(To be s ubmitted as a part of a requirement of DMAS course at Laparoscopy Hospital, New Delhi, India)

Background

The inquiry of whether there are benefits of laparoscopic appendicectomy (LA) in perforated appendicitis remain to be answered. The purpose of this study is to review literatures to find the role of the LA in perforated appendicitis. Many trials confirm some advantages of LA over open appendicectomy (OA) in acute appencitis, however, the significance of LA in perforated appendicitis is still much debated. Thus, the answer as to whether there are benefits of LA over OA in perforated appendicitis remains to be solved.

Methods

Articles of relevant studies are searched from the Internet using Google, Yahoo, HighWire Press, SpringerLink, PubMed etc, available at Laparoscopy Hospital, New Delhi.

Results

Many studies concerning both laparoscopic and open appendicectomy seem to be contradictorily. In fact, the average rate of abdominal abscesses, negative appendicectomies, and hospital stays are very similar according to a recent review of many retrospective studies. Laparoscopy has some advantages though, including decreasing postoperative pain, shorter time to return to usual activities, lower incidence of wound infections or dehiscence as well as cosmetic.

Conclusion

This review shows that laparoscopic appendicectomy is a safe and effective approach for perforated appendicitis. It results in shorter hospital stay and reduces wound infection complications than does the open approach. The advantage of laparoscopic appendicectomy for perforated appendicitis also is supported by the similar lengths of hospital stay and return to regular activity intervals between the laparoscopic groups in many studies. Laparoscopic appendicectomy also leads to a significant reduction of pain as well as of early postoperative complications in perforated appendicitis and therefore should be considered as the procedure of choice.

Keyword

laparoscopic appendicectomy, perforated appendicitis

Etiology

The etiology of appendicitis is obstruction of the lumen of the appendix followed by infection. In 60% of patients, obstruction is caused by hyperplasia of the submucosal follicles. A fecalith or fecal stasis causes luminal obstruction 35% of the time and is usually observed in adults. Obstruction may also be caused by foreign bodies (4%) and tumors (1%). Following obstruction, an increase in mucus production occurs, and cause an increased pressure. With increased pressure and stasis from obstruction, bacterial overgrowth developed. The mucus then turns into pus that leads a further increase in luminal pressure. This will distend the appendix and cause a visceral pain, typically located in the epigastric or periumbilical region. Since the luminal pressure continues to increase, lymphatic obstruction occurs, leading to an edematous appendix. This stage is identified as acute or focal appendicitis. The overlying parietal peritoneum becomes irritated, and the pain now localizes to the right lower quadrant (RLQ). This series of events results in the classic migrating abdominal pain described in patients with appendicitis.

Further increase in pressure leads to venous obstruction, edema and ischemia of the appendix. At this stage, bacterial invasion of the wall of the appendix occurs and is known as acute suppurative appendicitis. Finally, with continued pressure increases, venous thrombosis and arterial compromise occur, gangrene and perforation will develop. If the body successfully walls off the perforation, the pain may actually subside. However, symptoms do not fully resolve. Patients may still have underlying right lower quadrant pain, decreased appetite, change in bowel habits (eg, diarrhea, constipation), or intermittent low-grade fever. If the perforation is not effectively walled off, then diffuse peritonitis will take place.

Clinical Signs

The classic presentation of a patient with appendicitis includes a history of initial periumbilical or epigastric abdominal pain migrating to the RLQ. The pain is continuing in onset and gradually worsens. Anorexia, nausea, and vomiting are typically associated with the disease. Early on, the patient has a low-grade fever whereas in the patient with higher fevers is associated with a perforated appendix. On physical examination, we can find that movement of the patient worsens the pain. Local tenderness to palpation can be frequently observed. Tenderness on the right side during rectal examination may be found, whereas pelvic and testicular examination findings are normal. Other signs (eg, Rovsing, psoas, obturator) are undependable and typically occur late in the disease process. Nevertheless, only 55% of patients with appendicitis come with classic history and physical findings since the early signs and symptoms are primarily reliant upon the location of the tip of the appendix, which is greatly variable.

Therapy

Although many controversies exist over the non operative management of acute appendicitis, appendicectomy remains the only curative treatment of appendicitis. The first report of an appendicectomy came from Amyan, a surgeon of the English army. Amyan performed an appendicectomy in 1735 without anesthesia to remove a perforated appendix. Reginald H. Fitz, of Harvard who urged early surgical intervention, first described appendicitis in 1886. At the end of the 19th century, the English surgeon H. Hancock successfully performed the first appendicectomy in a patient with acute appendicitis and several years later the American C. McBurney brought out a series of reports that became the foundation of the subsequent diagnostic and therapeutic management of acute appendicitis in the present day.

Surgical Management

Appendicitis is the second most common cause of acute abdominal pain and thousands of open appendectomies (OA) have been undertaken and the mortality and morbidity have gradually decreased in the last few decades as a result of a more effective antibiotics, early diagnosis, and improvements in anesthesiology and surgical techniques. Prior to the advent of laparoscopy, appendectomies were conducted as an open technique with excellent outcomes. While other laparoscopic procedures such as cholecystectomy have shown a benefit over the open technique, the benefit of laparoscopic appendectomy especially in perforated appendicitis has not been demonstrated clearly. There have been many prospective randomized controlled trials in the comparing laparoscopic appendectomy with open appendectomy. (1–10)

Since 1987, many surgeons have begun to treat appendicitis laparoscopically and this procedure has now rapidly developed and conducted all around the world. Although laparoscopic appendectomy was performed since 21 years ago, the dispute between open and laparoscopic appendicectomy for perforated appendicitis remains active. Inspite the brief recovery time and generally good results the laparoscopic approach for perforated appencitis remains to be argued. Many studies concerning both laparoscopic and open appendicectomy seem to be contradictorily. In fact, the average rate of abdominal abscesses, negative appendicectomies, and hospital stays are very similar according to a recent review of many retrospective studies. Laparoscopy has some advantages though, including decreasing postoperative pain, a shorter time to return to usual activities, lower incidence of wound infections or dehiscence as well as cosmetic. (11-13)

Diagnosis of perforated appendicitis can be reasonably easy when there is unambiguous peritonitis with high fever or marked leukocytosis, while patients who have perforated but do not demonstrate these symptoms may not be diagnosed until surgery. Laparoscopic appendectomy is an acceptable alternative to OA or most patients and carries a special benefit for patients in whom the diagnosis is not easy to make. In a prospective randomized trial comparing OA to LA, Martin et al. observed that cases of perforated appendicitis that were operated laparoscopically enjoyed a significant decrease in hospital costs, resulting from a much shorter stay. (19)

Perforated appendicitis, on the other hands, is associated with an increased rate of postoperative abdominal and wound infections. The surgical management of perforated appendicitis generally requires longer operating time, longer incision and produces more surgical stress to the patients, compared with that for acute appendicitis. Moreover, the fact that surgical wound is exposed to contaminated fluid will result in an increased rate of wound infections. Hence, it is plausible that LA could represent clinically relevant advantages over OA in patients with perforated appendicitis, since LA is associated with less wound surface area exposed to contamination and potentially facilitates direct visualization during peritoneal lavage. However, whereas several studies have challenged the role of laparoscopy in perforated appendicitis, the results are controversial and the value of LA is not fully explained. (11–18) Several retrospective studies show that with perforated appendicitis have shown that the risks of intra-abdominal abscess and fistula formation are statistically similar between laparoscopic and open groups. It has also been recommended that the laparoscopic technique can result in a more complete and effective for the peritoneal cavity cleansing. This idea is back up by studies showing fewer wound infections with the laparoscopic approach. LA may also be advantageous in terms of optimizing exposure and thus minimising the risk of retraction- associated tissue disruption.

From the above mentioned studies we can find the fact that no statistically significant difference was found in the rate of infectious complications, including the development of an intra abdominal abscess or superficial wound infection. (20) Even numerous result of clinical studies on laparoscopic appendicectomy for perforated appendicitis have been controversial but no prospective randomized trial has shown a significant increase in the rate of intra abdominal abscess after laparoscopic appendicectomy for perforated appendicitis. However, in order for the surgery to be successful, the proper technique of laparoscopic appendicectomy should be emphasized that the surgeon must take great care to remove the complete appendix with a safe closure of the appendiceal stump. The surgeon should ensure the safe removal of the appendix while minimizing contact with visceral abdominal fascial surfaces in an endobag. If there is a collection of pus in the abdominal cavity, a thorough irrigation of should be performed with total aspiration of the lavage fluid. Several studies finds that the use of the endo-GIA stapler is the safest technique for stump closure and may avoid complications from the spillage of stool and breakdown of the appendiceal stump. (10,17) Another way is a closure of appendiceal stump by endoloop and the use of a simple intracorporeal Vicryl tie on the appendiceal stump. Wound protection may be achieved by removing the specimen through one of the trocars or by using an endobag or surgical glove, thus minimizing contact with visceral or fascial surfaces and reducing intra abdominal contamination.

It has also been suggested that the laparoscopic technique can result in a more complete and effective lavage of the peritoneal cavity. We hypothesize that during laparoscopic appendicectomy for perforated appendicitis, there is generalized intraabdominal contamination, which is reduced significantly by meticulous and targeted irrigation of the abdominal cavity. This reason is supported by studies demonstrating fewer wound infections with the laparoscopic approach. With this mind the European Association for Endoscopic Surgery and other interventional techniques stated the laparoscopic approach can be applied to cases of complicated appendicitis if the proper expertise is available. This reflects the surveillance that surgeons with less laparoscopic experience have a higher rate of conversion to on open procedure. The following is the study of WULLSTEIN et al (20) comparing LA vs OA which shows that in terms of complication, the difference of LA vs OA in perforated appendicitis is not significant whereas the benefit of LA vs OA has been scientifically proven.

Conclusion

Since the introduction of LA for the treatment of appendicitis more than 20 years ago, there has been no consensus on its advantages or disadvantages in comparison with OA. The above studies showed that LA is a safe and effective approach for perforated appendicitis. It resulted in shorter hospital stay and reduced wound infection complications than did the open approach. The advantage of LA for complicated appendicitis also is supported by the similar lengths of hospital stay and return to regular activity intervals between the laparoscopic groups. Equally important, the rates of postoperative complications are the same between the two groups. To sum up, we are in the favor of applying LA over OA in the case of perforated appendicitis, nevertheless, further studies are needed to confirm the role of laparoscopic appendicectomy in the management of perforated appendicitis.

References

•  Hansen JB, Smithers BM, Schache D, et al. Laparoscopic versus open appendectomy: prospective randomized trial. World J Surg 1996;20:17–21.

•  Chung RS, Rowland DY, Li P, et al. A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy. Am J Surg 1999;177:250–256.

•  Garbutt JM, Soper NJ, Shannon WD, et al. Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 1999;9:17–26.

•  Golub R, Siddiqui F, Pohl D. Laparoscopic versus open appendectomy: a metaanalysis. J Am Coll Surg 1998; 186:545–553.

•  Temple LK, Litwin DE, McLeod RS. A meta-analysis of laparoscopic versus open appendectomy in patients suspected of having acute appendicitis. Can J Surg 1999; 42:377–383.

•  Sauerland S, Lefering R, Holthausen U, et al. Laparoscopic vs conventional appendectomy: a meta-analysis of randomized controlled trials. Langenbecks Arch Surg 1998; 383:289–295.

•  Milewczyk M, Michalik M, Ciesielski M. A prospective, randomized, unicenter study comparing laparoscopic and open treatments of acute appendicitis. Surg Endosc 2003; 17:1023–1028.

•  Apelgren KN, Molnar RG, Kisala JM. Laparoscopic is not better than open appendectomy. Am Surg 1995;61:240–243.

•  Mutter D, Vix M, Bui A, et al. Laparoscopy not recommended for routine appendectomy in men: results of a prospective randomized study. Surgery 1996;120:71–74.

•  Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Ann Surg 2005;242:439–450.

•  Frazee RC, Bohannon WT. Laparoscopic appendectomy for complicated appendicitis. Arch Surg 1996;131:509–513.

•  Johnson AB, Peetz ME. Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis. Surg Endosc 1998;12:940–943.

•  Khalili TM, Hiatt JR, Savar A, et al. Perforated appendicitis is not a contraindication to laparoscopy. Am Surg 1999; 65:965–967.

•  Guller U, Hervey S, Purves H, et al. Laparoscopic versus open appendectomy: outcomes comparison based on a large administrative database. Ann Surg 2004; 239:43–52.

•  Bonanni F, Reed J, Hartzell G, et al. Laparoscopic versus conventional appendectomy. J Am Coll Surg 1994; 179:273–278.

•  Klingler A, Henle KP, Beller S, et al. Laparoscopic appendectomy dose not change the incidence of postoperative infectious complications. Am J Surg 1998;175:232–235.

•  Piskun G, Kozik D, Rajpal S, et al. Comparison of laparoscopic, open, and converted appendectomy for perforated appendicitis. Surg Endosc 2001;15:660–662.

•  So JB, Chiong EC, Chiong E, et al. Laparoscopic appendectomy for perforated appendicitis. World J Surg 2002;26:1485–1488.

•  Martin LC, Puente I, Sosa J, Bassin A, Breslaw R, McKenney MG, Ginzberg E, Sleeman D (1995) Open versus laparscopic appendectomy: a prospective randomized comparison. Ann Surg 222: 256–262.

•  Wullstein, C.,Barkhausen, S ,Gross JE, Laparoscopy In Complicated Appendicitis, Dis Colon Rectum, November 2001.

Abstract

Background:

Intestinal perforation from typhoid fever presents with challenges for the surgeon in developing countries. Laparoscopic surgery may be an option to improve outcome in the management of the disease.

Methods:

A search of Medline, EMBASE, High Wire Press from January 1998 to July 2008 for publications on typhoid perforation with special attention to the use of laparoscopy in diagnosis and management.

Results:

We could only access two publications on laparoscopic surgery for typhoid perforation, which were all from India. Twenty six(26) patients were treated without any mortality. Port site infection is the only significant complication. Review of cases managed with conventional open surgery show higher complication rates.

Conclusion:

Laparoscopy surgery should be considered as an option of treatment for haemodynamically stable patients who have typhoid intestinal perforation even in the presence of peritonitis

Key words:

Typhoid perforation, ileal perforation, laparoscopy

INTRODUCTION

Typhoid intestinal perforation is still a major health problem in the developing world with its attendant high morbidity and mortality 3-8 . Early surgery has become the accepted mode of treatment and this has improved survival in the patients. Surgeons have adduced several modalities of operations to improve outcome 13,14,22 . It is apparent though that mortality is still significant in those patients that present early to the hospital. However laparoscopy is becoming the preferred surgical approach to different pathologies due to the possibility of accurately diagnosing and treating them at the same time. It has become possible to carry out even complicated bowel surgeries with laparoscopic techniques. These are unquestionably advantageous to the patient in terms of decreased incidence of wound infections, shorter length of hospital stay and improved survival. However some authorities still consider peritonitis a contraindication to laparoscopic surgery because of the theoretical risk of enhanced bacteraemia and endotoxaemia by pneumoperitoneum 15 . The purpose of this study is to search the literature for minimally invasive approaches to the management of ileal typhoid perforation, and see how it compares to open surgery.

