Laparoscopic Rate Research Articles

Province-wide population survey of acute appendicitis in Canada. New twists to an old disease

This study, sponsored and conducted by Le Collège des Médecins du Québec, audited the management of acute appendicitis in the Province of Québec (Population 7.6 million), Canada, over a period of 1 year (April 2002-March 2003). A questionnaire was sent to the Health Records Department of all hospitals surgically treating appendicitis in the province. Data from 85 (100%) hospitals were received and reviewed. During the study period, 7,599 appendectomies were performed, and 5,707 (75%) were selected for study (55% men). The rate of normal and perforated appendix was 5.4% and 15.9% respectively. Median hospital stay for simple and perforated appendicitis was 2.6 and 5.8 days, respectively. At least one imaging procedure was done in 86% of cases (23% computed tomography [CT], 55% ultrasound). Antibiotics were not given in 7% of cases and in 8% of patients with a perforation. Seventeen percent of patients did not receive preoperative or intraoperative doses, and postoperatively, 69% of patients received unnecessary doses. Laparoscopy was used in 35% of cases and was associated with a reduction in postoperative stay for simple (2.6 versus 2.9 days, p < 0.001) and perforated appendicitis (4.6 versus 5.9 days, p = 0.004). A low rate of laparoscopy (<25%) was found in 53% of teaching (University and Affiliated) and 45% of nonteaching institutions. Conversion to open surgery was necessary in 9.7% of simple appendicitis and 29.3% of perforated ones (p < 0.001). Although results of this survey are comparable to those of similar published series, a few concerns emerge. Many have to do with patient noncompliance with recommended antibiotic usage for acute appendicitis. Further, although laparoscopy seems to be slowly making its way into the surgical armamentarium, the low rate of laparoscopic appendectomies in teaching hospitals raises the issue of appropriate resident training.

Laparotomy to laparoscopy: Changing trends in the surgical management of ectopic pregnancy in a tertiary care teaching hospital

Study objective To review the changing trends in the surgical management of ectopic pregnancy and to evaluate the effect of an ongoing training program for resident surgeons on the rate and success of laparoscopic surgery. Design Retrospective chart review (Canadian Task Force classification II-3). Setting University tertiary medical center. Patients One thousand forty-six patients with ectopic pregnancy treated at Jackson Memorial Hospital from January 1, 1995, through December 31, 2004. Intervention A formal, ongoing laparoscopic training program was established in 1999. Measurements The rate of laparoscopy, laparotomy, and conversion for each year was compared with the baseline year of 1995 and between the years before and after the establishment of the training program. Results Four hundred sixty-eight laparotomies and 578 laparoscopies were successfully completed. The laparoscopic approach rate has increased from 40.9% in 1995 to 86.3% in 2004. By year 2000 and thereafter, significantly more ectopic surgeries were approached through the laparoscope compared with in 1995 (p<.01). By 2000 and thereafter, significantly less conversions occurred compared with the baseline year of 1995 (4.0% vs 18.5%; p = .01). Conclusion Laparoscopy became the primary approach for the management of ectopic pregnancy in part because of resident participation in an ongoing laparoscopy training program.

Acute gallstone cholecystitis in the elderly

The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy. From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05. Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001). The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.

268: Rate of Negative Laparoscopy for Ectopic Pregnancy Depends on Diagnostic Clinical and Biochemical Criteria; and Ultrasound Expertise of the Department

Management of ectopic pregnancy has been revolutionized by the introduction of early pregnancy units with facilities for transvaginal sonography and the rapid immunoassay of serum human chorionic gonadotrophin (βhCG) and serum progesterone. Ultrasound assessment of ectopics is operator dependent and there is lack of consensus on the most appropriate diagnostic criteria including variations in clinical evaluation of the patients.

