López-Zepeda uterine manipulator: device description and its application in the total laparoscopic hysterectomy.

During the total laparoscopic hysterectomy (TLH) operation, small changes in the uterine and vaginal cuff position, provided by an adequate manipulator, may optimize the attack angles to the vulnerable structures involved during the procedure and facilitate their dissection. The uterine manipulators are effective because they raise the uterus when moving it from one place to another, leaving the fixing elements on tension. The Lopez-Zepeda uterine manipulator exposes all the anatomic structures involved in TLH, especially those in the vulnerable areas. It avoids dissection and mobilization of the bladder and therefore its innervation. It takes the ureter away from the risky area by 4 cm. to 5 cm. decreasing the injury risk. Finally, thanks to its anteflexion and anteversion movement, it puts the posterior culdotomy area further away from the ureter, the rectum and the sigmoid colon.

Laparoscopy versus minilaparotomy in women with symptomatic uterine myomas: short-term and fertility results.

OBJECTIVE: To retrospectively compare the feasibility, safety, morbidity, and pregnancy outcome of laparoscopy (LPS) and minilaparotomy (LPT) in the treatment of symptomatic uterine myomas. DESIGN: Retrospective, nonrandomized study. SETTING: Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy. PATIENT(S): 680 nonconsecutive patients with symptomatic uterine myomas. INTERVENTION(S): 350 women underwent LPS, and 330 underwent LPT myomectomy. MAIN OUTCOME MEASURE(S): Operative time, blood loss, hospital stay, pregnancy rate, and spontaneous abortion rate. RESULT(S): The mean operative time was 63 +/- 21 minutes (95% CI, 48-143) in the LPS group and 57 +/- 23 minutes (95% CI, 38-121) in the LPT group. The mean length of hospital stay was statistically significantly greater in the LPT group (3.1 +/- 0.5; 95% CI, 1-5) than the LPS group (2.1 +/- 0.8; 95% CI, 1-4). The overall spontaneous pregnancy rate after myomectomy was 53%; the pregnancy rate after LPS myomectomy (56%) was not statistically significantly higher than the rate for LPT (50%). CONCLUSION(S): Laparoscopy showed a lower morbidity than reported for the open approach and was characterized by less blood loss and a shorter postoperative hospitalization with an higher pregnancy rate. The operating time was not much longer in the laparoscopic group, and the intraoperative and postoperative complications appeared acceptable and not more than what is traditionally expected with the open approach.

Total laparoscopic hysterectomy versus abdominal hysterectomy with lymphadenectomy for early-stage endometrial cancer: a prospective randomized study.

OBJECTIVE: The aim of this study was to compare, in a series of 159 women the feasibility, safety and morbidity of total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early-stage endometrial cancer and to assess disease-free survival and recurrence rate. METHODS: 159 patients with clinical stage I endometrial cancer were enrolled in a prospective randomized trial and treated with LPS or LPT approach. The para-aortic lymphadenectomy was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation, in patients with poorly differentiated tumors with myometrial invasion greater than 50% (ICG3), and non-endometrioid carcinomas. RESULTS: The mean operative time was 136 min+/-31 (95% CI 118-181) in the LPS group and 123 min+/-29 (95% CI 111-198) in the LPT group (P<0.01). The mean blood loss was 50 ml+/-12 in the LPS group (95% CI 20-90) and 145 ml+/-35 in the LPT group (95% CI 60-255) (P<0.01). The mean length of hospital stay was 5.1+/-1.2 in the LPT group (95% CI 1-7) and 2.1+/-0.5 in the LPS group (95% CI 1-5) (P<0.01). CONCLUSIONS: Laparoscopy is a suitable procedure for the treatment of patients with early endometrial cancer and may offer the potential benefits of decreased discomfort with decreased convalescence time without compromising the degree of oncological radicality required; however, it does not seem to modify the disease-free survival and the overall survival, although multicenter randomized trials and long-term follow-up are required to evaluate the overall oncologic outcomes of this procedure.

Use of circular stapler for laparoscopic excision of rectosigmoid anterior wall endometriosis.

The objective of this study was to assess the feasibility and safety of laparoscopic rectosigmoid anterior wall discoid resection for endometriosis using the circular stapler. A retrospective analysis was conducted of nine consecutive patients undergoing laparoscopic radical excision of pelvic endometriosis, including bowel anterior wall discoid excision, at the Fertility and Pelvic Surgery Clinic and private hospitals in São Paulo, Brazil. The selected intervention was a radical laparoscopic endometriosis resection, including rectosigmoid anterior wall excision with the circular stapler. For certain types of bowel endometriosis, the anterior wall discoid stapler excision proved a suitable option that diminishes the chances of serious complications such as bowel fistula or anastomosis dehiscence.

Total laparoscopic hysterectomy: indications, techniques and outcomes.

PURPOSE OF REVIEW: The indications, techniques and outcomes of laparoscopic associated hysterectomy and especially total laparoscopic hysterectomy are thoroughly reviewed. RECENT FINDINGS: The original technique for total laparoscopic hysterectomy is detailed as it is still applicable. The total laparoscopic hysterectomy operation has not changed to any major degree over the past 15 years. The technique detailed works well and lessens the chance for a ureteral injury. Expansion of the technique has occurred in oncology. Evidence-based studies support the use of vaginal hysterectomy if possible over laparoscopic and abdominal hysterectomy. They also support a laparoscopic approach to hysterectomy over total abdominal hysterectomy. SUMMARY: Despite evidence-based studies, gynecologic surgical specialists have been slow to adopt both laparoscopic and vaginal hysterectomy into their practice. This trend may increase in the near future. Adoption of laparoscopic associated hysterectomy has been extremely slow.

