Adhesion reformation after reproductive surgery by videolaseroscopy

Nanotechnologies for intranasal drug delivery: an update of literature

Scientific research has focused its attention on finding an alternative route to systemic oral and parenteral administration, to overcome their usual drawbacks, such as hepatic first-pass which decreases drug bioavailability after oral administration, off-target effects, low patient compliance and low speed of onset of the pharmacological action in first-aid cases. Innovative drug delivery systems (DDS), mainly based on polymer and lipid biocompatible materials, have given a great prompt in this direction in the last years. The intranasal (IN) route of administration is a valid non-invasive alternative. It is highly suitable for self-administration, the drug quickly reaches the bloodstream, largely avoiding the first pass effect, and can also reach directly the brain bypassing BBB. Association of IN route with DDS can thus become a winning strategy for the controlled delivery of drugs, especially when a very quick effect is desired or needed. This review aims at analyzing the scientific literature regarding IN-DDS and their different ways of administration (systemic, topical, pulmonary, nose-to-brain). In particular, attention was devoted to polymer- and lipid-based micro- and nanocarriers, being the topic of most published articles in the last decade, but the whole plethora of colloidal DDS investigated in recent years for IN administration was presented.

Postoperative adhesion formation in a rabbit model: monopolar electrosurgery versus ultrasonic scalpel

Background and Objectives:

To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period.

Methods:

Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators.

Results:

There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30).

Conclusion:

Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.

Laparoscopic treatment of ovarian cysts in adolescents and young adults

STUDY OBJECTIVE

To investigate the laparoscopic management of ovarian cysts in adolescents and young adults.

DESIGN

A retrospective chart review study.

SETTING

Zekai Tahir Burak Women's Health Research and Education Hospital.

PARTICIPANTS

A total of 282 females aged 25 years or younger underwent laparoscopic surgery for a presumed benign ovarian cyst. Patients were grouped as adolescents (ages 12-19, n = 79) or young adults (ages 20-25, n = 203).

MAIN OUTCOME MEASURES

Surgical approach, operative findings and the correlation of intraoperative diagnosis with the definitive pathological reports.

RESULTS

The mean age of the patients was 21.2 years. At laparoscopic surgery, 89 patients (31.6%) had endometriomas, 47 (16.7%) had dermoid cysts, and 37 (13.1%) had paraovarian cysts. Ninety-seven patients (34.4%) had simple ovarian cysts. Pathological reports revealed that young adults were more likely to have endometriomas (34.0% vs 7.6%, P < 0.01), but dermoid cysts and simple ovarian cysts were more frequent (20.3% vs 15.3%, P < 0.01 and 60.7% vs 40.9%, P < 0.01, respectively).in adolescents. Eleven of the cases (3.9%) were found to have mucinous cystadenomas and fourteen (5.0%) to have serous cystadenomas. Four cysts were malignant (1.4%). Cystectomy was performed in 205 cases (72.7%), fenestration of cyst wall was performed in 53 cases (18.8%), and aspiration was applied in 22 cases (7.8%). The types of operation were not significantly different among adolescents and young adults (P > 0.05). The operative diagnosis was highly correlated with the final pathological reports (kappa value= 0.901, P < 0.001). There were no operative and postoperative complications in our series.

CONCLUSION

With a careful preoperative screening, the laparoscopic surgery of ovarian cyst is an efficient and safe treatment for adolescents and young adults.

Management of ovarian dermoid cysts in the pediatric and adolescent population

STUDY OBJECTIVE

To evaluate the surgical approach used in the management of ovarian dermoid cysts in the pediatric and adolescent population.

DESIGN

A descriptive retrospective chart review of all cases of ovarian dermoid cyst excision between January 2001 and January 2006.

SETTING

The Hospital for Sick Children, Toronto, Canada.

PARTICIPANTS

Forty-one female children and adolescents who underwent operative management of an ovarian dermoid cyst.

MAIN OUTCOME MEASURES

Surgical approach (laparoscopy vs laparotomy), intraoperative cyst rupture, length of hospital stay, and postoperative complications.

