Office microlaparoscopy under local anesthesia for chronic pelvic pain

Operative Gynecological Laparoscopy Under Conscious Sedation

BACKGROUND AND OBJECTIVES

Operative laparoscopy is generally performed under general anesthesia. Local anesthesia and conscious sedation may be useful in select short procedures. In the present study, we evaluated safety and efficacy of operative laparoscopy under conscious sedation.

METHODS

Retrospective observational study evaluating patients undergoing gynecologic laparoscopy. Laparoscopy under conscious sedation was performed for each patient with umbilical direct insertion of a 12-mm port, followed by 2 ancillary ports at 1 cm medially to the anterior superior iliac spine. Conversion to conventional laparoscopy or laparotomy was recorded. Conscious sedation was obtained using Remifentanil and Propofol, administered by an infusion system based on pharmacokinetic and pharmacodynamic models. Local anesthesia was administered at port insertion sites and for paracervical block. Pain intensity was evaluated with the Visual Analog Scale (VAS). Adverse events and drug concentrations throughout the procedure were retrieved.

RESULTS

Our study population included 166 patients. They underwent laparoscopic unilateral versus bilateral salpingo-oophorectomy, ovarian cystectomy, bilateral salpingo-oophorectomy and omentectomy for a borderline ovarian tumor, myomectomy; or underwent surgery for unexplained infertility evaluation, pelvic pain, staging of ovarian cancer. Mean duration of pneumoperitoneum was 22.3 ± 7.2 min. Rate of conversion to laparoscopy under general anesthesia was 17/166 (10.2%) and there were only 3 cases of patients with low tolerability to the procedure. No severe adverse events occurred. Hospital discharge occurred in all unconverted cases after 6 to 18 h.

CONCLUSIONS

Operative laparoscopy under conscious sedation and local anesthesia appears to be a feasible technique in gynecologic surgery with no adverse patient outcomes.

Feasibility and Safety of Laparoscopic Colon Surgery Performed Under Intravenous Sedation and Local Anesthesia Using Microinvasive (<3 mm) Instruments: An Acute and Survival Study on Porcine Model

PURPOSE

The purpose of the study was to evaluate the feasibility and safety of performing laparoscopic intestinal surgery using local anesthesia and intravenous sedation with instruments <3 mm in diameter.

METHODS

Porcine model with acute (n = 2) and the survival studies (n = 8): all female pigs, weight (median 36.4 kg, range 33.2-38.4 kg). Surgeries were performed using only intravenous sedation with ketamine-midazolam and local anesthetic infiltration at the sites of trocar insertion, with airway protection. CO2 pneumoperitoneum was maintained using pressure of 3 to 5 mm Hg. Commercially available instruments, sizes <3 mm in diameter were used. Surgical steps were as follows: (a) exploration of all quadrants of the abdomen and pelvis, (b) "running" the entire length of small bowel, (c) dissection of bowel attachments to the peritoneal sidewall, and (d) creating a 2.5 cm enterotomy in the colon and suture repair of this defect.

RESULTS

All 10 surgeries were completed successfully. Animals tolerated the procedure well, with no requirement of intubation. There were no decrements in vital signs during pneumoperitoneum or surgery. Despite spontaneous respiration movements, all planned surgical maneuvers were feasible. The median length of operations was 74 minutes (range 56-165 minutes). All survival animals had an uneventful recovery; there were no infectious complications, oral intake and bowel function returned within 24 hours.

CONCLUSIONS

It appears feasible and safe to perform simple laparoscopic intestinal procedures using instruments <3 mm in diameter and low CO2 insufflation pressure under local anesthesia and intravenous sedation. This methodology holds promise in the development of new approaches to intestinal surgery and disease diagnosis.

Recent Trends in Chronic Pelvic Pain Diagnosis

Chronic pelvic pain is a common and significant disorder of women. It is estimated to have a prevalence of 3.8% in women. The etiology of chronic pelvic pain in women is poorly understood. Although a specific diagnosis is not found in the majority of cases, some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. The initial history and physical examination can narrow the diagnostic possibilities, guide any subsequent evaluation, and rule out malignancy or significant systemic disease. If the initial evaluation does not reveal a specific diagnosis, a limited laboratory and ultrasound evaluation can clarify the diagnosis, as well as rule out serious disease and reassure the patient. Laboratory and imaging studies should be selectively utilized, as should laparoscopy. Conscious laparoscopic pain mapping has been proposed as a way to improve information derived from laparoscopic evaluations.

Relating pelvic pain location to surgical findings of endometriosis

OBJECTIVE

To study whether pain location is related to lesion location in women with chronic pelvic pain and biopsy-proven endometriosis.

METHODS

A secondary analysis was performed to compare self-reported pain location with recorded laparoscopy findings for location and characteristics of all visible lesions. All lesions were excised. Endometriosis was diagnosed using histopathology criteria. The pelvic area was divided into three anterior and two posterior regions. Lesion depth, number of lesions or endometriomas, and disease burden (defined as sum of lesion sizes, or single compared with multiple lesions) were determined for each region. Data were analyzed using t tests, Fisher exact tests, and logistic regression modeling, with P values corrected for multiple comparisons using the step-down Bonferroni method.

