Pelvic abscesses: pelviscopy or laparotomy.

Between 1983 and 1988, we treated 66 patients with pelvic abscesses. Twenty-five patients required laparotomy and 41 underwent pelviscopy for treatment. The choice of the operative procedure, laparotomy or pelviscopy, depended on the age of the patient, the clinical presentation and the operative findings. The two collectives demonstrated no differences in the duration of hospitalization and in-patient treatment with antibiotics. A conservative, organ-preserving procedure could be performed in 80% of patients operated pelviscopically. In follow-up examinations 1-2 years after operation, 27% of the patients treated per pelviscopy complained of chronic abdominal pain as compared to 37% of those treated per laparotomy. In young patients, pelviscopic treatment of pelvic abscesses is a valuable alternative to laparotomy.

PIP: Physicians at Christian Albrecht University Hospital in Keil, West Germany treated 66 women with pelvic abscesses between 1983-1986. Pelviscopically treated patients were younger than laparotomy treated patients and IUD usage occurred 17% vs. 20% respectively. They 1st treated many patients with ampicillin and metronidazole or ampicillin and clavulanic acid. They were able to perform pelviscopy on 25 of the 33 patients with inflamed Fallopian tubes. 9 of these women experienced either a uni- or bilateral salpingectomy or salpingo-oophorectomy. They were able to do an organ preserving procedure designed to preserve fertility in 80% of the women, especially pelviscopically treated patients (81% vs. 16% laparotomy patients). They performed a laparotomy on the 6 patients with bilateral total abdominal tuboovarian abscesses. Of the 25 women who underwent a laparotomy, 20 required only a uni- or bilateral salpingectomy or salpingo-oophorectomy and 5 required a total hysterectomy and bilateral salpingectomy. No differences existed between pelviscopically and laparotomy patients in number of days in the hospital and duration of inpatient antibiotic therapy. Even though more laparotomy treated patients (37%) experienced chronic abdominal pain following treatment than pelviscopically treated patients (27%), the laparotomy patients initially experienced more severe and extensive infections than did pelviscopically treated patients. Of the 45 patients who were able to be examined 1-2 years after surgery, only 3 experienced recurrent pelvic inflammatory disease (8% of pelviscopically treated patients and 5% of laparotomy patients) which the physicians found encouraging since pregnancies may occur. In conclusion, to preserve fertility, they advocated pelviscopy along with organ preservation for patients in their reproductive years.

Results of the use of a pure urinary FSH stimulation regime in patients unsuccessfully treated with hMG in an in vitro fertilization program.

63 infertile patients who failed in achieving pregnancy for several cycles with human menopausal gonadotropin stimulation protocol in our in vitro fertilization program were subsequently treated with urinary FSH regime. In 25 of these patients, the leading diagnosis was an elevated basal LH/FSH ratio (i.e. above 2), 29 women had an irreparable tubal factor, 9 patients had endometriosis, and 21 couples suffered from an additional male factor. The FSH stimulation protocol was initiated on day 2 of the cycle, the highest doses were given on the first days and reduced thereafter. Hormone measurements concerning estradiol and LH were started on day 2 of the cycle, ultrasonic evaluation on day 7 of the cycle. After 48 pelviscopic follicle punctures and 39 embryotransfers 12 cases resulted in clinical pregnancies. One case terminated in a miscarriage and 2 pregnancies were of ectopic location.

Delivery of breech presentation infants at term. An analysis of 304 breech-deliveries.

304 breech presentation infants greater than or equal to 2.500 g were delivered at the University Women's Clinic, Kiel, between 1984 and 1987. Only 2 of the vaginally delivered infants died; both had severe malformations sonographically diagnosed prior to delivery. The umbilical cord arterial PH was found to be significantly (p less than 0.001) higher in infants delivered per Caesarean Section as compared to those vaginally delivered. The same ratio was found in a control group of vaginally delivered infants compared to sectioned infants in the vertex presentation. In 13.3% of cases post primary section and in 14.4% of cases post vaginal delivery from breech presentation we found an apgar of less than or equal to 7 one minute post-partum. The transfer rate to a paediatric unit of vaginally delivered infants (7.2%) appeared to be double that of the infants delivered per Caesarean Section (3.6%). However, the indication for transferral is principally independent of the mode of delivery. Taking the 3-12fold increased maternal mortality rate post section as compared to vaginal delivery into consideration, a vaginal delivery of a breech presentation infant at term appears to be justifiable under certain presuppositions: exclusion of cranio-pelvic disproportion, and normal progression of labour. The indication for secondary Caesarean Section should be generously applied in cases of a suspicious C.T.G. and a slow progression of labour.

Pelviscopy.

Pelviscopy, along with the entire concept of minimally invasive surgery through endoscopically guided intra-abdominal surgery, has become a mainstay in gynecologic surgery. The review of instrumentation in this field includes comments on the CO2-Aqua-Purator, CO2 insufflator, round-grip instruments, electrocautery, endocoagulator, and lasers. Detailed procedural descriptions are given of visually controlled peritoneal perforation and second-look pelviscopic procedures are given in the second section, and the final section covers the role of pelviscopy in the treatment of endometriosis, polycystic ovarian syndrome, and pelvic inflammatory disease.

