Comparison of salpingectomy and tubal detorsion procedures after experimental ischemia-reperfusion injury in a rat fallopian tube model: biochemical and histopathological evaluation.

OBJECTIVE: To compare salpingectomy and detorsion procedures and investigate the biochemical and histopathological changes in the fallopian tubes in the experimentally isolated fallopian tube torsion model in rats. DESIGN: Experimental study. SETTING: Experimental surgery laboratory in a training and research hospital. ANIMAL(S): Twenty-seven Sprague-Dawley rats in the reproductive period. INTERVENTION(S): Group 1, control group (n = 6); group 2, bilateral total salpingectomy group after 4 hours of tubal ischemia (n = 7); group 3: 4 hours of bilateral tubal ischemia plus 1 week of reperfusion (n = 7); and group 4, 4-hour period of bilateral tubal ischemia plus 30 days of reperfusion (n = 7). A 22-gauge catheter was administered before and after surgery using methylene blue through the uterine horn of the rat to evaluate tubal patency. MAIN OUTCOME MEASURE(S): Preoperative and postoperative serum antimüllerian hormone (AMH) levels, histopathological examination of the rat tuba uterine and histopathological damage scores, antioxidant compounds (superoxide dismutase [SOD], catalase, and glutathione peroxidase [GSH-Px]), and oxidative stress end product levels (malondialdehyde [MDA] and 8-hydroxy-2'-deoxyguanosine [8-OHdG]). RESULT(S): Although a significant difference was observed in the tissue SOD, GSH-Px, MDA, and 8-OHdG values, no significant difference was observed between the groups in serum samples. The tissue SOD and tissue GSH-Px levels in group 2 significantly decreased, and a significant increase was observed in the tissue MDA and 8-OHdG values in group 2. Among the histopathological parameters, epithelial changes, vascular congestion, and the total fallopian tube mean damage score of 4 showed a significant decrease in group 4. When the methylene blue transitions before and after ischemia-reperfusion injury were compared, the values of the methylene blue transition after ischemia-reperfusion injury in groups 2-4 significantly decreased. When the serum AMH levels were analyzed, the postoperative AMH value in group 2 significantly increased. CONCLUSION(S): This study reveals that biochemical and histopathological improvement is observed in the fallopian tube tissues gradually when the detorsion procedure is performed for the necrotized tubal tissue instead of salpingectomy. Although there is restoration of epithelial integrity after reperfusion, tubal passage remains absent. CLINICAL TRIAL REGISTRATION NUMBER: This study was approved by the Local Ethics Committee for Animal Experiments of the Health Sciences University, Istanbul Hamidiye Medicine Faculty (approval number 27.05.2022-9269). The study followed the ethics standards recommended by the Declaration of Helsinki.

Current Management of Gynecologic Trauma.

INTRODUCTION: To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. OBJECTIVE: Describe the injury patterns and the preferred management of these injuries. METHODS: A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. RESULTS: 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. CONCLUSIONS: Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.

Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis.

OBJECTIVE: To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols. DATA SOURCES: PubMed, Embase, and the Cochrane library searched up to July 2018. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that compared women with ectopic pregnancies receiving the single-dose, two-dose, or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS: Odds of treatment success, treatment failure, side effects, and surgery for tubal rupture, as well as length of follow-up until treatment success, were compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in the groups with high human chorionic gonadatropin (hCG) values and a large adnexal mass, as defined by individual studies. The Cochrane Collaboration tool was used to assess risk of bias. RESULTS: The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00). The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9). The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant. The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, -12.2, -3.5). The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30). Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13) and a higher chance of side effects (OR, 2.10; 95% CI, 1.24, 3.54). The odds of surgery for tubal rupture (OR, 1.62; 95% CI, 0.41, 6.49) and time to follow-up (OR, -1.3; 95% CI, -5.4, 2.7) were similar. CONCLUSION: The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and a large adnexal mass.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma.

PURPOSE: Pelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. RESULTS: Of 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67-7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43-9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14-0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19-0.72, p < 0.001) compared to those managed nonoperatively. CONCLUSION: In the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.