RESULTS

Women with endometriosis (n = 96) had lower body mass indexes, were more likely to be white, had more previous surgeries, and had more frequent menstrual pain and incapacitation than did chronic pain patients without endometriosis (n = 37). Overall, few patients had deeply infiltrating lesions (n = 38). Dysuria was associated with superficial bladder peritoneal lesions. Other lesions or endometriomas were not associated with pain in the same anatomic locations. Lesion depth, disease burden, and number of lesions or endometriomas were not associated with pain.

CONCLUSION

In this group of women with biopsy-proven endometriosis, few had deeply infiltrating lesions or endometriomas. Dysuria and midline anterior pain were the only symptoms associated with the location of superficial endometriosis lesions. The lack of relationship between pain and superficial lesion location raises questions about how these lesions relate to pain.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00001848.

LEVEL OF EVIDENCE

: II.

Dissociative conscious sedation, an alternative to general anesthesia for laparoscopic peritoneal dialysis catheter implantation: a randomized trial comparing intravenous and subcutaneous ketamine

Laparoscopy is an effective method of implantation for peritoneal dialysis (PD) catheters. Use of the laparoscopic technique is increasing because of its potential advantages over other techniques. In most patients, selection for PD is based on negative criteria, and because of the need for general anesthesia, the laparoscopic technique can be life-threatening in these patients. On the other hand, local anesthesia is insufficient for laparoscopic catheter implantation. To avoid the need for general anesthesia and to achieve patient safety and satisfaction, we designed a type of conscious sedation (dissociative conscious sedation) and compared the efficacy of subcutaneous (SC) and intravenous (IV) ketamine added to narcotics in patients scheduled for laparoscopic implantation of a PD catheter.

METHODS

Our prospective randomized double-blind study enrolled 60 adult patients with chronic renal failure who were scheduled for laparoscopic implantation of a PD catheter. Patients were randomly assigned to one of two groups: one receiving IV ketamine, and the other receiving SC ketamine. In both groups, patients were premedicated with IV midazolam 0.015 mg/kg, fentanyl 1-2 μg/kg, and lidocaine 1.5 mg/kg. Patients then received 0.6 mg/kg ketamine either intravenously (IV group) or by subcutaneous injection at the anterior aspect of the forearm (SC group). If systolic blood pressure (BP) increased more than 20% from baseline or exceeded 170 mmHg, IV nitroglycerine (TNG) 50 μg was administered incrementally (repeated 50-μg doses). After a desirable level of conscious sedation was achieved, local anesthesia and nitrous oxide pneumoperitoneum were applied, and the PD catheter was implanted under laparoscopic guidance. Heart rate and BP were measured throughout the procedure. Adverse effects and recovery events were recorded.

RESULTS

All patients tolerated the procedure well. Administration of TNG was significantly more frequent in the IV ketamine group. Pain intensity during the surgery was similar in both groups. Both groups were comparable with regard to heart rate, but patients in the SC ketamine group had a significantly lower systolic BP at the 2nd measurement and a lower rate-pressure product at the 2nd, 4th, and 5th measurements. All patients in the SC ketamine group were cooperative during surgery and experienced uneventful recoveries; mild hallucinations were observed in 5 patients in the IV ketamine group. In the IV ketamine group, 3 patients lost the ability to cooperate during surgery. All catheters were successfully placed.

CONCLUSIONS

Dissociative conscious sedation is an acceptable alternative to general anesthesia in laparoscopic implantation of the PD catheter. Ketamine by the SC route is as effective as, but safer than, IV ketamine.

Camera trocar lifting in office gasless laparoscopic sterilization under local anesthesia

We evaluated 35 cases of a mechanical approach to abdominal wall lifting, used in office-based gasless laparoscopic sterilization under local anesthesia. Lifting of the abdominal wall, using the camera trocar as an anchoring device and complemented by suprapubic lifting by means of a towel clamp, led to passive intra-abdominal air filling, giving sufficient space to identify, anesthetize, coagulate and cut the Fallopian tubes. Only mild sedation was necessary. All women walked to and from the operating room. All had successful tubal ligation. The overall satisfaction rate was 97%. The mechanical lifting moment was not painful. With the exception of one woman with failed tubal anesthesia, all women had a low mean pain score of 2.6 (VAS 0–10). No complications occurred except one wound infection. The costs were < ¼ of those of traditional laparoscopic sterilization and office hysteroscopic sterilization. This approach is effective for office-based laparoscopic sterilization. Room air, two strings and a needle replace active gas insufflation and narcosis.

Practical guide to laparoscopic pain mapping

Conscious laparoscopic pain mapping, a technique that has been described in the literature for more than a decade, can be a particularly helpful tool to assist with pelvic pain diagnosis and treatment decisions. Several factors, when optimized, increase the likelihood of a good outcome. Herein, we review the literature and address common questions about pain mapping including appropriate patient selection, standard technique, typical outcomes, and how the results might influence treatment.

Pelvic pain and surgeries in women before interstitial cystitis/painful bladder syndrome

OBJECTIVE

The objective of the study was to compare subjects with interstitial cystitis/painful bladder syndrome (IC/PBS) with controls on prior surgeries.

