Faculty Bibliography

Fistulas between the anorectum and vagina may arise from several causes. Treatment depends on their etiology and location, as well as the surgeon's experience. Operative laparoscopy was successful in two women with type IV (mid)rectovaginal fistula in whom previous surgical attempts failed. Our experience suggests that mid and high rectovaginal fistulas can be effectively treated by laparoscopy in the hands of experienced endoscopic surgeons.

STUDY OBJECTIVE/OBJECTIVE:To determine the recurrence rate of myomas after laparoscopic myomectomy. DESIGN/METHODS:Retrospective review (Canadian Task Force classification II-2). SETTING/METHODS:Tertiary referral center. PATIENTS/METHODS:One hundred fourteen women (age 25-51 yrs, median 38 yrs) who were followed for an average of 37 months (range 6-120 mo). INTERVENTION/METHODS:Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS/RESULTS:Follow-up data were obtained by chart review and from returned questionnaires. Variables were date of surgery, first diagnosis of recurrence, and last follow-up visit. There were 38 (33.3%) recurrences after an average interval of 27 months. Twenty-four of these women did not require treatment. Eight underwent a second laparoscopic myomectomy, and one had a third. One patient had myomectomy and then hysterectomy, and six patients chose hysterectomy to treat the first recurrence. Cumulative risk of recurrence (Kaplan-Meier curve) was 10.6% after 1 year, 31.7% after 3 years, and 51.4% after 5 years. CONCLUSION/CONCLUSIONS:Although laparoscopic myomectomy is associated with less morbidity than removal by laparotomy, our results suggest that recurrence of myomas may be higher with the laparoscopic approach. Of 38 women with recurrent myoma, however, only 14 (36.8%) required additional surgery.

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.