MATERIALS AND METHODS

We searched the Medline, EMBASE and High Wire Press using the terms ‘typhoid perforation laparoscopy’, ‘typhoid perforation’, enteric fever perforation’, ‘intestinal perforation laparoscopy’ to identify studies reporting cases of typhoid perforation and its management. On account of the few reports of laparoscopic management of typhoid perforation, we have to limit our search to the period January 1998 till July 2008. Data extracted from these studies include country of origin, type of operation done, postoperative complications including mortalities and duration of hospital stay.

RESULTS

In the period under review there were 110 citations for typhoid perforation. There are only two papers on laparoscopic surgery for typhoid perforation, and they are all from the Indian subcontinent. There is no randomized clinical trial or comparative studies between open and laparoscopic surgery for typhoid perforation. A total of 41 publications reporting on open surgical management of typhoid perforation were also retrieved and studied. Nine of these met our selection criteria for the purpose of this review.

In the laparoscopic arm of the study a total of 26 patients were operated on without any mortality. Sinha R et al reported 2(10%) cases of wound infection and duration of patients’ stay to be 7-10days while Ramachandra’s patients stayed 6 days on the average. The duration of surgery ranges from 45-92minutes in Sinha’s series and a single layer intracorpooreal closure of the perforation with 3-0 polydioxanone was done. Ramachandra used 2-0 silk. Duration of perforation prior to surgery ranges from 3-5 days.

Table 1
Outcome of laparoscopic repair of Typhoid perforation

The result of the cases managed conventionally from different parts of the world is as given in Table 2. Wound infection is a very common complication of open surgery and mortality can range from 6-34%. Average duration of patients’ stay in the hospital was mentioned in 3 publications giving a combined average of 23.6 days

DISCUSSION

The management of thyroid perforation is still presenting challenges to the surgeon despite improvement in patient survival 10 . This disease condition affects predominantly the low socio economic class and some of the variables that determine the outcome are not within the interventional reach of the surgeon. These include poverty, poor sanitation and delay in seeking medical attention. However different approaches to the surgery of typhoid perforation have been described and these have impacted positively on the disease outcome 13,22 . There is yet a lot of ground to cover as a result of the unacceptably high post operative morbidity and mortality. Laparoscopic surgery has been proven to beneficial in other intestinal perforative conditions e.g. perforated duodenal ulcer and traumatic small bowel injuries 9,15 . It could have a place in the treatment of the patient with typhoid perforation.

Abdominal emergencies quite often pose diagnostic challenge to the surgeon. Accurate diagnosis is essential in the face of different pathologies giving similar clinical features so that appropriate therapies will be planned or unnecessary laparotomy avoided 11 . A negative laparotomy rate of 4.8% has been reported in one series 5 . Many patients with wit acute suppurative peritonitis do not have an obvious perforation,but rather an inflammatory and necrotic zone with oedema and abscess formation. Therefore they can be safely treated with drainage near the pathology zone with a large peritoneal lavage and antibiotic therapy. Diagnostic procedures are expensive and not readily available in the developing world. From these studies there is no evidence of a firm pre operative diagnosis. Laparoscopy is the only minimally invasive technique that provides the platform for adequate diagnosis, appropriate treatment and/or the best abdominal approach 11 .

Laparoscopic surgery for typhoid perforation is quite uncommonly done as shown by the only 2 publications on the procedure. And it may be unfair to compare these results with open surgery; the sample size is quite small and there may have been selection bias for haemodynamically stable patients. It can thus be argued that this cannot be applicable to the majority of patients with severe peritonitis because of the risk of exacerbation of septicaemia. However studies in CO2-insufflated septic animal models demonstrate survival advantage via interleukin-10-mediated downregulation of TNF-alpha 16 .

It has been observed that the least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results 6,7,11 . Laparoscopy is advantageous because of the better quality of peritoneal washing and easy cleaning in the abdominal recesses as well as minimal destruction of the abdominal wall. Open surgery has a high rate of wound dehiscence and intra abdominal abscess formation 4,19,20 . This is not the case with the patients who underwent laparoscopy, port site infection being the commonly reported morbidity 1,2 . Significantly there was no mortality in the laparoscopy group. This could be attributed to patient selection. However the surgeon can always convert in difficult cases. Even these converted cases(intention-to-treat laparoscopically) are likely to have a better outcome compared to the patient who had a planned open operation. This has been demonstrated in complicated appendicitis 23 .

Single layer closure was used during laparoscopic surgery which has also shown to be effective in enteric perforation 22 . Shorter duration of hospital stay is a well known benefit of laparoscopy 1,2 ,and this can significantly reduce the cost of patient management. Duration of surgery could also be shortened in expert hands 2 .

CONCLUSION

Laparoscopic surgery has a promising place in the management of thyroid perforation and every effort should be made to offer it to patients who will benefit from it.

REFRENCES

ABSTRACT

The role of diagnostic laparoscopy in the evaluation of female patients with suspected appendicitis is not in doubt. Opinion is however divided on the use of routine or selective diagnostic laparoscopy in the evaluation of these patients. A literature search using springelink , pubmed, and hirewire press of scientific articles and studies on the role of routine or diagnostic laparoscopy in female patients with suspected appendicitis was done. The negative appendectomy rate described as the presence of macroscopically normal appendix varied from 1.3% to 50% in the selective group and 5% to 26% in the routine group. Predominant non appendix pathologies were mainly gynecological .It was concluded that selective diagnostic laparoscopy after thorough clinical evaluation in consultation with Gynecologists is more cost effective with less morbidity.

INTRODUCTION

Appendectomy remain one of the most common abdominal operations in children and young adults (1).The clinical diagnosis of acute appendicitis based on symptoms, physical examination and serological test is relatively inadequate in women especially in the reproductive age group (2).Several reports (3, 4) have found the diagnostic accuracy of ultrasound and computed tomography (ct) to be of limited value in the pre operative evaluation of patients with suspected appendicitis. In female patients this diagnosis is further made difficult by the different pathological and physiological changes of the female reproductive organs .The incidence of wrong diagnosis as evidenced by negative appendectomy is therefore high especially in female patients .Rates of 15% to 50 % has been quoted in large prospective studies (5,6) for female patients. It has been widely accepted that diagnostic laparoscopy is reliable in assessing the appendix and has reduced the numbers of unnecessary appendicectomy in women (7,8). In addition it has been useful in the diagnosis of alternative pathology when it exists (9). There is however no concensus on whether diagnostic laparoscopy should be applied selectively or routinely in the diagnosis of suspected appendicitis in female patients.

The aim of this study is to review the literature for the practice of selective and routine diagnostic laparoscopy in women with suspected appendicitis. The negative appendectomy rate and its implication for practice guideline will be discussed.

METERIALS AND METHOD

This study was a literature review .Electronic search was made in the following websites for scientific journals

•  Springer link

•  Highwire press

•  Pubmed

The following headings were used for the search

•  Diagnostic laparoscopy

•  Laparoscopic appendectomy

The following selection criteria was adopted

•  All articles reporting routine and /or selective diagnostic laparoscopy in cases of suspected appendicitis, clinically diagnosed appendicitis or right lower quadrant pain.

•  “Routine” for the purposes of the review is when at least 75% of the appendectomies were preceded by a diagnostic laparoscopy.

•  The articles involving females alone were selected. Where an article involves men and women, the female subset is analysed only.

•  All ages of female were choosen; premenarchal, reproductive years and postmenopausal.

•  Articles involving less than 20 patients were not reviewed.

MEASUREMENTS AND MAIN RESULT

Rate of negative appendectomy: Negative appendectomy is defined as a surgical specimen of an appendix with normal histopathological features.

RESULT

The negative appendectomy rates reported in various studies when the policy of selective diagnostic laparoscopy was practiced ranged from 1.3% to 44% (10, 11, and 12). The rates when routine diagnostic laparoscopy was used ranged from 5% to 26 %( 11, 12, 13, 14, and 15).

A large retrospective study comparing selective versus routine policy noted a 32% negative appendectomy rate compared to 5% which was statistically significant (11).In this study no mention of removal of the normal looking appendix was made. There was also no follow up of the patients to evaluate possible morbidity for those reported to have negative appendix. The four other prospective studies of routine diagnostic laparoscopy noted rates of 14%,26%, 4% and 7%(12,13,14,15).However in the study with a negative appendectomy rate of 26% the authors had a practice of removal of normal looking appendix unless any other pathology was found. They recorded no increased morbidity with this approach. In the study with a negative appendectomy rate of 14%, the surgeons left the appendix and followed up their patients for 16 months. They were symptom free. The study also had an increased NAR of 44% in the selective laparoscopy group.

Most of the non appendix pathology was mainly gynaecological as expected (12, 13).They included ovarian cysts, ruptured follicles, pelvic inflammatory disease, fibroid degeneration and endometriosis.

Table 1 summarises the negative appendectomy rate and the practice of removal of normal looking appendix in the literatures reviewed.Table 2 summarises the various gynaecological pathology encountered during the study.

TABLE 1

NEGATIVE APPENDECTOMY RATE(NAR),PRACTICE OF REMOVAL OF NORMAL LOOKING APPENDIX(PMA),PERCENTAGE OF HISTOLOGICAL ABNORMALITY IN NORMAL LOOKING APPENDIX(PAA).

TABLE 2

Common Gynaecological Conditions Encountered at Laparoscopy

Ovary:

•  Ruptured ovarian follicle

•  Torsion of the ovary

Fallopian tube:

•  Ectopic pregnancy

•  Acute salpingit is

•  Pyosalpinx

Uterus:

•  Endometritis

•  Degenerating fibroids

•  Adenomyosis

Endometriosis involving various reproductive organs

DISCUSSION

The operations of acute appendicitis still remain one of the most common surgery in the developed and developing world (16). Despite more than 100years Experience ,accurate diagnosis still evades the surgeons and avoiding perforation and subsequent complication must be weighed against removal of a normal appendix –a negative appen dectomy .The issue of negative appendectomy is particularly relevant in female patients whose pelvis houses the internal reproductive organs with its regular physiological cyclical changes and pathology .These changes in many instances mimic the presentation of appendicitis and has been responsible for the high negative appendectomy in female patients (5,6).

The advent of laparoscopy in the last decade has brought the hope that the technology will greatly reduce the high negative appendectomy rates with or without the application of other emerging modalities like ultrasonagraphy and computed tomography. The results has however been variable albeit disappointing(3,4,17,18).This has resulted in variable application of laparoscopy routinely or selectively in dealing with suspected cases of appendicitis. The European Association of Endoscopic Surgeons (EAES) guidelines has emphasized the value of routine laparoscopy as a diagnostic tool in young women(19).There are also other large and small studies recommending routine laparoscopy in women(11,12,13,14)

Most surgeons agree that a negative appendectomy is a surgical specimen of the appendix devoid of any pathology (inflammation, malignancy etc).It is not the presence of a normal looking appendix during diagnostic laparoscopy. Reducing the population of patients with negative appendectomy and improving diagnosis has been in the mind set of Surgeons advocating for routine diagnostic laparoscopy. These surgeons will almost likely leave a normal looking appendix with or without an associated pathology. This practice will keep the negative appendectomy rate low but at what cost? Tzovaras et al (13) has demonstrated that with a policy of routine diagnostic laparoscopy and removal of the normal looking appendix, the rate of negative appendectomy remained high at 26%.The reduction of negative appendectomy will therefore be at a cost of incomplete analysis of possibly diseased appendix. Reports have emphasised the incompleteness of macroscopic examination of the appendix in the presence of symptoms. Prolonged relief of symptoms of the female patients in the presence of normal looking appendix has been well documented (13, 20, 21, 22).

The cost associated with “unnecessary” removal of the appendix for which routine diagnostic laparoscopy seeks to reduce may as well be cancelled by the cost of recurrencies, readmission and treatment. Reports of acute appendicitis days after leaving macroscopically normal looking appendix has been documented(22).Significant histopathological changes in normal looking appendix has also been documented(20,21) There is also the cost of routine use of laparoscopy as well as morbidity associated with an invasive procedure often requiring anesthesia.

A negative appendectomy rate of 1.3% one of the lowest in literature was achieved through a careful application of clinical examination, ultrasound when necessary and complete gynaecological evaluation of the patients (23). Most reviews that computed the incidental findings noted the preponderance of gynaecological pathology (12,13).The Gynaecologist should be involved early in equivocal cases of appendicitis. A study which suggested that Gynaecological examination did not improve the high negative appendectomy rate did not randomize the allotment of patients and could be biased (24).Pitfalls in diagnosis can not be completely eliminated even with the application of a routine invasive procedure like laparoscopy.

There is a fear that the current recommendation of routine diagnostic laparoscopy and subsequent laparoscopic appendectomy may be fuelled by the desire by surgeons to perform laparoscopic appendectomy. Selective diagnostic laparoscopic evaluation of the female patient suspected to have appendicitis should be the standard of care after a gynaecological consult has not resolved the diagnosis.Negative appendectomy should be seen in the light of relief of symptoms and avoidance of future diagnostic dilemma.

CONCLUSION

Selective diagnostic laparoscopy after thorough clinical evaluation, investigations and consultation with a Gynaecologist should be the standard of care in unresolved suspected appendicitis. It is cost effective and has no added morbidity.

REFERENCES

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•  Korner H,Soreide JA,Pederson EJ et al(2001):Stability in incidence of acute appendicitis .A population based longitudinal study. Dig Surg 18(1):61-66.

•  Van Dalen R,Bagshaw PF,Dabbs BR et al(2003):The utility of laparoscopy in the diagnosis of acute appendicitis in women of reproductive age.Surg Endosc 17(8):1311-1313

•  Vander Valpen Gc,Shimi SM,CuschieriA(1994):Diagnostic yield and management benefit of Laparoscopy :A prospective audit.Gut35:1617-1621

•  Wagner PL ,Echempati SR,Soe K etal(2008):Defining the current negative appendectomy rate :for whom is pre operative tomography making impact?Surg 144(2):276-282

•  Decou JM,Gauderer MWL,Boyle JT(2004):Diagnostic laparoscopy with planned appendectomy:an integral step in the evaluation of unexplained right lower quadrant pain.Paed Surg Int 20(2)123-126.

•  Gabrioni S,Shimi SM,(2008)Routine diagnostic laparoscopy reduces the rate of unnecessary appendicectomies in young women.Surg Endosc 464:9855-6

•  Mustafa A,Sedat S,Mahmut B(2008):Routine use of laparoscopy in patients with clinically doubtfull diagnosis of appendicitis .J laparoendosc Adv Surg Tech

•  Tzovaras G,Liakou P,Baloyiannis L et al(2007):laparoscopic appendectomy:Differences between male and female patients with suspected appendicitis .World J Surg 31:409-4131

•  Laine S,Rantala R,Gulliichsen Ret al(1997):Laparascopic appendectomy-is it worthwile?A prospective randomised study in young women Surg Endosc 11(2)95-97

•  Larsson PG, Henriksoon G, Olsson M, et al. Laparoscopy reduces unnecessary appendicectomies and im proves diagnosis in fertile women. A randomized study. Surg Engdosc (2001) 15:200-202.

