Laparoscopic lysis of adhesions for postappendectomy pain

Chronic pelvic pain: aetiology and therapy

Chronic pelvic pain (CPP) is a common condition in women and rates of consultation for CPP in general practice are similar to those for asthma and migraine. US and UK population-based studies, together with data from UK hospital settings demonstrate a substantial impact of CPP on health-related quality of life. In this review, we will examine the current evidence on the aetiology and management of CPP, focussing on the randomised controlled trials (RCTs) that are available to date. CPP is a heterogeneous condition and causation is often unclear. There are associations with specific pathological processes but a barrier to understanding is that many studies have data that are not comparable. In the community setting, as many as 60% of women with CPP have not received a specific diagnosis and up to 20% have not undergone any investigation. The factor most commonly associated with CPP in the community is irritable bowel syndrome, although in a tertiary setting with laparoscopy, pathology associated with CPP in ascending order of frequency is endometriosis (33%), adhesions (24%) and 'no pathology' (35%). Current RCT evidence provides some support for the use of ultrasound scanning as an aid to counselling and reassurance, progestogen (medroxyprogesterone acetate) or goserelin for pelvic congestion and a multidisciplinary approach to assessment and treatment. Adhesiolysis is not shown to be of benefit other than in women with extensive adhesions. While studied in relation to dysmenorrhoea rather than CPP, the short term results for presacral neurectomy (PSN) and laparoscopic utero-sacral nerve ablation (LUNA) seem to be similar, although PSN has better results in the long term. Selective serotonin reuptake inhibitor (SSRI) antidepressants have not been shown to be of benefit in CPP. Most of these conclusions are based on the outcome of single randomised trials and therefore need replication.

Diagnostic laparoscopy for chronic right iliac fossa pain: a pilot study

BACKGROUND

The aim of this study was to determine the value of diagnostic laparoscopy in patients with chronic right iliac fossa pain.

METHODS

A retrospective study at Echuca Hospital involving case-note review and telephone questionnaire of patients who had undergone diagnostic laparoscopy for chronic right iliac fossa pain at least 12 months earlier (September 1992 to August 1995) was carried out.

RESULTS

Forty-one cases were identified and followed up 12-40 months postoperatively (median 21 months). Eleven cases had positive findings at laparoscopy, of whom eight obtained lasting relief after treatment. Of the remaining 30 patients 17 had a normal-looking appendix removed and 12 were cured; these were younger patients with episodic symptoms and localized signs. Of eight patients who had adhesions divided, four with adhesions beneath old scars obtained relief. Altogether 32 of the 41 patients considered the laparoscopy worthwhile even though in some cases it did not relieve their chronic pain.

CONCLUSIONS

Diagnostic laparoscopy is worthwhile for patients with chronic right iliac fossa pain. Concurrent appendicectomy should be considered in young patients with episodic, well-localized symptoms associated with systemic malaise while adhesiolysis may be beneficial for viscero-parietal adhesions beneath abdominal wall scars.

Laparoscopic surgery for intestinal obstruction

The indications for laparoscopic surgery have steadily diversified over the last several years. At the present time, the level of comfort with laparoscopic procedures has allowed surgeons to perform procedures which several years ago never would have been attempted. One of the indications for surgery which has only recently been appreciated is bowel obstruction. Specifically, in the last several years a number of authors have described successful application of the laparoscope to treat patients with either acute or chronic bowel obstruction. This article reviews the indications and contraindications for the procedure as well as recommended preoperative evaluation and suggested surgical technique. Furthermore, the early results in these few series is discussed.

Is laparoscopic better than open appendectomy?

Laparoscopic appendectomy is becoming increasingly popular as surgeons strive to manage surgical problems via minimally invasive techniques. We reviewed our early experience in 38 patients with laparoscopic appendectomy and compared it to open appendectomies done during the same time period. We found no difference in hospital costs, stay, or wound infection rate. There was a significant difference in OR time: the laparoscopic approach took longer. We conclude that this new approach is not clearly superior to open appendectomy despite theoretical advantages. Newer instruments and further studies are needed.