Role of laparoscopy to assess the chance of optimal cytoreductive surgery in advanced ovarian cancer: a pilot study

Objective. To investigate whether laparoscopy can be considered as adequate and reliable as standard laparotomy in predicting optimal cytoreduction (RT ≤ 1 cm) in patients with advanced ovarian cancer. Methods. From March to November 2003, 95 patients with suspected advanced ovarian or peritoneal cancer have been evaluated. Thirty-one cases were excluded due to an anesthesiological class of risk ASA III–IV (51.6%) and for the presence of a large size mass reaching the xiphoid (48.4%). Sixty-four patients completed the study. All patients were submitted to preoperative clinico-radiological evaluation and then to both laparoscopy and standard longitudinal laparotomy, sequentially. Some specific preoperatively defined parameters were analyzed during each procedure in order to obtain the most accurate evaluation on the possibility to get an optimal cytoreduction. Results. The overall accuracy rate of laparoscopy in assessing optimal cytoreduction was 90%. The negative predictive value (NPV) of the clinical–radiologic evaluation corresponded to 73%, whereas in no case was the judgment of unresectable disease obtained by laparoscopy changed by the laparotomic approach (NPV 100%). On the contrary, an optimal debulking was achievable in 34 of 39 cases (87%) selected as completely resectable by explorative laparoscopy. Conclusions. Laparoscopy can be considered super imposable to standard longitudinal laparotomy in identifying not optimally resectable advanced ovarian cancer patients.

The Feny�-Lindberg scoring system for appendicitis increases positive predictive value in fertile women?A prospective study in 455 patients randomized to either laparoscopic or open appendectomy

Suspected appendicitis is one of the most common indications for acute laparotomy or laparoscopy. The negative laparotomy and laparoscopy rates are high, often in the range of 15-30%, and especially high in some groups of patients such as women of child-bearing age and young patients. Different scoring systems have been introduced in order to improve diagnostic accuracy. The aim of the present study was to analyse the outcome of the Fenyö-Lindberg scoring system in a prospectively randomized multicenter trial and to analyze how well the score performed in stratified subgroups. The variables of the Fenyö-Lindberg scoring system were collected in a prospective study comparing laparoscopic and open surgery in suspected appendicitis and with four participating centers. None of the hospitals had used the scoring system previously. Since surgeons were unfamiliar with the score, they could not use it as a diagnostic aid. When comparing the score with the clinical outcome, retrospectively, the investigators interpreting the score were blinded regarding the surgical outcome. Positive predictive value (PPV) of the Fenyö-Lindberg score was higher than that of the surgeon's clinical diagnosis in the patient cohort [0.90 vs 0.79 (p < 0.001)]. The score demonstrated an improvement of PPV in women [0.83 vs 0.70 (p < 0.01)]. PPV was increased in women between 15 and 50 years of age. In women aged 15-30 years and 31-50 years PPV increased from 0.69 to 0.82 and 0.68 to 0.86, respectively (p < 0.01). Both the sensitivity (0.77) and the specificity (0.69) of the score were, however, low. The Fenyö-Lindberg score is an inexpensive clinical tool that may improve the diagnostic accuracy for acute appendicitis in women of childbearing age, which is a group of patients where the diagnostic accuracy usually is low and where the arsenal of diagnostic tools such as computed tomography is limited because of radiation. The low specificity of the score in women of childbearing age must, however, be kept in mind.

Limitation of diagnostic laparoscopy for patients with a periampullary carcinoma

Background. Diagnostic laparoscopy has been generally accepted in staging of patients with a periampullary malignancy. In our institution diagnostic laparoscopy was routinely used since 1992. However, in 1998 it was eliminated from the protocol since in a prospective study a yield of only 13% was found with a histologically proven accuracy of 60% for distant metastases. The effect of implementation of the new protocol on the occurrence of unnecessary laparotomies and the outcome after bypass surgery was assessed.Methods. Between January 1999 and December 2001, 186 consecutive patients with a potentially resectable periampullary carcinoma after radiological staging without diagnostic laparoscopy underwent explorative laparotomy with the intention to perform a curative pancreatoduodenectomy. Incidence of unresectability and outcome of palliative surgery were assessed.Results. Resection could not be performed in 65 patients who underwent laparotomy because of metastatic disease (29 patients) and loco-regional tumour ingrowth (34 patients). These patients underwent a bypass procedure with a median survival of 216 days.Conclusion. At laparotomy distant metastases were detected in 16% of the patients. Considering the fact that the detection rate of diagnostic laparoscopy is lower than 100%, the use of staging laparotomy is too limited to justify it as a routine procedure.

Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma.

