Complex obstetric fistulas.

Obstetric fistulas are rarely simple. Most patients in sub-Saharan Africa and parts of Asia are carriers of complex fistulas or complicated fistulas requiring expert skills for evaluation and management. A fistula is predictably complex when it is greater than 4 cm and involves the continence mechanism (the urethra is partially absent, the bladder capacity is reduced, or both); is associated with moderately severe scarring of the trigone and urethrovesical junction; and/or has multiple openings. A fistula is even more complicated when it is more than 6 cm in its largest dimension, particularly when it is associated with severe scarring and the absence of the urethra, and/or when it is combined with a recto-vaginal fistula. The present article reviews the evaluation methods and main surgical techniques used in the management of complex fistulas. The severity of the neurovascular alterations associated with these lesions, as well as inescapable limitations in staff, health facilities, and supplies, make their optimal management very challenging.

Obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger.

OBJECTIVE: To determine the epidemiologic and therapeutic characteristics of obstetric vesico-vaginal fistulas at the National Hospital of Niamey, Niger. METHODS: From December 2003 to February 2005, 111 consecutive patients with vesico-vaginal fistulas presenting for treatment were included and prospectively followed up. Demographic and clinical data were collected. The patients were re-evaluated 3 months after surgery. RESULTS: Among the 104 patients treated surgically 87% were aged between 15 and 36 years; 84% were married before they were 19 years old; 51% were divorced; and 80% did not live with their husbands. The fistula was caused by the first delivery in 43% of the patients; 93% were in labor for more than 24 hours; 35% were delivered at home; and perinatal death was 100%. The overall cure rate was 73%. CONCLUSION: These epidemiologic characteristics provide data towards the development of an obstetric fistula prevention program in Niger.

Avoidance of permanent colostomy in pelvic malignancy using the surgical stapler.

The potential for reducing the number of gynecologic oncology patients left with a permanent colostomy may be achieved by the use of the end-to-end anastomosis (EEA) automatic surgical stapler. This instrument allows a rectocolonic anastomosis at a very low level (below the levator muscles), which is very difficult and poorly performed by hand-suture techniques. This report presents the author's experience with 6 patients in whom a low rectocolonic anastomosis was performed with the EEA surgical stapler.

Use of absorbable staples for closure of proximal end of ileal loops.

The use of the GIA stapler has reduced dramatically the operative time for the creation of urinary division ileal and colonic loops. It is widely known that steel staples in the urinary tract prompt stone formation around a foreign body. A case of stone formation around a GIA stainless steel staple is presented. A possible solution to this potential problem by the use of the new Polysorb-Lactimer absorbable TA55 stapler is presented.

The Gambee intestinal anastomosis in gynecologic surgery.

The Gambee single-layer, through-and-through, catgut suture anastomosis of the gastrointestinal tract has been in use from 1969 to 1974. Sixty-four anastomoses have been performed on 56 patients with gastrointestinal involvement or pelvic malignancy. There were no operative deaths, and no patients required reoperation for correction of intestinal anastomotic leaks or rupture of the suture line. This experience suggests that the Gambee intestinal single-layer anastomosis may be useful in the management of gastrointestinal complications of pelvic surgery and malignancy.

Laparoscopically applied hemoclips for tubal sterilization.

PIP: Although there have been very good results with laparoscopy sterilization, electrocoagulation injuries during the procedure continue to pose a problem. In order to reduce the incidence of electrocoagulation injuries and hemorrhage, a study was conducted on a new procedure. 2 hemoclips were placed on the fallopian tubes through the laparoscope, approximately 1 cm apart, but the tubes were not transected. 52 patients had the procedure performed. 22 of these were followed with hysterosalpingograms. 10 were noted to have a spill from 1 or both tubes. Complications of the procedure were rare and minor, and all patients were discharged 3-4 hours after surgery. 6 of the patients became pregnant. The hemoclips were noted to be intact in the patients. The 11.5% pregnancy rate discouraged any further research into this method.^ieng

Laparoscopic sterilization kit.

PIP: A suitcase size laparoscopic sterilization kit produced by Medical Technology Internationale, Inc. was tested on 50 patients at the Johns Hopkins Hospital and field tested in San Jose, Costa Rica. The pneumoperitoneum device has reduced overall size with 2 "pop-off" valves, one to prevent more than one l carbon dioxide from entering the abdomen and one to protect against sudden expansion of any carbon dioxide within the peritoneal cavity. Electrocoagulation capacity has been adequate for fulguration of the uterine tube. The miniaturization of the equipment should provide greater mobility in delivering family planning services.^ieng

Outpatient laparoscope sterilization under local anesthesia.

