimally to moderately involved operative procedures may be safely carried out by this method.

An evaluation of prophylactic doxycycline in hysterectomy patients.

Although data now exist that the use of prophylactic antibiotics reduces postoperative febrile morbidity in hysterectomy patients, some controversy remains about this point of view. This prospective, double-blind, randomized study evaluated the use of doxycycline before and during the first three postoperative days after abdominal and vaginal hysterectomy in private patients. The results indicate a reduction in the febrile morbidity in the drug group as compared to the placebo group.