Gynaecological Endoscopy最新文献

Objective

To use the experience of an international group of gynaecological laparoscopists to evaluate the prevalence, causes, sites, management and outcomes of bowel injury occurring during or as a result of laparoscopy.

Design

A questionnaire was sent to members of the International Society for Gynecologic Endoscopy (ISGE) requesting details of all laparoscopies complicated by bowel trauma and performed by them over a 2-year period. One year was retrospective and one prospective.

Results

A total of 135 members (24%) replied and reported 45 bowel injuries. The estimated prevalence was 1 in 1652 level 1 laparoscopies and 1 in 280 levels 2 and 3 laparoscopies combined. Injuries were caused by the Veress needle, primary trocar, forceps, scissors and by electro- and laser surgery. Adhesions from previous surgery or endometriosis were present in 78% of cases. Bowel trauma was statistically significantly related to the experience of the surgeon, defined by a cut-off at 100 procedures per year. In experienced hands trauma occurred as frequently during access as during the surgical procedure. The diagnosis was made during the laparoscopy in 38 cases. Expectant treatment was carried out in four cases after Veress needle injury without consequences, laparoscopic suturing in eight cases and conversion to laparotomy in 26 cases. The diagnosis was delayed in seven patients (15%) of whom two (28%) died 7 days after surgery without any further intervention.

Conclusions

Bowel injury during gynaecological laparoscopy is significantly related to the experience of the surgeon. With the experienced group, bowel trauma occurs as frequently during access as during the surgical procedure. The occurrence of two deaths in our study suggests that the mortality due to bowel trauma may be underestimated in reports from highly privileged societies.

Objective

To highlight the necessity of adequately testing rectosigmoid integrity after resection of infiltrating endometriosis.

Subject

A 25-year-old woman with a past history of ablative treatment for endometriosis, symptoms suggestive of disease progression, and a palpable anterior rectal nodule.

Interventions and outcomes

Excisional treatment of all visible disease, including the rectal nodule was carried out. Rectal integrity was confirmed intraoperatively via the ‘Betadine’ test. The patient presented again 3 days later with clinical findings suggestive of a bowel perforation. Repair of the defect and a de-functioning colostomy were performed.

Conclusion

Although clinical bowel perforation is an uncommon event, the sequelae have far-reaching consequences for the patient's quality of life. The use of electrosurgical dissection may have contributed to delayed tissue necrosis and the subsequent rectal perforation. Current methods for testing colorectal integrity are reviewed.

Three surgical units were involved in a prospective comparative study: the Pavillon Paul Gellé in Roubaix, France for vaginal hysterectomies; the Hôtel Dieu Polyclinic in Clermont-Ferrand, France for total percoelioscopic hysterectomies; and the Saint-Luc Clinic in Brussels, Belgium for subtotal percoelioscopic hysterectomies.

The inclusion criteria were age (38–55 years old), the patients were either not menopausal or else they had received alternative therapies for menopause, and had mild uterine pathology with or without castration signs, but without pelvic pain. The vaginal or coelioscopic approach had to be practicable. Those patients with psychiatric histories, or with prolapses or stress incontinence which demanded surgery were excluded. Contraindications to any of the approaches (uterine volume larger than umbilicus, major previous pelvic surgery, severe endometriosis and virginity) were also considered to be exclusion criteria. A total of 82 patients who had undergone 31 vaginal hysterectomies, 31 total coelioscopic hysterectomies and 20 subtotal coelioscopic hysterectomies were followed up 1 year after the operation.