•  Irving SB,Patel AG(2002):Managing acute appendicitis BMJ325:505-506

•  Tereisawa T,Blackmore CC, Bent S et al(2004):Systematuc review:Computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents.Ann Int Med 141:537-546

•  Perez J,Barone JE,Wibanks TO et al(2003):Liberal use of computed tomography scaning does not improve diagnostic accuracy in appendicitis Am J Surg 185(3) 194-197.

•  Edmond AM, Neeugebauer,Hans Troidi et al ed.(1994):EAES guideline for endoscopic surgery.Twelve years evidence based surgery in Europe.Springer Berlin 265-289

•  Nicola Z,Carla Z,Michele C et al( ):Recurrent abdominal pain in young pre menarchal female:Clinical and surgical observations Paed J Int 24(3) 277-281

•  Breton F,Barner MD,Shellaine R et al(2008):Case reports :Catamanial appendix.Obst Gyn 111:558-561

•  Greason KL,Rappold JF, Liberman MA(1998):Incidental laparoscopic appendicectomy for acute right lower quadrant abdominal pain.Its time has come Surg Endosc12:223-225

•  Ceriali A, Brignola E,Tonelli E et al(2001):Laparoscopic or open appendectomy.Critical review of the literature and personal experience G.Chir 22(10):353-357.

•  Sabali S et al (2005): Reliability of gynaecological examination in the differential diagnosis of appendicitis in women of reproductive age. Gynaecol Perinatal14(3):140-144.

Introduction

Ectopic Pregnancy, in which gestational sac is outside the uterus, is the most common life threatening emergency in early pregnancy. The incidence of ectopic pregnancy (EP) has increased all over the world from 0.5% thirty years ago, to a present day 1-2% (1) . This complication of early pregnancy, results in not only fetal loss, but also the potential for considerable maternal morbidity and the risk of maternal death (2), (3), (4) .

Until the risk factors that lead to EP are more fully understood, early detection and appropriate management will be the most effective means of reducing the morbidity and mortality associated with this condition (5), (6) . Although the incidence of EP increased, with the improvement of diagnostic approaches, patents were detected at an earlier stage and possible to be treated more conservatively (7) . Surgery remains the mainstay of treatment (8) . Surgical treatments may be radical (salpingectomy) or conservative (usually salpingostomy), and they may be performed by laparoscopy or lapartomy (9) . Improved anesthesia and cardiovascular monitoring, together with advanced laparoscopic surgical skills and experience, justifies operative laparoscopy for surgical treatment of EP even in women with hemodynamic instability (10) .

Ectopic Pregnancy usually occurs 98% of cases in the uterine tube. Trophoblast can be implanted at various site :-

•  The ampulla (64%)
•  The Isthmus (25%)
•  The infundibulum (9%)
•  The intramural junction (2%)
•  Ovarian (0.5%)
•  Cervical (0.4%)
•  Abdominal (0.1%)
•  Intraligamental (0.05%)

Aims & Objectives

The aim of the review to summarize the role of minimal access surgery as in the management of ectopic pregnancy.

Key word

Ectopic pregnancy, operative laparoscopy, laparoscopic, salpingectomy, cornua, surgical treatment, minimal access surgery.

Material and Method

A literature search was performed using the search engine google, highwire press and springerlink. Selected papers were taken for the further references. All articles, RCT, (randomized controlled trial) following predominantly laparoscopic protocol were included for review.

Patients selection of laparoscopic approach

•  Confirmed diagnosis
•  Absent fetal heart beat
•  Hemodynamic stable status
•  Accessibility for laparoscopic treatment and trained laparoscopist on duty

Non candidates for laparoscopic surgery

•  Large haemo peritoneum
•  Unstable hemodynamic status (stage II or stage III shook)
•  Severe pelvic adhesion
•  Refusal

Diagnosis

•  Historical features and physical findings

Ectopic Pregnancy is usually diagnosed in the fist trimester of pregnancy. The most common gestational age at diagnosis is 6 to 10 weeks. Documentation of risk factors is an essential part of history- taking, and asymptomatic clinic patients with risk factors may benefit from routine early imaging. However, more than half of identified ectopic pregnancies are in women without known risk factors (11, 12) .

Risk factors associated with ectopic pregnancy include:

•  Current use of intrauterine device
•  Use of clomiphene citrate
•  Prior tubal surgery
•  Pelvic inflammatory disease
•  Infertility
•  Induced abortion, adhesions
•  Myomata
•  Progestin only oral Pill

Use of Beta Human Chorionic Gonadotropin Measurement

In the emergency department, pregnancy is diagnosed by determining the urine or serum concentration of B human chorionic gonadotropin ?-hCG. This hormone is detectable in urine and blood as early as 1 week before an expected menstrual period. Serum testing detects levels as low as 5 IU/L, whereas urine testing detects levels as low as 20-50 IT/L (13, 14) . In most cases, screening is done with a urine test, since obtaining the result of a serum test is time-consuming and is not always possible in the evening and at night. A single serum measurement of the ?-hCG concentration, however, cannot identify the location of the gestation sac. If a low serum ?-hCG level (< 1000 IU/L) is associated with a higher relative risk of ectopic pregnancy, then can very low levels predict a benign clinical course? A single serum ?-hCG measurement cannot exclude ectopic pregnancy or predict the risk of rupture unless it is less than 5 IU/L (14) . In a normal pregnancy, the first trimester ?-hCG concentation rapidly increases, doubling about every 2 days. An increase over 48 hours of at least 66% has been used as a cutoff point for viability (15) . Ectopic pregnancy may present with rising, falling or plateau ?-hCG levels; thus, serial measurement is most useful to confirm fetal viability rather than to identify ectopic pregnancy.

Use of progesterone measurement

Measurement of the serum concentration of progesterone has been investigated as a potentially useful adjunct to serum ?-hCG measurement, since progesterone levels are stable and independent of gestational age in the first trimester. A Meta analysis, published in 1998, of studies assessing a single progesterone level demonstrated good capacity of low levels (? 5 ng/mL) to correctly diagnose pregnancy failure, but this cutoff was unable to discriminate between ectopic pregnancy and intrauterine pregnancy. Both high (? 22 ng/mL) and low (? 5 ng/mL) cutoff points have since been studied for their ability to correctly identify nonviable pregnancy and ectopic pregnancy (16, 17) . Invasive diagnostic testing (eg, D&C) could be postponed in the former patients but offered to the latter, as could treatment with methotrexate, without fear of interrupting a potentially viable intrauterine pregnancy.

Ultrasound imaging

A ?-hCG level that has risen above the discriminatory threshold in the absence of sonograhic signs of early pregnancy is considered presumptive evidence of an ectopic pregnancy. With the evolution in ultrasound technology, the discriminatory threshold has dropped form 6500 IU/L with a transabdominal approach to between 1000 and 2000 IU/L with transvaginal imaging (18) . The spectrum of sonographic findings in ectopic pregnancy is broad. Identifiation of an extrauteine gestatinal sac containing a yolk sac (with or without an embrayo) confirms the diagnosis. Suggestive finding include an empty uterus, cystic or solid adnexal or tubal masses (including the tubal-ring sign, representing a tubal gestational sac), hemoatosalpinx and echogenic or sonolucent cul-de-sac fluid. It is therefore found that the proportion of patients with the tubal rupture, heavy intra abdominal bleed and pre-shock/shock have decrease owing to early diagnosis.

Thorough physical and clinical examination with preanesthetic checkup was performed. Surgical intervention was done under general anesthesia, on an in patients basis.

Four different operative techniques were used (19, 20, 21, 22, 23, 24) . :

•  Laparoscopic Linear Salpingiotomy (tubal aspiration)
•  Laparoscopic Salpingectomy
•  Laparoscopic Fimbrial expression
•  Laparotomy

Laparoscopic Linear Salpingiotomy

Used as method of choice in patients with unruptured ampullary pregnancy. A linear incision was made over ant mesenteric border of tubal segment containing pregnancy with point needle monopolar diathermy. Prior injection of 5-8 ml of diluted solution containing 5 units of vasopressin in 20ml normal saline is made with 20 gauge spinal needle into the mesosalpinx. Product of conception extrudes itself, if not this can be completed by using hydrodessection or gentle traction with laparoscopic forceps. Copious irrigation is used to dislodge trophoblast. The opening of fallopian tube was left to heal by secondary intention.

Laparoscopic Salpingectomy

This method of chosen for treatment of isthmic pregnancy, with tubal distriction, hydrosalpinx, recurrent ectopic in the same tube, sever adhesions or patients choice. This procedure involve resection of segment of tube containing pregnancy in several ways including laser, stapling devices, endoloops, or progressive biopolar congaulation and cutting the mesosalpinx begins at proximal isthmus of tube, progressed to fimbriated end.

Laparoscopic Fimbrail expression

Milking of the tube was done for the patients with fimbrail ectopic pregnancy. Trophoblastic tissue either sucked out by suction, or retrieved through 10mm ports and sent for histopathological examination.

Laparotomy

Laparotomy was performed through a pfannenstiel incision and standard surgical techniques (the same laparoscopic techniques) were applied. Postoperative follow up consist of serial HCG assessment (twice weekly) until complete negativity (< 5IU/L), with weekly clinical examination and transvaginal ultrasound if needed. Postoperative management follows the normal practice. Analgesia was prescribed to the patients on demand, namely pethidine, 1.5ml/kg IM every 4 four hours or dislofenac sodium 100 mg.

Discussion

A large number of studies on the management of ectopic pregnancy can be found in the literature, ranging from case report to randomized trial, from expectant management to radical surgery. It is now accepted that the surgical treatment of ectopic pregnancy should be via laparoscopy except for a few exception (contra indication for laparoscopy, state of haemodynamic shock, surgeon with insufficient experience).

Success Rate – k. Clasen et al. (1997) had strict laparoscopic approach to 194 cases of ectopic pregnancy resulting in a 97.4% success rate (25) . Other series of studies also confirm the success rate of operative laparoscopic surgery in ectopic pregnancy between 87-97% (26, 27, 28, 29, 30) .

Some author had performed operative laparoscopic even in haemodynamically unstable patients with good success rate (9) .

Operative time

Lundorff P. et al 1991 conducted a randomized, prospective clinical trial was conducted to comparing the efficacy of laparoscopic treatment with conventional conservative abdominal surgery for tubal pregnancy. Laparoscopic surgery took less time (73 min) versus 88min for laparotomy group (24) . In fact it actually saves time, as during a laparotomy, opening and closing the abdomen just to gain access to the affected tube consumes precious operating time. Other comparative studies support this fact (22, 26, 27) .

Peri or postoperative complication

Chatwani A, et al in non-randomized study found statically significant decrease in operative blood transfustion rate in laparoscopic group. Another review article by mohammed H. (2002) suggested that there was no major difference in intraoperative or postoperative complications in laparoscopic group and laparotomy group (20, 21) .

Hospital stay

Various randomized control trial comparing laparoscopic surgery versus laparotomy in treatment of ectopic pregnancy showed shorter hospital stay and convalescence period (22, 24) .

Fertility outcome

Concern fertility restoration and pregnancy outcome following conservative or radical approach by minimal access surgery proved no significant difference when compared with open surgery. Overall conception rate of 77.3%, with an ongoing pregnancy rate 81.2% have been reported (30, 31) .

Cost effectiveness

In this current erra of minimal access surgery the cost of endoscopic/ laparoscopic set up is much high and need specialized theatre set up, more staff and maintenance. But owing to reduce hospital stay, faster recovery time, the expenditure can be considered cost effective (22, 23) .

Quality of life analysis

Minimal access surgery as an operative choice for management of life threatening condition like ectopic pregnancy lead to increased quality of life in term of shorter hospital stay, speedy postoperative recovery, reduce need of post operative analgesia, cosmetically good scar and less psychological trauma to the patients.

Conclusion

Critical overview of literature of all possible approach demonstrate that the minimally access surgery is not only save and effective, but also economical then open laparotomy in the treatment of ectopic pregnancy and should consider as the gold standard in treating in ectopic pregnancy.

Reference

•  Lehner R, Kucera E, Jirecek S, Egarter C, Husslein P, Ectopic pregnancy. Arch Gynecol Obstet 2000 Feb; 263(3): 87-92.

•  Centres for diseases control (CDC). Ectopic pregnancy—United states, 1988-1989. MMWR 1992; 41:591-4.

•  Centres for disease contral (CDC). Ectopic pregnancy—United states, 1990-1992. MMWR 1995; 44:46-48.

•  Why women die. Repord on condiential enquiries into maternal deaths in the United Kingdom 1994-1996. Norwich: Stationery Office, 1998.

•  Leach RE, Ory SJ. Management of ectopic pregnancy. Am Farm Physician 1990; 41: 1215-22.

•  Ory SJ. New options for diagnosis and treatment of ectopic pregnancy. JAMA 1992; 267:534-7.

•  Feng W, CAO B, Li Q. Advances in diagnosis and treatment of ectopic pregnancy during the past ten years. Zhonghu Fu Chan Ke Za Zhi 2000 Jul;35(7): 408-10

•  Tay J I, Moore J, Walker J J. Ectopic pregnancy: Clinical review BMJ 2000; 320(1):916-919.

•  Soriano D, Yefet Y, Oelsner G, Goldenberg M, Mashiach Seidman DS. Operative laparoscopy for management of ectopic pregnancy in patients with hypovolemic shock. J Am Assoc Gynecol Laparosc. 1997 May;4(3):363-7.

•  Murphy AA, Nager CW, Wujek JJ, Kettel LM, Torp VA, chin HG. Operative laparoscpy versus laparotomy for the management of ectopic pregnancy: a prospective trail. Fertil Steril 1992; 57:1180-5.

•  Buckley Rg, King Kh, Disney JD, Gorman JD, Klasen JH. History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical predication model. Ann Emerg Med 1999;34: 589-94.

•  Dart RG, KaplanB, Varaklis K. Predictive value of history and physical examination in patients with suspected ectopic pregnancy. Ann Emerg Med 1999;33: 283-90.

•  Brennam DF. Ectopic pregnancy- PartI: Clinical and laboratory diagnosis. Acad Emerg Med 1995;2: 1081-9.

•  Kaplan BC< Dart RG, Moskos M, Kuligowska E, Chun B, Adel Hamid M, et al. Ectopic pregnancy: prospective study with improved diagnostic accuracy. Ann Emerg Med 1996; 28: 10-7. Comment in Ann Emerg Med 1997;29:295-6.

•  Dart RG, Mitterando J, Dart LM. Rate of change of serial beta-human chorionic gonadotropin values as a predictor of ectopic pregnancy in patients with indeterminate transvaginal ultrasound findings. Ann Emerg Med 1999;34: 703-10.

•  Buckley RG, King KJ, Disney JD, Riffenburgh RH, Gorman JD, Klausen JH. Serum Progesterone testing to predict ectopic pregnancy in symptomatic irst-trimester patients. Ann Emerg Med 2000; 36:95-100.

•  Dart R, Ramanujam P, Dart L. Progesterone as a predictor of ectopic pregnancy when the ultrasound is in determinate. Am J Emerg Med 2002, 20:575-9.

•  Kadar N, De Vore G, Romero R, Discriminatory hCG Zone: its use in the sonographic evaluation for ectopic pregnancy. Obstet Gynecol 1981;58: 156-61.

•  Nama V, Manyonda I, Tubal ectopic pregnancy: laparoscopic and management. Arch Gynecol Obstet. 2008 Jul 30.