RESULTS

The mean age was 12.5 years. All cysts were unilateral. Twenty-three patients (56%) underwent laparoscopic cystectomy, 14 (34%) underwent cystectomy via laparotomy, and 4 (10%) oophorectomies were performed via laparotomy. Cyst size was significantly larger in the laparotomy group compared to the laparoscopy group (mean diameter 14.4 cm vs 7.1 cm, respectively, P < .001). A significantly higher rate of cyst rupture was experienced during laparoscopic cystectomy (100%), compared to excision via laparotomy (27.7%, P < .001). Length of hospital stay was significantly shorter in the laparoscopy group compared to the laparotomy group (median of 0 vs 3 days, respectively, P < .001). A single case in the laparoscopy group sustained a bladder injury and developed postoperative necrotizing fasciitis resulting in a prolonged hospitalization and recovery. There were no operative or postoperative complications related to cyst content spillage, regardless of the surgical approach.

CONCLUSION

Laparoscopic cystectomy is a safe and effective method of managing ovarian dermoid cysts in the pediatric and adolescent patient population.

Treatment of myomas by laparoscopic and laparotomic myomectomy and laparoscopic hysterectomy

The objective of this study was to evaluate the benefits, feasibility and limitations of laparoscopic myomectomy. It was a retrospective review (Canadian Task Force Classification II-2) at a university-based primary treatment centre for endoscopic surgery. The 216 evaluated patients were treated at the Department of Obstetrics and Gynaecology, University of Kiel, between January 1998 and November 2000. Of 216 patients with myomas, 178 (83%) underwent laparoscopic myomectomy, 27 (12%) laparoscopic hysterectomy and 11 (5%) laparotomic myomectomy. The study reviewed the indications and surgical techniques and evaluated the benefits and limitations of laparoscopic myomectomy. Nine patients were selected for Classic Intrafascial Supracervical Hysterectomy (CISH) and 18 for Laparoscopic Assisted Vaginal Hysterectomy (LAVH), i.e. 12% of the patients were selected for laparoscopic hysterectomy. In an additional 11 (5%) patients the laparoscopic approach was difficult because of the location of the myoma and the procedure converted to a laparotomic myomectomy. A total of 178 patients (83%) was treated by laparoscopic myomectomy. The mean hospital stay was three days. No serious complications occurred. Two patients suffered a uterine wound bleeding which was corrected and one patient an abdominal hematoma. Since this study mainly focuses on laparoscopic myomectomies (83%), hysteroscopic myomectomies were evaluated in a separate study. At our institution laparoscopic myomectomy is the first-step treatment for patients with myomatous uteri. Only a small percentage of patients had to undergo a laparotomy (5%) and for 27 patients (12%) hysterectomy proved to be the treatment of choice.

Medico-legal consequences of post-operative intra-abdominal adhesions

Post-operative adhesions are an almost invariable consequence of abdominal or pelvic surgery, no matter whether this is performed by the open or laparoscopic technique. Their most important morbidity is small bowel obstruction, but other sequelae include female infertility and dyspareunia, and increased risk of visceral injury at any subsequent laparotomy or laparoscopy. Whether chronic abdominal pain is truly a consequence of adhesions is still a matter of some discussion, but it is likely to be accepted as an entity both by patients and by their legal advisors. While there is currently a scarcity of published literature on the subject, a recent assessment of adhesion-related medico-legal claims dealt with by the British medical defence associations has been undertaken. Successful medico-legal claims include cases of bowel perforation after laparoscopic division of adhesions, delays in the diagnosis of adhesion obstruction of the small bowel, infertility as a result of adhesions and 'pain'. This problem is unlikely to be unique to the UK alone and general practitioners, surgeons and gynaecologists worldwide need to be aware of the increasing burden of medico-legal claims arising from the complications of intra-abdominal adhesions. Most importantly they need to consider whether it is now timely to take steps to avoid them.

ANÁLISE HISTOLÓGICA DA ENDOMETRIOSE EM RATAS DURANTE AS FASES DO CICLO ESTRAL

RESUMO A presente pesquisa teve como objetivo analisar morfologicamente os sítios de implantes endometriais sobre a região externa da musculatura da parede abdominal anterior de ratas, durante o ciclo estral. Para tanto foram utilizadas 16 ratas albinas (Rattus norvegicus albinus), da linhagem Wistar com 90 dias de idade, obtidas do biotério do Departamento de Morfologia e Fisiologia Animal da UFRPE, as quais foram submetidas à indução da endometriose. A análise histológica dos implantes foi realizada por meio da microscopia de luz, utilizando-se técnicas de colorações pela Hematoxilina-Eosina (H-E) e pelo Tricrômico de Mallory. O material coletado foi fixado em líquido de Boüin e processado para inclusão em “paraplast”. Os resultados mostraram que as fases de proestro, estro e diestro foram mais favoráveis para o desenvolvimento dos implantes endometriais em ratas, quando comparadas ao metaestro.