The population characteristics in the three groups were similar. Operating times were 70.8 min for vaginal hysterectomies (VH), 67.6 min for total percoelioscopic hysterectomies (TPCH) and 111.5 min for subtotal percoelioscopic hysterectomies (SPCH). The mean hospital stay was comparable in the three groups. The mean uterine weight was 225 g for the VH group, 281 g for the TPCH and 206.5 g for the SPCH group (P was not significant). The pain evaluation scales used by the patients during their hospital stay did not show any significant difference between the three groups. The mean times before patients could walk, return to work or resume sexual intercourse showed no significant differences between the groups. Mild urinary signs were reported in the mid-term without any significant difference. Physical activity improved in 38.7% of the patients who had undergone VH, in 46.6% who had undergone TPCH and in 60% who had undergone SPCH (P not significant). Those patients who had undergone SPCH resumed satisfactory sexual intercourse significantly earlier (P = 0.0002). Intercourse was not significantly modified in the three groups. Quality of life was generally and significantly improved for 80.6%, 96.5% and 70%, respectively, of the patients in the VH, TPCH and SPCH groups.

Although some surgical teams are still reluctant to practise coelioscopic hysterectomies, all three hysterectomy types were finally demonstrated to be equivalent in this study. They were proved to be feasible even in patients with a large uterus. Operating times are no longer unfavourable factors when coelioscopies are performed by highly skilled surgeons.

Objective

To report a case of breakage of the tip of a disposable trocar in the course of laparoscopic surgery, and to seek to establish the causes of the incident, analyse the incident itself, and to attempt to draw conclusions, in order to prevent recurrences.

Results

This was an generally difficult laparoscopic procedure in an obese patient, but no notable incident occurred. Towards the end of surgery, we noticed the presence of small plastic fragments and saw that the 10-mm disposable trocar was broken at its tip. Because it would be difficult to locate the small clear fragments, even if the abdomen were incised, and despite the fact that the fragments were sharp, we decided not to convert to laparotomy. We retrieved as many fragments as possible via laparoscopy. The postoperative course was completely normal.

Conclusions

The case illustrates the actual occurrence of a theoretical risk. In order to reduce the risk to a minimum, impacts between plastic trocars and metallic instruments should be avoided. Despite the lack of reaction from the manufacturers, it may be useful to raise the standard of robustness demanded for this product.

Objective

To assess the failure rate of diagnostic outpatient hysteroscopy using a 2.5-mm semirigid hysteroscope.

Design

Retrospective cohort analysis.

Setting

Outpatient hysteroscopy unit in a large district general hospital.

Sample

All patients who had a diagnostic outpatient hysteroscopy during the study period.

Main outcome measures

Hysteroscopy was considered a failure when the uterine cavity was not accessible or when the view obtained was unsatisfactory.

Results

A total of 1976 patients were seen in the direct-access hysteroscopy unit between November 1994 and May 1999. The procedure was performed successfully in 1898 patients (96.1%) but failed in 78 patients (3.9%). Causes for failure included: cervical stenosis (n = 54; 67.9%), severe discomfort (n = 7; 8.9%), unsatisfactory view (n = 6; 2.6%), obesity (n = 5; 6.4%), large cervical polyp (n = 4; 5.1%) and vagal reaction (n = 2; 2.6%). Overall failure was more likely in postmenopausal (46/894; 5.1%) than in premenopausal patients (32/1082; 2.9%).

Conclusions

Diagnostic outpatient hysteroscopy using a 2.5-mm semirigid hysteroscope is a simple, safe, effective and acceptable investigation. The most common reason for a failed outpatient microhysteroscopy was cervical stenosis particularly in postmenopausal women.

Objective

To assess the role of ultrasound with respect to management decisions in premenopausal women with abnormal uterine bleeding attending an outpatient hysteroscopy clinic.

Design

Retrospective analysis of ultrasound and hysteroscopic findings, in 264 women referred with abnormal uterine bleeding.

Setting

Outpatient hysteroscopy clinic in a busy district general hospital.

Results

In situations where hysteroscopy findings were normal, additional information gained from a preliminary ultrasound did not affect management decisions. No malignant adnexal pathology was detected, and ultrasound assessment of the endometrium did not correlate well with either hysteroscopic or histological findings.

Conclusion

Ultrasound findings do not alter management decisions in this situation. The presence of irregular bleeding, and patients' prior expectations, are more significant determinants.