•  Henderson SR. Ectopic tubal pregnancy treated by operative laparoscopy. Am J Obstet Gynecol. 1990 May; 162(5): 1348.

•  Reich H, Freifeld Ml, McGlynn F, Reich E, laparoscopic treatment of tubal pregnancy. Obstet Gynecol. 1987 Feb;69(2): 275-9.

•  Chatwani A, Yazigi R, Amin-Hanjani S., Operative laparoscopy in the management of tubal ectopic pregnancy. J Laparoendosc Surg. 1992 Dec;2(6): 319-24.

•  Fujishita A, Khan KN, Kitajima M, Hiraki K, Miura S, Ihimaru T, Masuzaki H. Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy.Eur J Obstet Gynecol Reprod Biol. 2008

•  Steiner RA, Ioannidis K, Wight E, Fehr M, Haller U, Minimally invasive surgery in the treatment of extrauterine pregnancy, Schweiz Rundsch Med Prax 1993.

•  K. Clasen, M Camus, H Tournaye and P. Devroecy, ectopic pregnancy: let’s cut! Strict laparoscopic approach to 194 consective cases and review of literatue on alternatives. Human reproduction Vol. 12 No. 3, 1997, pp.596-601.

•  Chapron C, Querleu D, Crepin G. Laparoscopic treatment of ectopic pregnancies: a one hundred cases study. Eur J Obstet Gynecol Reprod Biol. 1991 Oct 8; 41(3): 187-90.

•  Zouves C, Urman B, Gomel V. laparoscopic surgical treatment of tubal pregnancy. A sage, effective alternative to laparotomy, J Reprod Med. 1992 Mar; 37(3): 205-9.

•  Mohamed H, Maiti S, Phillips G. Laparoscopic management of ectopic pregnancy: a 5-year experience. J Obstet Gynaecol. 2002 Jul; 22(4): 411-4.

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•  Dubuission JB, Morice P, Chapron C, De Gayffier A, Mouelhi T. Salpingectomy – the laparoscopic surgical choice for ectopic pregnancy. Hum Reprod 1996;11:1199-203.

•  Lundorff P, Thorburn J, Hahlim M, Kallfelt B, Lindblom B, Laparoscopic surgery in ectopic pregnancy. A randomized trail versus laparotomy. Acta Obstet Gynecol Scand. 1991; 70(4-5)343-8.

ABSTRACT

Giant hiatal hernia is defined as greater then one third of the stomach in the thoracic Cavity (1) and representing 5 to 10 % of all hiatal hernia (8). The hiatal opening in a patient with a large hernia is wide, with the right and left Crura very thin and often separated by 5 cm or more (8). The aim of this review is to analyze the role of laparoscopy in the management of Giant hiatal hernia.

INTRODUCTION

Traditionally repair of giant paraesophageal hernia has been performed through and Open laparotomy or thoracotomy, with the advent of laparoscopy, nowadays giant Hiatal hernia are performed with laparoscopy

Saveral recent report have shown that laparoscopic repair of paraesophageal hiatal hernia

Is feasibadle and effective obtaining comparative result to open surgery (2)

MATERIAL AND METHOD

A review of article was done through the internate using search engine Google, high wire press springerlink pubmed through the internate facility available
In laparoscopy hospital in Delhi.–using

About 3500 article available on the net only selected article weve selected article were screened for further reference. Operative procedure selected only from the centre, where the study was done, are specialized in laparoscopic surgery.

KEYWORD

Giant hiatal hernia, Laparoscopy management, complication, recurrence.

SURGICAL PROCEDURE

Pre-operation workup including carefule history regarding patient symptom

• Barium swallow x-ray
• Upper gastrointestinal endoscopy
• Esophageal manometry
• Ph monitoring

Should be done

AIM AND OBJECTIVE

The aim of the study was to evaluate the effectiveness and safety to laparoscopy in the Treatment of hiatal hernia.

•  Operative time
•  Operative Technique
•  Post operative pain
•  Complication
•  Hospital stay
•  Functional index
•  Quality of life analysis

The following parameter were eveluated

OPERATIVE PROCEDURE

The surgical technique employed include

•  Standerd five cannula technique
•  Devide the lesser omantom to expose the right hilar piller with in the sac
•  reduction of hernia by means of atraumatic grasper in a hand over hand fashion
•  complete excision of sac
•  primary closure of hiatal hernia defect with either suture approximation of crura or by defferent type of mesh application (for tension free repair)
•  after closing the hiatus a fundoplication (Nissen or toupet) with or without collis gastroplasty will complete the operation depending upon the finding of intraoperative assessment of short esophagus and esophageal manometry.

Review of citation

M. Morino et all 2006. Performed laparoscopic repair of giant hiatal hernia on 65 patients Oct 1991- April 2003.

•  Primary closure of the hiatal defect was done in 14 cases
•  Tension free repair using a mesh was performed in 37 cases
•  14 patients underwent collies – Nissen gastroplasty.
•  There was no intra operative complication and no conversion to open technique
•  Mesh operation time was 130 min
•  No motility
•  One major complication (1.5%)
•  An esophageal perforation
•  Post operative complication – 12 patients has transient sub coetaneous emphysema in the neck, resolve spontaneously
•  Mean hospital stay was 4.8 day
•  Transient dysphagia occurred in 7 patients
•  Recurrent hernia present in 23 patients (35.4%)
•  Recurrent rate was 77% in direct suture and 35% when mesh was used.

Recurrence of hiatal hernia according to type of surgical technique are:

Table No: 1 – Result of Recurrences

PTFE, Polytetrafluoroethylene
Source: M. Morino et al

No patients with a collies- Nissen fundoplication experience recurrence.

R. parmeswaram et al 2006 performed laparoscopic repair of large paraesophageal hiatal hernia between Jan 2000 and July 2004 on 49 patients (12) .

•  The median age of these patients was 68 years
•  The techniques used Nissen fundoplication
•  There were two conversion to open surgery
•  Major morbidity was atrial fibrillation, pulmonary embolism and splenectomy rate was 10.2%.
•  Minor morbidity included – chest infection, jaundice, dysphagia, small pnumothorex rate was 20.4%
•  Recurrence rate of 27 patients that is 66% patients.

L. E Ferri et al 2005. Performed repair 60 cases paraesophageal hernia for reevaluation of result of laparoscopic repair against open laparotomy from 1990 to 2002 (13) .

•  For this study 25 cases repaired with open trans abdominal
•  35 cases laparoscopic repair
•  Laparoscopic repair resulted in
•  Lower blood loss
•  Fewer intraoperative complication
•  Shorter length of hospital stay
•  Radiological recurrence was 44% for open and 23% for laparoscopic procedure
•  Laparoscopic repair was associated with a significant reduction in time to oral intake, parental opoid use and length of hospital stay

Table 2 : operative and short tern outcome after open and laparoscopic paraesophageal hernia repair:

a Complication classification as proposed by Clavien et al.{14}

Source: L.E. Ferri et al (13)

Antomic recurrence was identified in 8 of 18 open and 7 of 31 that is (23%) patients in the laparoscopic group five recurrences occurred in the first 15 patients where only 2 of the last 20 patients have had recurrence.

James D Luketich M.D. et al : In October 2000 performed laparoscopic surgery for giant hiatal hernia from July 1995 to February 2000 on 100 patients.

•  There were three cases in which open conversion done due to adhesion
•  Then median surgical time was 3.6 hours
•  Median length of stay was 2 days.
•  The crural repair was primary in 96 patients and 4 had mesh repair
•  72 patients got Nissen fundoplication and 27 collies-nissen fundoplication
•  Intraoperative complication include
•  Pneumothorex 4 patients
•  Esophageal perforation 5 patients
•  Gastric perforation 3 patients
•  Major Perioperative complication include stroke 1 patients, MI-1 patients, ARDS-1 patients, Pulmonary emboli-3 patients, reoperation for abscess 2 patients, recurrent hernia 1 patients.
•  Overall surgical death rate 1 percent (5) .

Andrew F. Pierr. M.D et al (2002) performed elective repair of giant paraesophageal hernia in 2003 patients between June 1995 to July 2001.

•  Mean age was 67 year
•  Laparoscopic procedure included
•  69 patients Nissen fundoplication
•  112 collies-nissen fundoplication
•  19 other procedure
•  Three open correction due to adhesion
•  Median length of hospital stay was 3 day
•  Minor and major complication in 57, (28%) patients
•  Postoperative esophageal leak 3%
•  Death 1%
•  Recurrence hiatal hernia 5 patients
•  Result
•  Excellent in 128 patients
•  Good result in 12 patients
•  Fare result in 7 patients
•  Poor result in 5 patients
•  Based on post operative follow up and GERD questionnaire (1) .

Discussion

There are now several study report, the outcome of laparoscopic management of giant of hiatal hernia (5, 10, 11, 12, 13, 14) . Probably the first successful repair was described by Sir Alfred Cushieri and coworker in 1991. Since than laparoscopic technique have been used increasingly in the approach to patients with paraesophageal hernia (11) .

Rate of recurrence after laparoscopic repair have been variable. Some studies have reported a high recurrence rate of 42% in other study have reported lower recurrence rate. Than anatomic recurrence rate in the series of R. parmeswaram et al 2006 was 17.85%, which is consistent with other series.

Table 3. Review of various study with radiological follow up data

Source: R. Parmeswan et al.

Various methods have been used to reduce the rate of recurrence. Those are:

•  Prosthetic mesh insertion
•  Use of Teflon pledgetted horizontal mattress suture to encircle fiber bundle of both crus of diaphragm.
•  In case of short esophagus found on intraoperative endoscopy
•  Add an esophageal lengthing of procdure during the crural repair ie collies-nissen gastroplasty to achieve a tension free intra abdominal repair etc. the rate of recurrence is higher in the learning curve after which the failure rate diminished (13) .

Although laparoscopic repair of giant hiatal hernia is a techniqually challenging procure but, with the gain of experience result is compare favorably to the open operation (10, 11, 1,8) .

Laparoscopic approach to paraesophageal hiatal hernia offer an excellent visualization of the hiatal region during the phase of hernia reduction the laparoscopic approach allow very precise identification of the anatomic structure and dissection is facilitated by pheunoperitonium.

Laparoscopic repair of large hiatal hernia is now safe and effective technique for the management because patient population often consisting of elderly, debilitating patient, avoiding an open procedure, may prove beneficial. This is techniqually challenging procedure but as experienced gained and committed follow up is performed. We belief this approach well provide an excellent option for patient with paraesophageal hiatal hernia (10) .

Conclusion

Although techniqually demanding this approached provide better exposure of the surgical field than open transadominal procedure and add the known general advantage of laparoscopy in term of reduced morbidity, shorter hospital stay rapid and recurpation, and decreased pain medication. This advantage may be especially valuable in the paraesophageal hernia patient population because most patients are elderly and have multiple comorbid condition.

Acknowledge

I specially thank Prof Dr. R. K. Mishra for his guidance for completion of this review article.

Reference

1. Andrew F. Pierre, et al Aug-2007. Result of laparoscopic repair of giant paraesophageal hernia: 2000 consecutive patient.
2. Giovanni Ganinotto. Objectives follow up after laparoscopic repair of large type III hiatal hernia assessment of safety and durability .
3. Bas P.L Wijnhoven et al jan 2008 laparoscopic repair of a giant hiatal hernia. How I do it.
4. Eduardo M. Targarona MD, phd et al dec.2004 mesh in the hiatus a controversial issue
5. James D Luketich et al Oct (2000) laparoscopic repair of giant paraesophageal hernia: 100 consecutive case.
6. L. Fei, G. del genio et al. April 2006- crura ultrastructral alternation in patient with hiatal hernia: Pilot study
7. Frantzides CT et al: a prospective, randomized trail of laparoscopic poly tetrafluroethylene patch repair vs. simple cruroplasty for large hiatal hernia.
8. M. Morino et al. 2006 laparoscopic management of giant hiatal hernia factors influencing outcome
9. Bryan A et al July 2006. Wedge gastroplasty and reinforced crural repair: Important component of laparoscopic giant or recurrent hiatal hernia repair.
10. Wiech mann R.J et al- laparoscopic management of giant paraesophageal hernitation- Ann of thoracic surgery 2000
11. Surgio Diaz MD et al may 2002 laparoscopic paraesophageal hernia repair a changing operation: medium term outcome of 116 patients.
12. R. Paramswaran et al 2006- laparoscopic repair of large paraesophageal hiatal hernia: quality of life and durability.
13. L. E. Ferri et al 2005- should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach.
14. Clavien L A et al-proposed classification of complication of surgery with example of utility in cholecystectomy.
15. Aly A, Munt J, Jamieson GG, Ludemann R, Deitt PG, Watson Di (2005) laparoscopic repair of large hiatal hernias. Br J Surg 92: 648-653.
16. Buenaventura PO et al (2000) laparoscopic repair of giant paraesophageal hernia.
17. Hashemi M, et al (2000) Laparoscopic repair of large type III data hernia: objective follow-up reveals high recurrence rate.
18. Martin TR, et al (1997) management of giant paraesophageal hernia.
19. Trus TL, et al (1997), complications of laparoscopic paraesophageal hernia repair.
20. Wu JS, Dunnegan Dl, et al (1999).

BACKGROUND

Complications due to hysteroscopy are relatively rare events. They occur more frequently with operative hysteroscopy than with diagnostic hysteroscopy. Exact complications rates are difficult to determine owing to the natural tendency to report successes but not complications. Recognition of these situations will lead to prevention; in fact, all the most serious complications of operative hysteroscopy can be avoided when proper precautions are taken and close communication is maintained among gynaecologic surgeon, the anaesthesiologist and nursing staff.

Abstract

Objective:

To evaluate the rate of uterine perforation during different operative hysteroscopic procedures, whether it can be predicted by specific patient characteristics or type of hysteroscopic procedure and risks of uterine rupture during subsequent pregnancies. Methods: A web search was performed to identify the relevant publications with no limitations of languages from Jan 1995 till august2008.

Conclusion:

The incidence of complications from hysteroscopy varies widely by institution and operative procedure. The risk of uterine perforation was higher during hysteroscopic adhesiolysis than during other procedures. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase the risk of uterine rupture in subsequent pregnancy.

Keywords

complication in hysteroscopic procedures, uterine perforation subsequent pregnancy outcome , Metroplasty , Uterine rupture & Synechiae.

Introduction:

Hysteroscopy is the gold standard method for the abnormal uterine bleeding. Hysteroscopy is an important diagnostic and therapeutic tool for patients presenting with intrauterine diseases. During the past decade, the number of gynecologists doing operative hysteroscopy and the number of procedures done have increased. The incidence of complication from the hysteroscopy varies widely by institution and operative procedure. Appropriateness and safety of hysteroscopy depend on predicting complications (1)

Materials and Methods

A literature search was performed using Highwire press, Springerlink, Pubmed and the search engine Google. The following search terms were used: hysteroscopic surgeries (diagnostic procedure, polypectomy, myomectomy, endometrial ablation, uterine septum resection, lysis of adhesions, endometrial curettage), hysteroscopic complication (uterine perforation) risk factors for uterine perforation and for uterine rupture and uterine rupture with subsequent pregnancy. Three handerd citations used matching the above criteria, the institution where the study was done plus good patients number.