Our institution was one of the first to report the use of laparoscopy in the management of penetrating abdominal trauma (PAT) in 1977. Despite early interest, laparoscopy was rarely used. Changes in 1995 resulted in an increase in interest and use of laparoscopy. We present our recent experience with laparoscopy. Our trauma registry and operative log were used to identify patients with blunt and penetrating injuries to the abdomen, back, and flank who underwent laparotomy or laparoscopy during the past 5 years. Patient demographics, operative findings, complications, and length of stay were reviewed. The number of laparoscopic explorations, therapeutic, nontherapeutic, and negative laparotomies were trended. There were 429 abdominal explorations for trauma. The rate of laparoscopy after penetrating injury increased from 8.7% to 16%, and after stab wounds from 19.4% to 27%. There was an associated decrease in the negative laparotomy rate. Laparoscopy prevented unnecessary laparotomy in 25 patients with PAT. Four patients with diaphragm injuries underwent repair laparoscopically. An aggressive laparoscopic program can improve patient management after PAT.

Major Complications of Operative and Diagnostic Laparoscopy for Gynecologic Disease

Study Objective To compare complication rates of diagnostic and operative laparoscopy. Design Retrospective study (Canadian Task Force classification II-2). Setting One medical center and three teaching hospitals. Patients Six thousand four hundred fifty-one women with various indications for laparoscopic diagnosis and/or laparoscopic surgery from January 1994 through June 1999. Intervention Diagnostic and operative laparoscopies Measurements and Main Results Forty-two major complications occurred that directly resulted in one death. One patient had stomach injury, 3 had major vessel injuries, 5 had ureter injuries, 10 had intestinal injuries, and 23 had bladder injuries. The overall complication rate for all laparoscopies was 0.65% (42/6451); however, it rose to 0.80% (39/4865) for operative laparoscopy compared with 0.19% for diagnostic laparoscopy (3/1586; p <0.001, Fisher's exact test). Conclusion Laparoscopic surgery is appropriate for managing various gynecologic diseases and has an acceptable complication rate. However, operative laparoscopy should be performed carefully because its rate of complications is significantly higher than that of diagnostic laparoscopy, especially for laparoscopic-assisted vaginal hysterectomy.

Laparoscopic Management of 641 Adnexal Tumors in Kiel, Germany

Study Objective To evaluate the effectiveness and safety of laparoscopic and laparotomic management of ovarian tumors. Design Retrospective analysis (Canadian Task Force classification II-2). Setting University-affiliated hospital. Patients Six hundred forty-one women with benign and malignant ovarian tumors. Interventions Laparoscopy and laparotomy Measurements and Main Results Between January 1997 and December 1998, 493 (76.9%) ovarian tumors were treated laparoscopically and 138 (21.5%) by laparotomy. Criteria for laparotomy were high suspicion of malignancy and tumors larger than 10 cm that were technically too difficult for the laparoscopic approach. The mean size of tumors treated laparoscopically was 4.5 cm (range 1.1–11 cm) and by laparotomy 8.2 cm (range 3–20 cm). Mean operating times were 75.7 minutes (range 30–200 min) and 126 minutes (range 30–235 min), respectively, and mean blood loss was 193 ml (range 50–1200 ml) and 431 ml (range 50–2500 ml), respectively. Twelve laparoscopies were converted to laparotomy, six because of technical reasons such as severe adhesions, bleeding, or tumor size, and six for intraoperative suspicion of malignancy. Of the latter, four (66.7%) turned out to be ovarian carcinoma and two (33.3%) borderline tumors. Histologic evaluation clearly revealed predominance of functional ovarian cysts, endometriomas, and dermoid cysts in the group treated by laparoscopy, whereas ovarian carcinomas, large endometriomas, and serous cysts prevailed in the laparotomy group. Conclusion With careful preoperative screening, the rate of laparoscopies for treatment of benign ovarian cysts can be increased.

Perioperative Morbidity of Gynecological Laparoscopy: A Prospective Monocenter Observational Study