Imaging findings in Essure-related complications: a pictorial review.

Tubal sterilization with Essure inserts has become a prevalent alternative to laparoscopic sterilization because of its minimal invasiveness. It is a well-tolerated ambulatory procedure that provides reliable permanent contraception without the risks associated with laparoscopic surgery and general anesthesia. Correct positioning of the Essure device is necessary to achieve the fibrotic reaction induced by the polyethylene terephthalate fibers, subsequently resulting in tubal occlusion usually within 3 months. After uneventful procedures with satisfactory bilateral placement, only the correct position of the devices needs to be confirmed at follow-up. The imaging techniques used to asses Essure devices may vary depending on the country and its recommendations. The gold-standard test to ascertain tubal occlusion remains the hysterosalpingography but after uneventful procedures, vaginal-ultrasound proved to be a reliable alternative to confirm the proper position of the inserts. Radiologists have been increasingly confronted to post-procedural evaluations and despite the efficiency rate of the Essure device, its use still exposes to a low risk of complications and malfunctions such as unwanted pregnancies, device misplacement, tubal or uterine perforation, and chronic pelvic pain. Unintended pregnancies are mostly due to patient or physician non-compliance and misinterpretation of post-procedural examinations by radiologists which emphasizes the importance of their training in Essure device assessment. This pictorial review discusses the imaging methods used to asses Essure implants and illustrates the possible complications related to them.

Acute intestinal obstruction due to extrinsic compression by previa myoma and ectopic pregnancy: a case report.

BACKGROUND: Acute intestinal obstruction during pregnancy is a rare digestive surgical emergency with significant maternal and fetal mortality. Diagnosis is difficult, often delaying the management. Here, we report an exceptional association of mechanical acute intestinal obstruction due to compression by previa uterine leiomyoma, and a ruptured ectopic pregnancy. CASE PRESENTATION: This is the case report of a 43-year-old primiparous black woman from a rural area, who was admitted to the surgical emergency department for acute intestinal obstruction. At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days. A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area. A rectal examination found an empty rectum, and the mass was perceptible in Douglas's pouch. At the vaginal examination, we found the same mass and a finger holster was clean. The diagnosis of intestinal occlusion by a tumor was retained. The laparotomy revealed a distended intestine, a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge. A total hysterectomy was performed and histopathological examination of specimens confirmed myoma and ectopic pregnancy. The surgical follow-up was uneventful, and our patient was discharged on postoperative day 12. CONCLUSIONS: The etiological diagnosis of acute intestinal obstruction during pregnancy is not easy, especially in the context of a low-income country where the means of biological and radiological diagnosis are lacking. A laparotomy is required before diagnosis of acute surgical abdomen and its management will depend on the intraoperative findings and the condition of the patient.

Regeneration of the Fallopian Tube Mucosa Using Bone Marrow Mesenchymal Stem Cell Transplantation After Induced Chemical Injury in a Rat Model.

In this study, we describe a novel insight about the use of bone marrow-derived mesenchymal stem cells (BM-MSCs) for fallopian tube (FT) regeneration. Seventy rats' tubes were involved in this study and divided into 4 groups: control (15), ethanol injured (20), mesenchymal stem cell (MSC)-recipient without injury (15), and MSC recipient after injury (20). The BM-MSCs were isolated from male rats, and their incorporation into the tissues was confirmed by the detection of Sry gene in MSC-recipient rats using RT-PCR. Histological and immunohistological sections of the 4 groups were comparably evaluated. We found that direct injection of ethanol into FT caused structural impairment, which was restored largely after receiving MSCs. We have revealed for the first time that prominin 1 (Prom1, stem cell marker) was expressed in the fimbriated distal tubal end. The MSC transplantation caused (1) significant increase in the tissue level and immunoexpresstion of Prom1 ( P < .001 and P = .017, respectively) and vascular endothelial growth factor (VEGF; vasculogenic marker; P < .001 and P = .004, respectively), (2) significant increase in the immunoexpresstion of proliferating cell nuclear antigen (PCNA; proliferation marker; P < .001), and (3) significant decrease in the immunoexpresstion of caspase 3 (CASP-3; apoptotic marker; P < .001) compared to the injured tissues. In conclusion, MSCs could exhibit its restorative effect on FT through their ability to (1) activate the resident stem cells in the distal tubal end, (2) mediate the expression of VEGF and PCNA, and (3) influence tissue apoptosis. This study laid the foundation for assessing the contribution of stem cells in the distal tubal end in direct repair of the tube when required to assist reproduction.

