A pilot feasibility multicenter study of patients after excision of endometriosis.

OBJECTIVE: To serve as a pilot feasibility study for a randomized study of excision versus ablation in the treatment of endometriosis by (1) estimating the magnitude of change in symptoms after excision only at multiple referral centers and (2) determining the proportion of women willing to participate in a randomized trial. METHODS: We performed a multicenter prospective study of women undergoing excision for endometriosis (Canadian Task Force class II-3) at Duke University Center for Endometriosis Research & Treatment (currently the Saint Louis University Center for Endometriosis), Center for Endometriosis Care, Northshore University Health System, Memorial University (Canada), and Florida Hospital. The study comprised 100 female patients, aged 18 to 55 years, with endometriosis-suspected pelvic pain. The intervention was laparoscopic excision only of the abnormal peritoneum suspicious for endometriosis. The main outcome measures were quality of life, pelvic pain, dysmenorrhea, dyspareunia, and bowel and bladder symptoms. RESULTS: The mean follow-up period was 8.5 months. Excision of endometriosis showed a significant reduction in all pain scores except bowel symptoms, as well as significant improvement in quality of life. Of the patients, 84% were willing to participate in a randomized study. CONCLUSIONS: Quality of life is a needed primary outcome for any randomized study comparing excision versus ablation. A multicenter comparative trial is feasible, although quality assurance would have to be addressed. Patients were willing to be randomized even at surgical referral centers.

Complete laparoscopic excision of endometriosis in teenagers: is postoperative hormonal suppression necessary?

OBJECTIVE: To determine long-term outcomes after complete laparoscopic excision done at a tertiary referral center in a teenager population, who were not specifically advised to take postoperative hormonal suppression. DESIGN: Prospective observational case series (Canadian Task Force II-3). SETTING: A tertiary referral center that specializes in the laparoscopic treatment of endometriosis. PATIENT(S): Teenagers with symptoms suspicious for endometriosis who consented and were prospectively recruited to participate in the study. INTERVENTION(S): All patients underwent diagnostic laparoscopy and complete excision of all areas of abnormal peritoneum with typical and atypical endometriosis. Patients were not specifically advised to take postoperative hormonal suppression. MAIN OUTCOME MEASURE(S): Rate of recurrent (or persistent) endometriosis. RESULT(S): Twenty teenagers underwent complete laparoscopic excision of all areas of abnormal peritoneum with typical and atypical endometriosis. Seventeen patients had endometriosis confirmed by histology at initial surgery. Follow-up was up to 66 months (average 23.1 months). There was a statistically significant improvement in most pain symptoms, including bowel-related symptoms, during this time period. The rate of repeat surgery was 8 of 17 patients (47.1%), but the rate of endometriosis (diagnosed visually or histologically) found at surgery was zero. Only one-third of patients took postoperative hormonal suppression for any length of time. CONCLUSION(S): Complete laparoscopic excision of endometriosis in teenagers--including areas of typical and atypical endometriosis--has the potential to eradicate disease. These results do not depend on postoperative hormonal suppression. These data have important implications in the overall care of teenagers, regarding pain management, but also potentially for fertility. Further large comparative trials are needed to verify these results.

Comparative analysis of 5-mm trocars: dilating tip versus non-shielded bladed.

STUDY OBJECTIVE: To examine whether there are statistically significant differences in multiple variables evaluated at different times in the course of surgery and postoperative period when using 5-mm dilating-tip trocars (DTTs) and 5-mm non-shielded-bladed trocars (NSBTs) at randomly selected right or left lateral entry sites on the same patient. DESIGN: Randomized, single-blinded, controlled trial (Canadian Task Force classification I). SETTING: Center for Women's Care and Reproductive Surgery (CWCRS), Atlanta, Georgia. PATIENTS: Ninety-four women, median age 45, undergoing laparoscopic surgery at CWCRS for benign gynecologic conditions were randomly assigned to placement of a DTT to the right or left laparoscopic entry site. The NSBT was placed on the contralateral side of the same patient. INTERVENTION: Each patient had 2 lateral trocars placed, 1 of which was a DTT and the other of which was an NSBT. MEASUREMENTS AND MAIN RESULTS: Comparisons between the sites accessed with the DTT and the NSBT were made by the surgeons at the time of surgery and at the 2-week follow-up, by nurses at 1 and 4 hours after surgery, and by patients at the 2-week follow-up. The nurses and the patients were blinded as to the side of each trocar placement. A visual analog score of 1 to 5 was used for the assessment of 17 studied variables. Questionnaires were standardized and explained to examiners. Wilcoxon's signed-rank test was used for the analysis of time-specific data collected by the same examiner (evaluation by the nurses at 1 and 4 hours after surgery). Friedman's test was applied for analysis of the remaining data. Statistically significant differences were established in ease of placement (chi(2) = 4.691, p = .030) and displacement rate (chi(2) = 7.264, p = .007), in which the NSBT obtained the better results. No statistically significant differences were found in bleeding at the time of placement or removal of the trocars, hematoma/bruising formation, pain, or cosmetic results as assessed by surgeons, nurses, and patients at corresponding stages of intra- and postoperative care. CONCLUSIONS: When used for lateral laparoscopic access in gynecologic surgery, NSBTs were easier to place and had a smaller rate of displacement than DTTs. Despite substantial differences in the design of the trocars, no statistically significant differences in bleeding risk, hematoma/bruising formation, pain, or cosmetic results were established. Individual goals of the surgery and conditions specific to each patient appear to be the best criteria for selection of 1 or the other trocar.

