Segmental Rectum Resection for Deep Endometriosis and Excision Similarly Improve Sexual Function and Pain.

Segmental rectum resections for indications other than endometriosis were reported to result in up to 40% sexual dysfunctions. We, therefore, evaluated sexual function after low bowel resection (n = 33) for deep endometriosis in comparison with conservative excision (n = 23). Sexual function was evaluated with the FSFI-19 (Female Sexuality Functioning Index) and EHP 30 (Endometriosis Health Profile). The pain was evaluated with visual analogue scales. Linear excision and bowel resections improved FSFI, EHP 30, and postoperative pain comparably. By univariate analysis, a decreased sexual function was strongly associated with pain both before (p < 0.0001) and after surgery (p = 0.0012), age (p = 0.05), and duration of surgery (p = 0.023). By multivariate analysis (proc logistic), the FSFI after surgery was predicted only by FSFI before or EHP after surgery. No differences were found between low bowel segmental resection and a more conservative excision. In conclusion, improving pain after surgery can explain the improvement in sexual function. A deleterious effect of a bowel resection on sexual function was not observed for endometriosis. Sexual function in women with endometriosis can be evaluated using a simplified questionnaire such as FSFI-6.

Genetic Predisposition of Postoperative Adhesions Varies in Substrains of BALB/c Mice.

Postoperative adhesions are a major clinical problem because of the associated infertility, chronic pain, bowel obstruction, and the associated costs. Variability in adhesion formation was suggested by clinical observations that apparently similar interventions can cause little to severe adhesions. This is supported by the presence of polymorphisms and genetic predisposition to develop adhesions in animal models and humans. We previously demonstrated differences in postoperative adhesions between different mouse strains. In this study, we aimed to investigate the variability in adhesion formation in inbred substrains of BALB/c mice. Since genetic differences in inbred substrains are minimal, they might be an opportunity to tackle the genetics of adhesion formation.

Pneumoperitoneum induced mesothelial cell changes in a laparoscopic mouse model.

BACKGROUND: CO2 pneumoperitoneum (PP) during laparoscopic surgery, can cause hypoxia and desiccation in the peritoneal mesothelial cell, resulting in a time-dependent retraction and bulging of these cells, an acute inflammatory reaction and enhanced adhesion formation. Since hypoxia is prevented by adding 4% of oxygen (O2) to the CO2 PP, the aim of this study was to evaluate the effect of adding 4% O2 to the CO2 PP on mesothelial cell morphology. METHODS: In a standardized laparoscopic mouse model (n=8 mice per group), a control group with a 30- or 60-min PP with humidified CO2 + 4% of O2 (groups I and II) was compared to a hypoxic group with 30- or 60-min humidified pure CO2 (groups III and IV) and a desiccation group with 60-min of dry CO2 PP (group V). The effect upon the peritoneum morphology was evaluated by scanning electron microscopy (SEM) of abdominal wall peritoneal biopsies. Biopsies, taken immediately (n=4) and 24 hrs (n=4) after surgery, were compared to a group without PP (group VI, n=4). SEM pictures were blindly scored for cell retraction, deletion of microvilli, fibrin deposition, holes in the epithelial layer and visibility of cell borders using a semi-quantitative scoring system. RESULTS: PP Hypoxia (CO2 PP) has a deleterious effect upon mesothelial morphology, immediately (holes: p= 0.04) and 24 hrs later (cell retraction: p=0.005; total score: p=0.03) . Desiccation has also a deleterious effect immediately (microvilli p=0.0090; fibrin deposition p=0.05) and 24 hrs after surgery (cell retraction: p=0.0036; holes: p=0.0004; microvilli: p< 0.0001, fibrin deposition: p=0.0225; borders: p=0.0007). This deleterious effect increases with duration of CO2 PP, affecting cell retraction (p=0.016), holes (p=0.0441), and the total score (p=0.0488). The addition of 4% of O2 to the CO2 PP failed to reach statistical significance. CONCLUSIONS: These data confirm that CO2 PP and dry gas have a deleterious effect on mesothelial cell morphology. Humidification of the insufflation gas reduces this deleterious effect. The hypothesis of a protective effect of adding O2 failed to reach significance.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

What is the Best Surgeon's Knot? Evaluation of the Security of the Different Laparoscopic Knot Combinations.

