Gynaecological Endoscopy最新文献

To describe a case of gas embolism in association with VersaPoint hysteroscopic myomectomy.

A 40-year-old woman with menorrhagia secondary to uterine fibroids.

Hysteroscopic VersaPoint spring endometrial ablation and submucous myomectomy under general anaesthetic with saline as the distension medium. Intraoperatively an acute and profound drop in the patient's end-tidal carbon dioxide and oxygen saturation suggested gas embolism and the procedure was abandoned. The origin of the gas responsible for the embolism is uncertain.

The VersaPoint spring for endometrial ablation and submucous myomectomy requires further evaluation. Factors which may have contributed to the gas embolism are discussed.

Laparoscopically performed supracervical hysterectomy is becoming more widely accepted around the world. The objective of this case report is to describe a rare urinary tract complication associated with this operation.

Case report.

Referral practice for endoscopic surgery.

A 35-year-old nulliparous woman with recurrent endometriosis and chronic pelvic pain.

A laparoscopic supracervical hysterectomy with bilateral salpingo-oöphorectomy.

The patient developed a vesico-cervical fistula 3 weeks postoperatively. After urological consultation, this was treated successfully via minilaparotomy, transvesical excision, and repair of the fistula within 36 h of diagnosis.

Urinary tract fistulas can occur following laparoscopic supracervical hysterectomy. If they are diagnosed immediately and properly managed, standard repair can be successful and morbidity can be minimized.

To present a synopsis of the evidence supporting ablative laparoscopic surgery for endometriotic cysts.

Review article.

Endometriotic cysts can be managed laparoscopically by stripping, and excising or ablation of the capsule.

The clinical outcome of each technique in terms of cyst recurrence, pregnancy rates, pain relief and patient satisfaction are broadly similar, but this may reflect study design and in particular, the variable follow up periods, and methods used to document outcome measures. There are concerns that excision may result in post operative adhesion formation and damage to the underlying oocytes which may impair fertility, produce chronic pain, and premature menopause. These concerns arise from the postulated aetiology and pathogenesis of ovarian endometriomas.

There is no clear evidence to suggest that one minimal access surgical technique is superior to another for the management of endometriotic cysts. However, ablation of the capsule is a theoretically superior technique, with no demonstrable disadvantages.

To look at the current practice in outpatient hysteroscopy, in particular to determine the availability, staffing levels, equipment used, and facilities throughout the UK, and to ascertain why the service is not more widely available for patients.

A postal questionnaire with no follow up for non-responders.

National survey throughout the UK.

All consultant gynaecologists throughout the UK.

These were: the availability of outpatient hysteroscopy nationally; the reasons why outpatient hysteroscopy is presently not available in some units, and whether this facility was wanted in those units.

1148 questionnaires were mailed with 637 responses (55.5%), representing 80.7% of gynaecology units throughout the UK. Of the respondents, 55.6% had access to outpatient hysteroscopy, and of the respondents without access 77.7% would have liked the facility to be available. The reasons given for the lack of an outpatient hysteroscopy service were: lack of funding (35%); unavailable facilities (35%); alternative investigations employed (21.9%); not clinically appropriate (4.9%), and not cost-effective (3.2%).

Outpatient hysteroscopy is available but its extent could be improved. The clinics are generally run once per week, with about six patients per clinic. It appears to be a consultant-led service, and most of those consultants who do not have access to outpatient hysteroscopy would like the facility to be available but do not have the funding or facilities.

In the absence of definitive data, we sought to determine the consensus on the contribution of adhesions to pelvic pain.

Impressions about the role of adhesion location, extent, and severity of pelvic pain, were surveyed among 13 gynaecological surgeons. They were asked whether adhesions covering specific organs to a varying extent would be likely to cause pain significant enough to require pain medication, or to lead a woman to alter her normal activities, and when they would recommend surgery to reduce pelvic pain.

Women with dense vascular adhesions covering all of the uterus but not the bowel or adnexal structures were thought to have a 49 ± 9% likelihood of having pelvic pain; this fell to a 34 ± 7% and 18 ± 5% likelihood of pain if 60% or 20%, respectively, of the uterus was involved with adhesions. Similar observations were made for adhesions involving the posterior cul-de-sac and large bowel. However, adhesions involving the anterior cul-de-sac were thought to be less likely to cause pain. Women with total involvement of both tubes and ovaries with dense, vascular adhesions were thought to be 60 ± 9% likely to have pelvic pain; reduction in extent of adhesions to 50% or 25% reduced the prediction of pain to 38 ± 5% and 21 ± 3%, respectively. In contrast, filmy adhesions to both tubes and ovaries, were thought to cause pain in 46 ± 9%, 26 ± 5%, and 13 ± 3% of women, respectively, according to extent. Half the surgeons said they would recommend surgery for patients with pain and dense adhesions involving 15% of both tubes and ovaries; 10 recommended surgery if it was known that adhesions involved 100% of both ovaries and tubes. Surgeons were only slightly less likely to recommend surgery for pain relief for adhesions involving either both tubes or both ovaries or for pain associated with unilateral tubal and ovarian adhesions. For bilateral tube and ovary adhesions, surgery was equally likely to be recommended for relief of pain when adhesions were cohesive and dense; for adhesions which were filmy, surgery was less likely to be recommended. For dense adhesions involving 20%, 40%, 60%, and 80% of the uterine surface, surgery was recommended by 42%, 58%, 83% and 92% of surgeons, respectively. Posterior cul-de-sac involvement resulted in recommendation of surgery by 50%, 83%, 92%, and 100% of surgeons, respectively; however, for corresponding amounts of anterior cul-de-sac adhesions, surgery was recommended by only 17%, 33%, 67%, and 75% of surgeons.

(1) Adhesions are frequently considered to be a cause of pelvic pain; (2) the likelihood of discomfort is related to location, extent, and to a lesser degree, the severity of adhesions, and (3) adhesiolysis is thought to provide the potential for pain relief.

To describe the technique of laparoscopic reconstruction of the uterine wall defect after laparoscopic enucleation of intramural fibroid, using a modified type of reusable laparoscopic knot pusher which enhances precise positioning and adequate tightening of the Roeder knot.

A stand-alone one-day surgery unit.

Six patients having laparoscopic enucleation of an intramural fibroid.

The defect in the uterine wall was reconstructed with open surgery sutures tied extracorporeally using a Roeder knot which was slid and tightened with the knot pusher.

Since the Roeder knots were slid and tightened without blockage and the uterine wall was reconstructed without postoperative intramural haematoma in all patients, the impression is that the modified type of Roeder knot pusher used on standard sutures could be a low-price alternative to endoscopic sutures.

The development and evaluation of a model for use in the initial training of gynaecologists in endometrial ablation techniques.

A series of prototypes, created according to theoretical specifications, were evaluated by practitioners experienced in endometrial ablation, and modified accordingly. The final model was evaluated by both trainers and trainees.

An endoscopic training unit.

The Faculty of the Scottish Diagnostic and Operative Hysteroscopy Course (12 consultants) and course participants (88), the majority being trainees from Scottish hospital trusts.

A model was developed for use in laboratory training or for individual practice, which is inexpensive, made of readily available materials and easy to prepare.

The materials, method of preparation and presentation of the model are reported and the advantages and disadvantages of its use are discussed.