PIP: In 1971, 100 outpatient laparoscope bilateral partial salpingectomies were performed at Johns Hopkins Hospital under local anesthesia with systemic sedation. Ten percent of these patients (age, 21-45; parity, 1-8; weight, 110-200 lbs) had a history of pelvic surgery. The 2-incision technique, performed on 15 patients, used the viewing laparoscope and the Eder-Palmer biopsy tong through separate incisions. The large trocar incision was made in the inferior rim of the umbilicus rather than the lower midline, and the second incision was made in the midline rather than right or left lower quadrants to decrease the possibility of hemmorhage. The one-incision technique, performed on 85 patients, with the fiberoptic operating laparoscope with its associated electrocoagulation forceps, used a 1 cm incision in the inferior rim of the umbilicus alone. In all cases pneumoperitoneum was with CO2. The fallopian tube was thoroughly visualized by manipulating the uterus with Jacob's tennaculum and Rubin's cannula before the tube was grasped and cauterized. The incision was closed with a 4/0 chromic mattress suture placed subcuticularly and dressed with a bandaid. Discharge was after 2-3 hours routine observation in the recovery room with no restrictions placed on resumption of activities. The one-incision technique produced far less discomfort during the procedure and far greater acceptance than the 2-incision technique, which produced discomfort at two points and required the insertion of the second trocar with its associated additional manipulation of the peritoneum and fallopian tubes. Of the 85 patients having the one-incision technique, only three patients had some difficulty and required some systemic sedation.^ieng

A comparison of the flow of iodine 125 through three different intestinal anastomoses: standard, Gambee, and stapler.

Angiogenesis determines blood supply, and it is postulated that after surgery, the healing of a wound is directly related to the blood supplied to the surrounding tissues. As a first step in evaluating the process of flow through different surgical anastomoses, the flow rate of 125I through three different types of anastomoses in the intestines of dogs was determined. When the results were compared, the flow rate through the stapler anastomosis was significantly higher than the flow rate through the standard and Gambee anastomoses.

Failures of laparoscopy sterilization.

Female sterilization by laparoscopy has become widely accepted throughout the United States and Europe. The failure rate of this procedure is still speculative. In the course of 4200 operative sterilization, 32 failures have been identified and 31 of these have been subsequently evaluated. The most common finding was inadequate or superficial fulguration and resection. Operative errors such as round ligament fulguration were also more common than expected.

PIP: The failure rate of laparoscopic sterilization in 4200 patients aged 13-49 years is reported and suggestion are made to avoid such failures. Patients were treated at the Laparoscopy Sterilization Clinic of the Johns Hopkins Hospital over a 5-year period. 62 surgeons and about 250 visiting physicians being trained in laparoscopic technique participated. About 85% of the operations were on an outpatient basis. Indications for patients under age 18 were severe mental retardation. In the 1st 1000 cases the 2-incision method was used and a single large segment of each tube removed. For the 2nd 1000 cases a single inclision was used and only a small segment of tube removed. For the last 2200 patients a single incision was used but the proximal stump of each tube was fulgurated again. This was called the "3-burn-technique," it is the present preferred method. Of the first group 91% have been contacted and 5 failures have been recorded in a 66-month period. 3 were surgical failures and 2 were operative errors in which the round ligaments had been ligated. Among the 2nd 1000 there were 17 failures. In 12, inadequate fulguration and resection had been done, in 4, utero-overian ligament had been resected; 1 patient refused postoperative evaluation. The final group, with a 2nd fulguration of the proximal stump and wider separation of the stumps, had 10 failures in 2200 cases. There were 4 cases of unilateral incomplete section, 2 of ectopic gestation, and 3 resections of round ligaments. Of the total of 32 failures 23 occurred in the 1st 5 months after surgery. Since the adoption of the 3-burn-technique, only 6 failures have occurred when the tubes were correctly identified. In 2 of these ectopic gestation occurred. Only 2 patients in this group required laparotomy to control hemorrhage. Longer follow-up intervals will be needed before final figures are available.

Laparoscopic sterilization. Review of 3600 cases.

