Cul-de-sac insufflation: an easy alternative route for safely inducing pneumoperitoneum.

Since 1977, routine cul-de-sac insufflation to achieve a pneumoperitoneum for laparoscopy was performed on 350 women under local anesthesia. A van Schie/van Lith intrauterine tenaculum, used together with a self-retaining Trelat speculum, guaranteed maximum stretching of the posterior vaginal fault and fixation of the anteflexed uterus necessary for an accurate 1-cm deep penetration of a pneumoperitoneum needle into the cul-de-sac. The correct position of the tip of the needle was determined precisely by means of two manometers. The failure rate in the first study of 195 procedures was 3.6% and that in the following 155 cases was 1.9%. There were no serious operative complications. The authors recommended the cul-de-sac insufflation approach for inducing pneumoperitoneum as the technique of choice.

Cul-de-sac insufflation to induce pneumoperitoneum: an analysis of rare problems.

Since 1977, cul-de-sac insufflation has been used to achieve pneumoperitoneum for laparoscopic sterilization of 570 women. The authors have previously published findings on 350 of these women (Int J Gynaecol Obstet 17(4):375, 1980), reporting technical failure rates of 3.6% and 1.9% for a series of 195 and 155 women, respectively. The failure rate for the latest series of 220 women declined to 1.4%. Reasons for this lower rate and recurring causes of the failures are given, and recommendations for the use of cul-de-sac insufflation for inducing pneumoperitoneum are suggested.

Carbon dioxide hysteroscopy immediately after second trimester abortion.

The use of hysteroscopy has been restricted a.o. by the need for general anesthesia. This applies in particular to the pre- or post-partum period, because the hyperemic atonic uterus is easily over-inflated to a dangerous level. Over-inflation did not occur following 50 aspirotomy D & E procedures in the second trimester, using a para- and intracervical block with lidocaine 1% with adrenaline 1:200,000 only. The uterine cavity was always thoroughly evacuated in these cases in which final check suction had been performed. We recommend that postabortum hysteroscopy should be performed preferably under local anesthesia.

PIP: 50 aspirotomy dilatation and evacuation (D and E) procedures in women whose durations of gestation varied from 14-18 menstrual weeks were followed by hysteroscopy in a test to determine whether the use of local anesthesia with uterotonic drugs could alleviate the problem of low intrauterine pressure caused by anesthesia-related uterine atony. Anesthesia was achieved by paracervical and intracervical block with lidocaine 1% with adrenaline 1:200,000, which provides a vasoconstrictive effect on the vessels of the lower uterine segment. Routine hysteroscopy was performed. The rate of flow of CO2 averaged 50-75 ml/min and never exceeded 75 ml/min. The average amount of CO2 used was 300 ml. Intrauterine pressure varied from 40-60 mmHg and the time required to complete the procedure ranged from 2-5 minutes. The major hysteroscopic observation was that the uterine cavity was almost always thoroughly evacuated. In 6 cases blood obscuring the hysteroscope lens seriously impaired visibility. 4 patients developed a cough shortly after the initiation of CO2 insufflation, probably due to CO2 microembolization. Although no incidence of serious morbidity or side effects occurred, further well documented studies are necessary to assess the safety of CO2 hysteroscopy after 2nd trimester abortion. It is however recommended that postabortion hysteroscopy be performed under local anesthesia to which adrenaline has been added.

Diagnostic miniculdoscopy preceding laparoscopy when bowel adhesions are suspected.

Suspected bowel adhesions are often considered a relative contraindication to laparoscopy. To attempt preoperative diagnoses of intraabdominal adhesions, miniculdoscopy was performed on ten patients with a miniendoscope. It was possible to establish the presence or absence of adhesions and to determine a safe abdominal trocar insertion site. The laparoscope trocar could be inserted under direct controlled vision with the culdoscope in nine cases, suggesting that this procedure averts bowel adhesions. This technique may be a contribution to safer laparoscopy.

Postabortum insertion of multiload IUD.

PIP: This 1978 study of postabortum insertion of multiload copper 250 (ML Cu 250) IUDs involved 382 of 2881 patients who requested 1st or 2nd trimester abortions. 221 were subjected to a 2 year follow-up. In patients 30 years old and younger expulsions occurred at 2 weeks, 4 weeks, and 6 months. The accidental pregnancy rate was 0.9%, the expulsion rate was 1.3%, the removal rate due to bleeding was 9.5% and from infection (5.4%), the continuation rate was 80%. The bleeding and infection rates after 6 months (9.9%), 12 months (13.5%), and 2 years (14.9%) were higher than previous studies. The immediate postabortum ML Cu 250 insertion appears to be a safe and acceptable method of contraception. Menstrual and intermenstrual bleeding in women after postabortum ML Cu 250 insertion is significantly higher than after interim and postpartum insertion, but similar to that after interim Nova T insertion. Factors involved in the vaginal bleeding may be: 1) decreased fibrinolytic activity of the endometrium, 2) production of plasminogen-activator inhibitors by the decidua, or 3) increased myometrial contractility due to extra prostaglandin synthesis caused by copper IUDs.^ieng