Second-look Laparoscopy Research Articles

Endoscopic surgery for mature teratoma of the ovary.

This study was undertaken to assess the value of laparoscopic surgery as treatment for benign mature teratomas of the ovary. A total of 70 patients treated exclusively with laparoscopic surgery for ovarian mature teratoma were studied. The tumors were either enucleated with preservation of the ovary or removed by salpingo-oophorectomy. Ovary-preserving surgery was performed in 60 cases; salpingo-oophorectomy was accomplished in 10 cases. All tumors removed were histologically benign. No surgical complications were encountered throughout the series. In eight patients who underwent primary ovary-preserving surgery, a second-look laparoscopy was undertaken with virtually no pathological findings noted. Our findings confirm those of other authors- when performed by experienced surgeons, laparoscopic removal of ovarian mature teratomas is a safe and recommendable alternative to laparotomy. Preoperative diagnosis and intraoperative inspection of the tumor must be as thorough as possible.

Reduction of Adhesions with Fibrin Glue after Laparoscopic Excision of Large Ovarian Endometriomas

Study Objective. To evaluate the effect of fibrin glue on the formation of adhesions after laparoscopic excision of endometriomas. Design. Prospective case series. Setting. Department of Obstetrics and Gynecology at a university-affiliated hospital. Patients. Thirty women with ovarian cysts. Interventions. In 10 women (16 cysts) we performed laparoscopic resection of endometriomas leaving the ovarian capsule open. Twenty patients (25 cysts) underwent laparoscopic removal of endometriomas and fibrin glue approximation of the ovarian capsule, as well as coating of serosal defects with the glue. At second-look laparoscopy 4 to 6 months after the initial surgery, postoperative adhesion formation was assessed according to the revised American Fertility Society classification. Measurements and Main Results. The mean (± SEM) adnexal adhesion score in patients without fibrin glue was 8.6 ± 2.2 at initial surgery and increased slightly to 12.6 ± 2.6 at second-look laparoscopy. In patients treated with fibrin glue, the score decreased significantly from 10.9 ± 1.4 to 7.8 ± 1.3 ( p < 0.02). The decrease was most marked in women with endometriomas 5 cm or more in diameter and for those with a preoperative adhesion score of 8 or higher. Conclusion. Fibrin glue reduced postoperative adhesions after laparoscopic resection of endometriomas.

Adhesion formation after laparoscopic myomectomy

To determine the frequency of adhesion formation after myomectomy performed by operative laparoscopy or laparotomy. Case-control study. Setting. Academic women's hospital. Thirty-two premenopausal women scheduled for myomectomy by one of two techniques. Surgical removal of myomata. Of the 32 women, 16 underwent laparotomy and 16 laparoscopy. Second-look laparoscopy was performed in 28 patients, at which time adhesions were lysed. Compared with laparotomy, laparoscopy resulted in adhesions in significantly fewer patients, and in significantly lower scores when adhesions were detected. Laparoscopic removal of uterine myomata is associated with fewer adhesions than removal by laparotomy.

Laparoscopy in the treatment of tubal infertility

Since 1992 we have performed 371 bilateral salpingostomies in infertile women (age 20-32 yrs, infertility duration 2-9 yrs) with blockage in the ampullas. Salpingostomy was performed after retrieving the tube from the commisure and filling it with methylene blue. The ampullary part of the tube was grasped at 1 to 2 cm to place the stoma, the wall was coagulated, and the site of greatest thinness of the star scar was dissected by microscissors. The fimbriae were identified and washed with physiologic heparinized solution. The distal tubal serosa was lightly coagulated with point endocoagulation along the perimeter. The abdomen was irrigated with physiologic heparinized solution, and a small amount of solution was left for hydroflotation. Second-look laparoscopy with chromopertubation in 1.5 months revealed 234 patent tubes (63.1%), 66 commissures (17.8%), 23 cases of one patent tube and the other with a hydrosalpinx (6.2%), and 48 recurrent hydrosalpinges (12.9%). One hundred three women conceived within 6 months, with 86 (23.2%) uterine and 17 (4.6%) tubal pregnancies. Laparoscopic treatment of hydrosalpinges restored tubal patency with minimal risk of complications.