A new tubal classification system for fertility prognosis after laparoscopic salpingostomy for tubal pregnancy.

OBJECTIVE: To assess the objectivity and accuracy of a new system that predicts the pregnancy outcomes in patients with tubal pregnancy after laparoscopic salpingostomy. STUDY DESIGN: 480 tubal pregnancy patients were retrospectively stratified as mild, moderate, or severe group according to the new tubal classification system in which pelvic adhesions, tubal morphology, structure, and patency were included. The follow-up was performed for 24 months to determine spontaneous pregnancy outcomes. RESULTS: The tubal classification was significantly associated with intrauterine pregnancy rates (mild 70.9% vs. moderate 66.0% vs. severe 41.8%, P=0.001) and recurrent ectopic pregnancy rates (mild 2.8% vs. moderate 4.2% vs. severe 10.9%, P=0.047). The 24-month cumulative rate of intrauterine pregnancy was 73.5% in the mild group, 68.5% in the moderate group, and 45.8% in the severe group (P=0.002). The 24-month cumulative repeat ectopic pregnancy rate was 6.6% in the mild group, 9.1% in the moderate group, and 15% in the severe group (P=0.154). In Cox multivariate regression analysis, a lack of a history of infertility [hazard ratio (HR)=0.633, P=0.001] and tubal scoring (mild HR=2.408, P=0.008; moderate HR=2.147, P=0.010) were significantly associated with a higher rate of spontaneous intrauterine pregnancy. Having a history of infertility (HR=0.351, P=0.037) and no prior abdominopelvic surgery (HR=2.907, P=0.014) were significantly associated with a lower ectopic pregnancy rate. CONCLUSION: The new tubal classification system significantly correlated with spontaneous pregnancy outcomes in patients with tubal pregnancy following laparoscopic salpingostomy.

Patient Outcomes Following Injury from Hysteroscopic Sterilization.

OBJECTIVE: We present clinical data on two patients who underwent hysteroscopic sterilization (HS) 11 years apart using the Essure® (Bayer Inc., Whippany, NJ) device. MATERIALS AND METHODS: Symptoms and resolution are described for symptomatic Essure® patients. RESULTS: Case 1 (G3P1) underwent HS in 2004 at age 21. Performed in a physician's office without anesthesia, HS involved placement of >2 Essure® devices which was followed by severe, unrelenting pelvic pain. Confirmatory hysterosalpingogram (HSG) three months after HS revealed five devices. Surgical costs for laparoscopic assisted vaginal hysterectomy (LAVH) were fully reimbursed by the device manufacturer seven months later. Case 2 (G8P4) underwent HS in 2015 at age 32. One year earlier, the patient's right fallopian tube was removed due to ectopic pregnancy. Essure® devices were placed bilaterally in a physician's office without anesthesia; HS was accompanied by sharp pelvic pain. The patient obtained HSG three weeks after HS due to constant discomfort. Bilateral tubal occlusion was verified, but abnormal device loop configuration suggesting myometrial penetration was noted on the right. At laparoscopy, the left Essure® device was excised intact but the right coil could not be located. Thus far, there has been no offer in Case 2 from the device manufacturer to offset medical expenses. CONCLUSIONS: While HS has been FDA approved for use in the United States since 2002, this is the first description of clinical sequela when FDA labeling for the Essure® procedure is ignored. These cases illustrate the importance of proper physician training in HS and underscore the need for improved tracking of Essure® associated symptoms.

Serous tubal intraepithelial carcinoma, chronic fallopian tube injury, and serous carcinoma development.