Ectopic pregnancy treatment using pelviscopic or vaginosonographically-guided intrachorionic injection of methotrexate and POR 8.

It is believed by some that the basis of modern first-trimester pregnancy care should involve screening for ectopic pregnancy using vaginal ultrasonography. This has led to this condition being diagnosed in most cases at an earlier stage than has previously been possible. This advance in diagnostic ability has introduced the concept of conservative management for this condition. The authors describe the conservative management of nine cases of ectopic pregnancy using intrachorionic injection of either methotrexate alone or in combination with POR 8. In all cases less than 9 weeks had passed since the last menstrual period, and the ectopic pregnancies treated under ultrasound control were all thought to be viable. Five cases were treated using pelviscopy, whilst in another four the needle was guided using vaginal ultrasonography. There were no procedure-related complications. Following therapy, the women were followed up using serial levels of serum beta-hCG. In seven cases there was a gradual reduction to normal levels. There were two treatment 'failures'. In both these cases methotrexate alone, rather than in combination with POR 8, was used for injection. Although formal tests of tubal patency have not been performed in all cases, one woman in the series has since conceived and has a normal intrauterine pregnancy. It is concluded that vaginal instillation of methotrexate is an alternative treatment for early ectopic pregnancy. It should be limited to viable ectopic pregnancies whose chorionic cavities are less than 2.0 cm in diameter. A plan for the management of ectopic pregnancy is presented, involving selection for both ultrasound-guided injection and pelviscopic surgery. Laparotomy is not considered to be a treatment option in the majority of cases.

[Pelviscopic salpingostomy with everted suture]. / Pelviskopische Salpingostomie mit evertierender Naht.

From 1987 to 1990 pelvioscopic distal salpingostomy was performed in 47 patients at the University Hospital of Kiel. The tubal mucosa was everted and fixed with 4/0 PDS sutures. 35 patients (74%) responded to a questionnaire 2-4 years after surgery. A bilateral salpingostomy had been performed in 16 of these 35 cases, while the contralateral tube was either absent or intramurally occluded in 19 cases. Eight patients (23%) postoperatively had an intrauterine pregnancy, five patients gave birth to a healthy child, one patient was pregnant at time of follow-up. Three patients had abortions and three experienced a tubal pregnancy of one or both sides. Compared to the endoscopic procedure with the CO2 laser pelvioscopic salpingostomy with an everted suture represents an equally suited alternative.

Width of thermal damage after using the YAG contact laser for cutting biological tissue: animal experimental investigation.

At the University Women's Clinic in Kiel, the YAG contact laser has been used as a cutting instrument in pelviscopic operations since 1987. When the laser cuts, it produces only a scant amount of mechanical trauma. The determining factor is the amount of thermal damage produced along the wound margins and in direct neighboring tissue. The extent of the tissue change seen in the uterus and liver parenchyma of rats and the striated muscle of rabbits after application of the YAG contact laser was demonstrated using various staining techniques and stains. Liver parenchyma proved to be the most sensitive to thermal damage. In the uterine horn, enzyme-histochemical ATPase and alkaline phosphatase demonstrations showed a significantly wider zone of thermal damage after laser incision than did hematoxylin-eosin and Goldner staining techniques. A good understanding of the extent of thermal damage is essential for atraumatic pelviscopic operations using the YAG contact laser and also for the preventing of complications.

Incidence of adhesions in the true pelvis after pelviscopic operative treatment of tubal pregnancy.

33 patients with tubal pregnancies, who had been treated by pelviscopy with organ preservation between 1978 until the beginning of 1988 have had follow-up examinations from within 4 months to 2 years after their first operation. In 15 (45%) of these 33 patients we found adhesions in the true pelvis on initial pelviscopy; these adhesions were lysed in all cases. During a second inspection of the abdominal cavity-either by laparotomy (Cesarean section; 4 patients) or by repelviscopy (29 patients)-mainly avascular, filmy adhesions on one or both adnexae were found in 17 cases (52%). The pelviscopic treatment of ectopic pregnancy does not completely prevent the development of postoperative adhesions. The concomitant pelviscopic adhesiolysis during the treatment of ectopic pregnancy reduces the degree of severity of the recurring adhesions.

Treatment of precursors of endometrial cancer.

From 1985 to 1991, 73 hysterectomies were performed on patients suffering from histologically demonstrated adenomatous hyperplasia, grades 1-3, at the Kiel University Hospital of Gynecology. The operations were done within a month from the diagnosis. Three of the patients were under 40 years of age. An exact correspondence between the grade of adenomatous hyperplasia in the abraded material and the uterus specimen was found in only 44% of the cases. In the patients over 40 with adenomatous hyperplasia of any grade demonstrated in the abraded material, an already well-differentiated endometrial carcinoma was found in 16% of the cases, while such a carcinoma was found in 57% of the cases with grade 3 adenomatous hyperplasia! Even though drug therapy with gestagen may have a beneficial effect, a hysterectomy is nevertheless the treatment of choice for adenomatous hyperplasia of grade 2 and grade 3 in patients over 40 because it is not absolutely certain from a diagnostic point of view that the material is representative of the entire mucosa. In women under 40 years of age it is necessary to plan therapy on an individual basis.