Pregnancy outcome, and adhesion formation and reformation after laparoscopic cystectomy of ovarian endmetriomas

Unilateral or bilateral cystectomy for endometriomas was performed in 90 infertile women. Using a multipuncture technique, a cortical incision was made on the medial aspect of the ovary with sharp-tipped unipolar coagulation. Cystectomy was performed by stripping the cyst capsule from the normal ovarian cortex with the aid of atraumatic grasping forceps. If the capsule removal was incomplete due to technical difficulties, the remaining capsular fragments were vaporized with the carbon dioxide laser. Endometriosis implants elsewhere in the pelvis were vaporized and adhesions, if present, were lysed. The ovarian cortex was closed with a few interrupted 6-0 polyglactin sutures using extracorporeal knot technique. A second-look laparoscopy was performed in 25 patients to evaluate adhesion formation, reformation, postoperative crude pregnancy rates, and factors that would predict conception.

Long-term outcome of laparoscopic adhesiolysis in women with chronic pelvic pain after hysterectomy

The management of severe small and large bowel adhesions in patients suffering from chronic pelvic pain after undergoing hysterectomy remains highly challenging. A cohort of 48 women (median age 41 yrs, range 26-59 yrs) with chronic pelvic pain had severe bowel adhesions. Forty-two had undergone a total abdominal hysterectomy (27 with bilateral, 7 with unilateral salpingo-oophorectomy), five a vaginal hysterectomy (4 with bilateral salpingo-oophorectomy), and one a laparoscopic hysterectomy. After laparoscopic adhesiolysis, 23 patients were followed for up to 24 months, 23 for 48 to 60 months, and 2 were lost to follow-up. Three intraoperative complications (6.2%) were one ileus, which required a 2-day hospital admission, one pelvic abscess requiring readmission and second-look laparoscopy, and one episode of urinary retention requiring a 1-day readmission. Of the 23 women followed for more than 24 months, 11 (47.8%) required from one to three subsequent surgeries. Complete pain relief was reported by 10 (43.5%) women, 8 of whom did not require further surgery. Twelve (57.1%) of the 21 patients followed for 6 to 12 months reported complete pain relief. Laparoscopic adhesiolysis achieved complete pain relief in approximately half of the women.

Pelviscopic survey in eastern Germany

In 1994 a survey conducted in eastern Germany reported 27,595 pelviscopies from 101 clinics and 3307 hysteroscopies from 53 clinics. Clinics reported 129 serious complications by pelviscopy that required laparotomy or second-look laparoscopy. The complication rate was 4.6/1000 procedures. One death occurred during pelviscopy and none during hysteroscopy. The trend to perform endoscopy was 71.7% for pelviscopy and 80.5% for hysteroscopy, which is continuously increasing.

Treatment of polycystic ovary disease with laparoscopic low-watt bipolar electrocoagulation of the ovaries

To assess the efficacy of laparoscopic low-watt bipolar electrocoagulation of the ovaries in women with polycystic ovary disease (PCOD). Prospective case series. Hospital-based infertility clinic. Seventy-four consecutive infertile women with PCOD resistant to conventional ovulation-induction regimens. Laparoscopic bipolar low-watt electrocoagulation of the ovarian surface (25 W for 5-12 sec/cyst). Postoperative follow-up ranged from 18 months to 7 years. Menstrual rhythm returned to normal in all 74 women. All 40 women in whom infertility was solely due to anovulation eventually conceived. Overall, 62 (84%) of the 74 women conceived, 42 spontaneously after surgery and 20 after supplementation with clomiphene. These 62 women had a total of 93 pregnancies: 79 singleton live births, 4 sets of twins, and 10 miscarriages. Twenty-five women conceived twice and three conceived three times. At second-look laparoscopy or cesarean section in 20 women, fine stringlike adhesions on the ovaries were found in 2. Laparoscopic low-watt bipolar electrocoagulation of the ovaries is an effective treatment for women with PCOD who fail medical therapy.

Patient-assisted laparoscopy in the diagnosis and management of endometriosis

Traditionally, surgeons had to diagnose endometriosis and determine themselves which lesions were painful, since the patients were anesthetized. Performing laparoscopy under local anesthesia allows the woman to assist the physician in deciding which lesions are painful and require therapy, and lets the patient determine the results of therapy. Patients reported that black lesions were not painful or were the least painful, followed by white scarred areas. The vascular lesions around the outer edge of the white lesions were significantly more painful, especially the hypervascular areas and endometriotic windows. After a 6-month course of danazol, at second-look laparoscopy, patients reported that the treated areas were no longer painful. Having the patient assist the physician during laparoscopy under local anesthesia leads to a more accurate assessment of endometriosis and outlines the boundaries of therapy more precisely.