Ovarian carcinoma is the deadliest gynecological malignancy. Previous studies have suggested that the fallopian tube may be the primary site for high-grade serous carcinoma. In prophylactic salpingo-oophorectomies from women with hereditary high risk for ovarian cancer, precursors can be assessed prior to onset and studied as a model for serous cancer precursor lesions. Epidemiologic studies indicate that carcinogenesis may be a result of chronic fallopian tube injury. The aims of this study were to (1) to examine the incidence of serous tubal intraepithelial carcinoma (STIC) in relation to other clinical parameters and (2) to evaluate whether chronic fallopian tube injury was related to cancer development. This study enrolled 101 women, comprising the following three groups: hereditary (n = 60), sporadic serous cancer (n = 18; endometrial cancers were excluded), and control (n = 23). The cases were histologically examined and clinical risk factors were collected. The histological changes were compared between different patients and correlated to clinical risk factors. STICs were identified primarily on the fallopian tube fimbria. The incidence of STIC was 3 % in the hereditary patients. In sporadic serous cancer cases, 61 % were associated with STIC and tubal carcinoma (p < 0.001). No differences in tubal injury or inflammation were seen when comparing the sporadic serous cancer group and the control group or within the hereditary group. STIC and invasive cancer were seen more often in the older patients than in the younger patients (p = 0.528). This small study, no correlation with chronic tubal injury or inflammation was identified.

Management of perforated essure with migration into small and large bowel mesentery.

The Essure permanent birth control system (Conceptus Inc, San Carlos, CA) is currently the only Food and Drug Administration-approved hysteroscopic sterilization method and has been widely accepted as a safe and effective procedure. We present a rare case of tubal perforation, coil fragmentation, and distal migration into small and large bowel mesentery 8 days after the insertion of the Essure device. We describe the successful management of this complication using laparoscopy and intraoperative fluoroscopy. Providers using Essure must be aware of the possibility of fragmentation of the Essure coils. Intraoperative imaging, ideally fluoroscopy, should be strongly considered in the management of Essure migration to ensure localization and full retrieval of Essure material.

Novel reversible permanent contraception: an animal experiment of embedding contraceptive surgery in the fimbriated extremity of the fallopian.

AIM: According to female pelvic anatomical characteristics, we designed a novel reversible permanent contraception: embedding contraceptive surgery in the fimbriated extremity of the fallopian. This study involves embedding the oviduct of New Zealand rabbits into the peritoneum, and assesses contraceptive effect, morphological changes and recoverability. METHODS: Thirty New Zealand rabbits were divided into three groups: embedding in the fimbriated extremity of the fallopian group (A group); polyethylene film in the fimbriated extremity of the fallopian group (B group); and control (C group). Surgery was performed in each group, respectively. Contraceptive efficacy, morphological changes and recoverability were noted. RESULTS: As for contraceptive effect, mating experiences were successful. After 3 months, there were no pregnant rabbits in group A and B, while in group C all samples were pregnant. Regarding recoverability, after belly operation, 10 rabbits in group A showed dropsy in the bilateral oviducts. Tissue adhesion could be found in the fimbriated extremity of the fallopian with a large range of damage. All samples in group B also had dropsy, but only two of them had unilateral slight adhesions in the fimbriated extremity of the fallopian, while others had no pathological changes. After being released from the oviduct embedding, five rabbits in group A became pregnant and nine in group B. CONCLUSION: Embedding contraceptive surgery in the fimbriated extremity of the fallopian after being covered by polyethylene film is reliable and safe. Releasing the embedding may cause minor injury. Although there is a problem of hydrosalpinx, the pregnancy rate is high.

[Interest of 3D ultrasound in the follow-up of tubal sterilizations: case report of a rare tubal perforation]. / Intérêt de l'échographie en 3 dimensions dans le suivi des stérilisations tubaires : à propos d'un cas rare de perforation.

