Prevention and Management of Complications in Laparoscopic Myomectomy.

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

Simplified approach to the treatment of endometriosis--ECO system.

AIM: The aim of the present study was to develop a system to facilitate the approach for patients with endometriosis, mainly for non-specialized gynecologists. METHODS: This was a multicenter study (Canadian Task Force classification II-3). The study aimed to correlate three known parameters for endometriosis, qualifying and quantifying their importance in terms of disease severity and treatment complexity. Patients were divided into three groups. RESULTS: Each parameter was scored from 0 to 2 in order to determine medical or surgical management for endometriosis based on the clinical and imaging results, where the total score of 0 to 2 was for medical treatment, score 3 was possible medical treatment or surgical and score of 4 to 6 was for surgical intervention. A total score from the three parameters was obtained. Anatomical extent of infiltration and complaints and objective of the patient was helpful in deciding on management of patients with endometriosis. CONCLUSION: The ECO system can be a qualified and helpful tool in the approach to patients with suspected endometriosis, mainly for non-specialized gynecologists.

Gynaecological endoscopic evaluation of 4% icodextrin solution: a European, multicentre, double-blind, randomized study of the efficacy and safety in the reduction of de novo adhesions after laparoscopic gynaecological surgery.

BACKGROUND: Gynaecological laparoscopic surgery outcomes can be compromised by the formation of de novo adhesions. This randomized, double-blind study was designed to assess the efficacy and safety of 4% icodextrin solution (Adept(®)) in the reduction of de novo adhesion incidence compared to lactated Ringer's solution (LRS). METHODS: Patients undergoing laparoscopic surgery for removal of myomas or endometriotic cysts were treated with randomized solution as an intra-operative irrigant and 1l post-operative instillate. De novo adhesion incidence (number of sites with adhesions), severity and extent were independently scored at a second-look procedure and the efficacy of the two solutions compared. The effect of surgical covariates on adhesion formation was also investigated. Initial exploratory analysis of individual anatomical sites of clinical importance was progressed. RESULTS Of 498 patients randomized, 330 were evaluable (160 LRS--75% myomectomy/25% endometriotic cysts; 170 Adept--79% myomectomy/21% endometriotic cysts). At study completion, 76.2% LRS and 77.6% Adept had ≥ 1 de novo adhesion. The mean (SD) number of de novo adhesions was 2.58 (2.11) for Adept and 2.58 (2.38) for LRS. The treatment effect difference was not significant (P = 0.909). Assessment of surgical covariates identified significant influences on the mean number of de novo adhesions regardless of treatment, including surgery duration (P = 0.048), blood loss in myomectomy patients (P = 0.019), length of uterine incision in myomectomy patients (P < 0.001) and number of suture knots (P < 0.001). There were 15 adverse events considered treatment-related in the LRS patients (7.2%) and 18 in the Adept group (8.3%). Of 17 reported serious adverse events (9 LRS; 8 Adept) none were considered treatment-related. CONCLUSIONS: The study confirmed the safety of Adept in laparoscopic surgery. The proportion of patients with de novo adhesion formation was considerably higher than previous literature suggested. Overall there was no evidence of a clinical effect but various surgical covariates including surgery duration, blood loss, number and size of incisions, suturing and number of knots were found to influence de novo adhesion formation. The study provides direction for future research into adhesion reduction strategies in site specific surgery.

Free flaps in head and neck surgery.

Free flaps in head and neck reconstruction offer a one step reconstructive procedure with a decreased patient morbidity and an 85% successrate in 60 free flaps, including twenty-eight intra-oral free flaps. Groinflaps were used in twenty-five patients and latissimus dorsi flaps in 34 patients. The indications included benign conditions in 10 patients, from which six has an atrofia of subcutaneous fattissue in the face. Carcinomas were treated in 50 patients. Forty squamous cell carcinomas involved 11 tumors of the floor of the mouth and 11 tongue carcinomas, five orbita and four nose reconstructions. The facial artery was the recipient vessel in 70% of the extra-oral and 68% of the intra-oral free flaps. The lingual artery was used in 12% of the cases, and the superior thyroid artery in 10% of the cases. Free flap procedures, do not increase the operation time substantially. The wound healing is excellent and the hospital stay shortened to 10 days. This quick recovery improves the quality of life for patients with often extensive cancer. Also major salvage procedure can be carried out after conventional methods have failed.

[Fingerreplantation results since 1972 (author's transl)]. / Ervaring met vingerreïmplantaties sedert 1972.

With the use of microvascular techniques 31 out of 45 fingers were successful replanted since 1972. A primary reconstruction of all structures was performed, without bone shortening. Vein-grafts had to be used extensively. The microvascular and digital nerve repairs were performed with 11/0 nylon. The microvascular anastomosis was performed starting at the posterior wall, and progressively coming to the anterior wall, without rotation of the clamps. The results of near total amputations were always good. In complete guillotine amputations the successrate was 75%. In crush lesions 59% and in avulsions 40% success was obtained. After a period for improvement of our microsurgical techniques the results were 90%, 91% and 40% respectively. The functional rehabilitation of the replanted fingers resulted in a useful hand in crush and avulsion trauma and in a very useful hand in guillotine lesions.