STUDY OBJECTIVE: To investigate the security of various knot combinations in laparoscopic surgery. DESIGN: Prospective nonrandomized trial (Canadian Task Force classification II). SETTING: Storz Training Centre, Sao Paulo, Brazil. INTERVENTION: Different knot combinations (n = 2000) were performed in a laparoscopic trainer. Dry or wet 2.0 polyglycolic acid or dry 2-0 poliglecaprone 25 was used. The tails were cut at 10 mm, and the loops were tested in a dynamometer. The primary endpoints were the forces at which the knot combination opened or at which the suture broke. Resulting tail lengths were measured. MEASUREMENTS AND MAIN RESULTS: Surprisingly, the combination of a 2-throw half knot (H2) and a symmetric 1-throw half knot (H1s) (a surgical flat knot) opened at <1 Newton (N) in 2.5% of tests and at <10 N in 5% of tests. This occasional opening at low forces persisted after 1 or 2 additional H1s knots. A sequence of an H2 or a 3-throw half knot (H3) followed by a H2, either symmetric or asymmetric (H2H2 or H3H2), resulted in 100% secure knots that never opened at forces below 30 N. Other safe combinations were H2H1s followed by 2 blocking half hitches, and a sequence of 5 half hitches with 3 blocking sequences. CONCLUSION: A traditional surgical knot (H2H1s) occasionally opens with little force and thus is potentially dangerous. Safe knots are H2H2 and H3H2 combinations, a sequence of 5 half hitches with 3 blocking sequences, and H2H1s together with 2 blocking half hitches.

Predicting formation of adhesions after gynaecological surgery: development of a risk score.

PURPOSE: Risk factors for post-surgical adhesions following gynaecological surgery have been identified, but their relative importance has not been precisely determined. No practical tool exists to help gynaecological surgeons evaluate the risk of adhesions in their patients. The purpose of the study was to develop an Adhesion Risk Score to provide a simple tool that will enable gynaecological surgeons to routinely quantify the risk of post-surgical adhesions in individual patients. METHODS: A group of European gynaecological surgeons searched the literature to identify the risk factors and the surgical operations reported as carrying a risk of post-surgical adhesions. Through consensus process of meetings and communication, a four-point scale was then used by each surgeon to attribute a specific weight to each item and collective agreement reached on identified risk factors and their relative importance to allow construct of a useable risk score. RESULTS: Ten preoperative and 10 intraoperative risk factors were identified and weighed, leading to the creation of two sub-scores to identify women at risk prior to and during surgery. The Preoperative Risk Score can range from 0 to 36, and the Intraoperative Risk Score from 3 to 31. Several thresholds between these limits may be used to identify women with low, medium, and high risk of post-surgical adhesions. CONCLUSIONS: Gynaecological surgeons are encouraged to use this Adhesion Risk Score to identify the risk of adhesions in their patients. This will allow better informed use of available resources to target preventive measures in women at high risk of post-surgical adhesions.

A European survey on awareness of post-surgical adhesions among gynaecological surgeons.

The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and measures for reduction. From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction. Four hundred fourteen surgeons participated; 70.8 % agreed that adhesions are a source of major morbidity. About half of them declared that adhesions represented an important part of their daily medical and surgical work. About two thirds informed their patients about the risk of adhesion. Most cited causes of adhesions were abdominal infections and extensive tissue trauma, and endometriosis and myomectomy surgery. Fewer surgeons expected adhesion formation after laparoscopy (18.9 %) than after laparotomy (40.8 %); 60 % knew the surgical techniques recommended to reduce adhesions; only 44.3 % used adhesion-reduction agents on a regular basis. This survey gives a broad picture of adhesion awareness amongst European gynaecological surgeons, mainly from Germany and the UK. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.

Conditioning of the abdominal cavity reduces tumor implantation in a laparoscopic mouse model.