The Essure™ system's effectiveness is based on the follow-up at three months. The challenge is to find a minimally invasive imaging technique to locate the devices. Therefore, many authors recommend three-dimensional ultrasound in first-line. We report here an exceptional case of tubal perforation for which ultrasound failed to diagnose. Until then, only three cases have been reported in the literature, noting the difficulty to diagnose this complication. Indeed, although ultrasound is described as reliable, reproducible and non-radiating, it is a dynamic examination, operator dependent, exposing to the risk of misinterpretation.

[Permanent tubal hysteroscopic sterilization]. / Contraception permanente par pose hystéroscopique d'implants tubaires.

Tubal sterilization, of common practice all over the world, has had a quick spread in France since its legalization in 2001 and the income of a new hysteroscopic method. As a matter of fact, France is the second greater country for women having Essure® and the first country where Essure® method forestall surgical tubal ligation. Thus we focus on good practice and update knowledge about Essure® method.

A kink is not always a perforation: assessing Essure hysteroscopic sterilization placement.

OBJECTIVE: To highlight the fallacy of using a kink in the microinsert outline on plain abdominal x-ray as a marker for tubal perforation. DESIGN: Case report. SETTING: West London District general hospital. PATIENT(S): 36-year-old Asian woman requesting permanent sterilization. INTERVENTION(S): Essure hysteroscopic sterilization followed by abdominal x-ray, pelvic ultrasound, and laparoscopy. MAIN OUTCOME MEASURE(S): Absence of tubal perforation. RESULT(S): A patient presented with clinically suspected fallopian tube perforation 3 days after Essure hysteroscopic sterilization. Her transvaginal scan was inconclusive, but the plain x-ray demonstrated a kink within the left microinsert outline. Diagnostic laparoscopy did not identify a perforation, and bilateral tubal placement was confirmed after salpingectomy. CONCLUSION(S): This case highlights the difficulty of relying on imaging in the acute setting to establish a diagnosis of tubal perforation after hysteroscopic sterilization.

Predictive factors of Essure implant placement failure: prospective, multicenter study of 495 patients.

OBJECTIVE: To assess a new hysteroscopic method of tubal sterilization; specifically, to examine the factors associated with placement failure of Essure implants. DESIGN: Observational, multicenter, 6-month study. SETTING: Seven gynecology clinics, including five public hospitals and two private clinics, in France. PATIENT(S): A total of 495 women who provided informed consent. INTERVENTION(S): All procedures were done by a vaginoscopic approach with a 5-mm operating hysteroscope. MAIN OUTCOME MEASURE(S): Data collected were age, parity, type of anesthesia, premedication, endometrial aspect, ostia visualization, duration of the procedure, pain during the procedure, and associated procedures. Unilateral and bilateral placement rates were assessed. Adverse events at 3 months (expulsion, migration, perforation) were also recorded. RESULT(S): Mean parity was 2.45; 20 women were nulliparous. In 56.3% of cases (n = 277), none or local anesthesia was used for the placement procedure. Overall, 86% of the women (n = 423) had nonsteroidal anti-inflammatory drug (NSAID) premedication, and 8.1% (n = 40) had another intrauterine surgical procedure performed at the same time. In 24 cases, at least one of the tubal ostia could not be visualized well during hysteroscopy. CONCLUSION(S): The failure rate for Essure micro-insert placement was 6% at first attempt and 3.3% after two attempts. Success rate was not significantly associated with parity, mode of analgesia, NSAID premedication, or combination with another procedure. The only factor significantly associated with the failure rate was poor visualization of the tubal ostia.

Unintended pregnancies after Essure sterilization in the Netherlands.

OBJECTIVE: To analyze the data of cases of unintended pregnancies after Essure sterilization. DESIGN: Retrospective case series analysis. SETTING: National multicenter. PATIENT(S): Ten cases of unintended pregnancies after Essure sterilization in the Netherlands were reported from August 2002 through May 2008. INTERVENTION(S): Data on the hysteroscopic Essure sterilization procedures and postprocedure confirmation tests of the reported cases were reviewed and analyzed by two authors. The causes of the unintended pregnancies were determined in agreement with the physicians who performed the sterilizations. MAIN OUTCOME MEASURE(S): Most pregnancies occurred in patients with only one device placement and bilateral occlusion on hysterosalpingography (HSG). Other cases included misinterpretation of HSG, undetected abnormal device position by ultrasound, one undetected preprocedure pregnancy, and two patient failures to follow up with the physician advice. CONCLUSION(S): The risk of pregnancy after hysteroscopic sterilization may be reduced by strictly following the follow-up protocol, performing a urinary pregnancy test on the day of the procedure, and instructing the patient to return for the follow-up visit. A procedure with only a single device placement in a patient without a history of tubectomy of the heterolateral tube should be considered unsuccessful.

