Spigelian hernia in gynaecology.

BACKGROUND: A Spigelian hernia is a rare hernia through the Spigelian fascia between the rectus muscle and the semilunar line. This hernia is well known in surgery. Symptoms vary from insidious to localised pain, an intermittent mass and/or a bowel obstruction. RESULTS: The Spigelian hernia is poorly known in gynaecology. Spigelian hernias may be causally related to secondary trocar insertion. This review is written to increase awareness in gynaecology and is illustrated by a case report in which the diagnosis was missed for 4 years even by laparoscopy. Smaller hernias risk not to be diagnosed and will thus not be treated. Even larger Spigelian hernias might not be recognised and treated appropriately. CONCLUSIONS: The gynaecologist should consider a Spigelian hernia in women with localised pain in the abdominal wall lateral of the rectus muscle some 5 cm below the umbilicus. Smaller hernias can be closed by laparoscopy without a mesh. Larger hernias require a mesh repair.

Italian multicenter study on complications of laparoscopic myomectomy.

STUDY OBJECTIVE: To study intraoperative and postoperative complications of laparoscopic myomectomy and patients' characteristics influencing this risk. DESIGN: Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2). SETTING: Four Italian referral centers. PATIENTS: The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded. INTERVENTIONS: The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally. MEASUREMENTS AND MAIN RESULTS: Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 +/- 1.8, mean +/- SD). Myoma size ranged from 1 to 20 cm (mean 6.40 +/- 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 +/- 23.03 months (mean +/- SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001). CONCLUSIONS: This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

Laparoscopic myomectomy: a report of 982 procedures.

We have reported the experience of two referral laparoscopic gynecologic centers in Italy considering the results of almost 1000 laparoscopic myomectomies, including complication rate and fertility outcome. From January 1991 to December 2003, a total of 982 single or multiple laparoscopic myomectomies (LM) were performed. Indications were infertility, recent and significant uterine enlargement, and other symptoms such as pelvic pain, menometrorrhagia, and abnormal bleeding. All surgical procedures were performed by three surgeons in two different endoscopic centers. Surgery outcome and information about subsequent fertility and obstetric outcome were reported. Myomectomies were performed using a standard technique with three ancillary suprapubic ports. In cases of deep intramural myomas, we injected the myomas with vasoconstrictive agents. A vertical incision of the serosa was made and mechanical enucleation of the myomas was performed whenever possible. A suture in one or two layers with large, curved needles (CT 1, 30 mm) swaged to polyglactin 1 or 0 sutures was performed. Extraction of the removed myomas took place with electric morcellation. Most patients (47%) had more than one myoma, with a maximum of eight per patient (average myomas removed for patients: 2.23). Myoma size ranged from 1 cm to 20 cm (average 67.20 mm +/- 27.1 mm). Most of the myomas (75%) were intramural. The average drop in hemoglobin concentration was 1.06 g +/- 0.86 g/100 ml. The duration of the entire procedure ranged from 30 min to 360 min with a mean of 104.5 min. The conversion rate to laparotomy was 1.29% and no major intraoperative complications occurred. The mean postoperative hospital stay was 2.02 days +/- 0.61 days and we had three serious postoperative complications. The overall rate of intrauterine pregnancy following LM was 62.53% and the abortion rate was 15.9%. Data suggest that laparoscopic myomectomy is a safe and reliable procedure, even in the presence of multiple or very enlarged myomas, with a low complication rate and satisfying long-term results.

Optimizing the total laparoscopic hysterectomy procedure for benign uterine pathology.

STUDY OBJECTIVE: To evaluate the influence of the learning curve in total laparoscopic hysterectomy on short- and long-term clinical results. DESIGN: Retrospective comparative analysis (Canadian Task Force classification II-2). SETTING: Malzoni Medical Center of Avellino, university-affiliated hospital. PATIENTS: Three hundred and ninety-six women in the first time period (1997-1999) and 624 women in the second time period (2000-2002) were treated, using different techniques, by the same surgeon. Patients suffered from symptomatic myomas and uterine fibromatosis. No case was considered suitable for a vaginal procedure. INTERVENTION: Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: No statistical differences were found between the two groups for patient age, parity, body mass index, and indications for surgery (p = NS), except for uterine weight (395 g vs. 408 g; p <.01). In the first time period, the average operating time was 105 +/- 27 minutes (range, from 65-190). In the second time period, the average operating time was 80 +/- 21 minutes (range, 45-170) (p <.001). The postoperative hemoglobin drop was 1.44 g/dL (range, 0.8-6.1) and 1.39 g/d (range, 0.7-4.3) in the first series and second series, respectively (p = NS). In the first series, the mean postoperative hospital stay was 2.4 +/- 1 days (range, 2-7). In the second series, the mean postoperative hospital stay was 2.3 +/- 1 days (range, 2-6). A significant decrease in short-term complications occurred between the first and second time period, 7.7% and 5.55% respectively (p <.03). We performed three (0.75%) and four (0.6%) conversion to laparotomy procedures, respectively, in the first and second groups (p = NS). During the first period, two reoperations were necessary; in the second period, one patient (0.15%) required a reoperation (p = NS). The rate of postoperative blood transfusion was 0.5% (n = 2) in the first period versus 0.15% (n = 1) in the second period (p = NS). Significant decrease of long-term complications occurred between first and second series, 2.0% and 0.45% respectively (p <.05). There were no differences between the two groups regarding sexual symptoms p = NS). CONCLUSION: Laparoscopic hysterectomy is a safe, effective, and reproducible technique after completion of a period of training necessary to standardize the procedure. The results support the importance of optimizing some steps of the surgical technique to reduce severe complications.