Inappropriate Surgeries Research Articles

Appropriateness of Hysterectomy as Treatment for Benign Gynecological Conditions.

Objective: To assess the appropriateness of hysterectomies performed at a large tertiary health system using the 1997 RAND appropriateness classification system and an updated algorithm. Design: We abstracted structured and unstructured data from electronic medical records on patient demographics, primary indication(s) for hysterectomy, diagnosis codes associated with the hysterectomy, previous treatments, and laboratory results. Subjects: Patients aged 18-44 years. Exposure: Receipt of hysterectomy for benign and nonobstetric conditions from October 2014 to December 2017. Main Outcome Measures: Using these data, we provided a RAND-based (dichotomous: inappropriate/appropriate) and Wright-based (3-level: inappropriate/ambiguous/appropriate) appropriateness rating and characterized missing information patterns associated with inappropriate ratings. Results: We analyzed 1,829 hysterectomies across 30 nonmutually exclusive primary indications for surgery. Nearly a third (32.8%) of surgeries had only one primary indication for surgery. Using the RAND-based classifier, 31.3% of hysterectomies were rated as appropriate and 68.7% as inappropriate. Using the Wright-based algorithm, 58.1% of hysterectomies were rated as appropriate, 15.7% as ambiguous, and 26.2% as inappropriate. Missing information on diagnostic procedures was the most common characteristic related to both RAND-based (46.1%) and Wright-based (51.2%) inappropriate ratings. Conclusions: The 1997 RAND classification lacked guidance for several contemporary indications, including gender-affirming care. RAND also has an outdated requirement for diagnostic surgeries such as laparoscopies, which have decreased in practice as diagnostic imaging has improved. Sensitivity analyses suggest that inappropriate surgeries cannot all be attributed to bias from missing electronic medical record data. Accurately documenting care delivery for benign gynecological conditions is key to ensuring quality and equity in gynecological care.

Appropriateness of surgical antimicrobial prophylaxis in Japanese university hospitals

Surgical antimicrobial prophylaxis (SAP) is one of the major purposes of antimicrobial use. To determine the adherence to the Japanese SAP guidelines in Japanese university hospitals. This was a retrospective cohort study including 15 general hospitals and one dental university hospital. Up to three cases of 18 designated surgeries were evaluated regarding adherence to Japanese SAP guidelines: selection of antibiotics, timing of administration, re-dosing intervals, and duration of SAP. When all items were appropriate, surgery was defined as 'appropriate'. In total, 688 cases (22-45 cases per surgery) were included. The overall appropriateness was 46.8% (322/688), and the appropriateness of each surgery ranged from 8.0% (2/25, cardiac implantable electronic device implantation) to 92.1% (35/38, distal gastrectomy). The appropriateness of each item was as follows: pre/intraoperative selections, 78.5% (540/688); timing of administrations, 96.0% (630/656); re-dosing intervals, 91.6% (601/656); postoperative selection, 78.9% (543/688); and duration of SAP, 61.4% (423/688). The overall appropriateness of hospitals ranged from 17.6% (9/51) to 73.3% (33/45). The common reasons for inappropriateness were the longer duration (38.5%, 265/688) and choice of antibiotics with a non-optimal antimicrobial spectrum before/during, and after surgery (19.0%, 131/688 and 16.9%, 116/688, respectively), compared to the guideline. Adherence to the guidelines differed greatly between the surgeries and hospitals. Large-scale multi-centre surveillance of SAP in Japanese hospitals is necessary to identify inappropriate surgeries, factors related to the appropriateness, and incidences of surgical site infections.

Is it possible to eliminate the number of inappropriate thyroid surgeries combining scintigraphy and cytology?

