Faculty Bibliography

OBJECTIVE:To evaluate the long-term pain reduction achieved by laparoscopic presacral neurectomy. METHODS:One hundred seventy-six women with median (range) age 30 (18-45) years underwent presacral neurectomy combined with excision and vaporization of endometriotic lesions and were observed, using structured questionnaires, for up to 72 months postoperatively. The study included a convenience sample of the first 100 questionnaires returned. Forty of the women were studied for 12-23 months, and 60 for 24-72 months. The main outcome measures were reduction of pelvic pain, dysmenorrhea, and dyspareunia after surgery. RESULTS:Pelvic pain, dysmenorrhea, and dyspareunia were reportedly reduced by more than 50% in 74, 61, and 55 patients, respectively, more than 12 months after laparoscopic presacral neurectomy. More than 50% reduction in pelvic pain was reported by 69.8%, 77.3%, 71.4%, and 84.6% of the patients, respectively, with endometriosis stages I-IV, using the revised classification of the American Fertility Society. Comparatively, more than 50% reduction in dysmenorrhea was reported by 52.8% of the patients with stage I endometriosis, 68.2% with stage II, 71.4% with stage III, and 69.2% with stage IV. Reduction of dyspareunia by more than 50% was reported by 54.7% of the patients with stage I endometriosis, 50.0% with stage II, 28.6% with stage III, and 61.5% with stage IV. CONCLUSION/CONCLUSIONS:Long-term outcome of laparoscopic presacral neurectomy is satisfactory in the majority of patients. The stage of endometriosis is not related directly to the degree of pain improvement achieved.

Advanced operative laparoscopy is being performed increasingly for various indications and in diverse patient populations, including gravid women. In the United States approximately 1.6% to 2.2% of pregnant women require nonobstetric surgery for abdominal and pelvic pathology. Increasing numbers of case reports suggest the feasibility and safety of operative laparoscopy during pregnancy. We identified certain management issues specific to these procedures based on our experience with nine cases of operative laparoscopy in women with gestations up to 22 weeks.

OBJECTIVE:To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. MATERIALS AND METHODS/METHODS:A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. RESULTS:The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes. CONCLUSIONS:Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.

A retrospective case review was performed to determine the risk factors and frequency of incisional hernias after advanced operative laparoscopy. Ten incisional hernias occurred in nine women over 13 years, a frequency of about 0.1%. Omentum herniated in six women and bowel herniated in four. In one patient the bowel fat herniated through the peritoneum and not the fascia. The hernia occurred through a 5-mm cannula incision site in six patients. Since they all occurred on the left lower entry point, they were most likely related to the extensive manipulation of the suction-irrigation probe inserted through this cannula. Seven women required laparoscopic surgery to retract the entrapped omentum or bowel. In one, laparoscopic-assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using cannulas of 10 mm and larger, but also when extensive manipulation is performed through a 5-mm cannula port.

One hundred fourteen women (average age 37.1 yrs) underwent laparoscopic myomectomy for pain (77.8%), abnormal bleeding (53.1%), and infertility (20.8%). The location and depth of penetration of the myoma(s) were determined by ultrasonography and laparoscopic assessment. Follow-up data were obtained either by review of patient charts or returned questionnaires. Relevant risk factors for recurrence were isolated by discriminant analysis. The cumulative risk of recurrence was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. Associated risk factors were the number of myomas and the depth of infiltration. Patients without recurrence had an average of 2.5 ± 2.3 fibroids and those with recurrences had 4.1 ± 2.9 myomas (p <0.01). The recurrence rates for pedunculated, subserosal, and intramural myomas were 0.0%, 11.8%, and 44.9%, respectively (p <0.01). Myoma size, patient age, parity, and postoperative pregnancies had no influence on the recurrence rate. The cumulative risk of recurrence after laparoscopic myomectomy seems to be higher than that reported after laparotomy.

We evaluated the safety of laparoscopic myomectomy in 114 women (average age 37.1 yrs, mean 34.1 ± 3.6 yrs) who desired future pregnancy. The indications were pain (77.8%), abnormal bleeding (53.1%), and infertility (20.8%). Follow-up data were obtained by reviewing patient charts or returned questionnaires. Student's nonpaired two-way t test was used to compare characteristics of women with and without subsequent pregnancy complications. The average number of myomas was 3.0 ± 2.9 and the mean size was 5.9 ± 3.0 cm. In 52.4% of cases the deepest infiltrating myoma was intramural, in 42.9% subserosal, and in 4.7% pedunculated. Thirty-one pregnancies occurred in 29 women. Of the 26 that could be followed, 5 ended with vaginal delivery at term. Cesarean sections were performed in 14 women, 9 at term, 1 at 26 weeks, and 4 at unknown gestational age. Six women miscarried in the first trimester and one had an ectopic pregnancy. Spontaneous uterine rupture was not noted during pregnancy or at delivery. Compared with women with ectopic pregnancies, miscarriages, and preterm deliveries, those who delivered at term were younger (33.1 ±1.9 vs 36.6 ± 4.8 yrs, p <0.05) and had fewer myomas at surgery (1.9 ± 2.0 vs 4.8 ± 3.0, p <0.01). Those who had intramural myomas were most likely to develop complications during pregnancy. Uterine rupture during pregnancy and labor is a rare complication of myomectomy by laparotomy, and only a few cases have been reported after laparoscopic myomectomy.