STUDY DESIGN

IC/PBS subjects were compared with matched controls on surgeries and possible surgical indications prior to their index dates.

RESULTS

Adjusted for demographic variables, logistic regression showed subjects exceeded controls in surgeries longer than 12 months and less than 1 month before the index date. However, addition of possible surgical indications showed chronic pelvic pain (CPP) to have a strong association with IC/PBS, whereas associations with surgeries were reduced to nonsignificance.

CONCLUSION

Although women with IC/PBS were more likely to have experienced prior surgeries than controls, the apparent indications for surgeries, not the surgeries themselves, were stronger risk factors for IC/PBS. In particular, a prior history of CPP had a strong association with IC/PBS. Several features of study design, including extensive medical record review, suggest that prior CPP was not undiagnosed IC/PBS. Further investigation of CPP may yield insight into the pathogenesis of IC/PBS.

Treatment of chronic pelvic pain in men and women

Chronic pelvic pain syndrome (CPPS) is a common condition that is encountered by a variety of healthcare professionals. Unfortunately, physicians often misdiagnose this problem or recommend inappropriate and sometimes dangerous treatments that offer little hope of successful outcome. In addition, CPPS is typically a multifaceted disorder, simultaneously compromising psychological, peripheral nerve, autonomic, central nervous, visceral, connective tissue, hormonal and other systems. Thus, solo practitioners who may correctly diagnose CPSS are often ill-equipped to provide adequate comprehensive, multidisciplinary treatment. This article is intended as an overview of the most recent literature in support of various treatment modalities for chronic pelvic pain in men and women. We advocate a team-oriented approach in the treatment of CPPS, which employs the coordinated efforts of multiple practitioners, ideally in a subspecialty care setting.

Hysterectomy for treatment of pain associated with endometriosis

The literature was searched for endometriosis and hysterectomy on PubMed and the individual search engines of the Journal of Minimally Invasive Surgery, Fertility and Sterility, BJOG, Obstetrics and Gynecology, the American Journal of Obstetrics and Gynecology, and Human Reproduction. Eighty references of interest were identified and included in this review. Analysis of hysterectomy for pain associated with endometriosis is difficult for many reasons. These include a lack of differentiation of various forms of cyclic pain from other forms of non-cyclic pain, the retrospective nature of much of the literature, and a low specificity for identifying pain. Hysterectomy for chronic non-specified pelvic pain associated with endometriosis is a successful approach in many women. It can not be determined whether this is due to intermingling of patients with and without cyclic pain or if both of these respond equally well. Focused prospective research is needed to determine whether symptoms, signs, or laboratory findings might be useful in determining more specific response patterns.

Diagnosis, treatment and follow up of women undergoing conscious pain mapping for chronic pelvic pain: a prospective cohort study

OBJECTIVE

To assess the efficacy of conscious pain mapping in diagnosing and treating chronic pelvic pain (CPP).

DESIGN

Prospective cohort study. Setting Gynaecology Department, UK District General Hospital.

POPULATION

Forty-three women diagnosed with CPP.

METHODS

The cohort was followed up for 18-24 months after diagnosis and treatment based on conscious pain mapping.

MAIN OUTCOME MEASURES

Improvement of pain assessed by using visual analogue scale (VAS) pain scores at 6-month follow up.

RESULTS

Thirty-nine women had successful conscious pain mapping. Pelvic pathology was identified in 18, pelvic congestion in 13 and 8 women had normal pelvic organs. In 35 women (90%), conscious pain mapping identified the cause of pain. Five out of eight women (63%) who were judged to have a normal pelvis had positive findings at pain mapping. VAS scores fell significantly from pre-treatment to post-treatment values at 6-month follow up (P < 0.01). Overall, 26 women (74%) felt that their symptoms had improved after treatment based on findings at pain mapping. However, we concluded that pain mapping only contributed to the diagnosis and treatment in seven women (27%), who may not have received appropriate diagnosis and treatment if they had a laparoscopy under general anaesthetic. Conclusions CONSCIOUS: pain mapping is a useful additional investigation in the management of women with CPP. It can be employed in women with a negative laparoscopy or with visible pathology where the conventional treatment has failed.

Chronic pelvic pain in New Zealand: prevalence, pain severity, diagnoses and use of the health services

Chronic pelvic pain (CPP) in women is often debilitating and isolating. Problems with diagnosis continue to make CPP one of the most perplexing conditions in gynaecology, and one of the most difficult to treat.

OBJECTIVES

This paper reports the findings of a population-based study in New Zealand in 2001 designed to investigate the prevalence of chronic pelvic pain in women between the ages of 18 and 50. Chronic pelvic pain was defined as pain that is neither associated with the menstrual cycle nor sexual activity. The prevalence of dysmenorrhoea and dyspareunia was also sought. It further aimed to examine pain severity, diagnoses, and the use of the health services as these facets of CPP affect different groups of women within New Zealand.

METHODS

A random sample of 2261 was generated from the New Zealand Electoral Roll, and a postal questionnaire was administered during 2001. The response rate was 66% (adjusted for non-receivers), giving a study group of 1,160 respondents.