Objective: Although fine needle aspiration cytology (FNAC) is the most reliable, safe and accurate method for the clinical management of abnormal thyroid nodules, 5%-15% of cases lead to indeterminate diagnoses and surgery is the recommended practice for them as they may be malignant. Nevertheless, the majority of cases with indeterminate cytology are benign, so the risk of unnecessary surgery is significant. In our study we combined FNAC and scintigraphy in order to reduce the number of inappropriate surgeries. Subjects and Methods: From 219 patients with thyroid fine needle aspiration cytology 33(9 males and 24 females) aged 18-73 years, had indeterminate FNAC diagnoses and were referred for scintigraphy. Surgery was performed in all cases. The results of FNAC, scintigraphy and histology were collected and compared. Results: From 33 cases with indeterminate cytology 32 had a benign histological diagnosis and only one was malignant (follicular Ca). That case had a positive scan. All cases with negative thyroid scans (29/33) were benign. False positive scans were 3, whereas one scan was true positive with final diagnosis follicular carcinoma. Conclusion: This study showed that combining the FNAC with the thyroid scintigraphy in cases of thyroid nodules with indeterminate cytology it is possible to reduce the number of inappropriate surgeries from 32 to 3.

PREOPERATIVE ASSESSMENT OF PRIMARY VARICOSE VEINS OF LOWER LIMBS BY DUPLEX COLOR DOPPLER ULTRASOUND: A VALIDATION STUDY

INTRODUCTION: Varicose veins comprises a significant clinical problem representing underlying chronic venous insufficiency with ensuing venous hypertension leading to broad spectrum of clinical manifestations. MATERIALS AND METHOD: Our study is based on evaluation of 125 limbs in 103 patients of lower extremity symptomatic varicose veins. After establishing the nature of venous incompetence and abnormality on both clinical and duplex ultrasonography, patients were subjected to surgery and sensitivity, specificity, positive and negative predictive values and diagnostic accuracy was calculated based on operative assessments and findings. RESULTS: Non invasive diagnostic evaluation with duplex sonography in our study proved it to be suitable procedure when sensitivity, specificity and diagnostic accuracy was assesed. CONCLUSION: We conclude that in comparison to the cumbersome clinical assessments alone, the combination of clinical with Doppler duplex ultrasounds, proved to be more suitable and reliable procedures in avoiding the inappropriate surgeries.

A large Chinese pedigree of multiple endocrine neoplasia type 2A with a novel C634Y/D707E germline mutation in RET exon 11.

The present study identified the clinical features of the largest multiple endocrine neoplasia type 2 (MEN2) A pedigree from China, with a novel double missense rearranged during transfection (RET) mutation (C634Y/D707E). To the best of our knowledge, the D707E mutation has not been identified to date. In the present study, a total of 101 family members who originated from a large pedigree (134 members in total) underwent RET mutation screening by next-generation sequencing and polymerase chain reaction (PCR) amplification, followed by direct bidirectional DNA sequencing. The clinical features of this pedigree were carefully reviewed retrospectively, and statistical analyses were conducted using SPSS software. A total of 33 (32.67%) carriers were identified to exhibit the C634Y/D707E RET germline mutation. The mean age of the patients with medullary thyroid carcinoma (MTC) identified by RET screening was 38.4±16.5 years (n=11; range, 14–65 years). Only 4 patients with pheochromocytoma with a median age of 37 years were identified. No hyperparathyroidism was diagnosed. Persistent or recurrent disease developed in the patients of the present study who underwent inappropriate initial thyroid surgeries that were performed in previous decades (III10, III23, III24, III27 and IV46, as they had undergone two surgeries prior to the present study). A total of 66.70% (6/9) of patients, following thyroidectomy, continued to develop persistent or recurrent disease during the present screening study. In total, 3 patients succumbed to MTC or distant metastasis in the present study. The increase in carcinoembryonic antigen (CEA) levels correlated with the increase in basal serum calcitonin (Ct) levels according to Pearson correlation analysis in patients with MTC without surgery. Ct and CEA levels were also significantly correlated with tumor volumes. To the best of our knowledge, the present study is the first to identify a novel double RET missense mutation in the largest MEN2A pedigree from China. Additional in-depth study is necessary to elucidate the molecular mechanisms of the D707E mutation and its potential joint effects with the other C634Y mutation in the pedigree of the present study.