PIP: A review of 3600 cases of laparoscopy sterilization at the John Hopkins Hospital, between the years 1968-1972, is presented. Technics, complications and failure rate are discussed. The criteria for sterilization were: 1) that the patient be 21 years old (unless mentally retarded or unless the patient was a teenager whose parity was 3 or more) and 2) that she sign the hospital sterilization consent form. 3 technics were used: 1) the 2-incision technic, 1000 patients, general anethesia used, 75% outpatient; 2) 1-incision 1-burn technic, 1000 patients, local anethesia, 83% outpatient; 3) 1-incision, 3-burn technic, 1600 patients, local anethesia. Failure of the procedure to prevent pregnancy was noted in 24 patients, due to luteal pregnancies, or to surgical errors including electrocoagulation of the round ligament. The most serious complication of laparoscopy sterilization was inadvertent electrocoagulation of the gastrointestinal tract, occurring in 11 patients. Infection following laparoscopy sterilization was remarkably rare.^ieng

Gastrointestinal complications of laparoscopy sterilization.

PIP: The purpose of this study is to review the experience at the Johns Hopkins Hospital with gastrointestinal complications conincident with 3600 laparoscopic sterilizations done between the years 1968 and 1972. Patients' ages ranged from 13 to 48 years and parity 0 to 13. All patients, after giving histories, received physical examination, menatocrit, urinalysis, and Papanicolaou smears. 80% were outpatients. Inpatients had medical illnesses that required preoperative evaluation or had come from long distances. 18% had previous abdominal surgery, which was not considered a contraindication. The 2 incision laparoscope technic was used in the first series of about 1000 pateints. The 1 incision, one burn technic was used for the second series of 1000 patients. A third series of 1600 patients were operated on using a 3 burn modification of the 1 incision technic. Gastrointestinal complications are those noted in the first 30 days after surgery. In 5 patients electrocoagulated segment of the bowel was recognized at laparoscopy and the extent of the lesion less than .5 cm. Only 1 had immediate laparotomy, and experience shows perhaps she could have been treated expectantly. A second group of 5 gastrointestinal injuries, not recognized at surgery, were delayed bowel perforations due to electrocoagulation. All were readmitted from the third to the seventh day after the operation. All required laparotomy and resection of the perforated segment of the bowel, which was in the terminal ileum in all 5 cases. 3 recovered promptly, 2 had complicated recoveries with septic pelvic thrombophlebitis in 1. She was eventually discharged on the 32nd day. All perforations occurred opposite the mesenteric border and microscopic study confirmed the causes as thermal coagulation. Perforation size varied from .5 to 4 cm. 1 traumatic bowel injury occurred at the time of the insertion of laparoscope trocar. In this case the small bowel was adherent to the anterior abdominal wall following a previous laparotomy. Simple repair resulted in recovery. Complications were equally frequent with each technic. The 11 cases of gastrointestinal complication represent .3% of the 3600 operations. Laparotomy was required in .2%. Metal tubal clips applied with laparoscopy may replace electrocoagulation and thus reduce complications.^ieng

Gracilis myocutaneous flap in reconstruction of the vulva and female perineum.

For the past 2 decades there has been a definite trend among pelvic surgeons to immediately reconstruct the large defects created by deforming radical cancer surgery in the female pelvis and perineum. Extensive en bloc removal of more tissue has enhanced the probabilities of increased 5-year survival. At the same time, however, the quality of life following radical surgery has been of great concern to both patient and surgeon. Recent advances have been made in techniques for reconstruction. It is the purpose of this paper to present our experience using the gracilis myocutaneous flap for reconstruction of the vulva after radical excision of perineal tissue. The technique of the procedure is presented with the clinical results in 5 cases, and the complications noted therein.

Microcolpohysteroscopy compared with colposcopy in the evaluation of abnormal cervical cytology.

Microcolpohysteroscopy allows one to observe the cervix and endocervix at magnifications of 1:1-1:150. More important, it permits examination of the squamocolumnar junction when it is obscured within the endocervix. This preliminary report compares standard colposcopy with a microcolpohysteroscopy technique in 65 patients with abnormal Papanicolaou smears. Using contact microcolpohysteroscopy, the clinician can map out geographically entire cervical intraepithelial neoplastic lesions; locate correctly the epicenter of most lesions; and in cases of inadequate colposcopy, visualize the squamocolumnar junction within the cervix. Microcolpohysteroscopy was equivalent to traditional colposcopy in detecting abnormal histology. This technique predicted lesions with viral cytopathic effects, which correlated with histology in 83% of cases. The results of this study suggest that microcolpohysteroscopy is a diagnostic tool that can precisely qualify and localize a cervical lesion.

Anesthesia for diagnostic and operative laparoscopy.