RESULTS

The three-month CPP prevalence rate was 25.4% (95% CI 22.8-27.9). Half of those women reporting CPP (47.7%) remained undiagnosed. The three-month prevalence of dysmenorrhoea was 55.2%, and dyspareunia 19.7%. Recent or past consulters of health services for CPP contained a higher proportion of women with a high pain burden than those not consulting health services. Only one-third of New Zealand women (34%) reported no form of chronic pelvic pain (i.e. no CPP, dysmenorrhoea or dyspareunia). These prevalence rates indicate that CPP should receive greater public education and clinical attention.

Diagnostic conscious pain mapping using laparoscopy under local anaesthetic and sedation in general surgical patients

BACKGROUND

Patients in whom extensive investigations have failed to identify the cause of abdominal pain present a challenge to surgeons. We present our initial experience of using laparoscopy under local anaesthetic and sedation in the diagnosis of chronic abdominal pain.

METHODS AND PATIENTS

Nine patients with chronic abdominal pain and multiple normal investigations underwent laparoscopy under local anaesthetic and sedation. By touching and grasping intra-abdominal viscera and peritoneum, an attempt was made to reproduce the patient's pain.

RESULTS

Two patients were found to have pain arising from the gall bladder and subsequently underwent laparoscopic cholecystectomy with resolution of their symptoms. A third patient had a clinical presentation of chronic acalculous cholecystitis and a normal laparoscopy. She decided to undergo laparoscopic cholecystectomy, which cured her pain. Another patient had pain arising from the appendix, which resolved after an appendicectomy. Three patients had pelvic adhesions, which caused chronic abdominal pain. After adhesiolysis, one is pain free; the others declined surgery for adhesions and their pain resolved. Conscious pain mapping was negative in two patients.

CONCLUSION

Laparoscopy can be carried out in the conscious patient, who is then usually able to collaborate with the surgeon in establishing the source of the pain experienced during conscious pain mapping. Long-term effectiveness and diagnostic accuracy has not yet been established.

Progress in transvaginal hydrolaparoscopy

Reproductive performance is now more than ever determining the choice of treatment for each individual couple. The easy access to ART treatments, their financial benefits, and the relative high success rate per cycle are at the basis of a liberal referral to these treatments without an accurate diagnosis. The easy and comprehensive investigation by a transvaginal endoscopy as a first-line diagnostic procedure allows for an accurate diagnosis and the choice of the most appropriate treatment.

The role of laparoscopy in the diagnosis and treatment of conditions associated with chronic pelvic pain

Laparoscopy is a useful tool for the diagnosis and treatment of conditions associated with chronic pelvic pain. In the evaluation of chronic pelvic pain, laparoscopic techniques vary from conservative procedures, such as pain mapping, excision, and nerve ablation, to more extensive procedures like oophorectomy and hysterectomy. Although useful for diagnosis, laparoscopy continues to have a controversial role in the treatment of chronic pelvic pain.

Chronic pelvic pain: an integrated approach to diagnosis and treatment

Chronic pelvic pain affects upward of 15% of women and is a frustrating condition for both patients and physicians. Chronic pelvic pain is not a disease, but a syndrome that results from a complex interaction between neurologic, musculoskeletal, and endocrine systems that is further influenced by behavioral and psychologic factors. Traditional approaches to this disorder have been surgical, although long-term success rates have been disappointing. Placebo response to surgery is common, and many conditions that contribute to the pain cannot be identified or treated with a surgical approach. Many patients will require a combination of both pharmacologic and nonpharmacologic treatments in addition to various types of invasive procedures. It is now recognized that many disorders contribute to the chronic pelvic pain symptom complex; thus, an integrated multidisciplinary approach to diagnosis and treatment is essential to achieve the greatest success.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader will be able to describe the pathophysiology of chronic pelvic pain, to outline the evaluation of a patient with chronic pelvic pain, and to explain the treatment options for patients with chronic pelvic pain.

Adolescent pelvic pain

Chronic pelvic pain is a frequent complaint in adolescent females. It is a complex disorder with multiple causes. The assessment must attempt to differentiate between gynaecological and non-gynaecological sources of pain. An understanding of the physical, cognitive and environmental factors associated with the pain are essential. Laparoscopy has been used in the assessment of CPP but a significant number of patients will have no obvious aetiology at the time of laparoscopy. For the young patient with CPP, a multidisciplinary approach may be essential to facilitate diagnosis and management. Although the symptoms may not always be curable, management that allows the young female to obtain normal or near normal function may be possible. This chapter focuses on the various causes of pelvic pain in the adolescent female with a focus on the assessment, diagnosis and treatment of the different causes.

Focus on primary care: chronic pelvic pain in women

Chronic pelvic pain (CPP) is a major health problem. It is the reason for 10% of all outpatient visits to gynecologist as well as being responsible for approximately 40% of laparoscopies and 10% to 15% of hysterectomies. A significant number of patients have no obvious etiology for their pain at the time of laparoscopy. The condition may not be cured in a large number of patients. This is ultimately unsatisfying for both the patient and physician. Although CPP may not be curable, it can be managed so those patients attain normal or near-normal levels of functions. To identify and review the methods used for diagnosis and treatment of chronic pelvic pain in women, a MEDLINE and Cochrane systematic review search from 1980 to 2000 was performed to collect information and evidence on diagnosis and treatment of women suffering from chronic pelvic pain.