Idiopathic spinal cord herniation: an imaging diagnosis with a significant delay

Background contextIdiopathic spinal cord herniation (ISCH) is an underrecognized entity that is often underappreciated by the neurosurgery and neuroradiologic communities. This leads to delayed diagnosis, multiple imaging studies, other diagnostic tests, inappropriate surgeries, and repeat office visits. PurposeTo evaluate common associations between ISCH and patient demographics/clinical presentation and to analyze the potential for delayed diagnosis. Patient samplePatient sample included those diagnosed with ISCH on imaging at our institution from June 20, 2005 to December 3, 2012. Outcome measuresThese were based on the patient improvement/stability/decline based on the patients' most recent clinic/office visit when compared with initial presentation. MethodsA retrospective search of radiology reports was performed using Illuminate software from June 20, 2005 to December 3, 2012, using the search term “idiopathic spinal cord herniation.” Clinical data were reviewed including patient's age, sex, presenting clinical symptoms, number and type of imaging studies performed as part of the workup, other diagnostic tests, pain procedures, surgeries, and time between original presentation and diagnosis of ISCH on imaging. ResultsA total of 55 patients had the search term “idiopathic spinal cord herniation” included in their radiology report, of which 37 patients were found to meet the imaging and clinical diagnosis of ISCH. The median time from presentation to imaging diagnosis was 20 months in patients younger than 60 years and 5 months in those 60 years or older (p=.02). Of the 37 patients evaluated, 27 (73%) had no change in symptoms, 5 patients (14%) experienced worsening of symptoms, and 5 (14%) experienced symptom improvement from original presentation to most recent office visit. Among all patients evaluated, three underwent repair of the ventral dural defect in ISCH, resulting in clinical improvement. There was a median of nine outpatient office visits, three magnetic resonance images (MRIs), and one electromyography (EMG) per patient presenting with ISCH. The most frequent complaints were neck/upper back pain in 70%, upper/lower extremity numbness/paresthesias/weakness in 49%, hyperreflexia in 22%, and burning chest pain in 22%. ConclusionsProlonged time to diagnosis and subsequent treatment of ISCH protracts patient symptoms and is associated with redundant diagnostic tests and patient visits. Earlier use of MRI in younger patients (younger than 60 years) may be warranted in those with a clinical presentation suggestive of Brown-Sequard symptomatology. Increasing recognition of ISCH in imaging and surgical communities would lead to improved patient care.

The litigation cost of negligent scaphoid fracture management

The aims of the study were to quantify the litigation cost of scaphoid mismanagement, identify the main reasons why patients sought compensation and hence provide suggestions for reducing litigation. Data were obtained from the National Health Service Litigation Authority. All orthopaedic-related litigation between 1995 and 2010 in the UK was reviewed. Litigation specifically against mismanagement of scaphoid fractures were identified and grouped according to the plaintiff's complaint. Exclusions were all unsettled claims. There were 85 closed cases of scaphoid fracture mismanagement over 15 years. Reasons for litigation were as follows: seven failures in interpreting radiographs, 57 missed fractures, four fractures not immobilized, nine discharged too early, five delayed operations and three inappropriate surgeries. The mean cost was &OV0556;41 680 per case (range &OV0556;0-&OV0556;206 789), and a cumulative cost of &OV0556;3 542 855. The majority of litigation may relate to a lack of follow-up and may demonstrate a failure of protocol-driven reassessment. Secondary surveys following major trauma are also highly relevant.

