Suprapubic percutaneous sclero-embolization of symptomatic female pelvic varicocele under local anesthesia.

PURPOSE: To evaluate the safety and feasibility of supra-pubic percutaneous sclero-embolization (SE) in the treatment of symptomatic female pelvic varicocele (FPV), performed under local anesthesia. MATERIALS AND METHODS: The authors selected 28 patients screened by transabdominal and transvaginal ultrasound, with venous Doppler signal. Clinicians performed SE by transfemoral catheterization, under local anesthesia, using of a mix of 2 ml of lauromacrogol 400 (Atossisclerol 3%, Chemische F. Kreussler, Wiesbaden, Germany) and 2 ml of air, in a mixed foam fashion. RESULTS: The total operative time for SE was 7.6 +/- 2.1 min. Intra-surgical blood loss was 40 +/- 14 ml. No migration of sclerosant material occurred and postoperative analgesic request during a 48 hr period occurred in 6 patients. Technical success was 100%. The Authors embolized 8 women bilaterally (28.5%), 18 on the left ovarian vein (OV) (64.2%) and 2 only in the right OV (7.1%): 7 women complained of transitory flank pain (25%), which disappeared in few minutes. The major complications in 10 days after SE were: fever (> 38 degrees C for two days) in 2 patients (7.1%) and pelvic pain for 3 days in eight patients (28.5%). After 30 days only 6 women suffered of FPV lower symptoms which disappeared in 180 days. A substantial reduction in size of pelvic varicosities was noted in all patients. CONCLUSIONS: SE is a safe and feasible procedure. It reduces significantly the mean time of scopies, the intensity of radiation emission, and it is performed under local anaesthesia. This minimally invasive procedure could be proposed to all women with supra-pubic FPV for its reproducibility and feasibility.

Operative culdolaparoscopy: a new approach combining operative culdoscopy and minilaparoscopy.

The tendency is to use small cannulas for operative laparoscopy; however, working with these cannulas may have technical limitations. We developed a technique for performing appendectomy combining culdoscopy and minilaparoscopy. It uses 3- or 5-mm abdominal cannulas, and the large 10- or 12-mm cannula is inserted into the posterior vaginal fornix under laparoscopic surveillance. The vaginal port is used to introduce operative instruments and extract specimens, and for vision. Culdolaparoscopy avoids additional or large abdominal ports, thus overcoming limitations of small cannulas.

Culdolaparoscopy: a preliminary report.

OBJECTIVE: To introduce a surgical technique that combines culdoscopy with laparoscopy and microlaparoscopy. METHODS: This was a feasibility study conducted at The Mount Sinai Hospital of Queens. The technique is used when a larger port is required during laparoscopy or microlaparoscopy procedures. The additional port is placed in the vagina and, under laparoscopic surveillance, into the posterior cul-de-sac. RESULTS: This operation has been performed successfully in 5 oophorectomies, 4 myomectomies, 3 salpingoophorectomies, and 1 salpingectomy. CONCLUSION: This technique reduces the need for abdominal ports in excess of 5 mm. These ports can have a visual or operative function depending on the nature or stage of the procedure. The vaginal port can serve a visual function similar to that of culdoscopy or may be used for the introduction of operative instruments and the extraction of specimens. A principal benefit of using the larger vaginal port is derived from the capability of assisting laparoscopy and allowing the surgeon to use fewer and smaller abdominal trocars.

Laparoscopic myomectomy in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome.

A 36-year-old woman had primary amenorrhea, pelvic pain, Mayer-Rokitansky-Kuster-Hauser syndrome, and an 8.5-cm, solid pelvic mass. The leiomyoma uteri was removed laparoscopically from the vestigial mullerian duct with secondary vaginopoiesis. The patient had a satisfactory clinical outcome. Finding of a leiomyoma in a patient with Rokitansky syndrome is rare. To our knowledge this is the first such case in which the myoma was removed by laparoscopy.

Laparoscopic leash: a simple technique to prevent specimen loss during operative laparoscopy.

