Pelviscopic surgery: a key for conserving fertility.

As a result of experience with more than 16,000 pelviscopic operative procedures performed at the Kiel University Women's Clinic from 1971 to 1988 which in this time had been adapted and used around the world, it may be said that the pelviscopic operative techniques, based completely on the laparotomy techniques which employ the microscissors, needles and suture material, is superior for many of the classical gynecological indications to operation. Minimally invasive surgery reduces hospitalization for even the most difficult cases to approximately 3 days. Convalescence is also reduced to approximately 1 week. Postoperative complaints are few, particularly when the primary exudate is removed through an abdominal drain. Late complications are practically unknown. It must be said that even the most minimal of operative procedures can produce late postoperative complaints or can be ascribed as the source of late postoperative complaints. Experiences gathered from around the world with endoscopically guided intraabdominal surgery have shown that for some gynecological procedures laparotomy is now indicated only in the rare case. The leading example of this switch can be seen in the operative treatment of the ectopic pregnancy. Following closely are operations to correct sterility such as salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. Finally pelviscopic treatment is increasing for all benign ovarian tumors, and the enucleation of myomas of up to 400 grams in weight. Endoscopically guided intraabdominal surgery also has a place in the field of general abdominal surgery--that of treatment of chronic abdominal adhesions. These procedures in the future should basically commence with endoscopic adhesiolysis, the patient having had the proper preoperative bowel preparation. Because of this minimally invasive technique the surgeon will only rarely be forced to perform laparotomy. In the case of abdominal adhesions a prerequisite for pelviscopic treatment is the visually controlled perforation of the peritoneum. Endoscopic surgery, in contrast to open laparoscopy, has a large periumbilical radius of action and produces no postoperative scars. In Kiel operative pelviscopy has replaced 80% of the classic gynecological laparotomies. The recurrence rate of adhesions is 84% with laparotomy compared with a recurrence rate of less than 40% with postendoscopic adhesiolysis. Forty to sixty percent of the patients who underwent pelviscopic adhesiolysis are complaint-free; this is a result not attained with classical abdominal surgery. Adhesiolysis per laparotomy is now limited to the emergency situation, as in the cases of ileus, for example. Endoscopically guided intraabdominal surgery has now improved the quality of life for surgical patients.

Use of a modified test system to determine early pregnancy factor (EPF) levels in patients with normal first trimester pregnancy and after therapeutic abortion.

Human pregnancy can be recognized as early as 48 hours after conception using the rosette inhibition test (RIT) to detect early pregnancy factor (EPF). A modification of the test as originally described by Morton et al. is demonstrated using a monoclonal pan T-cell antibody. Studies were performed to investigate the relationship between EPF levels during normal first trimester intact pregnancies and therapeutic abortions. The change in EPF levels is compared with those of hormones after interrupted pregnancy.

Treatment of female infertility due to tubal obstruction by operative laparoscopy.

The advent in recent years of safe endocoagulation (thermocoagulation within the abdomen) has permitted operative laparoscopic treatment of the tubal factor in infertility in selected cases. This paper reviews the results of operative laparoscopy in 223 cases treated for infertility between 1971 and 1976. Tubal occlusion was present in 133 patients before surgical intervention. Following operative laparoscopy, tubal patency was demonstrated in 67% on testing at the time of operation and in 12% at the first postoperative hydrotubation. In only 21% of cases was tubal patency not achieved by these methods. Those cases requiring isthmic salpingostomy, ampullary or isthmic-tubal implantation, or end-to-end anastomosis were further treated by laparotomy and microsurgery. Ninety cases of pelvic endometriosis were treated by a combination treatment of thermocoagulation, ovarian cyst resection, and the antigonadotropin agent, danazol. Ovariolysis, salpingolysis, fimbrioplasty, and salpingostomy can easily be performed using operative laparoscopy as the method of choice with a minimum of complications, shortened hospitalization time (2 days), and the potential for a repeat procedure or a follow-up laparotomy should this be necessary. The pregnancy rate following laparoscopic treatment for the correction of distal tubal occlusion was 30.5% and for endometriosis genitalis externa, 40%. These rates compare favorably with the rates following procedures involving laparotomy and microsurgery for correction of similar lesions.

Human ovum recovery via operative laparoscopy and in vitro fertilization.