PURPOSE: The addition of 4 % O2 and 10 % N2O to the CO2 pneumoperitoneum (PP), together with slight cooling and humidification (conditioning), contributes to reducing adhesions by preventing mesothelial damage. We investigated the effect of peritoneal damage during laparoscopy on tumor implantation. METHODS: In Experiment 1, different tumor cell concentrations were injected into control mice without PP and into mice with 60-min dry CO2PP (mesothelial damage). In Experiment 2, tumor cells were injected into control mice (group I) and in mice with mesothelial damage (group II). In groups III to VI, mesothelial damage was decreased by adding humidification, humidification + 10 % N2O, humidification + 10 % N2O + 4 % O2, and conditioning, respectively. RESULTS: In Experiment 1, the tumors increased with the number of cells injected and with mesothelial damage in the abdominal cavity (p = 0.018) and abdominal wall (p < 0.0001). Experiment 2 confirmed that 60 min of dry CO2PP increased the number of tumors in the abdominal cavity and wall (p = 0.026 and p = 0.003, respectively). The number of tumors was decreased in the abdominal cavity by conditioning (p = 0.030) and in the abdominal wall using humidified CO2 (p = 0.032) or conditioning (p = 0.026). CONCLUSIONS: Tumor implantation was enhanced by peritoneal damage (60 min of dry CO2PP and desiccation), but this was prevented by conditioning. If confirmed in humans, conditioning would become important for oncologic surgery.

Prevention of adhesions in gynaecological surgery: the 2012 European field guideline.

Postoperative adhesions have become the most common complication of open or laparoscopic abdominal surgery and a source of major concern because of their potentially dramatic consequences. The proposed guideline is the beginning of a major campaign to enhance the awareness of adhesions and to provide surgeons with a reference guide to adhesion prevention adapted to the conditions of their daily practice. The risk of postoperative adhesions should be systematically discussed with any patient scheduled for open or laparoscopic abdominal surgery prior to obtaining her informed consent. Surgeons should adopt a routine adhesion reduction strategy with good surgical technique. Anti-adhesion agents are an additional option, especially in procedures with a high risk of adhesion formation, such as ovarian, endometriosis and tubal surgery and myomectomy. We conclude that good surgical practice is paramount to reduce adhesion formation and that anti-adhesion agents may contribute to adhesion prevention in certain cases.

"Adhesions after abdominal, pelvic and intra-uterine surgery and their prevention"

We here present the full text of a patient leaflet we have designed, and routinely use, to provide preoperative education about adhesions to patients undergoing open or laparoscopic gynaecological surgery. The leaflet presents appropriate, patient-orientated information on the nature of adhesions, their causes and the health risks they may involve as well as on adhesiolysis and modern methods of adhesion prevention. As adhesion formation is not specific to gynaecological surgery, the leaflet can also be adapted for the purposes of general abdominal surgery.

Laparoscopic ureteral repair in gynaecological surgery.

PURPOSE OF REVIEW: To review laparoscopic surgery in the treatment options for ureteral lesions in gynaecological surgery. RECENT FINDINGS: Laparoscopic treatment of ureteral injuries has been increasingly reported over the past years. Treatment has progressively shifted from ureteroneocystostomy performed by laparotomy to less invasive treatment options such as ureteral stenting or dilatation in case of stricture, stenting under laparoscopic guidance and laparoscopic stitching of lacerations, laparoscopic ureteral reanastomosis or laparoscopic ureteroneocystostomy for transections. Deep endometriosis surgery of an associated hydronephrosis is associated with a high incidence of ureteral lesions making preoperative stenting desirable in order to facilitate the eventual repair, while avoiding the more problematic insertion of a stent after a lesion is made.The available data confirm the excellent outcome of stenting obstructive lesions. When stenting proves difficult or in case of a ureteral leakage, laparoscopic aided stenting is strongly suggested, in order to avoid further damage while permitting simultaneous repair if necessary. Laparoscopic suturing of a laceration over a stent is clearly superior to stenting only. Results of ureteral reanastomosis of a transected ureter vary from 88 to 100%; an occasional subsequent stenosis can be treated with dilatation. Bladder reimplantation has become feasible by laparoscopy and results seem promising. Laparoscopic bladder reimplantation is suggested as the method of choice in case of failure of a previous laparoscopic treatment. SUMMARY: Data strongly support laparoscopy as the method of choice for the management of ureteral lesions.

Postoperative inflammation in the abdominal cavity increases adhesion formation in a laparoscopic mouse model.