PIP: Laparoscopic sterilization was performed on 50 racially distributed patients, aged 18-42 years, who were selected at random from the Outpatient Laparoscope Sterilization Clinic and offered sterilization under local anesthesia. The patients were injected with a systemic analgesic as well as a local anesthetic. One incision was made in the inferior rim of the umbilicus. The tubes were cauterized and a section removed. Patients were discharged after 2-3 hours in the recovery room with a prescription for an analgesic. Competent general anesthesia is considered safer than local anesthesia. Pain stimuli under local anesthesia can produce vasovagal responses at a higher rate than with general anesthesia.^ieng

Problems with tubal reconstruction following laparoscopic sterilization using the electrocoagulation and resection technique.

This paper reviews the results of attempted tubal reconstruction following laparoscopic sterilizations using the electrocoagulation and excision technique in the isthmic portion of the fallopian tube. The surgical technique, complications, and results are presented.

PIP: Tubal reconstruction was attempted on 11 patients who had undergone extensive thermocoagulation and division of the tube in the isthmic portion. Extensive counseling, gynecologic history, physical examination, Papanicolaou smear, basic laboratory tests, and hysterosalpingogram were conducted prior to surgery. If diagnostic laparoscopy revealed less than 4 cm of tube remaining on both sides, pelvic laparotomy and tubal reconstruction were not attempted. Only 1 patient had sufficient proximal Fallopian tube to allow a salpingosalpingostomy; in 10 patients tubal reanastomosis was not possible and tubal reimplantation was performed. The surgical technique is described. A postoperative pelvic abscess developed in 1 patient; postoperative hysterograms have shown total obstruction. In 9 patients, spillage of injected indigo carmine dye from the Fallopian tubes was found at repeat laparoscopy. To date, there has been 1 pregnancy. If restoration of fertility is considered, perhaps the ampullary portion of the Fallopian tube should be obstructed rather than the isthmus.

The effect of recombinant growth hormone on the strength of ileal anastomoses in a rat model.

OBJECTIVE: In gynecologic surgery, the ileum is the primary site of bowel injury. Recombinant growth hormone (rGH) has been shown to improve the strength of colonic anastomoses in experimental models. The purpose of this study is to evaluate the effect of rGH on small bowel anastomoses, specifically in the ileum. METHODS: Twenty large female rats underwent segmental ileal resections and end-to-end ileoileostomies. The rats were randomized to be treated for 7 postoperative days with either rGH (2.0 mg/kg/day) or placebo starting on the day of surgery. On the seventh postoperative day, a segment of ileum surrounding the anastomosis was resected. The anastomoses were tested for breaking strength on a tensiometer and for tissue concentrations of hydroxyproline. RESULTS: The ileal anastomotic breaking strength in the rGH group was 163.5 +/- 6.0 g (mean +/- standard error). In the placebo group, the breaking strength of ileal anastomoses was 125.0 +/- 3.0 g (P < .001). No significant difference was demonstrated with respect to the hydroxyproline concentration between the rGH group (15.2 +/- 2.0 micrograms/mg) and the placebo group (14.6 +/- 1.0 micrograms/mg). CONCLUSION: In an animal model, a 31% increase in ileal anastomotic breaking strength was induced by rGH administration. With further research this may translate into decreases in the surgical complications that occur in ileal anastomoses. Furthermore, these serve as preliminary data to a study that evaluates the effect of rGH on ileal anastomoses in radiation-injured bowel.

Stapling techniques in operations for malignant disease of the female genital tract.

The indications for operation, postoperative complications, and a brief description of operative technique are presented. Recent experience with new absorbable staplers is reviewed in the surgical closure of the bladder, vagina, and proximal end of an ileal loop conduit for urinary diversion.

Episiotomy: risks of dehiscence and rectovaginal fistula.

The obstetric literature was reviewed to assess the risk of episiotomy dehiscence and rectovaginal fistula formation from routine episiotomy, with and without third- and fourth-degree laceration into the rectal sphincter or rectal mucosa, respectively. Strong evidence suggests that elective episiotomy predisposes to severe 3rd and 4th degree perineal lacerations and that episiotomy dehiscence with rectovaginal fistula formation is strongly related to 3rd and 4th degree perineal lacerations.

The value of endocervical curettage at time of cervical cone biopsy.

Two hundred eighty-nine patients were evaluated over a 23-month period to assess the efficacy of postcone biopsy endocervical curettage at the time of cervical conization. One hundred eleven patients were excluded because the endocervical curettage was insufficient or not performed, the final pathology on the cone biopsy and endocervical curettage revealed no dysplasia or cancerous process, or the endocervical margins were not assessed, leaving a total of 178 patients in the study population. A negative conization endocervical margin virtually assures no disease in the upper endocervical canal. The negative predictive value in this study population was 97%. We conclude that routine endocervical curettage is unnecessary for most patients and should be primarily considered for patients who are postmenopausal or for those receiving suboptimal conizations.