Between January 1979 and December 1980, 142 laparoscopies were performed on 114 patients with long-standing tubal factor infertility. Twenty-eight were performed during spontaneous menstrual cycles, 20 following continuous human menopausal gonadotropin/human chorionic gonadotropin (hMG/hCG) therapy, and 94 following intermittent hMG/hCG stimulation. Follicular ripeness was judged by multiple criteria, which were also used to time the laparoscopy. Operative procedures were performed in all cases and follicular puncture was attempted in all but 16 subjects, where adhesions prevented access to the ovaries. In 28 spontaneous cycles, 28 follicles were punctured and 17 ova recovered; whereas in the 98 patients where ovulation was stimulated, 217 follicles were punctured and 43 ova collected. Following in vitro fertilization with the husband's spermatozoa and embryo culture, pronucleus formation, 2-cell, 4-cell, 8-cell, and 16-cell stages were observed in 18 oocytes obtained from 17 patients. Embryo transfer has, however, not yet been performed.

CIN and preclinical cervical carcinoma. A study of morbidity trends over a 10-year period.

Between 1971 and 1980 1312 cone biopsies were performed at the Department of Gynecology and Obstetrics, Kiel. Comparing the two intervals from 1971 to 1975 and 1976 to 1980 the number of cases with dysplasia and Carcinoma in situ significantly rose in the last 5 years in patients 16-30 years of age. Amongst other reasons for this increase, on the basis of our investigation, the regular gynecological examination in combination with the prescription of the ovulation inhibitors seems to be responsible. The average age of patients (36-44 years) undergoing cone biopsy for the first time decreased in the period between 1971 and 1980 (approx. 8 years). The excision of carcinoma in situ in women under 30 years of age mostly showed margins free of pathological epithelium. With increasing age the cases of not free margins increased to 70%. For the hemostasis of the conization crater up to 1977, the conventional suture technique was applied, since 1977 cone coagulation probe according to Semm was used. In this group (1977-1980) treated with coagulation after cone biopsy, 45% of the cases with carcinoma in situ not free margins had histologically normal epithelium of the extirpated uterus. In patients with the desire for a child or in pregnant women a secondary coagulation of the wound crater is achieved to preserve the uterus.

Macrophage- and lymphocyte-subtypes in the endometrium during different phases of the ovarian cycle.

The presence of immunocompetetive cells in the endometrium during the proliferative and secretory phase of the ovarian cycle is demonstrated on the light and electron microscopic level using monoclonal antibodies (MoAb). Subtypes of monocytes, macrophages and T-lymphocytes appear during the different phases in variable extent and different localization. Some subpopulations of the monocyte/macrophage system and T-helper lymphocytes increase in number on day 21/22. Our observations indicate that cells with bone marrow origin take part in functional events of the endometrium during the ovarian cycle.

Management of patients with persistent beta-hCG values following laparoscopic surgical and local drug treatment for ectopic pregnancy.

OBJECTIVES: To show that the beta-human chorionic gonadotropin (hCG) decline following tubal-preserving techniques for ectopic pregnancy (EP) can take a longer course than currently believed, indicating expectant management; and to define the indications for a second-look laparoscopy if beta-hCG persists. METHODS: Three hundred thirty-seven patients treated for EP were retrospectively reviewed. In order to define the 'normal' beta-hCG decline following tubal-preserving techniques we acquired a Kaplan-Meier curve for 98 patients treated by laparoscopic linear salpingotomy, the main method performed for EP (253 patients). The Mann-Whitney U-test served as a statistical test. The patient population requiring a second-look laparoscopy for proliferating trophoblastic remnants is described. RESULTS: Twenty-eight patients (8.3%) required a second-look laparoscopy (acute abdominal pain and sonographically suspect findings combined with increasing beta-hCG values). The majority (15 patients) underwent a preceding laparoscopic linear salpingotomy (6.5% unresolved cases). The relative beta-hCG values differed significantly from the unresolved group compared to the group with resolved EP starting at postoperative day 2 (P < 0.01). A maximal beta-hCG decline period of 77 days postoperatively was observed. CONCLUSIONS: Patients with slowly declining beta-hCG levels following tubal-preserving techniques for EP can be managed expectantly. Increasing beta-hCG values combined with abdominal pain and sonographically suspect observations indicate a second-look laparoscopy.

Endocoagulation: a new filed of endoscopic surgery.

Pelviscopy was predominantly concerned with diagnostic procedures until recent years. Modern electronically controlled coagulation instruments, such as the crocodile forceps and the point coagulator, permit the application of destructive heat without any risk of electric current within the abdominal cavity. The electronically regulated apparatus for these coagulation instruments is the Endo-Coagulator, which indicates the coagulation temperature optically and acoustically. The endocoagulation technique opens a new area of operative gynecology. In the field of sterility operations, adhesion cuttings and the treatment of endometriotic and juvenile ovarian cysts, the application of modern endocoagulation has reduced the frequency of laparotomy by about 30% to 40%.

