Reduction of postoperative adhesion formation after laparoscopic ovarian cystectomy.

The purpose of this randomized, open-label study was to assess the efficacy of the product Interceed absorbable adhesion barrier in the prevention of adhesion formation on the ovary after laparoscopic ovarian cystectomy. A total of 25 patients requiring laparoscopic bilateral ovarian cystectomy were enrolled into this study. After removal of ovarian cysts, peri-adnexal adhesions, and peritoneal irrigants, and the attainment of meticulous haemostasis, the random assignment of one ovary for wrapping with Interceed was revealed to the surgeon. The other ovary served as the untreated control. A follow-up laparoscopy was performed 8-30 weeks after the initial procedure in 17 patients. Significantly fewer adhesions formed at the Interceed treated ovaries compared with the control (untreated) ovaries (P < 0.05). In terms of adhesion-free outcome, 76% (13/17) of Interceed treated ovaries and 35% (6/17) of control ovaries were free of adhesions. A significant reduction was observed in the area of the sutured ovaries involved with adhesions when Interceed (6%) was used, compared with controls (20%). The reduction of adhesion formation was not related to the size of the cysts at the initial procedure. No adverse events were reported by any patient during the study. In conclusion, Interceed was found to be safe and effective in reducing the incidence of postoperative adhesion formation in patients undergoing laparoscopic ovarian cystectomy.

Endoscopic Nd:YAG Laser Coagulation of Intramural Endometriosis of the Bladder

Treatment of intramural endometriosis of the bladder using the Nd:YAG laser is described. An operative cystoscope fitted with a 600 µ fibre is introduced into the bladder. At a power setting of 50 W, superficial coagulation of the visible lesion is performed. The coagulation technique corresponds to that used for the treatment of superficial bladder carcinomas. Three patients were managed in this way. In all patients dysuria and hematuria either significantly decreased or disappeared altogether. No intraoperative complications were observed. This new technique appears to be superior to surgical excision techniques, especially in cases where the lesion is situated on the roof of the bladder. Further studies need to be conducted to compare results obtained from this technique with those of the CO2 laser or excision technique.

Laparoscopic Myomectomy: Sonographic Follow-Up and Second-Look Laparoscopy for the Evaluation of a New Technique

Between 1988 and 1993, 100 women underwent laparoscopic myomectomy in the Department of Obstetrics and Gynecology of the University of Ulm. Indications varied, although most myomectomies were done for fertility enhancement or preservation. Closure of the incision, especially with an open uterine cavity, was done in two or three layers. Several technical limitations specific to laparoscopic surgery impair complete and satisfactory closure of the myomectomy incision. In this study we evaluate the new technique by sonographic control and second-look laparoscopy. In 22 cases second-look laparoscopy was undertaken to assess post-operative adhesion formation and to effect adhesiolysis. The rate of adhesion formation was 28%, depending on site, size, and number of myomas. Adhesion formation was significantly higher (p<0:005) in myomas located on the posterior wall. The density of adhesions did not vary significantly. In 22 cases sonography was done preoperatively, one day after the operation and 6 weeks postoperatively to compare wound healing, depending on myoma site and size. In 74% of cases an intramural hematoma of varying size was observed. By the third control, 6 weeks later, an irregular hypodense area was seen in only 8%. This study demonstrates that laparoscopic myomectomy entails the risks of postoperative adhesion formation and impaired wound healing, including intramural hematoma. So far no data are available showing a correlation between these risks and post-operative infertility or higher incidence of uterine rupture.

Laparoscopic Treatment of Distal Tubal Occlusion-Reocclusion and Pregnancy Rate

There is still controversy about the question of which approach is best to treat tubal infertility: microsurgery, laparoscopic treatment, or in vitro fertilization. Our study comprised 161 patients with distal tubal occlusion. Various instruments (argon laser, CO2 laser, Nd:YAG laser, monopolar electrical needle, scissors) were used for laparoscopic salpingostomy, and a variety of techniques applied for tubal wall eversion (flowering technique according to Bruhat with and without suturing, suturing alone, or no eversion at all). Thirty-seven women with a total of 63 laparoscopically treated tubes were followed over a period of 2-72 months. Tubal patency was 38.9%. The reocclusion rate correlated with severity of tubal wall pathology and state of reduction of the tubal mucosa. After laser treatment tubal patency proved to be higher (41.1%) compared with treatment with conventional instruments. The Argon laser scored best results. The majority of patent tubes in the follow-up were found in the cohort with "perfect" and "good" eversion (95.8%), whereas none of the tubes where eversion was classed "insufficient" remained patent. The technique according to Bruhat without the use of additional suturing yielded better results regarding tubal patency (66.6%) than the other eversion methods described (33.4%). The pregnancy rate could be assessed in 81 out of 161 laparoscopically treated cases. A total of 19 patients (23.3%) became pregnant. In 9.8% pregnancy was intrauterine and in 13.5% extrauterine. The highest intrauterine and lowest extrauterine pregnancy rate was seen in the group with "mild" distal tubal occlusion (according to AFS classification). In 84.2% of women who had conceived postoperatively, tubal wall eversion had been done by the Bruhat technique without suturing. Taking into account tubal wall pathology, tubal patency, eversion techniques, and rate of intrauterine pregnancies, it can be concluded that patients with thin-walled tubes allowing "perfect" or "good" eversion will benefit most from laparoscopic salpingostomy.

Laser techniques in gynaecology.

Lasers have been in use for 15 years in laparoscopic surgery. The CO2-laser in particular has become very popular in the field of gynaecology for the treatment of endometriosis and adhesions. Results achieved with the CO2-laser seem to be superior to those of conventional instruments, although only a small number of randomised prospective studies exist. Fibre lasers, such as the Nd:YAG-, KTP, and Argon-lasers combine vaporisation- and/or coagulation-effects within the same operating instrument. Time-consuming changes of instruments during the procedure are unnecessary. Nevertheless, technical problems and high costs of these laser systems on the one hand, and unfulfilled and unrealistic expectations by physicians and patients alike on the other hand hinder wide-spread use of this technique.