Laparoscopy for ovarian endometriomas

Thanks to advances in endoscopic technique and instrumentation, it is possible to remove endometrial cysts by laparoscopy, including total ablation of the cyst capsules. It is difficult to make a clear diagnosis laparoscopically, because some of pathologies have the same appearance (e.g., luteal cysts, follicular cysts). Macroscopically, endometroid cysts are round or elongated. The external surface may be whitish or rust-colored, smooth or covered by adhesions. We analyzed 103 laparoscopic endometrioma resections performed from 1993 to 1995. Laparoscopies consisted of dissection of the ovarian cortex above the cyst, evacuation of cyst contents, cystoscopy, total ablation of its capsule, and bipolar coagulation of its site. Histologically we found endometriosis in 70% of cases, luteal cysts with blood effusion in 20%, follicular cysts in 4%, cysts deprived of epithelial lining in 2%, and serosal cysts in 4%. Unilateral endometriomas were found in 60.9%, and were bilateral in 39.1%. Each patient with a histologically proved diagnosis received danazol 400 to 600 mg/day for 6 to 8 months, and we performed 21 second-look laparoscopies among infertile women after therapy. No adhesion formation was seen. Follow-up was 12 to 14 months after laparoscopy and included vaginal sonography, which showed one (1.28%) recurrence of the ovarian endometrioma.

Office microlaparoscopy under local anesthesia

We assessed the utility, tolerance, and costs associated with office microlaparoscopy under local anesthesia using fiberoptic microlaparoscopes (<2 mm) and accessory instrumentation (<2 mm) for 100 of the following procedures: diagnostic laparoscopy to evaluate infertility including chromopertubation; diagnostic laparoscopy for chronic pelvic pain (CPP), including biopsy of endometriosis and conscious pain mapping; and early second-look laparoscopy including lysis of adhesions. A prospective nonselected cohort study was conducted on all women with CPP or infertility who consented to office microlaparoscopy under local anesthesia. A questionnaire was developed to follow all aspects of patient acceptance and tolerance of the procedures, and women were screened preoperatively, and 30 minutes and 1 week postoperatively. Pain was evaluated with modification of the McGill pain inventory relative intensity scale. A subset of questions evaluated the recovery period, and time and length of all aspects of the procedure and recovery were recorded. Second-look procedures were significantly more painful than diagnostic ones, and women with CPP experienced significantly greater pain than those with infertility. Virtually all expressed high satisfaction with the procedure. There were no complications, and no procedures required general anesthesia. Compared with traditional laparoscopy, there was a reduction in costs greater than 70%.

Second-look microlaparoscopy

Second-look laparoscopy performed a short time after corrective surgery to determine reproductive function has always been controversial. The need for general anesthesia and additional abdominal wall trauma make it unpopular. However, postponing pelvic evaluation after the original surgery results in a large proportion of women attempting pregnancy with deformed anatomy as the result of reformation of pelvic adhesions. Since November 1995 we performed microlaparoscopy for a second look in 20 patients. Original procedures were performed for endometriosis, salpingo-oophorolysis, tubal repair, and complicated ectopic pregnancy. Six of the women had adhesions that interfered with fertility and were referred to an assisted reproduction technology (ART) program. Procedures lasted 14 minutes (range 10-17 min). We encountered no complications. Patients were discharged after 2 hours of recovery and resumed normal activity. Second-look microlaparoscopy can be an important tool in assessing the efficacy of reconstructive reproductive surgery, and in accelerating referral to ART programs in women with poor results.

A study of second-look laparoscopy after acute salpingitis.