OBJECTIVE: To investigate acute inflammation in the peritoneal cavity in adhesion formation. DESIGN: Prospective randomized, controlled trial. SETTING: University laboratory research center. ANIMAL(S): 9- to 10-week-old BALB/c female mice. INTERVENTION(S): In a laparoscopic mouse model, acute inflammation in the peritoneal cavity evaluated in CO(2) pneumoperitoneum enhanced adhesions, by CO(2) pneumoperitoneum plus manipulation, and in the latter group plus dexamethasone. MAIN OUTCOME MEASURE(S): Qualitative and quantitative adhesion scores and an acute inflammation score (neoangiogenesis, diapedesis, and leukocyte accumulation). RESULT(S): Adhesions at the lesion site were enhanced by the CO(2) pneumoperitoneum, further enhanced by manipulation, and decreased by the administration of dexamethasone. The acute inflammation scores (total, neoangiogenesis, diapedesis, and leukocyte accumulation) strongly correlated with the total adhesion score. Inflammation scores were similar at both the surgical lesion and the parietal peritoneum. CONCLUSION(S): Acute inflammation of the entire peritoneum cavity is an important mechanism involved in adhesion formation and enhances adhesion formation at the lesion site.

Effect of upper abdomen tissue manipulation on adhesion formation between injured areas in a laparoscopic mouse model.

STUDY OBJECTIVE: These experiments were designed to examine the effect of manipulation during surgery as a cofactor in adhesion formation at trauma sites. DESIGN: Randomized, controlled trial. Canadian Task Force Classification-class 1. SETTING: University laboratory research center. SUBJECTS: A standardized laparoscopic mouse model (Balb\c mice 9-10 weeks old) for adhesion formation after opposing bipolar lesions and 60 minutes of carbon-dioxide pneumoperitoneum. In this model adhesions are known to decrease after the addition of 3% of oxygen, dexamethasone, or both. In addition, adhesions decrease with experience (i.e., with a decreasing amount of manipulation during the learning curve). INTERVENTIONS: A factorial design was used to evaluate the effects of dexamethasone and of adding 3% of oxygen on manipulation-enhanced adhesion formation during a learning curve. Blocks of 4 animals were thus randomized as controls (carbon-dioxide pneumoperitoneum only) or received an additional 3% of oxygen, dexamethasone, or both. In a second experiment, the effects of manipulation on adhesion formation were quantified. In a third experiment we evaluated whether dexamethasone had a specific effect on manipulation-enhanced adhesion formation. MEASUREMENTS AND MAIN RESULTS: Qualitative and quantitative adhesion scoring 7 days after the intervention. The first experiment confirmed that adhesion formation decreased during the learning curve (p <.0001) and after the addition of dexamethasone whether assessed as the total adhesion score (p <.0001 and p =.0009, respectively) or a quantitative score (p <.0001 and p <.0001, respectively). The second experiment showed that adhesion formation increased by standardized touching and grasping of omentum and bowels (proportion score p =.0059 and p =.0003, respectively) and this effect increased with duration of touching (p =.0301). In the third experiment, dexamethasone was confirmed to decreased adhesion formation (p =.0001) but this effect was not specific for manipulation-enhanced adhesion formation. CONCLUSION: Manipulation of intraperitoneal organs in the upper abdomen enhances adhesion formation at trauma sites, confirming that the peritoneal cavity is a cofactor in adhesion formation. Dexamethasone decreases adhesion formation but the effect is not specific for manipulation-enhanced adhesion formation.

Intercoat gel (oxiplex): efficacy, safety, and tissue response in a laparoscopic mouse model.

STUDY OBJECTIVE: To study the efficacy and safety of Intercoat gel in a laparoscopic mouse model with pneumoperitoneum-enhanced adhesion formation. DESIGN: Randomized controlled trial. Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I). SETTING: University laboratory research center. SUBJECTS: Balb\c female mice 9 to 10 weeks old. INTERVENTIONS: Two laparoscopic mouse models for adhesion formation were used. In the first model, adhesions following bipolar opposing lesions in the pelvis were enhanced by 60 minutes of carbon-dioxide pneumoperitoneum. In the second model, adhesions were further enhanced by bowel manipulation. The first experiment evaluated the efficacy of Intercoat in both models. The second experiment evaluated the efficacy of Intercoat in the first model, when applied immediately on the lesion, when applied at the end of the pneumoperitoneum, and when applied in the upper abdomen. Biopsy specimens were taken after 7 days and were evaluated after hematoxylin-eosin and CD45 staining. MEASUREMENTS AND MAIN RESULTS: Qualitative and quantitative adhesion scoring. Morphology was evaluated by standard light microscopy. In both models, Intercoat decreased adhesion formation whether applied immediately on the lesion or at the end of the pneumoperitoneum (qualitative and quantitative scoring p <.0001 and p <.0001, respectively). Intercoat application is associated with tissue redness, vascular congestion, and cellular edema but without an inflammatory reaction. Applied in the upper abdomen, Intercoat does not increase adhesions, but decreases adhesions at higher doses (p =.0024). Intercoat in high doses had a toxic effect (p =.0058). CONCLUSION: Intercoat is an effective antiadhesion product. It is associated with tissue edema and vasodilatation as observed after 7 days both macroscopically and by histology.

