Faculty Bibliography

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.

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.

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.

BACKGROUND:The proper treatment of bladder endometriosis is unknown. CASE/METHODS:Two women with endometriosis involving the full thickness of the bladder wall experienced persistent hematuria during menstruation. They had not responded to previous conservative medical or surgical therapy, so we performed laparoscopic segmental resection, with satisfactory results. CONCLUSION/CONCLUSIONS:Hematuria during menstruation due to endometriosis of the bladder is uncommon. In the two cases presented, good results followed laparoscopic segmental resection.

Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging.

We report the first case of a laparoscopic radical hysterectomy and paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.

A specific technique of advanced operative laparoscopy, known as videolaseroscopy, using the CO2 laser and videomonitor, is described. Operating room setup, anesthesia considerations, and specific applications to pelvic disease are elaborated.

A randomized prospective study was conducted to evaluate the ease of use and safety of direct insertion of laparoscopic trocars. Comparison of previous pneumoperitoneum by Veress needle insertion with direct insertion of the reusable conventional laparoscopic trocar and direct insertion of the disposable shielded trocar revealed minor complication rates of 22, 6 and 0%, respectively. No major complications occurred in this series of 200 patients.