Background. To study the morbidity rate of gynecological laparoscopy and to the most influential variables. Methods. We conducted a prospective observational study from January 1st 1992 to December 31st 1998 in a single tertiary care center. It concerned patients who underwent gynecological laparoscopic surgery performed by seniors and residents. We have prospectively recorded patients characteristics, indications for laparoscopy, leading diagnosis, main operative procedures, post-operative course, surgical and anesthetic incidents and accidents. Complications were defined as any event that would modify the usual course of laparoscopy or of the post-operative period. Results. One thousand and thirty-three laparoscopies were included. 80.1% of the procedures were major or advanced laparoscopies. The overall complication rate was 3%, with a laparotomy rate of 1.2%. About half of those complications (54.8%) occurred during the installation of laparoscopy. Veress needle and first trocar insertion accounted for 23.5% of those accidents (0.3% of the procedures) and suprapubic trocar insertion for 76.5%. Hemorrhages constituted almost all of the complications occurring during the operative stage (80%). The risk increased with the level of surgery and decreased with surgeon's experience. Prior abdominal surgery had no significant effect on the overall morbidity rate. Post-operative and anesthetic complications were rare. The overall complication rate as well as the laparotomy rate were stable all along the course of the study. Conclusions. Complication rate of gynecological laparoscopy is not negligible. Efforts should be made to lower the complications induced by the installation of laparoscopy, especially for secondary trocars.

Perioperative morbidity of gynecological laparoscopy. A prospective monocenter observational study.

To study the morbidity rate of gynecological laparoscopy and to the most influential variables. We conducted a prospective observational study from January 1st 1992 to December 31st 1998 in a single tertiary care center. It concerned patients who underwent gynecological laparoscopic surgery performed by seniors and residents. We have prospectively recorded patients characteristics, indications for laparoscopy, leading diagnosis, main operative procedures, post-operative course, surgical and anesthetic incidents and accidents. Complications were defined as any event that would modify the usual course of laparoscopy or of the post-operative period. One thousand and thirty-three laparoscopies were included. 80.1% of the procedures were major or advanced laparoscopies. The overall complication rate was 3%, with a laparotomy rate of 1.2%. About half of those complications (54.8%) occurred during the installation of laparoscopy. Veress needle and first trocar insertion accounted for 23.5% of those accidents (0.3% of the procedures) and suprapubic trocar insertion for 76.5%. Hemorrhages constituted almost all of the complications occurring during the operative stage (80%). The risk increased with the level of surgery and decreased with surgeon's experience. Prior abdominal surgery had no significant effect on the overall morbidity rate. Post-operative and anesthetic complications were rare. The overall complication rate as well as the laparotomy rate were stable all along the course of the study. Complication rate of gynecological laparoscopy is not negligible. Efforts should be made to lower the complications induced by the installation of laparoscopy, especially for secondary trocars.

Traitement cœlioscopique des occlusions du grêle

Laparoscopic surgery for small bowel obstruction is still under evaluation. A review of the literature retrieved over 200 published cases. Technically, the open laparoscopy procedure seems mandatory to avoid bowel injuries. Grasping the enlarged bowel and using monopolar cautery should be avoided. The surgeon should also be sure that at the end of the procedure adhesiolysis was correct. Evaluation of the results must also take into account that most studies were retrospective and included few patients. The cumulative effectiveness rate of laparoscopy was 60%. Failures were mainly due to multiple adhesions, iatrogenic perforations to the intestine, and colonic cancers not recognized before the procedure. There was no prospective study comparing laparoscopy with laparotomy. Finally, it is not proved at present that laparoscopy prevents the recurrence of adhesions after digestive surgery. Owing to the results of the literature, laparoscopic surgery for acute small bowel obstruction does not appear as based on fact.

Second Look for Ovarian Cancer: Laparoscopy or Laparotomy? A Prospective Comparative Study

Objective.The objective of this study was to evaluate, for patients with ovarian cancer, the feasibility, reliability, and complications of a laparoscopic second look and to compare them with those of a second look by laparotomy.Methods.Twenty patients treated by initial surgery and adjuvant chemotherapy for ovarian carcinoma underwent a laparoscopic second look, immediately followed by a comparative laparotomy. All were in complete remission after chemotherapy. Both operations were performed according to a predefined checklist, identical for both surgical techniques and for each patient: after liberation of adhesions, an exhaustive intraperitoneal inspection was performed, with systematic peritoneal cytology and biopsies. Each patient therefore was her own control for the two techniques.Results.The positive predictive value of laparoscopy for the diagnosis of residual disease was 100% (6 of 6 cases), while the negative predictive value was 86% (2 false-negative cases out of 14). Because of the presence of postoperative adhesions, the rate of complete intraperitoneal investigation was 95% for laparotomy versus 41% for laparoscopy. The complication rate of laparoscopy requiring laparotomy was 5.3%.Conclusions.After treatment of ovarian cancer, a laparoscopic second look appears to be less reliable than one performed by laparotomy. The presence of severe postoperative adhesions is the main obstacle to an exhaustive, reliable, and safe laparoscopic second look.