Effect of Reteplase and PAI-1 antibodies on postoperative adhesion formation in a laparoscopic mouse model.

BACKGROUND: Postoperative adhesions remain an important clinical problem, accounting for infertility, chronic pain and bowel obstruction. Its prevention is still inadequate and overall poorly understood. The aim of this study was to investigate the effect of Reteplase (a recombinant plasminogen activator, r-PA) and of PAI-1 antibodies upon adhesion formation in a laparoscopic model. METHODS: Pneumoperitoneum-enhanced adhesions were induced by performing a bipolar lesion in female BALB/c mice and by using pure and humidified CO(2) as insufflation gas for 60 min. In experiment 1, four doses of 0.125, 0.25, 0.5 and 1 mg/0.5 ml r-PA and one and two doses of 1 mg r-PA were administrated i.p. Two control groups were included, one without any treatment and the second one receiving four times 0.5 ml of saline. In experiment 2, four doses of 0, 1, 10 and 100 microg/0.5 ml r-PA were administrated i.p. In experiment 3, PAI-1 neutralising and non-neutralising antibodies were injected i.p. after performing the lesion on day 0 and days 2 and 4. Adhesions were scored after 7 days. RESULTS: Adhesion formation was less with the administration of four doses of 1 microg r-PA (proportion, p < 0.04, Wilcoxon). An increase in adhesion formation was observed when higher number of doses and amounts of r-PA were used (Proc GLM, eight groups, two variables, p = 0.05 for the amount of r-PA and p < 0.02 for the number of doses administrated). No effect was observed with the PAI-1 antibodies. CONCLUSIONS: Low-dose i.p. administration of rPA is effective in the prevention of adhesions in a laparoscopic mouse model.

Laparoscopic management of ureteral lesions in gynecology.

OBJECTIVE: To investigate the outcome of laparoscopic repair of ureteral injury in laparoscopic gynecologic surgery. DESIGN: Prospective trial. SETTING: University hospital. PATIENT(S): Forty patients with a ureteral lesion in laparoscopic surgery between 1991 and 2007. INTERVENTION(S): Laparoscopic ureteral repair, laparoscopic-assisted or blind stent insertion. MAIN OUTCOME MEASURE(S): Treatment outcome of ureteral lesion analyzed by type of injury, time of diagnosis, and management. RESULT(S): In 4,350 consecutive laparoscopic gynecologic interventions, 42 lesions occurred, 5 during hysterectomy, 1 during adnexectomy, and 36 during deep endometriosis surgery. In the latter group (n = 1,427), the incidence was 1.5% and 21% in women without and with hydronephrosis, respectively. In eight women in whom a stent was inserted after surgery without laparoscopic guidance, five were uneventful and three needed a second intervention. In all 34 women in whom a laparoscopic repair over a stent was performed, the outcome was uneventful, whether diagnosed and treated during surgery (n = 25) or after surgery (n = 9). CONCLUSION(S): Laparoscopic repair over a stent was uneventful for all lacerations, transections, and fistulas, whether performed during or after surgery, and was superior to blind stent insertion. In women with hydronephrosis and deep endometriosis, a preoperative stent insertion seems to be mandatory.

Efficacy of barriers and hypoxia-inducible factor inhibitors to prevent CO(2) pneumoperitoneum-enhanced adhesions in a laparoscopic mouse model.