Laparoscopic completely extraperitoneal repair of inguinal hernia in children: a single-institute experience with 1,257 repairs compared with cut-down herniorrhaphy.

BACKGROUND: Conventional open herniorrhaphy in children has been reported to have 0.3-3.8% recurrence and 5.6-30% postoperative contralateral hernia rates. We developed a unique technique to achieve completely extraperitoneal ligation of PPV without any skip areas under laparoscopic control. This report introduces our technique and results compared with the cut-down herniorrhaphy. METHODS: A consecutive series of 1,585 children with inguinal hernia/hydrocele (1996-2006) was analyzed. In laparoscopic patent processus vaginalis (PPV) closure (LPC), an orifice of PPV was encircled with a 2-0 suture extraperitoneally by a specially devised Endoneedle and tied up from outside of the body achieving completely extraperitoneal ligation of the ring. The round ligament was included in the ligation, whereas the spermatic cord and testicular vessels were excluded by advancing the needle across them behind the peritoneum. Cut-down herniorrhaphy (CD), with or without diagnostic laparoscopy, or LPC was selected according to parental preference under informed consent. RESULTS: Parents gave more preference to LPC (LPC in 1,257 children, CD in 308, and miscellaneous in 20). Age ranges were equal for both groups. Sex distribution showed female preponderance in the LPC group (44.8% vs. 26.6%, p < 0.001) and umbilical hernia/cysts were predominantly included in the LPC group (11.9% vs. 2.9%, p < 0.001). Mean operation times were equal for both groups for unilateral repair (28.2 +/- 9.2 for LPC vs. 27.8 +/- 13.5 for CD) and were shorter for bilateral repair in the LPC group (35.8 +/- 11.6 vs. 46.7 +/- 17.7). The incidence of postoperative hernia recurrence and contralateral hernia in the LPC group was 0.2% and 0.8%. Two children in the CD group had injuries to their reproductive system during the operation (0.6%). CONCLUSIONS: The advantages of our technique include following: technically simple, short operation time, inspection of bilateral IIRs with simultaneous closure of cPPV, reproductive systems remain intact, routine addition of umbilicoplasty if desired, and essentially indiscernible wounds.

Incorrect position of Essure microinserts 3 months after successful bilateral placement.

OBJECTIVE: To describe incorrect positions of Essure microinserts detected at 3 months' follow-up. DESIGN: Case report. SETTING: Outpatient department of obstetrics and gynecology in a Dutch teaching hospital. PATIENT(S): Initial series of 100 patients who underwent hysteroscopic sterilization using Essure between December 2003 and June 2004. INTERVENTION(S): Hysteroscopic placement of the Essure System, follow-up at 3 months with transvaginal ultrasound (TVU), and hysterosalpingography. MAIN OUTCOME MEASURE(S): Bilateral placement rate, tubal obstruction, and detection of incorrect Essure microinsert localization at follow-up after apparent successful bilateral placement. RESULT(S): Bilateral placement of Essure microinserts in one session was successful in 93 women (93%). In 90 of these women (96.8%), tubal obstruction was proven at follow-up 3 months later. Three incorrect positions of an Essure insert were seen: two expulsions and one perforation into the abdominal cavity. CONCLUSION(S): Incorrect position of Essure microinserts was seen only when the initial placement procedure was difficult. When a placement procedure was difficult or other suboptimal conditions are present during the procedure, we advise performing a TVU or pelvic X-ray in these women 4 weeks after the procedure or after the first vaginal bleeding, instead of waiting for follow-up after 3 months.