Discussion

Minimally invasive procedures have many benefits compared with traditional procedures, including lower costs, shorter hospital stays, and shorter recovery time. Complications during hysteroscopic surgery are rare (1) The incidence of complications from hysteroscopy varies widely by institution and operative procedure (1,9). Operative complications occurred in 2.7% hysteroscopies, excessive fluid absorption was the most frequent complication.(1)

Hysteroscopic myomectomy and resection of uterine septum were associated with greater odds of complications (odds ratio [OR] 7.4, 95% confidence interval [CI] 3.3, 16.6 and OR 4.0, 95% CI 0.9, 19.6, respectively). Hysteroscopic polypectomy and endometrial ablation were associated with lower odds of complications (OR 0.1, 95% CI 0.0, 0.7 and OR 0.4, 95% CI 0.1, 3.3, respectively). Hysteroscopies done by reproductive endocrinologists and preoperative GnRH agonist therapy were associated with 4–7 times higher odds for operative complications(1) Excessive glycine absorption occurred only in more complex procedures, including myomectomy, uterine septum resection, and endometrial ablation, diagnostic hysteroscopy with or without D&C and polypectomy had low risks of complications,(1). American Association of Gynecologic Laparoscopists member survey reported 17,298 operative hysteroscopies with a complication rate of 3.8%, including perforation in 1%, hospital admission in 0.7%, hemorrhage in 0.2%, and unplanned laparotomy in 0.2% of women.(2) The most important complications were (1.7%) uterine perforations, (6.9%) intraoperative haemorrhages and (5%) excessive hypotonic fluid absorptions.(3)

Risk factors for uterine perforation

Belloni recorded 1.7% (2), similar to Agostini reported 1.6% uterine perforation (3, 11) Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures [endometrial ablation RR 9.39 (3.46-25.52), p <0.0001; uterine septa section RR 6.78 (0.91-50.6), p = 0.026; polyp RR 8.52 (2.60-30.80), p <0.0001 or myoma resection RR 7 (2.83-17.62), p <0.0001](4),(9,11).Frank found the most frequent surgical complication was perforation of the uterine cavity (rate 0.76%)(5).Approximately half of the perforations were entry-related. , attentionhas to be paid to the method of entry with the hysteroscope (ie, no unnecessary dilation of cervix and introduction of the scope under direct vision(5), The other half of complications were related to surgeons’ experience and type of procedure. (Obstet Gynecol 2000; 96:266–70. © 2000 by The American College of Obstetricians and Gynecologists.)(5,9). The total complication rate was 3%, with 1% of uterine perforations, two-thirds of the complications were related to cervical dilation or uterine entry, and infertility was found to be a risk factor(6). Efforts therefore should be focused on identifying the patients at risk and finding novel techniques for cervical priming (6).In most German centers, hysteroscopy is just being established. Nevertheless, the rate of complications such as perforation of the uterus, fluid-overload syndrome, infection and preoperative bleeding is small. This may be due to the high proportion of documented procedures performed by the more experienced centers (7).

Prevention of uterine perforation

To avoid any problems concerning the application of hysteroscopic procedures, it is important to take the necessary precautions both preoperatively and intraoperatively. For example, the preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument(8). Using monopolar cutting devices and saline-free distension media, hysteroscopic surgery bears specific risks. The knowledge of these risks is important to avoid typical complications of operative hysteroscopy (10).

Management of uterine perforation

Complications during hysteroscopic surgery include) excessive glycine absorption, uterine perforation, technical problems,bleeding and postoperative sepsis. Imbalances were identified quickly and treated. Among women with excessive glycine absorption, the lowest serum sodium recorded was 126 mEq/L, hysteroscopic surgery is to stop the procedure when the glycine deficit is 1 L or greater. Serum sodium levels decrease about 10 mEq/L for every 1 L of hypotonic fluid (1).

When perforations occurred during the dilation of the cervical channel. Since the distention of the uterine cavity could not be achieved, the procedures were stopped. In patients intraoperative bleeding could not be controlled with electrocautery. In these cases in the operating room a Foley catheter was inserted into the uterine cavity and the bulb inflated with 10 to 30 mL of liquid to tamponade the bleeding. The catheters were removed 12 to 24 hours later(2).

Risk factors for uterine rupture in subsequent pregnancy

Uterine ruptures secondary to operative hysteroscopy are rare but serious. They can occur before onset of labor, and compromise vital maternofetal outcome. Hysteroscopic metroplasty subjected patients to high risks of uterine rupture during subsequent pregnancies (12). Uterine perforation and/or the use of electrosurgery increase this risk but are not considered an independent risk factor (12). Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome (13).

The late complications of operative hysteroscopy result from either persistent endometrium after ablation or myometrial damage during surgery. Residual endometrium can become neoplastic, cause pain, or support a pregnancy. Myometrial damage can produce catastrophic consequences during a later pregnancy (14). Surgical correction of the complete uterine septum with preservation of the cervical septum is associated with low morbidity and satisfactory postoperative obstetric outcome (15).

Prevention of uterine rupture

Apart from favourable use of scissors for hysteroscopic metroplasty, no accurate methods to prevent or detect impending ruptures in subsequent pregnancies were found (12). Physicians providing care for patients with previous hysteroscopic metroplasty or complicated operative hysteroscopy, should be aware of the potential risks for uterine rupture during pregnancy (12). Considering hysteroscopic metroplasty, the use of coaxial bipolar electrode should be preferred (13). The obstetrician’s vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified (16).

Fluoroscopically Guided Hysteroscopic Division of Adhesions in Severe Asherman Syndrome

This technique provides an intraoperative fluoroscopic view of pockets of endometrium behind an otherwise blind-ending endocervical canal in women with severe Asherman syndrome, allowing guided division of adhesions and reducing the likelihood of perforation and formation of false passageways (17).

Conclusion

Complications during hysteroscopic surgery are rare. The incidence of complications from hysteroscopy varies widely by institution and operative procedure. Perforation risk was higher during hysteroscopic adhesiolysis than during other procedures. The preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument. Uterine perforation and/or the use of current monopolar section during operative hysteroscopy increase this risk. Uncomplicated hysteroscopic resection of submucous myomas and endometrial polyps do not alter obstetrical outcome. Myometrial damage can produce catastrophic consequences during a later pregnancy. The obstetrician’s vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified.

References

•  Anthony Mp, Rebecca Fl, Bernard Lh And Elizabeth SG,Complications of Hysteroscopic Surgery: Predicting Patients at Risk , May 11, 2000.

•  Hulka JF, Peterson HB, Phillips JM, Surrey MW. Operative hysteroscopy. American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993;38:572–3.

•  Belloni C,Pasini A, Intraoperative complications of 697 consecutive operative hysteroscopies Minerva Ginecol. 2001 Feb;53(1):13-20.

•  Agostini A, Cravello L, Bretelle F, Shojai R, Roger V, Blanc B Risk of uterine perforation during hysteroscopic surgery J Am Assoc Gynecol Laparosc. 2002 Aug;9(3):264-7

•  FRANK WJ, CORLA BV KARIN VU, JO H C. M. TRIMBO complications of hysteroscopy: a prospective, multicenter study The American College of Obstetricians and gynecology12000,96 266-70

•  Shveiky D, Rojansky N, Revel A, Benshushan A, Laufer N, Shushan A6) Complications of hysteroscopic surgery: “Beyond the learning curve”J Mi.nim Invasive Gynecol. 2007 Mar-Apr;14(2):218-22 LinksComment in:J Minim Invasive Gynecol. 2007 Jul-Aug;14(4):530-1; author reply 531.

•  Aydeniz B, Gruber IV, Schauf B, Kurek R, Meyer A, Wallwiener D A multicenter survey of complications associated with 21,676 operative hysteroscopies Eur J Obstet Gynecol Reprod Biol. 2002 Sep 10;104(2):160-4.

•  Paschopoulos M, Polyzos NP, Lavasidis LG, Vrekoussis T8) Dalkalitsis N Paraskevaidis E Safety issues of hysteroscopic surgery Xia EL, Duan H, Zhang J, Chen F, Wang SM, Zhang PJ, Yu D9) Zheng J, Huang XW.

•  Analysis of 16 cases of uterine perforation during hysteroscopic electro-surgeries Zhi. Zhonghua Fu Chan Ke Za 2003 May;38(5):280-3

•  Meyer A, Aydeniz B, Kurek R10) Wallwiener D Hysteroscopic surgery–complications and their prevention CONTRIB GYNECOL OBST2000;20:161-70

•  Agostini A, Bretelle F, Cravello L, Ronda I, Roger V, Blanc B11) Complications of operative hysteroscopy AORN J. 1999 Jan;69(1):194-7, 199-209; quiz 210, 213-5, 21. Links

•  Sentilhes L12) Late complications of operative hysteroscopy: predicting patients at risk of uterine rupture during subsequent pregnancy Sergent F, Roman H, Verspyck 2005 Jun 1;120(2):134-8eurJ Obst Gyn Repr Bio.

•  Sentilhes L,Sergent F,Berthier A,Catala L,Descamps P, Marpeaull Uterine rupture following operative hysteroscopy

•  Cooper JM, Brady RM , Late complications of operative hysteroscopy 2000 Jun;27(2):367-74.

•  Rock JL,Roberts CP,Hesla JS HYSTEROSCOPIC METROPLASTY OF THE CLASS Va uterus with preservation of cervical septum,fertility sterili,1999Nov ,72 (5)94-5)

•  Journal de Gynécologie Obstétrique et Biologie de la Reproduction Vol 33, N° 1-C1 - janvier 2004 pp. 51-55 Doi : JGYN-02-2004-33-1-C1-0368-2315-101019-ART10 Facteurs prédictifs de rupture uterine obstétricale après hysteroscopic operator.

•  Jonathan DBe, and thierry g. V, instruments & methods fluoroscopically guided hysteroscopic division of adhesions in severe asherman syndrome.

INTRODUCTION:

Obesity is the commonest form of malnutrition and it has been increasing over the last few decades globally [1-3]. In India up to 50% of women and 32.2% of men in the upper socio-economic class comes under the obese category. In Delhi the prevalence of obesity is 33.4% in women and 21.3% in men [4-5]. According to Framingham data for each pound weight gained between ages 30 to 42 years, there is 1% increased mortality within 26 years, and for each pound gained after that, it is the 2% increased mortality. In morbid obese, average life expectancy is reduced by 12 years in men and 9 years in women [6]. Type II diabetes, hypertension, hyper-lipidemia, stroke, atherosclerosis, osteo-arthritis, hypoventilation, sleep apnea syndrome, GERD, infertility and urinary stress incontinence in females, certain cancers(endometrium, colon, breast, prostate) and sudden death are co-morbidities [7]. Surgical management of morbid obesity is increasing in response to its epidemic rise [8]. Between 1998 and 2002, there was a 450% increase in the number of bariatric operations performed in the United States , a 144% increase in the number of American Society for Bariatric Surgery bariatric surgeons, and a 146% increase in the number of bariatric centers. The growth of laparoscopic bariatric surgery during this 5-year period greatly exceeds that of open bariatric surgery [9]. National Institutes of Health Consensus (NIH) Conference convened in 1991, specifically identified Roux-en- Y gastric bypass (RGB) and vertical banded gastroplasty (VBG) as surgical options that provide significant benefits for patients with clinical severe obesity. In 1994, Wittgrove, Clark, and Tremblay performed the first laparoscopic RYGB (LRYGB), which at the time was considered a technical tour de force [10] .

There are following different options available in bariatric surgery [11].

AIM:

The aim of this study is to review the various aspect of the laparoscopic Roux-en-Y Gastric Bypass to emphasize its significance in Bariatric Surgery.

Materials and Methods:

A thorough literature and clinical search was performed by using search engines Google, HighWire Press, Springer Link etc .The following search terms was used: morbid obesity, laparoscopy Bariatric Surgery, Roux-en-Y, Comparison obesity surgery, open laparoscopy bariatric, complication Roux-en-Y .

History:

In 1954, Kremen et al performed the first intestinal bypass via jejuno-ileostomy, and in 1956, Payne and DeWind performed a distal jejunocolonic anastomosis. Later it was modified by Sherman et al, who sutured 14 inches of proximal jejunum end-to-side to the terminal ileum,4 inches proximal to the ileo-cecal valve. Mason and Ito devised a gastric bypass procedure for morbid obesity in1966, after noting the weight reduction in gastric resection for gastric ulcer. Initially, they transected the stomach horizontally and performed a loop gastro-jejunostomy to the proximal portion of the stomach. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of intestine (RYGBP).In 1994, Wittgrove, Clark , and Tremblay reported the first case series of laparoscopic RYGBP [10].

Surgical Technique:

In LRYGBP procedure, six small incisions are made, through which ports are inserted for abdominal access. Dissection is started at the fundus of stomach with division of phrenico-gastric ligament. The stomach is divided with laparoscopic straight four row cutting 60 mm stapler to create a 15-20cc pouch. The ligament of Treitz is identified initially, and the proximal jejunum is divided approximately 50 cm distal to this point. A gastro-jejunostomy is performed either hand sutured, linear staplers or by circular staplers. A jejuno-jejunostomy is performed with laparoscopic staplers. A Roux limb of between 75 to 200 cm is formed depending on the BMI, and the jejuno-jejunal mesenteric defect is closed to avoid postoperative internal hernias. The Roux limb is placed in an ante-colic fashion. The anastomosis is tested by gastroscopy for evidence of any leak after the procedure.

Comparison of LRYGBP with other methods of laparoscopic bariatric surgery:

Laparoscopic Roux-en- Y gastric bypass is, in reality, a well-structured and well-understood operation that is valuable for the treatment of clinical severe obesity. Longer follow-up evaluation and experience with Vertical Banded Gastroplasty shows that patients frequently changes dietary habits postoperatively, ingests high-calorie soft foods and liquids, and regains weight [12]. Because of these long-term results, the operation has been largely abandoned.

A Prospective, Comparative Analysis performed by Wilbur B. Bowne et al(2006), has shown the laparoscopic Gastric Bypass is superior to Adjustable Gastric Band in super morbidly obese patients. The patients who underwent Laparoscopic Adjustable Gastric Banding (LAGB) experienced a greater incidence of late complications ( P <0.05), re-operations ( P <0.04), less weight loss ( P <0.001), and decreased overall satisfaction ( P <0.006). Likewise, patients who underwent LRYGB had a greater resolution of concomitant diabetes mellitus ( P <0.05) and sleep apnea ( P <0.01) compared with the LAGB group. Furthermore, postoperative adjustments to achieve consistent weight loss for LAGB recipients ranged from 1 to 15 manipulations. Single mortality was also in this LAGB group [13]. In one another study, LAGB is found significantly associated with more late complications, re-operations, less weight loss, less reduction of medical co-morbidity, and patient dissatisfaction compared with LRYGB [14].

The following table shows the outcome of different types of bariatric operations .

Table 1 . Outcomes of laparoscopic bariatric operations:

VBG, vertical banded gastroplasty; RYGB, Roux-en-Y gastric bypass;BPD, biliopancreatic diversion; DS, duodenal switch; LOS, length of hospital stay Source: [15] a: Data for laparoscopic BPD and DS are few, and these are based largely on available data for open procedures.