Survey Among Members of the Roman Group of Gynecologic Endoscopy on the Use of Agents for Postoperative Adhesion Prevention

STUDY OBJECTIVE

To evaluate patterns of use of agents for postoperative adhesion prevention.

DESIGN

Mail survey.

SETTING

Departments of Obstetrics and Gynecology, university-affiliated and public hospitals, Rome, Italy.

PARTICIPANTS

Members of the Roman Group of Gynecologic Endoscopy.

INTERVENTION

Evaluation of forms returned.

MEASUREMENTS AND MAIN RESULTS

The response rate to either electronic or regular mailing was 31%, for a total of 42 forms evaluated. For laparoscopy, the perceived postoperative de novo adhesion formation rate was 0%-25%, whereas the adhesion reformation rate was 26%-75%; for laparotomy, the rates were 26%-75% and >75%, respectively. Sixty-five percent of the respondents were using at least one method for postoperative adhesion prevention during laparoscopy, and 68% during laparotomy. The most frequently used method during laparoscopy was Ringer's lactate (77% of the respondents), followed by ferric hyaluronate gel (46% of the respondents), and 4% icodextrin (39% of respondents). During laparotomy, the most frequently used methods were Ringer's lactate (28%), normal saline (20%), and 4% icodextrin (20%). Antibiotic prophylaxis was used by 87.5% of respondents.

CONCLUSION

Postoperative adhesion formation, and especially reformation, are perceived as significant problems. Sixty-five percent of the respondents used some method for adhesion prevention after operative laparoscopy, with Ringer's lactate, ferric hyaluronate gel, and 4% icodextrin being the most frequently used.

Incidence of postoperative adhesion formation after transperitoneal genitourinary laparoscopic surgery

OBJECTIVES

To evaluate adhesion formation after urologic laparoscopy, a multi-institutional review was conducted among adult patients who underwent a second procedure after an initial transperitoneal laparoscopic procedure. Adhesion formation after abdominal surgery remains a major cause of postoperative morbidity. Peritoneal adhesions result in hospitalizations and interventions that result in healthcare costs of more than 1 billion dollars annually. The risk of adhesion formation from transperitoneal genitourinary laparoscopy in adults has not been previously studied.

METHODS

Twenty-seven patients (mean age 45.5 years, range 24 to 71) were identified who underwent a second laparoscopic procedure after their initial urologic laparoscopic procedure was performed. The mean time between the procedures was 11.4 months (range 8 days to 38 months). At the time of the repeated laparoscopy or open surgery, the peritoneal cavity was examined and mapped for type (grade), extent (length), and location of any adhesions at the operative and trocar sites. The adhesions were graded as 0, no adhesions; 1, flimsy; 2, dense; and 3, cohesive. The extent was graded as 0, no adhesions; 1, less than 2 cm; 2, 2.1 to 10 cm; 3, greater than 10.1 cm.

RESULTS

Overall, adhesions occurred in 6 (22.2%) of 27 patients. Operative site adhesions occurred in only 3 (8.2%) of 34 possible operative sites (gastric augmentation cystoplasty, renal cyst ablation, nephropexy). Trocar site adhesions occurred in 4 (3.5%) of 114 possible sites (two nephrectomies, one cyst decortication, and one orchiectomy). All adhesions were classified as grade 1 and extent 1, except for a single grade 2, extent 2 adhesion. In most patients, retroperitonealization occurred with minimal or no scarring noted. None of the patients developed symptoms as a result of the adhesion formation.

CONCLUSIONS

Although intraperitoneal adhesions do occur with adult urologic laparoscopy, the incidence is low. Also, in the few patients who do form adhesions, they are flimsy and short. This evidence, when contrasted with the available data on adhesion formation after open surgery, suggests that transperitoneal laparoscopic approaches to genitourinary surgery may have advantages over traditional open transperitoneal approaches by lowering the incidence and severity of adhesion formation.