Response to Marik

To the Editor: I read Dr. Marik’s letter with interest. There is no debate on the issue of the efficancy of laparoscopy in the investigation of infertility in women, although the question when to perform it is controversial. The difference in the percentages of pathological findings can be explained not only by the different stages at which the procedure is performed, but also by the population on which it is performed. In our population, the percentage of sexually transmitted diseases and endometriosis is quite low. We suggest that centers tailor their laparoscopy rate to the specific populations they serve. Population at high risk for tubal disease should likely have a higher rate of diagnostic laparoscopies performed. Similarly, populations at low risk for tubal disease may not require a high rate of diagnostic laparoscopies. Along with the many advantages of diagnostic laparoscopy as Dr. Marik described, there are a few complications associated with this procedure. These include injury to abdominal organs and to major blood vessels and complications due to the anesthesia (1–3). It can be assumed that these complications occur more often than are reported. One must remember that laparoscopy can reveal the anatomical state of the fallopian tubes but cannot give any information on their functional state (i.e., there may be a problem getting the ovum to or through the tubes). On the other hand, it is a known fact that there have been spontaneous pregnancies in women who have been diagnosed, using laparoscopy, as suffering from bilateral adhesions. Today, with the option of in vitro fertilization (IVF), it is often hard to persuade a woman with a normal human serum gonadotropin to undergo an invasive procedure such as laparoscopy. These women often prefer to have IVF, with a good chance for a pregnancy. The efficiency of laparoscopy should not be measured according to the number of pathologies it discovers, but according to the improvement of the outcome from performing the procedure.

Complications of minimal-access surgery in children

Minimal-access surgery (MAS) is rapidly becoming the surgical approach of choice for a variety of surgical disorders in adults, but its use in children remains a relative novelty. Most pediatric surgeons continue to harbor justifiable concerns about the morbidity of this modality owing to the cumbersome nature of the instruments and the technical difficulty associated with two-dimensional views. The purpose of this study was to determine the complication rate and the lessons learned from the use of MAS in performing a variety of procedures in a large series of children. To determine complications, the authors reviewed the medical records of all children (n = 636; age range, 1 month to 19 years) who underwent laparoscopy (LAP) or thoracoscopy (THO) during a 5-year period (January 1, 1990 through December 31, 1994). The follow-up ranged from 1 week to 45 months. THO was performed in 62 children. Conversion to thoracotomy occurred in eight children (13%), because of inability to localize the lesion (3), unresectibility (2), inadequate tissue sample (1), unsafe access (1), hypoxemia (1), or inadvertent esophagotomy (1). Postoperatively, two ventilator-dependent children had tension pneumothorax after lung resection and required chest tubes. LAP was performed on 574 children, with conversion to laparotomy occurring in 15 (2.6%), because of technical reasons (10) or intraoperative complications (5). The complication rate of LAP was 2% (12 of 574). Early in the experience, intraoperative complications that led to laparotomy included hemorrhage during appendectomy (2), cholecystectomy (1), and splenectomy (1); and esophagotomy during a fundoplication (1). Other technical problems in the postoperative period were a malpositioned Nissen fundoplication and a gastric volvulus after gastrostomy and Nissen fundoplication owing to improper gastrostomy tube position. In addition, two children had a hernia at the umbilical trocar site that had been used for contralateral inguinal exploration, and cellulitis developed in three patients when a gastrostomy tube was brought out through a trocar site. Other complications not specific to MAS included pelvic abscess after appendectomy (5); small bowel obstruction after jejunostomy catheter placement (1) and combined cholecystectomy/appendectomy (1); enterocolitis (1) and severe hyponatremia (1) after pull-through for Hirschsprung's disease; and pneumonia after splenectomy (1). The overall complication rate of MAS was 4% (25 of 626), and there were no deaths. The initial use of MAS was associated with technical errors, which decreased with experience. Based on this study, the authors recommend (1) routine placement of a thoracostomy tube in children after THO if they require postoperative ventilator support; (2) using the open hernia sac to place a 70° telescope for contralateral inguinal exploration; and (3) not using a trocar site for gastrostomy tube placement in immune-suppressed patients. With appropriate training and experience, MAS can be used safely in children, for a wide variety of diseases, with minimal morbidity and mortality.