RYGBP is safe as well as effective procedure:

The laparoscopic Roux-en-Y gastric bypass has been shown to be safe and effective for the non super-obese patient (BMI <50) by Wittgrove et al [16]. Using same techniques, Nguyen et al were able to perform RYGBP on a patient with a BMI of 61 [17]. Kelvin D. Higa et al (2000) studied a case series of 400 morbidly obese and super-obese individuals who underwent the laparoscopic Roux-en-Y gastric bypass over a 22-month period. They observed that RYGBP can be safely and effectively performed in the community setting using advanced laparoscopic techniques [18].

Laparoscopic Roux-en-Y gastric bypass is a re-do procedure for failed restrictive gastric surgery:

Conclusion Based on the various text, it can be assume that restrictive surgery for morbidly obesity will certainly require many re-operations in the future. The standard operation of choice is LRYGBP. In a study conducted by Van Dessel et al (2006 ) , has shown this procedure a higher, but not significantly early morbidity rate when the indication for re-do surgery was a technical complication of the initial procedure [19].

Effect of Roux-en-Y gastric bypass on the level of serum Ghrelin:

Ghrelin, an acylated protein, is an orexigenic hormone, decreases after feeding and increases before meals, achieving concentrations sufficient to stimulate hunger and food intake. This hormone is basically produced from entero-endocrine cells of gastric mucosa and somewhat from the duodenum. RYGBP seems to achieve a very strong suppression of serum ghrelin level in contrast with gastric banding procedure. These findings are consistent with the assumption that by suppression of ghrelin, gastric bypass can reduce body weight in long term, more than gastric banding. Still, the mechanism by which gastric bypass leads to a reduction in ghrelin level, is not completely understood. It was advanced by the hypothesis that a permanent absence of food in stomach resulting from gastric bypass could cause an uninterrupted stimulatory signal that ultimately decreases ghrelin production by overriding inhibition [20].

RYGBP is the most effective treatment for Type 2 Diabetes Mellitus in morbidly obese patients:

Many studies clearly demonstrated that LRYGBP is highly effective in achieving excellent control in patients with T2DM.After six months of surgery, most patients easily withdraw there all anti-diabetic medications including insulin. Improvement in glucose metabolism occurs early after LRYGB and therefore is not entirely related to weight loss. A study by Alfonso et al (2005) suggests that central obesity negatively influences the likelihood of T2DM resolution after RYGB. They also suggests that RYGBP should be considered as standard treatment of T2DM in obese [21].A resent research paper of Luigi (2007)also says that bariatric surgery appears to be an effective and beneficial intervention in selected obese(BMI > 35 kg/m 2 ) patients with diabetes, when medical and nutritional approaches have failed to achieve the desired outcomes. This becomes especially true when metabolic control in these individuals has not been achieved despite aggressive medical therapy [22].

LRYGBP and effect of learning curve:

Studies conducted by Papasavas et al (2002) and C.Bal et al(2004) tells that it is a technically demanding procedure with significant morbidity during the learning curve. The learning curve soon overcomes, and reaches a rate plateau of complications after adequate training. The mean operating room time and the conversion rate improves with experience. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results [23-24].

Totally Robotic Roux-en-Y Gastric Bypass:

In 2003, Muhlmann et al. conducted a study to compare laparoscopic vs. robotic bariatric procedures. The robotic aided procedure proved to be 30% faster than were even experienced laparoscopic surgeons [25]. Catherine et al (2005) study details the report demonstrates the feasibility, safety, and potential superiority of such a procedure. They say that learning curve may also be significantly shorter with the robotic procedure [26].

COMPLICATIONS:

Complications can be of 2 types, early and late.

Early

1. Anastomotic leak

2. Pulmonary embolism

Late

1. Anastomotic stricture

2. Internal hernia

3. Dumping syndrome

4. Nutritional deficiencies

Comparison with open and laparoscopic RYGBP is associated with reduction in frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there is an increase in the frequency of early and late intestinal obstruction, gastrointestinal tract bleed and stomal stenosis. There are no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia [27]. Retrospective study of 400 consecutive RYGB patients ( from 1999-2002) supports that ,enteric leakage is an important complication of the RYGB. Leaks that are more insidious can be treated successfully with per-cutaneous drainage [28].Leak after LRYGB may be difficult to detect. Evidence of respiratory distress and tachycardia exceeding 120 beats per min may be the most useful clinical indicators of leak after laparoscopic Roux-en-Y gastric bypass [29].

E. Comeau et al (2003) documented 35 cases of internal hernia (overall incidence of 3.3 % ). The IH occurred in 6.0 % of patients with retro-colic procedures and 3.3 % of patients with ante-colic procedures. Most were in the Petersen defect (55.9 % ) and at the entero-enterostomy site (35.3 % ). A bimodal presentation was observed, with 22.9 % of patients with IH diagnosed in the early postoperative period (2–58 days) and 77.1 % in a delayed fashion (187–1,109 days). A laparoscopic approach to the repair of IH was possible in 60.0 % of patients. Complications occurred in 18.8 % of patients, including one death (2.9 % ) [30].

Figure 2. Sites of retroanastomotic or transmesenteric internal hernias, including mesocolic window or retrocolic tunnel ( green arrow ) mesenteric defect, Petersen’s mesenteric defect ( blue arrow ), and enteroenterostomy or distal anastomosis mesenteric defect ( red arrow ).

CONCLUSION:

The selection of surgical technique for a particular patient must be decided by a surgeon who has all of the tools accessible to him in his surroundings. Decisions should be made depending on the individual clinical scenario. No single tool or procedure can be

considered suitable for all patients. Assimilation of all the known data is essential for the surgeon to offer the correct procedure to the correct patient. The well-informed and well-trained individual will recognize that the best preference for most patients looking for surgical treatment of clinical severe obesity is laparoscopic RYGBP.

REFRENCES:

Abstract

Objective

To ruleout whether there was a difference in, recurrence rate, morbidity,and duration of hospital stay between patients undergoing open or laparoscopic ventral hernia surgery.

Materials and Methods:

Cohort study in single-institution was compared prospectively collected from patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Literature search was performed using search engine Google and our online facility of Springer Link. The following search terms were used. Laparoscopic versus ventral hernia repair, ‘laparoscopic repair of ventral hernia, controversies in laparoscopic ventral hernia repair, comparison of laparoscopic and open (Ventral Hernia) repair, Laparoscopic Repair of Ventral Hernia during obesity. About 143 citations found in total. Data collected from 360 consecutive patients who had undergone laparoscopic or open intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected from October 1995 and December 2005 are recorded .

Main Outcome of the study

Hernia recurrence and Duration of hospital stay and morbidity. Postoperative complications of Clavien grade 2 or more than grade 2 were considered as major complications.

Results:

Intraperitoneal onlay mesh surgery was performed in 233 patients by open approach and in 127 patients by laparoscopic approach. Groups were similar for sex and body mass index and it is calculated by weight in kilograms divided by the height in meters squared and the mean age for the laparoscopic group was 3 years younger; and the mesh was selected larger for the laparoscopic group. Mean follow-up for both laparoscopic and open groups was 30 and 36 months; and the conversion rates are 4%. Major morbidities were 15% in the open group and 7% in the laparoscopic group. Recurrence rates were 9% in the open group and 12% in the laparoscopic group. Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% and 16%, respectively)

Conclusions:

Outcomes of the study shows not much difference with respect to recurrence rates after long-term follow-up; however, lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.

Introduction

More than 2 million abdominal surgery’s take place yearly in USA; with an estimated 3% to 20% of those patients develop ventral incisional hernia. With 90 000 ventral incisional hernia repairs are performed every year, the question of whether an open or laparoscopic repair should be performed it depends on general surgeons interest. Data are still inconclusive on morbidity and recurrence rates. The main purpose of this study is to compare the outcome of the patients undergoing open and laparoscopic intraperitoneal onlay mesh repairs in a single institution for a period of 10 years.

Data

Data from all 651 patients who underwent ventral incisional hernia repair between October 1995 to December 2005 at a single institution were collected prospectively. Patients who had undergone an intraperitoneal onlay mesh repair, either open or laparoscopic, are only considered. The techniques of both repairs have been described here.

Open mesh techniques :

Rives, Stoppa and Wantz popularized Open surgical technique

After taking patients to operative theater and under general anaesthesia, endotracheal intubation and with close monitoring operation was started. After painting and draping of abdomen the incision was made according to the site and size of the hernia subcutaneous flap was raised up to 4 to 5 cm around the hernia and the hernial sac was found, contents was reduced sac was excised The mesh is placed in the intraperitoneally and fixation of the mesh done with interrupted sutures at minimum of two centimeters from the fascial edge. Anterior rectus sheath closed over the mesh with a loop of polypropylene without tension, and then skin closed over the drain depending upon size and extension of the wound

Laparoscopic repair of ventral hernia :

Almost all types of Ventral Hernia can be operated by minimal access surgical techniques except if the size more than 10cm and it should be explained clearly to the patient that the laparoscopic repair will not help cosmetically if the skin is very lax and hanging loosely in the large hernia. In Laparoscopic Ventral Hernia Repair evacuation of urinary bladder in lower abdominal surgery and Nasogastric tube in upper abdominal surgery  is necessary, because in most of the cases the access is through the palmers point which is about 2 to 3cm below the left costal margin in mid clavicle line. Day before surgery bowel should be prepared, that will give more working space during surgery in the abdominal cavity. Laparoscopic Ventral Hernia Repair can be done with various methods either intraperitonial or extraperitonial. But in our study repair was done intraperitonially.

Anaesthesia:

General anaesthesia with endotracial intubation and close monitoring.

Patient position :

Supine position without any tilt, so that the bowel is distributed evenly.

Port position :

Port placement technique

The patient is painted and draped and after that checking light cable, insuffilation tube, electro surgical cautery, suction irrigation canula and veress needle patancy with focusing and white balancing of the camera, then pneumoperitoneum is created by veress needle in the left palmers point (this point is contraindicated in splenomegaly) other site like right hypochondrium, flank or iliac fossa can also used for telescope port. Once pneumoperitoneum created then 10mm port put after desirable insufflation another one 5 mm port and 10mm port according to Baseball diamond concept put under vision, after diagnostic laparoscopy the procedure if there is any adhesion careful Adhesiolysis is done. Content of sac returned back which is either omentum or bowel then the extent of defect assessed thoroughly then measurement of the defect drawn on the external surface of anterior abdominal wall and adequate size mesh that cover the whole defect  and overlapping  up to 4 to 5cm from the edge of the defect, all the necessary precaution to be taken to avoid contamination of the mesh, then the mesh rolled and inserted in port to the abdominal cavity, then mesh unrolled and It is fixed by means of  Tacker, Endoanchor or Protack, to abdominal wall with out opening the peritoneum technique. After completing the repair the ports withdrawn under vision and telescope port are removed last. Ports of 10mm better to be repaired because cases of incisional hernia reported in some articles. Recently two port laparoscopic ventral hernia repairs were also reported in some articles.

Choice of mesh

For the hernia repair laparoscopically meshes underwent many changes over the last few years, in general the ideal mesh is characterized by economic aspects, functionality, operative handling, sterility and even anti infective property and optimized biocompatibility.

•  It should be rapid and permanent in growth in to the prosthesis

•  It should decrease the risk of intestinal adhesion

There are two type of mesh commonly used synthetic and collagen based in most article ePTFE were used with polypropylene, because of a low affinity for adhesion, the PTFE mesh is probably the first choice for intraperitoneal prosthesis .In summary the use of mesh can reduce the recurrence rate from 40 to 50% to about 10% only.

The type of operation was determined by surgeon preference. Patients were referred from the same patient pool to members of a surgical group

Exclusion criteria

Patients, who underwent additional procedures at the time of hernia repair, such as planned bowel resection or nonmesh repairs, are excluded from this analysis.

Additional dates were collected from the review of patient records. Variables are assessed by patient demographics like age, sex, body mass index [BMI is calculated as the weight in kilograms divided by the height in meters squared], and co morbidities like obesity diabetes, IHD, pulmonary diseases, details about the operative procedure (open versus laparoscopic repair and type and size of mesh used), and outcome data such as morbidity, recurrence rates, and duration of stay. The type of mesh used depends upon the operating surgeon’s preference and mesh availability. Polypropylene was used by some surgeons and it was determined by intraoperatively so that the amount of omentum present will prevent bowel contact with the mesh to prevent adhesion. The duration of hospital stay was recorded either as outpatient surgery and assigned the value of 0.5 days or as a postoperative inpatient admission with the number of days recorded. Comorbidities are specifically addressed were the corners. IF a patient was identified to have pulmonary disease that was stated in the medical record for follow up. Patients who underwent a conversion to open repair remained in the laparoscopic group for an intention-to-treat analysis.

Complications

Clavien classification was used for staging postoperative complications. Complications of grade II or higher are considered as major complications. In this classification, grade I complications not require pharmacological treatment or intervention; grade II complications that includes patients those requiring pharmacological treatment, total parenteral nutrition or blood transfusions, grade III complications require surgical, radiological or endoscopic intervention; grade IV complications are life threatening and require intensive care unit management; and grade V complications result in death. Postoperative occurrences of a seroma are identified by examine the patient. In laparoscopic hernia surgery, the hernia sac are not excised. This effectively leaves behind a potential space for seroma formation . It happens to be one of the complications inherent to this procedure. A significant seroma was defined as a seroma that caused pain or discomfort, erythema, or infection. Most seromas resolve with time, some requiring eight to 12 weeks for complete resolution. Majority of the authors considered the seromas for conservative management. Some surgeons have advocated using dressing or abdominal binder to cause compression on abdominal wall to occlude the potential dead space.

In the laparoscopic group patients, significant seromas are aspirated. In the open group, drains are placed at the time of operation to prevent the formation of a seroma. No data were collected regarding fixation-related pain. A statistical analysis was done by using Fisher exact test and Wilcoxon rank sum test, and test with SAS statistical software version 9.3 (SAS Institute, Inc, Cary, NC).

Results

From the year 1995 October to December 2005, a total of 651 patients underwent ventral hernia repair at single institution. Around 514 (79%) underwent an open ventral hernia repair and 137 (21%) underwent a laparoscopic ventral hernia repair. Around two hundred eight one patients (55%) who have underwent the open repair and 10 patients (7%) who have underwent the laparoscopic repair were excluded from the study because they underwent either additional procedure, like planned bowel resection or a nonmesh ventral hernia repair. A total of two hundred and thirty three patients who underwent an open procedure and one hundred twenty seven patients who underwent a laparoscopic procedure are used in the final statistical analysis. Five patients (4%) required conversion from the laparoscopic to the open procedure because of hemodynamic instability, or inability to obtain visualization, or technical difficulties during the mesh placement.

Diagnosis of cancer in sixteen patients (7%) in the open hernia group and 7 patients (6%) in the laparoscopic hernia group had diagnosed prior to surgery. There are no data on preoperative prealbumin levels are collected. The mean BMI as a proxy for obesity-related malnutrition are similar for both the groups. Describes the different types of mesh used for the repairs, with the polypropylene mesh used in the earlier phase of the study in patients with sufficient omentum present. No mesh-related bowel fistula was recorded.