Non-invasive methods for diagnosing diseases of the ear: Wideband acoustic immittance and umbo velocity

Measurements of ossicular motion using laser Doppler vibrometry (LDV) in patients with various ear diseases, along with fresh cadaveric experiments, have increased our understanding of how sound is transduced to the cochlea and how this transduction is modified by various conductive pathologies. These studies have dispelled some misguided beliefs, changed clinical treatments, and shown the potential of LDV as a diagnostic. LDV, however, has substantial limitations as a clinical tool. For patients with conductive hearing loss of unknown etiology (where general otologic exam and conventional tympanometry are not diagnostic), another non-invasive measurement, wideband acoustic immittance (WAI, directly related to power reflectance), in conjunction with audiometric measurements, can differentiate between ossicular fixation, ossicular discontinuity and superior canal dehiscence (SCD). Furthermore, WAI measurements show a common pattern in power reflectance in patients with SCD, with or without a conductive hearing loss. An algorithm to identify this pattern in power reflectance suggests that WAI may be a simple, inexpensive screening tool for SCD. Evidence will be presented from our studies on patients with various otologic diseases, as well as from fresh cadaveric preparations simulating various diseases. Power reflectance can assist in treatment decisions and prevent unnecessary and inappropriate treatments and surgeries.

Selective Neck Dissection: A Novel Technique for Second Branchial Arch Anomalies

ABSTRACT Introduction To propose an operation similar to selective neck dissection (levels II, III and IV) as a method of successful management of second arch branchial anomalies. Materials and methods We did a prospective study on patients with branchial arch anomalies from the years 2009 to 2013. They underwent minimal radiological workup. All of them underwent a novel surgical procedure similar to selective neck dissection (levels II, III, IV) that lead to excision of the tract. Patients were followed up for an average period of 2 years. Results We had seven patients which included two branchial sinus, three cysts and two fistulae. All of them were operated and the tract was identified and completely excised by the above approach. None of them had any complications or recurrence on follow-up. Conclusion Branchial arch anomalies are rare congenital problems posing a significant challenge to an ENT surgeon. Inadequate and inappropriate surgeries resulting in recurrences are quite common. Attempts to get either a sinogram or fistulogram are often a failure and cumbersome. Selective neck dissection from levels II to IV is a surgical maneuver which allows access to the involved anatomical segment of the neck. Thus, it is a structured and methodical approach that comprehensively leads to excision of the complete tract. It also reduces the chances of complications. Recurrences are rare with this technique. How to cite this article Merchant S, Mohiyuddin A, Deo RP, Raj S, Nawaz S, Mohammadi K. Selective Neck Dissection: A Novel Technique for Second Branchial Arch Anomalies. Int J Head Neck Surg 2014;5(2):57-60.

Study of the relations between progressive/idiopathic condylar resorption and impaired bone/cartilage metabolism caused by chemokine receptor disorder

Object: Progressive condylar resorption (PCR) is defined as diminishing condylar head volume with changes in condylar shape, often associated with decreased mandibular ramus height, mandibular retrusion and counter clockwise rotation, resulting in progressive Class II basal bone in relation with anterior open bite. Patients are known to have relatively small and retruded mandible. Because of it, PCR patients often undergo inappropriate surgeries or unnecessary orthodontic procedures under misdiagnosis with maxillary protrusion and/or mandibular retrusion.

