Comment on “Isobaric (gasless) laparoscopic uterine myomectomy—An overview” [Eur. J. Obstet. Gynecol. Reprod. Biol. 129 (2006) 9–14

Abstract

We read with interest Sesti's review [ [1] Sesti F. Melgrati L. Damiani A. Piccione E. Isobaric (gasless) laparoscopic uterine myomectomy—an overview. Eur J Obstet Gynecol Reprod Biol. 2006; 129: 9-14 Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar ] on gasless laparoscopic uterine myomectomy and commend these authors’ efforts. However, certain issues need to be clarified: 1.The authors opine that this procedure can be performed under local and regional (epidural or spinal) rather than general anesthesia. However, general anesthesia with muscle paralysis and tracheal intubation remains the preferred technique for most laparoscopic procedures [ [2] Song D. Joshi G.P. White P.F. Fast-track eligibility after ambulatory anesthesia: a comparison of desflurane, sevoflurane, and propofol. Anesth Analg. 1998; 86: 267-273 PubMed Google Scholar ]. Shorter laparoscopic procedures such as diagnostic laparoscopy, pain mapping, laparoscopy for infertility and tubal ligation can be performed under local or regional anesthesia [ [3] Collins L.M. Vaghadia H. Regional anesthesia for laparoscopy. Anesthesiol Clin North Am. 2001; 19: 43-56 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar ]. 2.The authors did not mention whether or not the CO2 gas stopcock to be kept open to relieve negative intra-abdominal pressure, as soon as the vented instrument tip enters the sealed peritoneal space. It is postulated that the viscera fall away from their parietal apposition prior to contact with advancing sharp trocar [ 4 Dingfelder J.R. Direct laparoscope trocar insertion without prior pneumoperitoneum. Obstet Gynecol. 1978; 21: 45-47 Google Scholar , 5 Byron J.W. Markenson G. Miyazawa K. A randomized comparison of Veress needle and direct trocar insertion for laparoscopy. Surg Gynecol Obstet. 1993; 177: 259-262 PubMed Google Scholar ]. When the abdominal wall is lifted with the Laparotenser, space will be created between the abdominal wall and viscera. This space will be occupied by atmospheric gas, which contains oxygen. Electrocoagulation in the presence of oxygen raises the possibility of electrical burns. 3.The authors suggested the use of tenaculum clamps, scissors or scalpel for removal of the myoma. The option of electromechanical morcellation facilitates easy removal of the myoma and significantly saves time [ 6 Carter J.E. McCarus S. Time savings using the steiner morcellator in laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 1996; : S6 Google Scholar , 7 Carter J.E. McCarus S.D. Laparoscopic myomectomy. Time and cost analysis of power vs. manual morcellation. J Reprod Med. 1997; 42: 383-388 PubMed Google Scholar ]. 4.Among the disadvantages of laparoscopic myomectomy using CO2, the authors mention that cleavage is more difficult if the myoma exceeds 8 cm in size. Such a problem also exists with gasless laparoscopy. 5.It is not clear why laparoscopic myomectomy using CO2 is preferred over gasless laparoscopic myomectomy when the total number of myomas does not exceed 2 or 3. Authors’ Response to Comment on “Isobaric (gasless) laparoscopic uterine myomectomy—An overview” [Eur. J. Obstet. Gynecol. Reprod. Biol. 129 (2006) 9–14]European Journal of Obstetrics and Gynecology and Reproductive BiologyVol. 132Issue 1PreviewWe are grateful to Dr. Mahajan for commenting on our review and requesting elucidation on isobaric (gasless) laparoscopic myomectomy. Regarding his first question, we specify that in our first series of patients, 57 out of 279 women preferred peridural anesthesia. In no case was a conversion to general anesthesia necessary. There were no anesthesiologic complications. Indeed, any (peripheral or general) anesthetic technique can be employed in isobaric laparoscopic procedures, as in “open” surgery, because there is no pneumoperitoneum. Full-Text PDF