Diagnostic and operative transvaginal hydrolaparoscopy for infertility and pelvic pain

STUDY OBJECTIVE

To review our experience with diagnostic and operative transvaginal hydrolaparoscopy (THL), a procedure that is less invasive than operative laparoscopy.

DESIGN

Prospective, observational cohort study (Canadian Task Force classification II-2).

SETTING

Private institute and university-affiliated hospital.

PATIENTS

Twenty-nine women with infertility and 11 with pelvic pain.

INTERVENTIONS

Diagnostic and operative THL.

MEASUREMENTS AND MAIN RESULTS

Thirty-five (88%) diagnostic THLs were performed in the office and the other five were done in hospital for insurance reasons; all six operative THLs were performed in the office under conscious sedation. The procedure was conclusive (all organs seen) in 37 patients (93%). Based on THL, no further surgical intervention was recommended in 18 (62%) infertile women and 5 (45%) of those with pain. Further surgical intervention was required in 5 (56%) of 9 infertility patients with a previous normal hysterosalpingogram (HSG) and 6 (32%) of 19 infertility patients with no previous HSG.

CONCLUSION

Transvaginal hydrolaparoscopy can be performed in the office with minimal pain, with a conclusive examination anticipated in 93% of cases. The procedure is more accurate than HSG and similar to laparoscopy.

Microlaparoscopy in gynecology: analysis of 16 cases and review of literature

Microlaparoscopy represents the development of endoscopic surgery towards a minimally invasive surgical procedure. The advantages include fewer surgical complications, faster return to daily activities, more comfortable postoperative recovery, and satisfactory aesthetic results. The possibility of performing surgery under sedation may result in shorter hospitalization, lower hospital costs, and easier anesthetic procedures. The authors report their preliminary experience with the use of microlaparoscopy, using optics and 2mm instruments, as well as a review of the literature since the introduction of this new technique. The report of these 16 cases demonstrates that microlaparoscopy is a feasible technique with satisfactory results. On the other hand, this new technique requires precise indications and a training period for the development of the skills necessary for performing these surgeries.

Effect of heating and humidifying gas on patients undergoing awake laparoscopy

STUDY OBJECTIVE

To determine the effect of heating and humidifying CO2 on the tolerance of awake laparoscopy and frequency of shoulder pain and patient recovery.

DESIGN

Randomized, controlled study (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

Forty consecutive women.

INTERVENTION

Awake laparoscopy with and without heating and humidifying CO2.

MEASUREMENTS AND MAIN RESULTS

Heating and humidifying CO2 decreased the frequency of shoulder pain and increased tolerance of the procedure. Thirty percent of patients required no intravenous sedation and did not experience shoulder pain when 3 L of gas or 15 mm Hg pressure was achieved. When shoulder pain did occur with heated and humidified gas, it was brief.

CONCLUSION

Heating and humidifying CO2 increases tolerance of awake laparoscopy and decreases the frequency and duration of shoulder pain.

Clinical utility of pelvic pain mapping

STUDY OBJECTIVE

To survey physicians' opinions concerning the impact of pelvic pain mapping on clinical management and surgical decisions.

DESIGN

Opinions of physicians based on clinical experience (Canadian Task Force classification III).

SETTING

Evening meetings appended to two national meetings.

MEASUREMENTS AND MAIN RESULTS

After viewing videotaped interviews, physical examinations, standard laparoscopy, and pelvic pain mapping at laparoscopy in two patients, practicing gynecologists completed questionnaires recording their opinions about the utility of pelvic pain mapping. A second group of gynecologists viewed only one tape. The first group considered pain mapping to be moderately or extremely useful (patient 1, 57.9%; patient 2, 73.7%). Mapping data either made surgeons change the surgical procedure they would have chosen or further clarified the diagnosis (patient 1, 68.4%; patient 2, 84.2%). Of the second group of 67 surgeons, 73% thought that mapping results would have made them change their surgical approach.

CONCLUSION

In appropriate cases, pelvic pain mapping during microlaparoscopy under conscious sedation can provide information that may influence surgical decisions as well as general clinical management.

Needlescopic urology: current status

Technological miniaturization is an emerging trend that encompasses virtually all surgical subspecialties. Minimization of surgical trauma while maximizing surgical cure through gradual progression from maximally invasive to minimally invasive to ultimately noninvasive technologies must be the goal. Needlescopic techniques represent a natural evolution and sophistication of conventional laparoscopy. At the author's center, needlescopic techniques have been used to particular advantage in four specific clinical applications: adrenalectomy, pediatric orchiopexy, detaching the bladder cuff during laparoscopic nephroureterectomy, and as an adjunctive needlescopic port for retraction purposes during conventional laparoscopic surgery. Given the urologist's natural facility with small-diameter endoscopes, the specialty is uniquely positioned to take a leadership position in this emerging field. Increased experience and careful comparisons with conventional laparoscopy will determine the true role of needlescopic technology in the armamentarium of the urologic surgeon.