Acute salpingitis (AS) has a major impact on the reproductive health of women. In this study second-look laparoscopy was assessed for its ability to predict reproductive function after AS. We questioned 158 women who had had a second-look laparoscopy with tubal dye insufflation after laparoscopically proven AS between September 1984 and August 1989. The answers of 69 women with at least two years of involuntary infertility were analyzed. The mean follow-up period was 76 months (range 53-108 months). Second-look laparoscopy revealed bilateral tubal occlusion in 21.7% (15/69). Bilateral tubal occlusion was found in 9.5% (2/21) after mild stage, 20% (4/20) after moderate stage and 32.1% (9/28) after severe stage AS. The rate of infertility during follow-up was 9.5% (stage I), 35% (stage II) and 39.9% (stage III). Eighty per cent (12/15) of women with proven bilateral tubal occlusion after treated AS had involuntary infertility, and 14.8% (8/54; P = 0.000001) of women with one or both tubes patent also had infertility. Specificity, sensitivity and positive predictive value for subsequent infertility were 85.2%, 80% and 84.1%, respectively. Pelvic adhesions (21/69) were strongly correlated with bilateral tubal occlusion (8/21; 38.1%; P = 0.029), a history of chronic pelvic pain (14/21; 66.7%; P = 0.00024), as well as failure to achieve an intrauterine pregnancy (10/21; 47.6%; P = 0.024). Recurrent pelvic infections occurred in 16% (12/69) and ectopic pregnancies in 7.3% (5/69). Operations for infertility and pelvic pain (excluding ectopic pregnancy), were carried out in 11.6% (8/69). We conclude that second-look laparoscopy after treated AS have accurate evaluation of reproductive function.

Adhesion formation and reformation after laparoscopic removal of ovarian endometriomas

Study Objective. To evaluate the extent of adhesion formation after laparoscopic removal of endometriomas. Design. Prospective case series. Setting. A university hospital. Patients. Nineteen infertile women with ovarian endometriomas. Interventions. All patients underwent laparoscopic cystectomy with total stripping of the cyst capsule when possible. A second-look laparoscopy was performed after 3 months of postoperative treatment with a gonadotropinreleasing homone analog. Measurements and Main Results. The extent of adhesion reformation was dependent on the extent and severity of adhesions at initial laparoscopy. One (5.2%) woman had a residual ovarian endometrioma at second-look laparoscopy. De novo adhesion formation was not seen. Nine women (42.8%) conceived during the postoperative follow-up period (range 11–22 mo). Conclusions. Laparoscopic removal of endometriomas is effective in eradicating the disease. Adhesions at second-look laparoscopy depend on adhesions at the initial laparoscopy. Crude pregnancy rates are satisfactory in infertile women.

Laparoscopy for adhesion prevention following myomectomy

Objective: To evaluate adhesion formation after classic abdominal myomectomy and the role of early, second-look laparoscopic adhesiolysis in the management of post-myomectomic pelvic adhesions in a prospective study. Method: Forty-eight patients with infertility, recurrent abortion or symptomatic myoma underwent second-look laparoscopy (SLL) 8 days after abdominal myomectomy. The degree of adnexal adhesions were scored according to the American Fertility Society Classification and were lyzed laparoscopically. The success of the SLL was evaluated in 18 patients who underwent a third-look procedure (cesarean section or laparoscopy) Results: Myomectomy incisions on the posterior uterine wall were associated with more adhesions than that on the fundus or anterior wall ( P < 0.01). Myomectomies performed on uteri larger than 13 weeks gestation resulted in significantly higher adhesion scores than smaller ones ( P < 0.001) and mainly intra-mural myomas than only sub-serous ones ( P < 0.01). More than one uterine incision was found to result in more adhesions ( P < 0.05), while the number of myomas removed were not found to affect adhesion formation ( P > 0.05). In the patients who underwent a third-look procedure, adhesion scores were found to be significantly lower than the SLL (6.2 ± 6.4 vs. 3.1 ± 3.4) ( P < 0.01). Conclusion: Myomectomy operations frequently result in pelvic adhesions, which may impair fertility. Early laparoscopy and adhesiolysis after myomectomy is useful for assessing the degree of adhesions, technical ease in performing adhesiolysis and resulting in lower adhesion scores as shown by third-look procedures.