STUDY OBJECTIVE: To investigate the effects of hypoxia-inducible factor (HIF) inhibitors, flotation agents, barriers, and a surfactant on pneumoperitoneum-enhanced adhesions in a laparoscopic mouse model. DESIGN: Prospective randomized trial (Canadian Task Force classification I). SETTING: Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Catholic University of Leuven. SUBJECTS: One hundred fourteen female BALB/c mice. INTERVENTIONS: Adhesions were induced during laparoscopy in BALB/c female mice. Pneumoperitoneum was maintained for 60 minutes with humidified CO(2). In 3 experiments the effects of HIF inhibitors such as 17-allylamino 17-demethoxygeldanamycin, radicicol, rapamycin, and wortmanin, flotation agents such as Hyskon and carboxymethylcellulose, barriers such as Hyalobarrier gel and SprayGel, and surfactant such as phospholipids were evaluated. MEASUREMENTS AND MAIN RESULTS: Adhesions were scored after 7 days during laparotomy. Adhesion formation decreased with the administration of wortmannin (p <.01), phospholipids (p <.01), Hyalobarrier Gel (p <.01), and SprayGel (p <.01). CONCLUSIONS: These experiments confirm the efficacy of barriers and phospholipids to separate or lubricate damaged surfaces. They also confirm the role of mesothelial hypoxia in this model by the efficacy of the HIF inhibitor wortmannin.

Iatrogenic ureteral lesions and repair: a review for gynecologists.

Ureter injuries are a well-known complication of gynecologic surgery and a frequent cause of medicolegal problems. Because there are no randomized, controlled trials and the available studies are small series and case reports, the evidence on which to base treatment is weak. We therefore reviewed the complete English-language literature of ureter repair since 1990. In total, 608 ureter injuries were reported. Although it is widely believed that for laceration or section the prognosis is affected by a delay in diagnosis, we could not find evidence to substantiate this. An obstruction requires stenting only. For a laceration, stenting with suturing was more effective than stenting only (p = .006). A ureter anastomosis was successful in over 94% of cases either by laparotomy or laparoscopy. In conclusion, the literature data are scanty and heterogeneous and do not permit solid conclusions. Evidence, however, is emerging that a laceration should be treated by stenting and suturing. A ureter anastomosis over a stent could become a valid option especially when performed by laparoscopy.

Outcome after rectum or sigmoid resection: a review for gynecologists.

It remains unclear when to perform a discoid or segmental bowel resection for large endometriotic nodules with intestinal invasion. Moreover, endometriosis series are rather small to fully evaluate functional consequences of bowel resection. We therefore reviewed the incidence of leakage and functional problems after anterior and sigmoid resection as reported in the surgical literature albeit for other indications. Endoscopic resection clearly is feasible but requires an experienced surgeon. The incidence of leakage is not different after hand-sewn or stapled anastomosis, but is higher after a low rectum resection than after a sigmoid resection. Similarly, functional bowel problems are higher after a low rectum resection than after sigmoid resection. Low rectum resection in addition can be associated with functional bladder problems and sexual disturbances as anorgasmia. In conclusion, short- and long-term complications are much higher after a low rectum than after a sigmoid resection. This seems to be important in making the decision to perform a discoid or a segmental bowel resection for severe endometriosis.

Effect of desiccation and temperature during laparoscopy on adhesion formation in mice.

OBJECTIVE: To investigate the effects of desiccation (without cooling) and of oversaturation of the pneumoperitoneum on adhesion formation. DESIGN: Prospective randomized trial. SETTING: Academic research center. ANIMAL(S): BALB/c and NMRI female mice. INTERVENTION(S): The effect of desiccation using nonhumidified CO(2) on adhesion formation was evaluated in a laparoscopic mouse model. Body temperature (BT) was maintained at 37 degrees C using a homeothermic blanket. In addition to controls without desiccation, the effect of both hypothermia and desiccation on adhesion formation was evaluated. Subsequently the effect of oversaturating the pneumoperitoneum using a high energy gas to avoid any desiccation was studied. MAIN OUTCOME MEASURE(S): During surgery BT, pneumoperitoneum temperature, and relative humidity were monitored. Adhesions were scored after 7 days. RESULT(S): Adhesions increased with increasing levels of desiccation when BT was kept at 37 degrees C. This was prevented with humidified gas. If BT decreased, adhesions were fewer. Oversaturating the pneumoperitoneum increased adhesions due to high energy gas causing an increase in both BT and pneumoperitoneum temperature. CONCLUSION(S): Adhesions increase with desiccation and decrease when BT is reduced. Adhesions are minimized when humidified gas is used. Since desiccation is associated with cooling, its effect is generally underestimated because of the counterbalance with cooling. The concept of combining controlled intraperitoneal cooling with a rigorous prevention of desiccation might be important for clinical adhesion prevention.