Amyotrophic Lateral Sclerosis

Amyotrophic Lateral Sclerosis

Analysis of Rating Appropriateness and Patient Outcomes in Cataract Surgery

PurposeUsing the RAND/UCLA methodology to create the appropriateness criteria, we assessed that the appropriate ratings in cataract surgery can be a better prognosis of outcomes in postoperative 12 months than uncertain or inappropriate ratings. In addition, we indentified the degree of the appropriate rating surgery associated with the outcome changes in postoperative 12 months.Materials and MethodsThe patients in this study were followed up prospectively in preoperative and postoperative 12 months periods. The 20 ophthalmologists in 14 hospitals were asked to refer about 20 patients who were scheduled to undergo cataract surgery from March and June of 1997. A multiple regression analysis was used to identify the degree of the appropriate surgery associated with the changes of outcomes. The outcomes were designed as the clinical and functional outcomes (visual acuity, visual function, satisfaction with vision, and satisfaction with overall care).ResultsThe outcome changes of vision acuity (p < 0.001), vision function-14 (p < 0.001), and symptom score (p < 0.006) were significantly different between four appropriateness ratings (crucial, appropriate, uncertain, and inappropriate). There was a trend that the appropriate rating surgeries were related to the successful change of the vision function (2.29, p = 0.015) and satisfaction with vision (3.84, p = 0.014) in 12 month postoperative period.ConclusionThe crucial or appropriate rating surgeries may indicate better outcomes than uncertain or inappropriate rating surgeries do. The appropriate rating surgeries were more closely related to functional outcome vision function, VF-14 and subjective outcome (satisfaction with vision) in postoperative 12 months than inappropriate rating surgeries.

Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria.

A cross-sectional study carried out at a teaching hospital in Kaduna, Nigeria, to investigate the extent and reasons for the delay between onset of symptoms and admission for treatment of symptomatic breast cancer. The patients had histologically proven breast cancer and had been admitted for treatment. Data were obtained from interviews and patients' clinical and referral records. One hundred and eleven consecutive breast cancer patients were interviewed from July 2003 to June 2005. Only 12 (10.8%) could be admitted for treatment within a month of onset of symptoms. Delays were significantly associated with younger patients, elementary or no Western education, and domicile outside the Kaduna metropolitan area. Patients who were referred from, or received initial treatment at, peripheral hospitals had longer delays than those who came for first consultation at the teaching hospital. The proportion of early breast cancer cases (stages I and II) decreased from 45.9% at diagnosis to 25.2% at treatment, as concerns about mastectomy and hospital treatment led a significant number of the patients to temporarily abandon hospital treatment for alternatives, only to return with advanced cancers. The predominant reasons among the 99 patients who had delays of more than a month before admission were: ignorance of the seriousness of a painless breast lump (47.5%), non-acceptance of hospital treatment (46.5%), and preference for traditional treatment (38.4%). A significant number of patients referred from peripheral hospitals had inappropriate surgeries and biopsy management which contributed to the advanced stage on admission. This study shows that delayed treatment of symptomatic breast cancer at this centre in Nigeria is as much related to the quality of medical care as it is to local beliefs, ignorance of the disease, and lack of acceptance of orthodox treatment.

Pitfalls in the Diagnosis and Management of Obstructive Uterovaginal Duplication: A Series of 32 Cases

Obstructive uterovaginal duplication is rare and frequently misdiagnosed. The aims of this study were to review all the patients managed for this malformation in our institution, evaluate their long-term outcomes, and discuss the embryologic origin of this malformation. From 1984 to 2007, we treated 32 patients for obstructive uterovaginal duplication in our institution. We separated them in 2 groups (prepubertal [n = 8] and pubertal [n = 24]) and analyzed their clinical and radiologic presentations and their treatments. Patients >18 years of age (n = 22) were recontacted. For the prepubertal group, the median age at diagnosis was 6 months. Postnatal ultrasound showed an absent ipsilateral kidney in 6 case subjects, although 4 patients had a prenatal diagnosis of ipsilateral multicystic dysplastic kidney. This renal anomaly was associated with a pelvic sonolucent mass in 3 case subjects, allowing us to prenatally suspect the diagnosis. All of the patients were cured by vaginal approach. For the pubertal group, the median delay of diagnosis after menarche was 9 months. Among patients managed in an emergency setting (n = 11), there were 9 misdiagnoses with inappropriate abdominal surgeries, including 3 hysterectomies of the obstructed hemiuterus. Concerning long-term results, 5 patients were attempting to have children, with successful pregnancies for 4 of them. One patient suffered from infertility attributable to contralateral isthmic stenosis after a hysterectomy of the obstructed hemiuterus. Obstructive uterovaginal duplication is a benign pathology when properly managed. Therefore, management of abdominal pain in peripubertal girls should include systematic abdominal and gynecologic examinations completed by radiologic pelvic and renal evaluation. Surgical treatment should be performed by vaginal approach to avoid infertility. Concerning the origin of the malformation, the high association of prenatal dysplastic kidneys and postnatal absent kidneys suggests anomalies of both wolffian and müllerian duct development, contrasting with the classic definition of this malformation.

Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis

Initial symptoms of amyotrophic lateral sclerosis (ALS) may mimic radiculopathy, myelopathy, mononeuropathy, or arthropathy. A retrospective review of 260 consecutive patients with ALS evaluated between 1996 and 2004 revealed that 55 (21%) had had surgery within the 5 years prior to ALS diagnosis. Thirty-four of these 55 (61%) had surgery for symptoms and signs that retrospectively were attributable to early manifestations of ALS. Misdiagnosis of early ALS may lead to unnecessary surgeries with their attendant potential complications.

Shared Patient Analysis

Referral to specialized physicians or institutions often is deemed necessary in clinical medicine, but no method exists to assess the clinical benefit of such referrals. To describe a method, which is shared patient analysis, to measure the expected improvement in clinical management associated with referrals and to apply that method in the field of abdominal and pelvic oncological radiology. All patients referred, during a 4-year period, to surgical oncologists at four academic centers (the referral providers, or RPs) with radiographs performed before referral at a community site (the initial providers, or IPs). Patients (n = 396) for whom both the IP interpretation and a final diagnosis was available were eligible. All IP and RP readings were placed in random order and presented to surgical oncologists, who then recommended a treatment course. Diagnostic accuracy of the IP and RP readings and the proportion of patients who were assigned to an appropriate treatment by the oncologist were determined. When the indication for imaging was primary diagnosis or staging, the kappa for presence of cancer was 0.70. When the indication was cancer follow-up, the kappa for presence of recurrent/progressing cancer was 0.66. There were disagreements between the IP and RP radiologists over the interpretation of 162 films, with the RP radiologists being correct in 153 (94%). Had the patients been treated using IP readings, there would have been 19 more inappropriate surgeries and 19 more admissions (both P <0.05) than if the oncologists had based their recommendations on RP readings. The technique of shared patient analysis permits assessment of the clinical benefits associated with referrals.

Reduced uncertainty as a diagnostic benefit: an initial assessment of somatostatic receptor scintigraphy's value in detecting distant metastases of carcinoid liver tumours.

This paper employs classical concepts of diminishing marginal utility to demonstrate that risk-aversion can increase the perceived value of diagnostic procedures and thus raise optimum diagnostic expenditures. The theory is applied to a model in the spirit of Phelps and Mushlin's initial technology assessments. The specific evaluation is the cost-effectiveness of somatostatin receptor scintigraphy used to detect distant metastases of carcinoid liver tumours in a patient otherwise eligible for surgical resection of the liver. Data for the model are taken from published sources and financial databases, when available, and otherwise from a senior clinician's experience (LKK). The quantitative results indicate that receptor scintigraphy may have two beneficial impacts to risk-neutral individuals. First, it may reduce the combined costs of therapy and treatment because the diagnostic procedure costs less than the expected savings generated by avoiding inappropriate surgeries. Second, it may improve the patient's expected health-status-adjusted life years (HSALY) because the information allows physicians to better match treatment to the cancer's stage. Finally the paper demonstrates that risk aversion, as embodied in classical diminishing marginal utility applied to health status, can increase the value of the diagnostic tests and can lead the patient to choose a less beneficial treatment. An illustrative risk-averse utility function changed the optimum treatment from surgery to chemotherapy and increased scintigraphy's benefit by 500%.