Pain relief after combined medical and laparoscopic conservative treatment of stage III–IV endometriosis: A comparison with medical therapy

SummaryIn this prospective clinical trial, we evaluate the efficacy of combined medical and laparoscopic conservative treatment of extensive endometriosis associated with chronic pelvic pain. Thirty-two patients with stage III–IV endometriosis allocated to combined medical and laparoscopic surgical treatment were compared with a control group of 20 patients with the same characteristics who were given medical treatment alone. The second-look laparoscopy in the combined treatment group showed good anatomic outcome. Results in terms of pain relief were also very good in the patients who underwent combined treatment, with a highly significant difference (P lt; 0.001) in comparison with the medical treatment control group. Unfortunately, no conservative treatment of endometriosis protects the patient from the risk of recurrence. Nevertheless, we believe that the combination of laparoscopic conservative surgery with medical treatment is useful in achieving optimal anatomic results and is very effective in relieving pain.

Pregnancy in Five Patients After Laparoscopic Myomectomy with the Harmonic Scalpel

ABSTRACT This is the first published series of case reports of pregnancy following laparoscopic myomectomy with the Harmonic scalpel. Uterine dehiscence during pregnancy and adhesion formation, which might prevent pregnancy, have been the main concerns with performing a laparoscopic myomectomy. All patients in this study achieved pregnancies within 3 months of discontinuing contraception. None of the patients with second-look laparoscopies or laparotomies had formation of adhesions. Three patients delivered at term without evidence of uterine dehiscence. (J GYNECOL SURG 12:129, 1996)

Reduction of ovarian adhesions by the use of interceed

To evaluate the efficacy of Interceed (TC7) Absorbable Adhesion Barrier, an oxidized regenerated cellulose fabric, as a barrier to the development of postsurgical ovarian adhesions after surgery involving the ovaries. In a multicenter randomized study, 55 patients with bilateral ovarian disease were treated at initial laparotomy. At the end of the procedure, one ovary was assigned randomly to be wrapped with Interceed and the other was left uncovered. A second-look laparoscopy was performed 10-98 days later to evaluate the occurrence and severity of adhesions and the raw ovarian surface area exposed after lysis of adhesions. At second-look laparoscopy, 26 of 55 Interceed-treated ovaries were free of adhesions, compared with 14 of 55 untreated control ovaries, a statistically significant difference (P = .028, Fisher exact test). At second-look laparoscopy, ovaries treated with Interceed formed adhesions less extensively (1.66 +/- 0.34 cm2) than did untreated ovaries (2.75 +/- 0.60 cm2) and with a greater reduction of raw ovarian surface area (difference in area differential -1.89 +/- 0.96 cm2; P = .055, paired t test). Adhesion scores at second-look laparoscopy were reduced significantly for ovaries treated with Interceed compared with untreated ovaries (P = .02, Wilcoxon signed-rank test). No adverse events were recorded during the course of the study. Treatment of ovaries with Interceed significantly reduced the occurrence and severity of postsurgical ovarian adhesions.

Postoperative goserelin depot in women with severe endometriosis at second-look laparoscopy

Postoperative goserelin depot in women with severe endometriosis at second-look laparoscopy

Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane ) is superior to oxidized regenerated cellulose (Interceed TC7 ) in preventing adhesions

To compare the impact of expanded polytetrafluoroethylene (PTFE; Gore-Tex Surgical Membrane; W. L. Gore & Associates, Inc., Flagstaff, AZ) and oxidized regenerated cellulose (Interceed TC7, Johnson & Johnson Medical, Inc., Arlington, TX) on the development of postsurgical adhesions. A multicenter, nonblinded, randomized clinical trial. University medical centers. Each barrier was allocated randomly to the left or right sidewall of every patient. Thirty-two women with bilateral pelvic sidewall adhesions undergoing reconstructive surgery and second-look laparoscopy. Adhesion score (on a 0- to 11-point scale), the area of adhesion (cm2), and the likelihood of no adhesions. The use of both barriers was associated with a lower adhesion score and area of adhesion postoperatively. However, those sidewalls covered with PTFE had a significantly lower adhesion score (0.97 +/- 0.30 versus 4.76 +/- 0.61 points, mean +/- SEM) and area of adhesion (0.95 +/- 0.35 versus 3.25 +/- 0.62 cm2). Overall, more sidewalls covered with PTFE had no adhesions (21 versus 7) and, when adhesions were present on the contralateral sidewall, the number of sidewalls covered with PTFE without adhesions was greater than those covered with oxidized regenerated cellulose (16 versus 2). Expanded polytetrafluoroethylene was associated with fewer postsurgical adhesions to the pelvic sidewall than oxidized regenerated cellulose.