Around, 43 patients (12%) experienced Clavien grade II complication or much higher. in the open hernia repair group major complications were significantly seen when compared to laparoscopic hernia group. One patient (0.4%) had a postoperative DVT after open ventral hernia repair which was complicated by Candida septicemia and he was died. In the laparoscopic group one patient manifested sepsis by an unrecognized enterotomy on the first postoperative day and it required reoperation for mesh removal. The patient was recovered and underwent open ileostomy takedown and hernia repair done one year later. Six patients experienced mesh infection in the open group which required removal of the mesh. None of the patients from the laparoscopic group had mesh infection. Major complications seen in patients with preexisting pulmonary comorbidities; Around 27% of patients with pulmonary comorbidities versus 10% of patients without pulmonary disease suffered postoperative complications The recurrence rate and complication rate were not correlated with the type of operation performed (laparoscopic vs. open) in patients with pulmonary comorbidities. By using a logistic regression model, and the occurrence of the complication was associated with the operative method without the adjustment for pulmonary disease and the remained associated after adjustment for pulmonary disease .BMI did not alter these conclusions, and BMI did not contribute significantly to the model In 16 patients (13%) in the laparoscopic group and 21 patients (9%) in the open group had recurrence at a mean follow-up between 30 and 36 months respectively. Median follow-up was done 25 months for patients with open hernia repair and 36 months for the patients with laparoscopic hernia repair .75 patients (32%) in the open hernia group and 45 patients (36%) in the laparoscopic group had more than 36 months duration for follow-up. Determination of recurrence was done by physical examination and documentation in the record. In addition to the records, all the available imaging studies that include computed tomography scans obtained in asymptomatic patients for unrelated diagnoses like cancer follow-up or injury are reviewed. Any information of recurrence in the record or on the imaging studies, whether they are symptomatic or not, are taken as recurrence. Statistical analysis did not reveal about the effect related to the type of mesh used on the recurrence rate. Studies revealed that patients who developed a postoperative abscess had increased recurrence rate that is 4.4-fold recurrence when compared with those who did not develop an abscess. Patients with higher BMI rates more than 30 had a 5-fold risk of recurrence when compared with patients with normal weight (BMI<25) Postoperative inpatient admission was more frequent in the open procedure than after the laparoscopic procedure respectively; The higher rate of outpatient surgery in the laparoscopic group than in the open group was associated with a shorter mean duration of stay (mean ± SD length of stay, 0.9 ± 1.4 days vs. 1.4 ± 2.0 days, respectively) .

Discussion

Ventral hernias are more common, and controversy are still exists as to the best method for surgery. There are no large randomized or multicenter trial has been completed till today, although one systematic review was published in the year 2004.Datas from smaller trials and cohort studies represent the available evidence. Some of these studies are summarized in our study has provided an additional experience in a large patient population and a long follow-up.

Systematic review performed by the auspices of the Royal Australasian College of Surgeons Australian Safety and Efficacy Register of New Interventional Procedures–Surgical and other recent studies shows clear differences in the duration of the hospital stay, operating room supply cost, and the total hospital cost between open and laparoscopic ventral incisional hernia repair. Studies shows patient underwent laparoscopic hernia repair had significantly shorter the hospital stay, the instrument cost was significantly higher, and the overall cost was significantly lower. Large variations without a clear difference between the open and laparoscopic hernia repair methods in comparison with complication rates and recurrence rates. Our study used the Clavien classification of complications to account not only for the occurrence of a complication but also for the severity. By using this classification, data suggest that more severe complications occurred in patients undergoing open ventral hernia repair, whereas seromas were more frequently noted in patients undergoing laparoscopic repair. The most significant patients for complications are patients with preexisting pulmonary disease. This study did not have enough statistical power to examine any correlation between the complication rates and mesh type .

Older studies described obesity as a risk factor for the development of ventral incisional hernias and also risk factor for recurrence and complications. studies shows that patients with a BMI more than 30 had a risk of recurrence 5 times higher when compared to patients with a BMI less than 25. The high BMI combined with a relatively long follow-up may have contributed to our recurrence rates, which were at the upper end of the reported spectrum. Laparoscopic patient group required significantly fewer inpatient admissions, a finding that may be explained by better pain control or faster recovery from operative trauma, as suggested by others.

Conclusion

This study confirms that laparoscopic ventral incisional intraperitoneal onlay mesh hernia repair is associated with less severe complications, equivalent recurrence rates, and shorter hospital stays when compared with open repair. It further validates the use of the laparoscopic approach.

References

Abstract

Introduction

Tubal sterilization is an operation which blocks the tubes carrying a woman’s egg to her uterus. Worldwide, it is the most commonly used method of birth control. Often the operation is performed through a laparoscope. This instrument is inserted through a small incision in the abdomen. The tubes are visualized so the surgeon can place rings on, or apply clips to, the tubes or burn the tubes .

After a tubal sterilization the egg cannot reach the uterus, and the man’s sperm cannot reach the egg. This operation should be considered permanent. You must be certain you do not want t to deliver more children and will not change your mind .Complete information about this surgical procedure is available from your clinician. In 1994, the WHO in Geneva convened current investigators in sterilization to assess research developments 1 . The following are excerpts from the summary report as concerns laparoscopy:

“The most appropriate method of female sterilization in a particular family planning programme often is determined by local situations and constraints. The ideal female sterilization method would involve a simple, easily learned, one-time procedure that could be accomplished under local anesthesia and involve a tubal occlusion technique that caused minimum damage. The procedure would be safe, have high efficacy, be readily accessible, and be personally and culturally acceptable. The cost for each procedure would be low and there would be minimal costs for the maintenance of equipment. No currently available procedure meets all of these criteria, although minilaparotomy and laparoscopy come close.

Training, to ensure adequate surgical skills, and counseling to ensure that women accepting the method understand fully the possibility of both pregnancy and ectopic pregnancy should the method fail and the highly permanent nature of the procedure, are of major importance in sterilization programmes. The potential reversibility of sterilization was touched on by several speakers. It was agreed that where procedures used in a programme have a high potential for reversibility there should be centers established where the necessary surgical skills are available. It also was agreed that sterilization methods should be presented to potential acceptors as being permanent methods of fertility regulation

The abdominal procedures that have been developed, namely minilaparotomy (postpartum and interval), and laparoscopy, meet the essential requirements of efficacy, safety, and can be carried out under local anesthesia with a minimum use of sedatives. Training in technical skills should put emphasis on the use of local anesthesia and correct site for placement of clips or rings. Accurate placement of clips and rings on the tube is critical to ensure high rates of efficacy World-wide development of laparoscopic sterilization. The following are excerpts pertaining to laparoscopy from a recent WHO overview of the evolution of female sterilization. 2

“Sterilization of women, by surgical occlusion of the Fallopian tubes, is the most widely accepted of all modern family planning measures, being currently used by an estimated 140 million eligible couples worldwide (United Nations 1992), and is the most commonly used modern contraceptive method in many developing countries 3 .

The re-emergence of laparoscopy in the 1960s, made possible by the development of fibre-optics, resulted in a rapid adaptation of this approach to the tubes for sterilization. Initially the technique was employed under general anesthesia, with carbon dioxide being used to provide abdominal distention. Early instrumentation required a two-puncture technique, but refinement of the instruments soon led to procedures being carried out through a single, sub-umbilical puncture. The use of local anesthesia and alternative gases, such as nitrous oxide or operating room air, were further simplifications.

The wider introduction of laparoscopy in the 1970s was a major contributor throughout the world to women’s acceptance of sterilization as a method of family planning. The original unipolar electro coagulation technique by Steptoe in 1967, described in his classic text book of laparoscopy 4 , paved the way for worldwide use of the laparoscope and development of simpler and safer techniques.

The training required the cost of the instruments and the skilled maintenance needed meant that laparoscopy was principally confined to hospital settings where there were established surgical facilities. This was challenged by some. In (the Philippines and) India many saw the potential of laparoscopy for accomplishing large numbers of procedures in a short time. Camp sterilization programs were set up with some spectacular claims being made for the numbers of sterilization that could be done in a day 5 .

Sterilization, other than postpartum, was infrequent before the acceptance of laparoscopy. Many vaginal surgeons were performing a vaginal fimbriectomy as described by Kroener6 in 1969. Other vaginal approaches incorporated the use of tantalum clips. Compared to laparoscopic approaches, however, the vaginal methods have been associated with a higher morbidity from postoperative infection, as well as higher pregnancy rates due to incomplete removal of the fimbriae or incomplete closure of the tantalum clips.

Similarly, the concept of minilaparotomy has been introduced in developing countries as a means of avoiding the expensive equipment necessary for laparoscopy. In trained hands, and under general anesthesia, a minilaparotomy is an effective and comfortable method of accomplishing sterilization with the simple Pomeroy technique. Under local anesthesia, the abdominal invasion is usually sufficiently uncomfortable to make this procedure less acceptable by patients, particularly if laparoscopy is available as an alternative. A large, multi centre study comparing minilaparotomy and laparoscopy has shown few differences between the two approaches, as well as very low short-term complication rates 7 . For these reasons, minilaparotomy has also been abandoned except by a few skilled practitioners.

From the mid 1960s and extending to about 1983, when the last extensive review of the field was undertaken, the period was characterized by the development of new ways of approaching the tubes, such as by laparoscopy and hysteroscopy, and the use of new materials, both plastic and metal, to achieve tubal occlusion. Electro coagulation was refined during this period.” 2

Laparoscopic techniques

1. Unipolar coagulation and division

This technique was the first described by Steptoe and used by gynecologists learning both laparoscopy and electro coagulation techniques. The tube is grasped, and current is passed through the tube (and body) to a base plate. The method produced considerable destruction of tube with electric current but was also associated with hemorrhage from incompletely coagulated vessels severed at the time of tubal division. Deaths were associated with unipolar coagulation8, perhaps as much because of complications of trocar entry as electro coagulation of bowel. This method was abandoned by most laparoscopic in favor of the less destructive techniques described below.

2. Bipolar coagulation

This technique was developed simultaneously and independently in the early 1970s by Rioux in Canada , Kleppinger in the United States , and Hirsch in Germany . The Kleppinger technique emerged as the most popular method of laparoscopic sterilization in the United States . The bipolar technique is the simplest to perform technically and is the most common method of laparoscopic sterilization today. The poles of the forceps conduct the electricity between them, with no current flow beyond the forceps, so the patient is not part of the circuit. Failures after bipolar coagulation have been due to incomplete coagulation, sometimes using inappropriate generators 9 .

The end point of successful coagulation is indicated by a current flow meter on the appropriate or matched generator. When the flow diminishes and ceases, the tubal tissue has been desiccated to the point that it no longer conducts electricity and the forceps can be moved to the next area for coagulation. Kleppinger stresses that three contiguous areas are to be coagulated. This results in at least 3 cm of tube being destroyed and prevents spontaneous recanalisation occurring as a result of the healing process bringing the two stumps closely together 10 . Recent reports of a high incidence of ectopic pregnancy following bipolar coagulation 11 (see Table 1) may be the result of fistula formation between the uterus and peritoneum when the tube is destroyed too close to the uterus 12 . Sperm can travel through these utero-peritoneal fistulas, reach the egg in the distal tube segment, and cause an ectopic pregnancy by this route. This has led to the recommendation that the tube be grasped at least 2 to 3 cm away from the utero-cornual junction at the time of sterilization so that a stump of isthmus remains to absorb the intrauterine fluid under pressure and minimize fistula formation.

3. Silastic band application

The Silastic band for sterilization was developed simultaneously by In Bae Yoon and Coy Lay in the early 1970s. Widely distributed by the U.S. Agency for International Development, the band was offered as a non-electric (and presumably therefore safer) method of tubal occlusion. A loop of the fallopian tube is drawn 1.5 cm into a 0.5 cm diameter metal cylinder, destroying 3 cm of tube. A Silastic ring stretched on the outside of the cylinder is released to form an occlusion at the base of this knuckle. Over time, about 3 cm of constricted tube undergoes necrosis and the tubes separate. Similar to the Pomeroy technique in theory, the laparoscopic application of band is associated with a 2-3% incidence of hemorrhage from stretching the vessels underneath the tube or tearing the tube itself. For this reason, Yoon and associates13 have recommended that bipolar coagulation be available to manage this complication. Post operatively, patients experience pain arising from hypoxic necrosis of the tube in the band. This pain has led to a high incidence of readmission to hospitals (see table 1). This subsides in 48 to 96 hours and can be diminished somewhat by topical application of anesthesia at the time of band application.

4. Spring clip application

Devised in the 1970s to offer a mechanical alternative to electrocoagulation, the spring clip (Hulka Clip) occludes the isthmus of the tube by 2 plastic jaws, compressing the tube by a gold-plated stainless steel spring pressing the jaws together 14 . This is the only clip that does not rely on a latch which can potentially tear through a meso-salpingeal vein. Spring clip application by laparoscopy requires careful surgical technique to assure that the clip is completely across the isthmus of the tube. Although the initial pregnancy rates were high as a result of misapplication, the current pregnancy rates for clip, coagulation, and band are comparable. The spring clip is the most reversible of the techniques 15 (see table 1) since less than 5mm of tube is destroyed between the jaws of the clip. For this reason, it should be considered when one is selecting a method for a woman under 30.

5. Cautery techniques

True cautery is the direct application of heat to tissue, in contrast to electro coagulation and desiccation, where electrical energy flows through tissue and heats it. In Germany , the Semm Endotherm forceps is placed across the tube and one prong of the forceps is heated to 100c, cauterizing the tube. The time (30 to 60 seconds) required for each cautery, as well as the high postoperative ectopic pregnancy rate, has limited the popularity of this method.

Techniques under investigation

The laser has been tried for tubal division at laparoscopy but offers no advantage over standard techniques. Burying the fimbriae in a pouch of broad ligament peritoneum, and burying the ovary in an artificial plastic pouch, has been evaluated in animals but have not been used with humans because of the increased morbidity compared to standard techniques. Various other clips have been devised (Bleier and Filshie clips). The Bleier clip has been discontinued because of a high pregnancy rate due to the tube slipping into spaces within the jaws of the clip. The Filshie clip is heavier and more expensive than the Spring clip and is associated with occasional hemorrhage on application due to the latch going through meso-salpingeal vessels. It received approval by the FDA in 1996, but comparative efficacy data are lacking.

A number of hysteroscopic approaches have reached the human trial stage only to prove less cost-effective than the standard laparoscopic techniques. In Europe, plastic tubal plugs developed by Steptoe in England and Hamou in France were abandoned after ectopic pregnancies developed. In the United States , the Silastic plug16 was extensively evaluated17 and found to be efficacious in about 85% to 90% of candidates, but technical failures persisted despite two or three hysteroscopic re-applications. The technique is intended to be reversible, but reversibility has not been demonstrated. Other hysteroscopic approaches have included destroying the endometrium by freezing or coagulation by heat or chemicals, but these approaches have been abandoned or are still in pre-clinical evaluation stages. Similarly, the introduction of methyl cyanoacrylate (crazy glue) into the tube has been clinically tested overseas but is not ready for clinical use. The Chinese have experimented with formalin injection into the tube, but reports of the efficacy and safety of this approach are incomplete. Although there are still active research projects concerning alternative sterilization techniques, the existing laparoscopic approaches of mechanical or electro coagulation tubal occlusion remain the standard against which these alternatives must be measured in terms of cost, efficacy, and safety.