PIP: The successful use of the Endo-Coagulator, an electronically regulated apparatus for pelviscopy and coagulation of tubes, adhesions or, bleeding areas after ovarian biopsy is reported. The need for laparotomy has been reduced by about 30-40%. The instrument provides automation for the production of pneumoperitoneum by carbon dioxide. The lower pelvis is illuminated with cold light without danger of burning. The uterus can be mobilized with an intrauterine vacuum sound. These instruments have the advantage that the electric current does not touch the patient but heats a resistant wire. The heating temperature can be preselected. Tissue can be coagulated at the temperature of boiling water. A sound device signals an increase in temperature and indicates cooling of the forceps which can then be used as a palpation rod. The whole coagulation time can be set by the surgeon. The tubes may be sectioned with the hook scissors but this is not always done. Peritoneal adhesions can be separated and a sactosalpinx opened bloodlessly. After pelviscopic salpingolysis the lower pelvis is cleansed with saline solution and 500 mg of cortisol preparation introduced. Prolonged hydroperitubation follows for 5 or 6 days. The cervix adapter remains 6-8 hours to hinder outflow of the instilled solution. More than 500 sterilizations have been done successfully with no subsequent pregnancies. Over 250 ovarian cyst wall resections have been performed with no recurrences.

Ovarian surgery via pelviscopy.

A retrospective study of operative pelviscopy was undertaken at the Department of Obstetrics and Gynecology at the Christian-Albrechts-University of Kiel to review the spectrum of ovarian surgery performed from 1987 to 1989. The purpose of this study was to assess the scope of surgery (cystectomies, ovariolysis, ovarian biopsy and cyst puncture), and to identify any advantages or disadvantages associated with the procedure.

An initial comparison of coagulation techniques of sterilization.

For nearly 50 years reports have been published on laparoscopic sterilization techniques. However, the different procedures vary greatly with regard to the extent of the tube destroyed and the magnitude of damage to the mesosalpinx. In 1981 we proved that a clear relationship exists between the extent of destruction of the circulation and nervous system within the mesosalpinx and the occurrence of menstrual disorders as well as menopausal symptoms. Because two-thirds of the ovarian blood supply passes through the ramus tubarius of the ateria uterina, after destruction of larger areas of the mesosalpinx striking disturbances within the ovarian metabolism must be expected. With numerous animal experiments we are currently studying the expansion of the coagulated area following the use of mono- and bipolar high-frequency current, endocoagulation and CO2 laser coagulation. With the aid of conventional histologic techniques, in addition to enzyme histochemical and electron microscopic examinations, attempts are being made not only to determine the extent of the destroyed zone but also to gain additional information on damage of the vascular and nervous systems of the tubes and ovaries. Although these studies have not yet been completed, it is possible at this time to state that the unipolar high-frequency coagulation technique, because of its tremendous primary and secondary complications, should not be used for laparoscopic female sterilization.

Late complications of sterilization according to method.

By using a patient questionnaire, we checked the effects of two tubal sterilization procedures (high-frequency [HF] and endocoagulation techniques) in relation to late complications. In the years following high-frequency sterilization, 23 women (8.9%) had hysterectomies; in the endocoagulation group only 9 patients (2.3%) underwent hysterectomy. Patients sterilized by the unipolar high-frequency technique required one to three curettages in 7.8% of cases, whereas only 2.1% of the endocoagulation group required this procedure. Seventy-nine patients in the high-frequency group (30.9%) exhibited menstrual disorders as compared to only 45 (11.7%) in the other group. The combination of menstrual irregularities and menopausal complaints was found in 7.4% of the HF group, while only 2.8% of the endocoagulation group experienced these problems. Menopausal complaints only, without menstrual disorders, occurred in 4.7% and 3.9% of the women, respectively. Eighty-five percent of 330 patients sterilized by the Semm endocoagulation technique had no menstrual complaints or menopausal symptoms; in the HF group this was the case for 160 women (62%). Our results demonstrate that late postoperative complications arise less often in patients sterilized by endocoagulation.

Ovarian failure phenomena after hysterectomy.

Previous studies have shown that simple hysterectomy with both ovaries left intact may cause ovarian failure. Questionnaires on climacteric symptoms were mailed to 243 patients between 27 and 42 years old who had been hysterectomized during the past ten years in the Kiel University obstetrics and gynecology clinic. From the 164 replies we found typical signs of ovarian failure in 39%. Some of the patients were asked to undergo endocrinologic investigation, which showed biphasic cycles in most cases. However, the average progesterone and estrogen concentrations in the suspected luteal phases were lower than in healthy women in the same age group.

Endocrine findings in rabbits after sterilization with electrocoagulation.