Ectopic pregnancy from surgical emergency to medical management

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Adhesions: laparoscopic surgery versus laparotomy

This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

[Laparoscopic treatment of small intestine obstruction]

Laparoscopic surgery for small bowel obstruction is still under evaluation. A review of the literature retrieved over 200 published cases. Technically, the open laparoscopy procedure seems mandatory to avoid bowel injuries. Grasping the enlarged bowel and using monopolar cautery should be avoided. The surgeon should also be sure that at the end of the procedure adhesiolysis was correct. Evaluation of the results must also take into account that most studies were retrospective and included few patients. The cumulative effectiveness rate of laparoscopy was 60%. Failures were mainly due to multiple adhesions, iatrogenic perforations to the intestine, and colonic cancers not recognized before the procedure. There was no prospective study comparing laparoscopy with laparotomy. Finally, it is not proved at present that laparoscopy prevents the recurrence of adhesions after digestive surgery. Owing to the results of the literature, laparoscopic surgery for acute small bowel obstruction does not appear as based on fact.

The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery

OBJECTIVE

To document rates of adhesion development after abdomino-pelvic surgery, stratified by adhesion type, access method, and use of crystalloid solution instillates.

DESIGN

Reports from a MEDLINE search (1/1/1966-12/18/1996) detailing rates of adhesion development and meeting the inclusion criteria were subjected to meta-analysis.

SETTING

Meta-analysis.

PATIENT(S)

Patients undergoing abdomino-pelvic surgery.

INTERVENTION(S)

Intraperitoneal crystalloid solution instillates.

MAIN OUTCOME MEASURE(S)

Percentage adhesion-free outcome in patients ("patients") or surgical sites ("sites").

RESULT(S)

Adhesion-free outcome (sites) was lowest for reformed (26.3% laparotomy; 14.3% laparoscopy), higher for de novo 1b (direct trauma) (45.2% laparotomy, 37.2% laparoscopy), and highest for de novo 1a (indirect trauma) adhesions (82.4% laparoscopy). Crystalloid solution instillates reduced adhesion-free outcome at sites (45.2% versus 20% de novo 1b adhesions in laparotomy) and in patients (43.5% versus 19.9% reformed, laparotomy; 71.7% versus 25% de novo 1b, laparoscopy).

CONCLUSION(S)

Adhesion-free outcome was lowest for reformed, higher for de novo 1b, and highest for de novo 1a adhesions. Surprisingly, it was lower in laparoscopy than in laparotomy for de novo 1b and reformed adhesions. Crystalloid instillates did not increase adhesion-free outcome. Although limited by the retrospective and heterogeneous nature of the data, these conclusions nonetheless provide a basis on which to formulate future hypotheses.

Laparoscopic adhesiolysis in a horse

OBJECTIVE

The purpose of this report was to describe the use of laparoscopy as a method of treatment for abdominal adhesions in the horse.

CLINICAL REPORT

Unilateral ovariectomy for removal of a granulosa cell tumor was performed through a diagonal paramedian approach in a 14-year-old Arabian mare. Progressive incisional swelling and hemorrhage culminated in acute incisional dehiscence with herniation of ileum on the sixth postoperative day. Septic peritonitis that responded to parenteral antibiotic therapy was identified 7 days after hernia repair. Seven days later, the mare had signs of abdominal pain, and adhesions of small intestine to the paramedian incision were identified on rectal palpation. Transrectally assisted laparoscopic adhesiolysis was performed. No further complications occurred.

CLINICAL RELEVANCE

Laparoscopic adhesiolysis may provide better observation of adhesions and reduced postoperative morbidity compared with laparotomy.

Use of medroxyprogesterone acetate in the prevention of postoperative adhesions

OBJECTIVES

To evaluate the efficacy of a commonly used progestogen, medroxyprogesterone acetate (MPA), in the prevention of postoperative adhesion formation.

DESIGN

A double-blind, controlled study evaluated the efficacy of MPA to reduce postoperative adhesion formation and compared it with other adjuvants and controls in a rat model.

SETTING

Animal Care Facility of an academic research setting.

SUBJECTS

Seventy-five Sprague-Dawley female rats randomly divided into five groups.

INTERVENTIONS

Three weeks before surgery, the animals from each group were administered an IM injection of one of the following regimens: [1] 15 mg MPA; [2] both 15 mg MPA and 0.75 mg leuprolide acetate (LA); [3] 0.75 LA; or [4] and [5] comparable volumes of sterile saline. A standardized surgical trauma was inflicted in all animals. Before abdominal closure, 2 mL of Ringer's Lactate was instilled in the abdominal cavity of all groups except group 5 (controls). Three weeks after surgery, the rats were killed and the adhesions were scored on a scale of 0 to 3 according to their size, thickness, and vascularity.