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.

One hundred consecutive patients, age 24-62, status post total hysterectomy with and without bilateral oophorectomy (BSO), presented with chronic pelvic pain. All underwent laparoscopy. Of those who did not have BSO, 30 had definite endometriosis found at laparoscopy and five had questionable endometriosis. Of the 30 patients found to have definite endometriosis, 24 had a positive history of endometriosis, five had a negative history and one had a questionable history. Sixty-four underwent total hysterectomy with BSO. Of these 64, definite endometriosis was found in 22 at laparoscopy, questionable endometriosis was noted in 3, and findings for 39 were negative. Of the 22 women with positive endometriosis, 19 had a positive history of endometriosis, 2 had a negative history and 1 had a questionable history. Of these 22 patients, 13 were on estrogen replacement therapy, 2 were on estrogen and progesterone, 2 were on testosterone estradiol pellets, 2 were on GnRH analogs, 1 was on danazol and 2 received no medication. In this group, the time between hysterectomy and our laparoscopy was eight months to 15 years. Twenty-four of the 100 patients had a positive history of endometriosis with negative findings at laparoscopy. Our findings support the view that endometriosis will be found at laparoscopy in a significant number of women with chronic pelvic pain status post hysterectomy with or without BSO, especially if the woman has a positive history of endometriosis.

We randomly assigned 95 women, age 17-55 (mean 36.5) with unilateral or bilateral ovarian cysts measuring 1.1 to 6.1 cm in greatest diameter, to four groups to determine the efficacy of hormonal suppression. Eleven did not complete the study, and 9 did not follow up, for a study population of 75. Of these 75, 29 women had a history of endometriosis and 12 were treated with ovulation induction within 6 months of inclusion. Group I (24), received no treatment and served as a control; Group II (15) took oral contraceptives (OCP) containing 35 &mgr;g ethinyl estradiol and 1 mg norethindrone; Group III (23) received OCP's with 50 &mgr;g ethinyl estradiol and 1 mg norethindrone; and Group IV (13) took danazol 800 mg/day. All medications were taken continuously for 6 weeks. Patients were then re-evaluated by pelvic examination and transvaginal ultrasound. If the cysts persisted, the patient was scheduled for diagnostic and possible operative laparoscopy. Complete resolution of cysts was found in: Group I - 14 (58%), Group II - 6 (40%), Group III - 15 (65%), and Group IV - 7 (54%). Of the 33 women with persistent cysts, 28 underwent videolaparoscopy. The results were as follows: Group I (42%) - five functional, two endometriomas, one hydrosalpinx, and one benign paraovarian serous cyst; Group II (60%) - three functional, one endometrioma, and one benign simple cyst; Group III (35%) - two functional, five endometriomas, and one loop of bowel; and Group IV (46%) - four functional and two endometriomas. The results, analyzed using the chi2 test, indicated that there is no significant difference between expectant management and hormonal suppression in treating functional ovarian cysts. A CA 125 was obtained on 48 women. Using the t-test, we compared values for cysts which persisted and those which did not. There was no correlation between CA 125 levels and persistence or resolution.

To determine the usefulness of noninvasive clinical tests to diagnose symptomatic endometriosis, we retrospectively reviewed the medical records of 91 patients with chronic pelvic pain and laparoscopically confirmed endometriosis. Thirty-seven women (41%) had pelvic peritoneal endometrial implants with adhesions; in 44 (48%) the ovaries were also affected, and in 10 (11%) the disease involved both the uterus and ovaries. Seventy-nine (87%) women had dysmenorrhea, dyspareunia, or both. Forty-three (47%) had a normal bimanual pelvic examination and 37 (41%) an unremarkable transvaginal sonographic evaluation (no significant difference). The women were divided into two groups: group 1, in whom the disease extended to the ovaries and uterus, and group 2, those in whom only peritoneal implants and adhesions were present. In group 1, 48 women (89%) had an abnormal ultrasonographic evaluation compared with only 4 (11%) in group 2 (p <0.001). Our findings indicate that bimanual pelvic examination and transvaginal sonography are equally accurate in detecting endometriosis; however, when the uterine surface and ovaries are involved, the latter is more informative. Therefore, patients with chronic pelvic pain, especially pain related to menstruation or coitus, should be evaluated laparoscopically to diagnose mild endometriosis adequately.