Transvaginal hydrolaparoscopy, a new technique for pelvic assessment

Transvaginal hydrolaparoscopy is based on classic culdoscopy. With alterations in equipment and method, the procedure holds promise for evaluation of pelvic pathology. We performed transvaginal hydrolaparoscopy in the operating room just before operative laparoscopy in 15 patients, to evaluate the feasibility of this procedure. Excellent images of the cul-de-sac, fimbriae, and caudal surface of the uterus, ovaries, and pelvic sidewall were obtained. We believe this is a practical and convenient office diagnostic procedure.

Current state of office laparoscopic surgery

STUDY OBJECTIVE

To summarize office laparoscopic surgery practice profiles with emphasis on microlaparoscopy.

DESIGN

Survey (Canadian Task Force classification III).

SETTING

General gynecology and reproductive endocrinology laparoscopic surgery practices in the United States and abroad.

INTERVENTION

Surveys were distributed to members of the American Association of Gynecologic Laparoscopists during 1999.

PARTICIPANTS

Of 6200 members to whom surveys mailed, 1504 (24.3%) responded.

MEASUREMENTS AND MAIN RESULTS

Of these respondents, 114 (7.6%) perform office laparoscopy and 187 (12.4%) microlaparoscopy.

CONCLUSION

Clinicians who perform office laparoscopy are more likely to perform microlaparoscopy than macrolaparoscopy. The 2-mm microlaparoscope is preferred by most physicians.

The role of laparoscopy as a diagnostic tool in chronic pelvic pain

More than 40% of laparoscopies are performed for the diagnosis of chronic pelvic pain (CPP). Although laparoscopic evaluation is sometimes considered a routine part of the evaluation, ideally the decision to perform a laparoscopy should be based on the patient's history, physical examination and findings of non-invasive tests. About 65% of women with CPP have at least one diagnosis detectable by laparoscopy and it is common to attribute causality to this diagnosis. Endometriosis is diagnosed in one-third of laparoscopies for CPP. Endometriosis requires histological confirmation to assure an accurate diagnosis. Adhesions are diagnosed in about one-quarter of laparoscopies. Ovarian cysts, hernias, pelvic congestion syndrome, ovarian remnant syndrome, ovarian retention syndrome, post-operative peritoneal cysts and endosalpingiosis are other diagnoses that can be made laparoscopically in some cases. Laparoscopic conscious pain mapping has the potential to improve the accuracy of laparoscopy as a diagnostic tool in CPP.

Pitfalls of the medical paradigm in chronic pelvic pain

This article reviews specific clinical and philosophical problems in the medical and psychiatric literature on chronic pelvic pain since 1993. The problem of the dichotomy of 'organic' and 'psychogenic' pain has been well established in previous literature. The aim here is to consider recent developments purporting to respond to the impasse presented by this dichotomy. An evaluation of emergent trends towards multi-disciplinarity, and the 'biopsychosocial model' is developed. The resulting pitfalls discussed include the failure to develop understandings of the 'subjective' aspects of pain, the tendency to reduce causal processes to 'mechanisms', and the tendency to consider the psychosocial as purely reactive to the biological, inevitably positioned as prior. It is argued that these trends are only partial solutions to the problems and do not fully address the issues at stake. A greater diversity of theoretical and empirical perspectives needs to be introduced into medical research on chronic pelvic pain.

Development and initial trial of the minilaparoscopic argon coagulator

BACKGROUND

A major limitation of minilaparoscopic or needlescopic instrumentation is the lack of a proficient mechanism by which to effect coagulation and hemostasis. Our purpose was to test the feasibility of the first minilaparoscopic argon coagulator (MAC). Performance requirements insist on a system that ensures noncontact ignition and coagulation, a low argon gas flow rate, and safety and efficacy at a variety of wattages.

MATERIALS AND METHOD

The first MAC was formulated and produced in the laboratory. Among its unique properties was that it contained a corona ignition system. The efficacy of the system was measured in the laboratory by advancing the prototype instrument, while under power and with the argon flowing, toward a brass screen connected to the electrosurgical generator return. The distances at which an arc formed at various wattages were measured via a micrometer translation stage and recorded as the ignition gap. After the successful laboratory trials, an experiment was conducted in four 30-kg pigs. A gastroscope was introduced for vision and insufflation, and transcutaneous, transgastric placement of needlescopic instruments and the MAC was performed. Areas of mucosa 1 x 2 cm were coagulated at 15, 25, 35 and 40 W in each animal. Ulcers of 1 cm were created and coagulated with the MAC. Two animals were sacrificed immediately and one each at 12 and 14 days, and the coagulated areas were examined histologically.

RESULTS

In the laboratory, ignition of the beam was induced without surface contact, and the desired 5-mm ignition gap was seen at power as low as 15 W. The argon gas flow rates were limited to 1.5 L/min. At each wattage, the mucosa was entirely ablated. The depth of injury varied (submucosa to 2.2 mm) according to the wattage applied. Ulcerative hemorrhage was controlled in each instance. There were no complications attributable to coagulation effects. Surviving animals tolerated a regular diet on postoperative day 1. Histologic examination of tissue from surviving animals revealed growth of normal mucosa in the superficially coagulated areas and mixed normal mucosa and fibrosis in the more deeply injured regions.