BACKGROUND: Surgical specimens can be lost in the peritoneal cavity during operative laparoscopy. Although specimens left might cause no complications, peritonitis and adhesion formation have been reported, requiring subsequent laparoscopy or laparotomy. We report a simple technique to prevent loss of surgical specimens during laparoscopy. TECHNIQUE: A suture is placed through the specimen, and the trocar sleeve is removed. Free ends of the suture are held with a clamp outside the abdomen while the port is reinserted into the abdomen. The suture is pulled to see the specimen when necessary. When morcellation is required, the leashed area of the specimen is the last to be extracted. This procedure takes less than 2 minutes. EXPERIENCE: We have used this technique for longer than 1 year for 18 myomectomies and seven bilateral salpingo-oophorectomies. No specimens were lost in the peritoneal cavity, and there were no complications related to the procedure. CONCLUSION: The laparoscopic leash is a simple and reproducible preventive technique that adds insignificant time to operations but saves much time that might be wasted localizing a misplaced specimen.

Laparoscopic techniques for extracting ovarian teratomas.

We performed two techniques for laparoscopic extraction of benign ovarian teratomas. For cysts up to 5 cm, we used the pouch technique, with partial extraction followed by enlargement of the hypogastric port. A skin incision was enlarged to allow the use of a scalpel in the pouch. This enabled us to perform several stab incisions in the cyst to spill its contents while still holding it in the pouch. This was followed by suction irrigation and forceps removal of the contents until the collapsed cyst could be removed in the pouch. For a cyst over 5 cm, we performed endoscopic aspiration irrigation with hot water inside the cyst, followed by partial extraction of the cyst; an opening was made in the exposed cyst wall and the contents extracted as described. When the cyst wall collapsed, we proceeded with the final extraction. When spillage occurred, it was managed with extensive warm lavage of the peritoneum, skimming the floating debris with suction tubing until clear, and underwater inspection and removal of teeth and other solid material. With these techniques, we experienced no complications.

Laparo-vaginal treatment of uterine procidentia.

The following is a description of a combined vaginal and laparoscopic repair of vaginal eversion with uterine prolapse (procidentia). There are few procedures that seek to correct the condition while preserving vaginal function. Among them are (1) vaginal approach for sacrospinous fixation, (2) abdominal sling procedures, and (3) abdominal and laparoscopic approaches for promontorial fixation. We are presenting a technical report of a modified sling procedure done via laparoscopy. This technique achieves the functional vaginal reconstruction and avoids the potentially dangerous bleeding associated with the sacral fixation. It has also been our experience that the sacrospinous fixation technique affords limited visual exposure, and henceforth the laparoscopic vaginal sling procedure may be a better alternative.

Laparoscopic and hysteroscopic approach for tubal anastomosis.

The laparotomy approach for microsurgical repair of tubo-tubal anastomosis is a well-established method. This article describes a novel technique of end to end tubo-tubal re-anastomosis using the minimally invasive methods of video laparoscopy, video hysteroscopy, and lasers in four women. This procedure is applicable to women of reproductive age who have previously been subjected to voluntary sterilization procedures. The long-term results of this new technique remain to be evaluated. However, the minimal surgical approach has met with early success and patient approval.

PIP: The laparotomy approach for microsurgical repair of tubo-tubal anastomosis is well-established. A novel technique of end-to-end tubo-tubal re-anastomosis using the minimally invasive methods of video laparoscopy, video hysteroscopy, and laser in 4 women in described. All 4 women were of reproductive age, had been sterilized, and wanted a reversal of sterilization. A traditional work-up was performed on each involved couple. When possible, a hysterosalpingogram was done. The procedure was performed during the proliferative phase shortly after menses. The patients were given a bowel prep with a liquid diet for 2 days; a laxative was given the day before surgery and laminaria medium thick was inserted into the cervix. The patient received iv antibiotics immediately before operation, and general anesthesia was used. After induction, the laminaria was removed, pelvic examination performed, and a uterine cannula was inserted for manipulation and perturbation. If tubal occlusion was to be established, normal saline was injected via the uterine cannula. If peritoneal spillage occurred, the tubes were patent. As no spillage occurred, tubal occlusion was confirmed. The tubes were then observed to see if an endoscopic tuboplasty could be performed. The tube was cannulated through the fimbria, and the catheter was passed until it bordered the level of the obstruction. The blocked end was then cut, utilizing a laparoscopic scissor and bipolar coagulation for bleeders. Occlusions secondary to sterilization procedures cannot be undone via hysteroscopy, falloscopy, or other glide wire techniques. Such patients were candidates for in vitro fertilization of laparotomy with microsurgical repair. The minimal surgical approach has met with early success and patient approval. The longterm results of this technique remain to be evaluated.