The introduction of a serum β-hCG threshold for suspected ectopic pregnancy, in a district general hospital, is safe and cost effective

SummaryWe assessed the effect of introducing a rapid, serum /?-hCG assay as part of a routine ‘early pregnancy assessment’ service in a District General Hospital on treatment costs and the negative laparoscopy rate.Eighty-five consecutive women presenting who had an empty uterus on transvaginal scan and a positive urinary pregnancy test had a serum β-hCG measured. They were managed according to a simple algorithm. Laparoscopy was performed when a serum β-hCG was above a threshold level of 1000 iu/1.he algorithm had a sensitivity of 100 per cent and the negative laparoscopy rate was reduced from 61 to 9 per cent. There were no false negative diagnoses and no emergency admissions in those patients discharged home.This simple addition to an already established early pregnancy assessment service, in our unselected population, has provided a safe and cost effective method which can reduce unnecessary admissions and operative morbidity in the management of suspected ectopic pregnancy.

Mortality after gynaecologic operations in Finland, 1986-1991.

To study the current in-hospital, 30-day and 42-day mortality after conventional gynaecologic procedures in Finland, with special reference to hysterectomy. Nationwide six-year annual study. Data were from the Finnish Population Register Centre, the Finnish Cause-of-Death and Hospital Discharge Register, and the Register for Legal Abortions and Sterilisations. Gynaecologic operations (n = 299,257) performed between January 1986 and December 1991. The overall and age-adjusted mortality rates during the initial hospitalisation, as well as 30 and 42 days after the operations. Age-adjusted probability of dying within 42 days after hysterectomy compared with the overall probability of age-matched Finnish female control population. Overall mortality rates per 10,000 hysterectomies increased gradually from 6.0 during initial hospitalisation to 9.1 and 12.9 when calculated 30 and 42 days post-operatively. The overall 42-day mortality rates of radical hysterectomy, curettage and laparoscopy (other than sterilisation) exceeded the post-hysterectomy mortality rate, while the rates after caesarean section, legal abortion and laparoscopic sterilisation did not. No deaths occurred after laparoscopic sterilisation (n = 40,346). The patients who died after radical hysterectomy, curettage and for other laparoscopy than sterilisation were old, and the great majority of them died of cancer. The mortality rates after gynaecologic procedures in Finland are currently very low and have clearly decreased in recent decades. Patients may be reassured that conventional gynaecologic operations are safe.

Laparoscopy for right lower quadrant pain in children

One hundred seventy children with recurrent episodes of right lower quadrant pain were submitted to diagnostic laparoscopy including an appendectomy. The diagnostic gain was excellent. Postoperative pain medication requirements and recovery time were reduced compared to conventional laparotomies. However, the complication rate of laparoscopy was far higher than with conventional-approach techniques: 170 laparoscopies with appendectomies involved 2 stump insufficiencies, 2 large-vessel injuries, 1 thrombosis of the deep pelvic veins, and 9 minor complications. One-half of the complications originated from the additional appendectomy.

Comparative trial of tubal insufflation, hysterosalpingography, and laparoscopy with dye hydrotubation for assessment of tubal patency

A World Health Organization-sponsored multicentered trial comparing the efficacy of gaseous tubal insufflation with hysterosalpingography (HSG) and/or laparoscopy plus dye hydrotubation in the assessment of tubal patency was undertaken. Three hundred ninety-three women in eight centers were involved (365 insufflations, 289 HSG, 189 laparoscopy). Patency was proven positive in 56% of insufflation, 45% of salpingography, and 52% of laparoscopy cases. Laparoscopy showed some women to have fibroids and a number of others to have ovarian abnormalities, endometriosis, pelvic adhesions, and/or congenital uterine malformation. Comparison of insufflation and HSG showed a false-positive rate of 42% and false-negative rate 24% in 363 cases. The false-positive rate of insufflation versus laparoscopy was 35% and the false-negative rate 38% of 180 cases. Only 55% of 125 women undergoing both HSG and laparoscopy had similar findings. The results suggest that gaseous tubal insufflation should not be employed as a method of investigating tubal patency. Diagnostic reliability of HSG is poor, but it is useful as a primary screening procedure, particularly when complimented with laparoscopy plus dye hydrotubation, which is the optimum method not only for assessing tubal patency but for discovering other hitherto unsuspected disease.