The role of peritoneal lavage in benign gynecologic laparoscopic surgery

OBJECTIVE

Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain.

PATIENTS AND METHODS

277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures.

RESULTS

Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05).

CONCLUSIONS

Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

Role of transvaginal ultrasound in evaluation of ureteral involvement in deep infiltrating endometriosis

OBJECTIVE

To assess whether routine examination of the ureters on transvaginal sonography (TVS) can identify reliably potential silent ureteral involvement by endometriosis and should therefore be recommended in all patients with deep infiltrating endometriosis (DIE).

METHODS

This was a prospective study of 200 consecutive patients scheduled for surgery for DIE, evaluated between January 2012 and December 2014 at a tertiary endometriosis center at Fondazione Policlinico Universitario A. Gemelli, Rome, Italy. Routine TVS, abdominal ultrasound and gynecological examination were performed within 3 months before surgery, and patient history, signs and symptoms were recorded. Surgical and histological findings were compared with the preoperative ultrasonographic diagnosis. The main outcome of interest was the presence of ureteral dilatation or hydronephrosis caused by endometriosis.

RESULTS

Of 200 patients with DIE, associated ureteral dilatation was diagnosed on TVS in 13 (6.5%) cases. Ureteral involvement was confirmed intraoperatively in all 13 cases by detection of ureteral dilatation caused by endometriotic tissue surrounding the ureter and causing stenosis. Of the 13 patients with ureteral dilatation, renal ultrasound detected six (46.2%) cases of hydronephrosis. Mean duration of visualization and study of dilated ureters was 5 min (range, 3-9 min). Ureteric diameter was ≥ 6 mm in all cases of ureteral dilatation, with a median diameter of 6.9 mm (range, 6-18 mm). Both ureters were identified on TVS in all 200 patients with DIE.

CONCLUSIONS

Our study confirms a relatively high incidence of ureteral involvement in patients with DIE. TVS appears to be a reliable tool for the diagnosis of ureteral involvement and, additionally, it allows the detection of both the level and degree of obstruction. Our findings confirm that TVS examination is an accurate non-invasive diagnostic tool for the detection of ureteral involvement by endometriosis. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery

PURPOSE

To evaluate the role of post-surgical medical treatment with GnRHa in patients with DIE (Deep Infiltrating Endometriosis) that received complete or incomplete surgery laparoscopic excision.

METHODS

Hundred fifty-nine patients with deep infiltrating endometriosis of the cul-de-sac and of the rectovaginal septum with pelvic pain undergoing laparoscopic surgery in academic tertiary-care medical center. Eighty patients underwent complete laparoscopic excision of DIE (Arm A) while 79 patients underwent incomplete surgery (Arm B). After surgery each surgical arm was randomized in two groups: no treatment groups 1A [40 pts] and 1B [40 pts] and GnRHa treatment for 6 months groups 2A [40 pts] and 2B [39 pts]. Pain recurrence and quality of life were evaluated in follow-up of 12 months and compared between groups.

RESULTS

No differences were observed between patient groups 1A and 2A. Groups 1A, 2A and 2B obtained significantly lower pain scores than those achieved by the group 1B undergoing incomplete surgical treatment and no post-surgical therapy. At 1-year follow-up patients treated with en-block resection (Groups 1A and 2A) showed the lowest pain scores and the highest quality of life in comparison with the other two groups (Group 1B and 2B).

CONCLUSION

GnRHa administration is followed by a temporary improvement of pain in patients with incomplete surgical treatment. It seems that it has no role on post-surgical pain when the surgeon is able to completely excise DIE implants.