CO2 pelviscopy or laparotomy was performed on 370 New Zealand white rabbits and followed by coagulation of the distal uterine horns with unipolar or bipolar coagulation, endocoagulation or CO2 laser coagulation. After 1, 2, 4, 8 or 12 weeks, laparotomy was done. After a macroscopic description was done, photographic documentation and measurement of the destroyed area were done, and the uterine horns were excised. In addition to the normal histologic and electron microscope evaluation, 5 microns-thick cryostat sections were screened for the presence of nine enzymes. Progesterone levels were determined in 47 rabbits before and after stimulation with 50 IU HCG administered intravenously. As we reported at the Tenth Meeting of the American Association of Gynecologic Laparoscopists in 1981, we found a definite correlation between the type of coagulation technique and the extent of the destruction. The average progesterone levels of the animals coagulated with the monopolar high-frequency technique were significantly lower than in the endocoagulation, bipolar coagulation and control groups.

Pelviscopy/laparoscopy and its complications in Germany, 1949-1988.

The fourth German pelviscopy/laparoscopy statistical report includes survey data on a total of 219,314 laparoscopies from 354 clinics and 40,892 laparoscopies from 161 private practices. Clinics' response rate was 44.7%; 98.9% of them reported performing laparoscopies; and the number of serious complications requiring laparotomy or control laparoscopy was 492 (2.2/1,000). For private practices, the comparable figures were 66%, 90.8% and 123 (3/1,000), respectively. Compared with data from the third laparoscopy statistical survey, the data show a slight increase in serious complications, most of which were mechanical lesions of blood vessels in the abdominal wall or in the mesosalpinx, followed by mechanical lesions of the intestine. As shown by the previous survey, 16.5% of the complications were burns. For tubal sterilization, bipolar techniques were still predominant; approximately equal numbers of departments used this method, with or without subsequent transsection of the tubes. Endocoagulation by the method of Semm was the second most popular procedure; the use of clips and rings was of little significance. Monopolar high-frequency (HF) current was still used with transsection by 4.1% of clinics (4.7% of private practices) and without transsection by 2.5% (5.3%). Sterilization failure rates remained the same as those previously reported (4.6/1,000 in clinics, 5.3/1,000 in private practices); the highest rates were observed after the use of monopolar HF techniques. Sixty-six percent of the clinics and 41% of the private practices reported their intention to increase the use of endoscopic operational methods.

[Endoscopic intraabdominal surgery in gynecology]. / Endoskopische Intraabdominalchirurgie in der Gynäkologie.

Modern technique leads to abdominal surgery under "miniature" conditions. The combination of electrically monitored pneumaperitoneum, cold light optic, new mini-instruments, the newly developed hemostatic procedure "endocoagulation" (the patient is not in contact with the electrical current) and intraabdominal ligation techniques allows a new spectrum of operative procedures to be performed in gynecology. The following endoscopic gynecological operations have become routine: adhesions, ovario- and fimbriolysis, sharp and blunt opening of the ampulla tubae (sterility-operations), enucleation of pedunculated subserous myomas, conservative and radical tubal therapy of ectopic pregnancy, ovarian biopsy, ovarian cyst enucleation, ovarectomy ("3-sling-technique"), coagulation of endometriosis, tubal ligation. As examples of non typical gynecological operations in general surgery, omental adhaesiolysis, lysis of bowel adhesions and appendectomy can be mentioned. These new operative techniques have been developed in more than 10,000 pelviscopies. They stand for laparotomy in up to 80% of all cases in tubal and ovarian surgery. The complication rate lies in the area of 2%. Hospitalization has diminished by more than 50%, the period of reconvalescence by more than 75%.

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.

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.

25 years of laparoscopic surgery, personal reflections: problems in laparoscopy in the past and present.

Laparoscopy was developed by Kalk of Germany in 1929 as a routine procedure in internal medicine for diagnosis of liver diseases. Air was insufflated to create the pneumoperitoneum, and an electric lamp was placed at the end of the laparoscope to provide illumination of the abdominal cavity. Entrance into the peritoneal cavity was in the upper abdomen two finger breadths under the ribs. The danger of damaging the bowel by burning, etc. was very low. Previously laparotomized patients were considered an absolute contraindication for Laparoscopy. In 1946 Palmer, France turned the laparoscope from the upper abdomen to look into the lower abdomen. He called this technique Coelioscopy. It was used as for a diagnostic procedure mainly for the sterility patient in Gynecology. For coelioscopy Palmer used the same instruments as were used for Laparoscopy. The danger of burning bowel increased enormously as the protector of the upper abdomen, the omentum, was missing in the lower abdomen.

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.