Assessment of Appropriateness of Cataract Surgery at Ten Academic Medical Centers in 1990

To develop criteria for the appropriateness of cataract surgery (extracapsular cataract extraction or phacoemulsification with planned implantation of a posterior chamber intraocular lens) and to apply these criteria to patients from ten academic medical centers. The study is a retrospective case series from ten academic medical centers. One thousand one hundred thirty-nine patients who had had cataract surgery in 1990 at the medical centers were selected randomly. Patients, identified by specific ICD-9-CM or CPT-4 codes, had no other ocular surgery performed at the same time as cataract surgery. Rates of inappropriate, uncertain, appropriate, and appropriate and crucial surgeries were determined by application of the criteria established by a multidisciplinary expert panel. Approximately 2% of the procedures were classified as inappropriate, after adjusting for missing or nonspecific visual function by use of discriminant analysis. Ninety-one percent of the procedures were classified as appropriate (52%) or appropriate and crucial (39%). Seven percent were designated as uncertain, either due to a median rating in the uncertain range or to disagreement in ratings among the panelists. Significant variation occurred in the results among the different institutions: inappropriate surgeries ranged from 0% to 4%, uncertain from 1% to 14%, appropriate from 35% to 66%, and appropriate and crucial from 21% to 62% (P=0.02). A small percentage of cataract surgeries was performed at these ten academic medical centers for inappropriate indications using the study criteria. Given the large number of cataract surgeries performed annually, the small percentage of uncertain and inappropriate surgeries may translate into a large number of surgeries performed for less than appropriate or appropriate and crucial indications. Significant variation existed among the institutions in the distribution of appropriate and crucial and appropriate compared with uncertain and inappropriate surgeries.

The role of laparoscopy in the evaluation of candidates for sterilization reversal

An algorithm that avoids preliminary laparoscopy for sterilization reversal (SR) candidates with previous Pomeroy, loop, Hulka clip, Irving, and single-burn cautery tubal ligation techniques was used. Anastomosis was attempted only when it could be anticipated that the final length of at least one tube would be 3 cm or more. Of 259 SR candidates evaluated according to the algorithm, 235 had SR procedures. Seven of 185 patients (3.8%) who did not undergo laparoscopy were found to have inoperable tubes at laparotomy. Four of these patients had histories of a prior unilateral salpingectomy. The authors conclude that, given their criteria for proceeding with tubal anastomosis, laparoscopy can be avoided in properly selected SR candidates. The results also indicate that patients with a history of unilateral salpingectomy should undergo preliminary laparoscopy.An algorithm intended to minimize both the preliminary screening laparoscopy and futile laparotomies was used on 259 consecutive women presenting for sterilization reversal, and the results evaluated. Records were reviewed from 1979 to 1986. First a history, preoperative exam and evaluation including semen analysis, and review of operative records were made. Women with Pomeroy, single-burn cautery, loop, clip or Irving tubal ligations were scheduled for laparotomy for microsurgical reanastomosis. Those with multiple burn tubal ligations or unknown procedures had screening laparoscopy. Of these, women with at least 1 tube 3 cm long underwent laparotomy. Results were considered in terms of successful reanastomosis procedures, since no pregnancy data were available. Of the 8 women who had futile laparotomies, 4 had unilateral salpingectomy and a contralateral Pomeroy ligation, but insufficient tube remained for reversal; 2 others had single-burn cautery, but had insufficient tube length, and the Pomeroy procedures in 2 others left insufficient distal tissue. The benefit of this algorithm was that 71.4% of patients avoided laparoscopy, but the cost was that 7 (3.8%) of these had futile laparotomy. The authors concluded that using 3 cm for the criterion of tube length was optimal, but an unnecessarily high proportion of women had futile operations because of only 1 operable tube, so they recommended that the algorithm be altered to reflect this finding. There could still be inappropriate surgeries due to inaccurate operative records or discrepancies between observations during laparoscopy and actual laparotomy.