CONCLUSIONS

Both in the laboratory and in animal experiments, the first MAC demonstrated noncontact ignition and operation, a low flow rate, and safety and efficacy at all wattage settings applied. It arrested ulcerative bleeding and ablated the mucosal surface at various depths according to the applied power. The MAC may be a solution to the lack of a consistent and reliable means for coagulation in needlescopic or minilaparoscopic surgery.

Is local anesthesia an affordable alternative to general anesthesia for minilaparoscopy?

STUDY OBJECTIVE

To determine if minilaparoscopy under local anesthesia is at least as reliable and affordable as that performed under general anesthesia.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

One hundred sixty-four consecutive women evaluated for infertility.

INTERVENTION

Diagnostic minilaparoscopy performed after women were randomized to receive general or local anesthesia with conscious sedation.

MEASUREMENTS AND MAIN RESULTS

Levels of postoperative pain measured by visual analog scale; volume of CO(2) used; length of procedure, complete pelvic evaluation, and hospitalization; complications; and pathologic diagnosis were evaluated. The groups were comparable in age, years of infertility, and symptoms. For women receiving local anesthesia, 5.5% required general anesthesia to complete the procedure. Women in both groups required postoperative analgesics. The groups had no statistically significant differences in pain level 1 hour after the procedure, number of complications, and pelvic pathology. Patients who had local anesthesia required a smaller volume of CO(2) (p <0.01) and their hospitalization was significantly shorter (p <0.01). However, in 15% of these women pelvic visualization was incomplete, compared with 7.2% in the general anesthesia group.

CONCLUSION

Minilaparoscopy performed under local anesthesia was as reliable and affordable as when performed under general anesthesia.

Comparison of anesthetic methods for microlaparoscopy in women with unexplained infertility

STUDY OBJECTIVE

To evaluate the effectiveness of ketamine compared with fentanyl as analgesia or sedation for microlaparoscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

University-affiliated hospital.

PATIENTS

Forty-one infertile women.

INTERVENTIONS

Twenty-one patients were randomly assigned to have analgesia with fentanyl and 20 sedation with ketamine during microlaparoscopy. Maximum doses were 0.2 and 200 mg, respectively. Local anesthesia was provided with 0.25% bupivacaine 5 ml injected into cannula sites.

MEASUREMENTS AND MAIN RESULTS

Abnormal findings such as endometriosis and periadnexal adhesions were identified in 24 patients. Ablation, coagulation, and adhesiolysis were easily performed in 14 (82.4%) of 17 women receiving ketamine, but difficulties were encountered in operating on 16 patients receiving fentanyl. Ketamine was administered to 10 patients (47.6%) in the fentanyl group because anxiety and pain were not sufficiently controlled by fentanyl. There were no significant differences in visual analog scale scores and recovery time between groups. On questionnaire, 19 (95%) of 20 patients receiving ketamine indicated they would choose the same anesthesia again if offered, compared with only 4 (19%) of 21 receiving fentanyl (p <0.001).

CONCLUSION

Microlaparoscopy in infertile women was performed more effectively under sedation with ketamine than with fentanyl.

Microlaparoscopy under local anesthesia and conscious pain mapping for the diagnosis and management of pelvic pain

Chronic pelvic pain is a complex disorder with multiple etiologies. Recently, the technique of microlaparoscopy under local anesthesia has been applied to chronic pelvic pain. The specialized technique of conscious pain mapping has been developed to aid in the diagnosis of these patients. This paper will review the history and usage of office and microlaparoscopy in general. It will then discuss specific applications for patients with acute or chronic pelvic pain.

Microlaparoscopy with conscious sedation in adolescents with suspected pelvic inflammatory disease

STUDY OBJECTIVE

To develop a protocol for emergency department microlaparoscopy with conscious sedation in adolescents with clinically suspected pelvic inflammatory disease (PID), and to evaluate the feasibility and tolerability of microlaparoscopy in this population.

DESIGN

Prospective study involving adolescents and young adults age 13 to 24 meeting clinical criteria for uncomplicated PID. Laparoscopy subjects underwent microlaparoscopy in the Children's Hospital Emergency Department (ED) and comparison subjects were admitted for treatment of PID. Chi-square, Mann-Whitney U tests, Wilcoxon Rank Sum tests, and repeated measures of analysis of variance (MANOVA) were used for analysis.

RESULTS

Twenty-four patients were enrolled: 6 laparoscopy subjects and 18 comparison subjects. Laparoscopy and comparison subjects did not differ with respect to age, mean white blood cell (WBC) count, mean temperature, or mean erythrocyte sedimentation rate. Mean surgical induction time was 13.5 minutes, operative time 19.0 minutes, and total procedure time 32.5 minutes. Mean requirement for midazolam was 2.8 mg and for fentanyl 225 microg. Pain assessment over the first 90 minutes did not differ significantly between laparoscopy and comparison subjects. Four of 6 laparoscopy subjects (67%) and 10 of 18 comparison subjects (56%) were diagnosed with PID (p = NS).