MAIN OUTCOME MEASURE

Postoperative adhesions.

RESULTS

The preoperative administration of MPA resulted in the least number and the least severe adhesions. The combination of LA and MPA did not reduce postoperative adhesion formation. Both Ringer's Lactate and LA reduced postoperative adhesions but not to the same extent as MPA.

CONCLUSION

The preoperative administration of MPA in our laboratory animal model results in the most significant reduction of postoperative adhesion formation. This action of MPA may be mediated by the induction of both a progestational and a hypoestrogenemic milieu. However, the ultimate role of MPA in a clinical situation requires further investigation.

An evaluation of laparoscopic adhesiolysis in patients with chronic abdominal pain

The purpose of this prospective study was to determine whether laparoscopic adhesiolysis ameliorates chronic abdominal pain in patients with abdominal adhesions. Forty-five patients with chronic abdominal pain lasting for more than 6 months but with no abnormal findings other than adhesions found at laparoscopy underwent laparoscopic adhesiolysis. Thirty-six patients (80%) were available for follow-up after a median time interval of 10 months (range: 6-36 months). Seventeen patients (47.2%) were free from abdominal pain and 13 patients (36.1%) reported significant amelioration of their pain. Six (16.6%) patients had no amelioration. Twenty-nine patients (80.6%) judged the outcome of the operation to be good or beneficial and 35 (97.2%) said that they would undergo the operation a second time if that were necessary. Laparoscopy is an effective tool for the evaluation of patients with chronic abdominal pain, and laparoscopic adhesiolysis cures or ameliorates chronic abdominal pain in more than 80% of patients.

Videolaseroscopy and videolaparoscopy

Laparoscopic surgery is not a new idea, but it has only recently found widespread acceptance. The introduction of technological advances such as improved light sources, lasers and video capability has made laparoscopy a surgical technique that offers many advantages to the patient and the surgeon. Because videolaseroscopy must be performed using a completely different set of skills, the only limit to the expansion of this type of surgery is training enough surgeons to meet the growing demands of the public. We believe that videolaseroscopy will become a larger part of the surgical operations performed in the future as technology becomes available to improve upon the instruments and methods.

The role of laparoscopy in the management of gynecologic malignancy

With the advent of minimally invasive laparoscopic techniques, most gynecologic procedures for benign conditions can be performed in an outpatient setting. However, the role of such techniques in gynecologic oncology is not well defined. By reviewing the literature and presenting some new data, we attempt to elucidate the applications of operative videolaparoscopy in gynecologic oncology. Advanced laparoscopic techniques are utilized for the management of cervical cancer as well as the staging and treatment of endometrial and ovarian cancers. Such techniques are used in performing radical hysterectomy for early stage cervical cancer, pelvic and paraaortic lymphadenectomy, and second look laparoscopy following chemotherapy for ovarian cancer. Even though preliminary data are encouraging, large prospective controlled studies with long-term follow-up are necessary to better define the role and limitations of laparoscopy in the treatment of gynecologic malignancies.

Laparoscopy versus laparotomy for ovarian conservative surgery: a randomized trial in the rabbit model

OBJECTIVE

Our purpose was to compare postoperative adhesion formation and reproductive outcome after the same ovarian surgical procedure performed by laparoscopy or laparotomy by means of microsurgical techniques.

STUDY DESIGN

Twenty-eight New Zealand White female rabbits were randomly assigned to laparotomy or laparoscopy for the same standardized surgical procedure: both ovaries were grasped with atraumatic forceps and longitudinally incised on the antimesenteric side from the cortex to the hilum with a microelectrode delivering a tissue power density of 66,666 W/cm. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer for the evaluation of postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side.

RESULTS

At second look no statistically significant differences were found in postoperative adhesion formation, number of corpora lutea, number of embryos, and nidation index between the laparoscopy and the laparotomy groups.

CONCLUSION

Laparoscopy or laparotomy for ovarian conservative surgery do not appear significantly different in postoperative adhesion formation and reproductive outcome in the rabbit model.

Fibrin sealant in laparoscopic adhesion prevention in the rabbit uterine horn model

OBJECTIVE

To assess the effects of fibrin sealant on adhesions after laparoscopic surgery.