An innovative bipolar instrument for laparoscopic surgery.

OBJECTIVE: Bipolar electrosurgery is an excellent method for obtaining hemostasis at laparoscopy. The present study describes and evaluates a bipolar device that can be more versatile and cost effective in advanced operative procedures than the traditional instrumentation. METHODS: This was a retrospective, case-controlled analysis of bipolar instrumentation with a design classification of II-2. A single surgeon in a private practice setting performed all procedures. Sixteen patients, matched for age and pathology were evaluated by videotape review to determine the comparative efficiency of the BiCOAG bipolar dissector/grasper versus traditional Kleppinger bipolar forceps. Efficiency here is defined as comparative operating times in each group. RESULTS: The number of instrument changes per case was counted because this appeared to be the only variable other than time that differentiated the 2 groups. The BiCOAG bipolar dissector/grasper device group had 4 times fewer instrument changes and significantly decreased operating room times when compared with that of the Kleppinger forceps group. Because cost per unit of operating room time was a constant figure, the decrease in cost that resulted due to the decrease in operating time is considered a cost-effective measure. CONCLUSIONS: The BiCOAG bipolar dissector/grasper is a cost-effective, efficient instrument for use in operative laparoscopic procedures.

Laparoscopic supracervical hysterectomy for the large uterus.

STUDY OBJECTIVE: The purpose of this study was to review outcomes of laparoscopic supracervical hysterectomy (LSH) performed on patients with large uteri and compare those outcomes with existing series of hysterectomies reporting removal of large uteri. DESIGN: Retrospective analysis (Canadian Task Force classification II-3). SETTING: Single surgeon, independent surgery center. PATIENTS: Women with symptomatic myomas and/or menorrhagia. INTERVENTION: Laparoscopic supracervical hysterectomy. MEASUREMENTS AND MAIN RESULTS: All patients undergoing LSH procedures for uteri weighing more than 300 g between the years 1997 and 2001 were evaluated. A retrospective chart review and videotape review were used to assess outcome measures including operative time, complications, estimated blood loss, uterine weight, and pathologic diagnoses. A quality of life questionnaire was submitted to the patients postoperatively. During the 5 years of the study, 329 LSHs were performed, 54 (16.4%) involved uterine weight greater than 300 g, and 31 (67%) of this group had a uterine weight greater than 500 g. Seven patients (2%) had complex pathologies with leiomyomata and endometriosis. There were five cases of reported complications: two intraoperative complications and three postoperative fevers. One procedure was converted to laparotomy. Transfusion rate was 0%, with an average estimated blood loss of 77 mL. The mean number of days to return to work or normal activity was 10.1. Sexual relations were reported to be as good as or better than before the procedure in 88.9% of patients. All the patients reported being satisfied with the procedure. CONCLUSION: The LSH procedure in this series provided an effective, low-morbidity alternative for patients with large uteri to accomplish uterine extirpation. Since reduction of morbidity and improved quality of care for women undergoing hysterectomy are goals of all gynecologists, we believe that LSH is an alternative that should be considered.

Ovarian remnant with bilateral duplicate ureters.

A 27-year-old woman had a history of acute chronic pelvic pain. She had had a previous salpingo-oophorectomy for an endometrioma. A computerized tomographic scan showed a left adnexal mass. She was known to have bilateral duplicate ureters shown on intravenous pyelogram. She underwent laparoscopy and retroperitoneal dissection of endometriosis with excision of the mass from the pelvic sidewall. The final pathology was consistent with a hemorrhagic corpus luteal cyst.