CONCLUSIONS

ED microlaparoscopy appears to be feasible, safe, and well tolerated in this small sample of adolescents and young adults with suspected PID.

MRI of the female pelvis

MRI is a proven modality to evaluate the female pelvis. Excellent soft tissue contrast, sensitivity for the detection of fluid, and the multiplanar imaging capabilities of MR allow noninvasive demonstration of normal anatomy and pathological processes. Most female pelvic MRI studies are performed to answer specific questions and must, therefore, follow carefully developed protocols, which are discussed in this article. The principal MRI techniques and strategies outlined in this work include: (1) the evaluation of reproductive dysfunction, anatomic variants; (2) specific obstetrical applications; (3) oncologic evaluation and tumor staging; (4) problem solving (i.e., the characterization of abnormalities detected by ultrasound); and (5) the evaluation of urethral disease.

Anesthesia for gynecologic laparoscopy

Despite developments in instruments and improvements in surgical and anesthesia techniques, laparoscopy is still associated with complications that may be lethal, including those related to anesthesia. Both anesthesiologist and surgeon must thoroughly understand potential complications of the procedure, including physiologic alterations, principles of anesthetic management and postoperative pain control, and problems related to anesthesia. (J Am Assoc Gynecol Laparosc 6(3):245-258, 1999)

Adhesion formation after microlaparoscopic and laparoscopic ovarian coagulation for polycystic ovary disease

STUDY OBJECTIVE

To compare the effects of microlaparoscopy and decreased CO2 exposure on peritoneal microcirculation and potential adhesion formation after ovarian surgery with those of conventional operative laparoscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Teaching hospital.

PATIENTS

Eighteen women with polycystic ovary disease.

INTERVENTIONS

Microlaparoscopic or laparoscopic ovarian coagulation of the ovaries.

MEASUREMENTS AND MAIN RESULTS

Approximately 10 to 12 coagulation points were applied to each ovary. Two to 3 weeks after the initial surgery second-look microlaparoscopy was performed to determine the extent of adhesions in both groups. The frequency of adhesion formation and changes in glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), catalase (CAT), and glutathione (GSH) levels were studied in homogenized peritoneal tissues obtained during surgery in each group.

RESULTS

Clinical profiles were similar between groups. Mean exposure, amount, and pressure of CO2 were significantly less in the microlaparoscopy group (p <0.05). The laparoscopy group had significantly more adhesions than the microlaproscopy group (24% vs 48%, p <0.05). The GSH-Px, SOD, CAT, and GSH levels were significantly lower in the laparoscopy group (0. 425 micromol, 1.2 ng, 37.55 micromol, and 0.9 nmol vs 0.755 micromol, 2.l ng, 625 micromol, and 2.6 nmol, respectively).

CONCLUSION

Reduced exposure to and amount of CO2 during microlaparoscopy may result in decreased adhesion formation compared with conventional laparoscopy. This effect may possibly be due to lack of or minimal adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms for adhesion formation and closely related to peritoneal injury. In addition, microlaparoscopy may be a cost-effective alternative to conventional laparoscopy. (J Am Assoc Gynecol Laparosc 6(2):159-163, 1999)

Office microlaparoscopy under local anesthesia

Office laparoscopy under local anesthesia is especially suited to meet the current pressures of quality versus cost in an era of managed care. It is likely that this technique will soon become a major part of the practicing gynecologist's diagnostic operative armamentarium. Advantages of office microlaparoscopy under local anesthesia are realized by the practitioner, the patient, and the managed care provider. Office microlaparoscopy under local anesthesia is a safe, effective, and less costly tool for the evaluation of patients with many different indications. To date, the procedure has been primarily used for patients with infertility, chronic pelvic pain, and tubal ligation. The ease of scheduling, reduced costs, and rapid recovery suggest that it may be the preferred initial procedure for these patients.

Pain mapping during minilaparoscopy in infertile patients without pathology

STUDY OBJECTIVE

To draw a map of pelvic pain and quantify the level of provoked pain during minilaparoscopy under local anesthesia and conscious sedation.

DESIGN

Observational study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Twenty infertile women.

INTERVENTIONS

Minilaparoscopy was performed under local anesthesia and conscious sedation, and cognitive performance was evaluated with the Rey auditory verbal learning task.

MEASUREMENTS AND MAIN RESULTS

The diagnostic procedure was performed with one 2-mm micrograsper and one 2-mm microprobe to evaluate the pelvis. In particular we grasped utero-ovarian ligaments; we touched, grasped, and distended fallopian tubes with blue dye; we moved the uterus with a manipulator inserted at the cervix; and we touched and grasped bowel and omentum. Level of pain was recorded on a visual analog scale. Patients had no pathologic findings, including minimal endometriosis and pelvic adhesions. The highest level of pain was recorded when we distended the tubes. No pain was elicited when we touched and grasped ovary, omentum, and bowel. In 10% of women when we stretched the tubo-ovarian ligament we provoked a minimal vagal reaction.

CONCLUSION

Minilaparoscopy under conscious sedation for pelvic pain mapping in women without pain or pathology revealed consistently negative findings, validating the value of this measurement. (J Am Assoc Gynecol Laparosc 6(1):51-54, 1999)