DESIGN

Standardized surgical trauma was induced in 60 female rabbits. The animals were randomized in three groups for different adhesion prevention treatment.

SETTING

University research laboratory.

INTERVENTIONS

After standardized trauma was induced, group 1 (n = 20) received no treatment, group 2 animals (n = 20) were injected in the abdominal cavity with 60 mL of Ringer's lactate, and human fibrin sealant was applied on the surgical lesions under laparoscopic vision in group 3 (n = 20).

MAIN OUTCOME MEASURES

Five weeks after laparoscopy, a laparotomy was performed, and the adhesions were scored.

RESULTS

Fourteen of 20 rabbits in the control group (70%) presented postoperative adhesions, 11 of 20 (55%) in the Ringer's group, and 5 of 20 (25%) in the fibrin sealant group. High-score adhesions were seen in 15% of cases in control and Ringer's group and in 5% of cases in the fibrin sealant group.

CONCLUSIONS

When used during laparoscopic surgery, fibrin sealant has a preventive effect on de novo postsurgical adhesions. To assess the efficacy in reproductive surgery, a trial on recurrent postsurgical adhesions is required.

Complications of laparoscopic surgery

As with all surgical procedures, prevention and proper patient selection is the key to avoid complications. High-risk patients should be clearly identified from the outset. Properly maintained equipment, along with a thorough working knowledge of all instrumentation is essential. An often overlooked but vital aspect of laparoscopy is the laparoscopy team, including anesthesia and nursing personnel. A final point: there is no substitute for experience in avoiding laparoscopic complications. A survey by Phillips et al. found the complication rate for physicians who had performed fewer than 100 laparoscopic procedures to be almost four times greater than surgeons with more experience. A survey of eight centers active in urologic laparoscopic surgery reported that 10-20 pelvic lymph node dissections were necessary before they felt comfortable and 25-50 cases before they were proficient with the procedure. Since the learning curve with laparoscopy is initially quite steep, urologists beginning to apply the technique should work closely with experienced laparoscopic surgeons.

Laparoscopic repair of small bowel and colon. A report of 26 cases

This is a retrospective review of laparoscopic repair for enterotomies created during therapeutic or diagnostic laparoscopy in 26 women. All patients had mechanical and antibiotic bowel preparation preoperatively. The indication for operative laparoscopy was endometriosis (18), severe abdominal adhesive disease (7), and adhesions with Crohn's disease (1). Enterotomies were secondary either to CO2 laser vaporization or excision of endometriosis and/or lysis of adhesions (23) and trocar insertion (3). The injuries included small-bowel enterotomies (9), colotomies (4), and rectotomies (13). No clinical complications related to enterotomy repair were noted. Twenty-three patients were discharged 1 day after surgery; one was discharged on postoperative day 2; and two were discharged on postoperative day 3. We concluded that small- and large-bowel enterotomies can be repaired safely via the laparoscope with minimum morbidity in patients with prepared bowel.

Operative laparoscopy for the treatment of ovarian remnant syndrome

OBJECTIVE

To present the technique and assess the efficacy of operative laparoscopy to manage ovarian remnant syndrome.

DESIGN

Observational with a follow-up of 6 to 32 months.

SETTING

Private subspecialty practice with a large referral base.

PATIENTS

Thirteen women, 9 with previous bilateral salpingo-oophorectomy and 4 with previous unilateral salpingo-oophorectomy and pain on the ipsilateral side.

INTERVENTIONS

Multipuncture advanced operative laparoscopy.

MAIN OUTCOME MEASURES

Patient pain relief was assessed through return examinations, telephone interviews, or contact with referring physicians.

RESULTS

Nine patients reported complete pain relief. One reported incomplete but satisfactory pain relief. Two required bowel resection by laparotomy to obtain pain relief, and one, despite subsequent laparotomy, had persistent pain. No intraoperative or postoperative complications were noted.

CONCLUSION

Laparoscopy can be effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.

Videolaseroscopy for oophorectomy

Laparoscopic oophorectomy was performed on 94 ovaries in 76 patients. Indications included recurrent pain associated with endometriosis and adhesions in 17 patients (18 ovaries), ovarian endometriomas in 40 patients (40 ovaries), prophylactic oophorectomy (breast cancer) in one patient (2 ovaries), removal of the ovaries at the time of laparoscopic assisted vaginal hysterectomy in 15 patients (30 ovaries), and other indications in three patients (four ovaries).