Laparoscopic treatment of recurrent small bowel obstruction secondary to ileal endometriosis.

Endometriosis is a relatively common condition characterized by implantation and proliferation of endometrial glands outside the uterus affecting 8% to 15% of women. Intestinal involvement is common, reported in 12% to 37% of individuals with the disease. The sites most often affected are the sigmoid colon and rectum (85%), while small bowel involvement is seen less frequently (7%) and usually confined to the distal ileum. The cecum (3.6%) and appendix (3%) are the sites least affected.

Adhesiolysis in severe and reccurent cases of adhesions related disorder (ARD) - a novel approach utilizing lift (gasless) laparoscopy and SprayGel adhesion barrier.

We investigated the feasibility and outcome of adhesiolysis in patients with severe and reccurent adhesions using lift (gasless) laparoscopy and a SprayGel adhesion barrier at the Institute for Endoscopic Gynecology (EndoGyn). The design included a prospective evaluation of lift (gasless) laparoscopic adhesiolysis in combination with a SprayGel adhesion barrier. A new score for bowel adhesions was developed and applied. All 35 patients with severe and reccurent adhesions underwent a lift-laparoscopic adhesiolysis with the Abdo-Lift and SprayGel adhesion barrier, a second-look laparoscopy at Day 7 and, in case of continuation of pain, a third-look laparoscopy within 6 months after the initial surgery. All patients were operated upon without conversion to laparotomy. The reduction in the adhesion score of adhesions at the second-look laparoscopy was overall (sum) 89.8% (90.1% reduction in extent, 89.3% reduction in severity, and 89.9% reduction in grade). Five patients (14.3%) had a third-look laparoscopy within 6 months after the initial surgery, in which four cases of adhesion reformation were confirmed. However, the scores were reduced compared to the initial surgery, especially in grade (94.2%) and severity (93.2%). In these analyses, SprayGel was uniquely effective in improving the success rates of adhesiolysis when combined with lift (gasless) laparoscopy and good hemostasis techniques. Adhesiolysis with Abdo-Lift and SprayGel had unparalleled efficacy in the adhesiolysis procedure even in those patients in whom other solutions have not worked. An overall reduction of adhesions by 89.9% at second-look laparoscopy was found. Even if five patients (14.3%) required a third-look laparoscopy where four cases of adhesion reformation were confirmed, the scores were reduced when compared to the initial surgery, especially in grade and severity.

Laparoscopic hysterectomy for advanced endometriosis including rectosigmoid disease.

Endometriosis is best treated by surgical excision. This can be accomplished either by excision of the endometriosis with reproductive tract preservation or by excision of endometriosis with hysterectomy. This latter approach eliminates endometriosis in the muscle of the uterus (where it is called adenomyosis) and is especially effective for pelvic pain. Ovarian preservation can be considered using hysterectomy if the surgeon excises most of the endometriosis. Techniques to excise endometriosis, including rectosigmoid disease, and perform hysterectomy are detailed in this chapter.

Lift-laparoscopic total hysterectomy as a routine procedure.

In this study, laparoscopic hysterectomy was done with a special lift system that elevates the abdominal wall without carbon dioxide (CO2) insufflation. During this procedure, bipolar diathermy scissors also were used, which disconnected the uterus from its vessels and ligaments. The uterus was then removed through the vagina. In 403 cases, variables including operation time, complication rate, blood loss, postoperative pain, hospital stay, vaginal discharge, and convalescence time were examined. Compared with other laparoscopic methods [laparoscopic-assisted vaginal hysterectomy (LAVH), supracervical hysterectomy, and total laparoscopic hysterectomy], all those examined showed better results. Further advantages of the gasless Lift-laparoscopic total hysterectomy are lower costs and an effective "learning curve." Use of this method routinely could decrease the number of conventional-surgical hysterectomies that result in additional complications.

Extraperitoneal endometriosis with catamenial pneumothoraces: a review of the literature.

OBJECTIVE: To present a case of recurrent catamenial pneumothorax and diaphragmatic endometriosis that was managed thoracoscopically. A review of the literature is also presented. METHODS: A-28-year-old woman presented with bloody stools, chronic constipation, and chest pain. A review of systems was positive for monthly chest pain associated with her menses. A preoperative chest x-ray revealed a right pneumothorax. Colonoscopy revealed biopsy proven endometriosis of the sigmoid colon. A pelvic computed tomography scan revealed bilateral complex, cystic and solid adenexal lesions. RESULTS: A right thoracoscopy was performed. A lesion on the right hemidiaphragm was excised and confirmed to be endometriosis. A wedge section of lung tissue containing a bleb was resected and also contained endometriosis. Three months later, the patient underwent laparoscopic excision of her pelvic endometriosis, including a low anterior rectal resection. Five months later, she presented again with right-sided chest pain. A thoracoscopic right total pleurectomy was performed for recurrent pneumothorax. CONCLUSION: Pullmonary endometriosis may present as chest pain, shortness of breath, or hemoptysis associated with menstrual cycles. This case emphasizes the importance of a careful review of systems in patients with known endometriosis. Management now includes an endoscopic alternative and all of its known benefits.

An Update on Laparoscopic Hysterectomy and Pelvic Floor Reconstruction.

Laparoscopic hysterectomy and pelvic floor reconstruction have recently undergone some degree of evolution. New instrumentation has appeared, such as the vaginal delineator, but overall most of the instruments used have remained basically unchanged. This is related mostly to the need of keeping costs down by limiting the use of disposable instrumentation. For pelvic reconstruction, the laparoscopic approach is now usually considered the optimal approach, as it allows the surgeon to visualize structures that the vaginal surgeon could in the past only palpate.