Sterilization failures

A large number of patients (over 1000) must be followed for a 2 to 3 year period with a high rate (over 85%) of follow-up to study the pregnancy rate following sterilization techniques,. This enormously difficult task has been accomplished very few times: by Johns Hopkins University in the early days of electro coagulation and by the University of North Carolina in the development of the spring clip. Currently, the CREST study of the Centers for Disease Control (CDC) is following several thousand patients sterilized by a variety of techniques. This prospective 10 year national study has recently been concluded 18 and is revealing a much higher pregnancy rate than was first appreciated for all methods of sterilization - approaching 1 pregnancy per 100 sterilizations within 3 years, and 2-3 per 100 over 10 years. The latest education pamphlet on sterilization by the American College of Obstetricians and Gynecologists (ACOG 1991) states, “More than 99 out of every 100 women who have this procedure will not become pregnant, but you should be aware that the procedure does not guarantee sterility. Although the risk of failure is low, sometimes the procedure does not work.”

Ectopic pregnancy is a rare but life threatening form of pregnancy failure requiring early intervention for safe management. The CDC study has revealed that the late pregnancies after bipolar coagulation are mostly ectopic in nature. For this reason, we strongly recommend that when this technique is used a segment of isthmic tube next to the uterus be left to minimize the risks of fistula formation. Women with less tissue damage (from Pomeroy, band, and spring clip sterilization) have relatively less risk of ectopic pregnancy.

Conti filure

Whether a reversible method or sterilization is being considered, the goal of clinician-patient dialogue is to ensure that the woman has enough information and time to determine the best method for her at that point in her life. If sterilization is chosen, the clinician should assess, through two-way dialogue, whether the woman has adequately considered the implications of ending her childbearing potential. Each woman’s knowledge base, cultural context, and experiences are different; each woman has her own unique contraceptive history and contraceptive requirements. As a facilitator, the clinician should strive to convey information that is medically accurate yet understandable, unbiased, and provided at such a time and in such a manner as to permit sufficient time for patient deliberation. Helpful clinician-patient conversations vary in detail and focus as dictated by individual patient circumstances.

Any woman who has completed childbearing is a potential candidate for sterilization. Parity, once considered important in determining eligibility for sterilization, does not correlate with sterilization regret and is not a reason to deny the procedure. 11,12 While regret is associated with having the procedure performed at ages younger than 30, 11,12 age is not a criterion for procedure eligibility. However, younger age should signal the need for a careful, thoughtful dialogue about how desire for sterilization can change with changing life events.

While tubal sterilization is intended to permanently prevent conception, failures do occur. Reasons for failure include undetected luteal pregnancy, occlusion of an incorrect structure (most commonly the round ligament), incomplete or inadequate occlusion, slippage of a mechanical device, development of a tub peritoneal fistula, and spontaneous re-anastomosis or recanalization of the cut ends.11

The U.S. Collaborative Review of Sterilization (CREST) is the landmark prospective, multi center, observational study14 on the use of sterilization in this country. The CREST study was conducted by the Centers for Disease Control and Prevention with support from the National Institute for Child Health and Human Development. CREST recently reported a 10-year (1978 to 1987) cumulative failure rate for sterilization of 1.85 percent in 10,685 women.14 CREST, which reports failure rates that are higher than previously expected, is the largest body of data, thus far, for this length of follow-up.

The CREST study found a higher-than-expected failure rate (i.e., 2.01 per 100 women over 10 years) for interval minilaparotomy sterilization, an office-based procedure14. Most likely, this was a consequence of the low numbers of minilaparotomy cases (i.e., 425 women among a total of 10,685). The higher failure rate also might be caused by the fact that in the United States , interval minilaparotomy often is performed in surgically challenging circumstances, such as when severe pelvic adhesions are present and laparoscopy is deemed inappropriate.14

The risk of sterilization failure persisted throughout the study period14. This finding contradicts the widely held but inaccurate belief that if pregnancies are to occur after sterilization procedures, they will do so within one to two years after the operation. Although the CREST study revealed cumulative 10-year failure rates higher than previously thought, the study confirms that sterilization, when performed with appropriate technique by an experienced clinician, continues to be an extremely effective long-term contraceptive. Contraceptive candidates can be reassured that long-term risk of failure is low and that only the intrauterine device and levonorgestrel (Norplant) implant system (currently unavailable in the United States ) have comparable, long-term failure rates.8-10

The CREST study did not include data on the Filshie clip, which was unavailable in the United States at the time of study enrollment. A 10-year cumulative failure rate of 0.5 percent for 200 women was recently reported for the Filshie clip.11, 15

By preventing pregnancy, female sterilization has an overall protective effect on the risk of ectopic pregnancy. However, when pregnancy does occur it is likely to be ectopic. Of the 143 pregnancies reported in the CREST study, one third were ectopic.16

Regret

The two most common factors associated with regret are young age and unpredictable life events, such as change in marital status or death of a child.11, 17 Regret also has been shown to correlate with external pressure by the clinician, spouse, relatives, or others.11 Interestingly, marital status at the time of the operation, level of education, and the absence of children do not, in many studies, correlate with regret.11, 12, 17

Regret is difficult to measure because it encompasses a complex spectrum of feelings that can change over time. This helps to explain that while some studies have shown “regret” on the part of 26 percent of women, fewer than 20 percent seek reversal and fewer than 10 percent actually undergo the reversal procedure.11, 18, 19.

Depending on such factors as the technique used for sterilization, the resulting length and portion of undamaged fallopian tube remaining, the woman’s age, and the surgeon’s skill, success rates for reversal range from 47 to 90 percent.11 Women who are ambivalent about the permanence of the procedure should be counseled to strongly consider another contraceptive method.

Complications

Overall, major complications of tubal ligation are rare, occurring in fewer than 0.5 percent of cases.11, 20-22 Complications are influenced by factors such as choice of anesthetic, patient characteristics, positioning, technique, and operator experience.11 Short-term complications (e.g., anesthetic difficulties and hemorrhage) occur in the operating room and manifest immediately or in the first several weeks after surgery. Trauma to organs such as the bowel, bladder, ureter, uterus, and cervix can result from cautery, occlusion, and sharp and blunt traumas. Death, a rare outcome of tubal ligation, occurs in only one or two of every 100,000 cases in the United States.23 Currently, the U.S. death rate secondary to complications of pregnancy is seven per 100,000 live births.24 The 29 sterilization-associated deaths reported in the United States between 1977 and 1981 were associated with complications of anesthesia (11 women), sepsis (seven women), hemorrhage (four women), myocardial infarction (three women), and “other causes” (four women).25

Potential risk of tubal ligation. As with any surgical procedure, tubal ligations pose certain risks. These include:

There are disadvantages to both minilaparotomy and laparoscopic sterilization that must be weighed by the patient. Disadvantages of minilaparotomy include:

Disadvantages of laparoscopic sterilization chiefly revolve around certain medical conditions that may prohibit use of the procedure. Women who have heart or lung disease or a history of bleeding may not be candidates for tubal ligation. In addition, women who are obese or have intra-abdominal scarring may be prohibited from the procedure. According to the Food and Drug Administration (FDA), less than 1 percent of women who have had a tubal ligation become pregnant each year. However, failure rates increase over time, as the fallopian tubes can fuse back together. This is especially true of women who had the procedure early in their reproductive years. Some medical centers have reported a failure rate in young women of 5 percent during the first decade after the surgery. Women who get pregnant after a tubal ligation are at higher risk for an ectopic pregnancy. Recently published results from a 14-year study that was supported by the National Institutes of Health (NIH) found that the likelihood of ectopic pregnancy varied according to the method of sterilization used and the age at which the patient underwent the tubal ligation. Generally, women who are younger than age 30 at the time of sterilization are at greater risk of experiencing a subsequent ectopic pregnancy than older women. The researchers also found that ectopic pregnancy may occur as many as 10 years after tubal ligation.

Patients who experience symptoms of an ectopic pregnancy should seek immediate medical care. These symptoms include:

Feelings of faintness or dizziness

While major complications are uncommon after tubal ligation, there are risks with any surgical procedure. Possible side effects include infection and bleeding. After laparoscopy, the patient may experience pain in the shoulder area from the carbon dioxide used during surgery, but the technique is associated with less pain than mini-laparotomy, as well as a faster recovery period. Mini-laparotomy results in a higher incidence of pain, bleeding, bladder injury, and infection compared with laparoscopy. Patients normally feel better after three to four days of rest, and are able to resume sexual activity at that time.

The possibility for treatment failure is very low—fewer than one in 200 women (0.4%) will become pregnant during the first year after sterilization. Failure can happen if the cut ends of the tubes grow back together; if the tube was not completely cut or blocked off; if a plastic clip or rubber band has loosened or come off; or if the woman was already pregnant at the time of surgery

About 1–4% of patients experience complications following tubal ligation. There is a low risk (less than 1% or seven per 1,000 procedures) of a later ectopic pregnancy. Ectopic pregnancy is a condition in which the fertilized egg implants in a place other than the uterus, usually in one of the fallopian tubes. Ectopic pregnancies are more likely to happen in younger women, and in women whose tubes were closed off by electro coagulation.

Rarely, death may occur as a complication of general anesthesia if a major blood vessel is cut. The mortality rate of tubal ligation is about four in 100,000 sterilizations.

Tubal ligation reversal

More than 650,000 women undergo tubal ligation in the United States annually, thus ending their ability to have children. What happens when circumstances change and a woman decides that she really does want to become pregnant? Approximately six percent of women who originally decided that tubal ligation was the way to end their childbearing years will, within five years, decide that she does indeed want to experience pregnancy and the birth of a new baby.

Post Tubal Ligation Syndrome

Sometimes, tubal ligation reversal is desired not for the purpose of having children, but to reverse the effects experienced by many women of post tubal ligation syndrome. The symptoms of post tubal ligaiton syndrome may include:

Rates of Tubal Ligation Reversal?

Several factors play a key role in the success rate of tubal ligation reversal. These include:

Women who make the best candidates for tubal ligation reversal are those whose tubal ligations included either the removal of a small section of the fallopian tubes, or those whose tubal ligation was achieved by clips or rings placed around the tubes to prevent eggs released during ovulation from traveling through the fallopian tubes. Overall, success rates for tubal ligation reversal can vary from 20 percent to 70 percent.

Tubal Reversal Procedures

Before your health care provider can advise you about the potentialfor successful tubal ligation reversal, you will need to provide him with all the facts and records from your tubal ligation procedure. The type of tubal ligation procedure used will determine the best procedure for tubal reversal, and have a major impact on your chance of success.

The tubal ligation reversal procedure uses microsurgery to rejoin the two remaining sections of the fallopian tubes. Certain factors have a direct effect on the potential for a successful tubal reversal procedure. Because the fallopian tube’s diameter varies from one end to the other, the best chance for success occurs when the diameters of the two remaining sections of fallopian tube are almost identical. In cases where the two remaining ends of the tubes are of different diameter (for example, a narrow end of tube close to the uterus is being connected to a wider end near the end of the fallopian tube), success rates for pregnancy are lower.

The ideal candidate for tubal ligation reversal is a woman who has nearly equal diameter of the remaining ends of the tubal sections, and whose tubes are at least three to four inches long following reversal of the tubal ligation. (Before tubal ligation the fallopian tubes are approximately eight inches long.) The decision to undergo tubal ligation reversal should be carefully weighed against the potential for successful in vitro fertilization. Women who have little chance of successful tubal reversal should be advised to consider in vitro fertilization. You should discuss your personal situation with your health care provider to determine your best option for achieving successful pregnancy either by tubal ligation reversal

Counselling issues

Counseling for reversible contraceptive methods generally involves clinician and patient dialogue regarding safety, efficacy, potential side effects, and integration of the method into the woman’s lifestyle. All health care professionals who counsel women about contraception should recognize the advantages and disadvantages of female sterilization compared with nonpermanent, long-acting methods (Table 1).3, 7-10 Sterilization counseling should include discussing permanence of the method, possibility of future regret, and information about the surgical procedure. Assessment of whether the woman’s partner might consider undergoing sterilization rather than the woman also is appropriate (Table 1).3, 7-10.

Whether a reversible method or sterilization is being considered, the goal of clinician-patient dialogue is to ensure that the woman has enough information and time to determine the best method for her at that point in her life. If sterilization is chosen, the clinician should assess, through two-way dialogue, whether the woman has adequately considered the implications of ending her childbearing potential. Each woman’s knowledge base, cultural context, and experiences are different; each woman has her own unique contraceptive history and contraceptive requirements. As a facilitator, the clinician should strive to convey information that is medically accurate yet understandable, unbiased, and provided at such a time and in such a manner as to permit sufficient time for patient deliberation. Helpful clinician-patient conversations vary in detail and focus as dictated by individual patient circumstances.

Any woman who has completed childbearing is a potential candidate for sterilization. Parity, once considered important in determining eligibility for sterilization, does not correlate with sterilization regret and is not a reason to deny the procedure.11,12 While regret is associated with having the procedure performed at ages younger than 30,11,12 age is not a criterion for procedure eligibility. However, younger age should signal the need for a careful, thoughtful dialogue about how desire for sterilization can change with changing life events

Final Comment

Permanent sterilization is the contraceptive choice of many women. Whether performed in the interval time period or immediately postpartum, tubal sterilization is a safe and effective procedure. While safety and efficacy should be discussed with each prospective candidate, a more important issue for deliberation is whether the woman is making an informed decision. Is she choosing the best possible option for her current and future life circumstances? While ultimately the decision must be hers, clinicians can facilitate informed decision-making through the counseling content and approach. Counseling dialogue should include the permanence of the procedure, the lack of protection against STDs, the need for continued gynecologic preventive care (e.g., Papanicolaou smears, bimanual examination, mammography), and the context surrounding who may or may not be influencing the woman’s decision.

Minilaparotomy under local anesthesia is a safe alternative to conventional interval sterilization by laparoscopy and belongs in any general discussion of provision of this service.

References

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•  Peterson HB, Pollack AE, Warshaw JS. Tubal sterilization. In: Rock JA, Thompson JD, eds. Te Linde’s Operative gynecology. 8th ed. Philadelphia : Lippincott-Raven, 1997:529.

•  Hatcher RA, Trussell J, Stewart F, Cates W, Stewart GK, Guest F, et al. Contraceptive technology. 17th ed. New York : Ardent Media, 1998.

•  Henshaw SK. Unintended pregnancy in the United States . Fam Plann Perspect 1998;30:24-9, 46.

•  Haws JM, Pollack AE, Beattie KJ, Koonin LM, MacKay A, Kieke BA, et al. New data on sterilization use in the United States . National Institutes of Health, Bethesda , Md. , June 1998.

•  Westhoff C, Davis A. Tubal sterilization: focus on the U.S. experience. Fertil Steril 2000; 73:913-22.

•  World Health Organization. Improving access to quality care in family planning: medical eligibility criteria for contraceptive use. 2d ed. Geneva : Reproductive Health and Research, World Health Organization, 2000.

•  Trussell J, et al. Chapter 31: Contraceptive failure. In: Contraceptive technology. 18th ed. New York : Ardent Media (in press).

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Abstract

Laparoscopy has become an accepted method of management for ovarian cysts. Large ovarian cysts, however, have traditionally been, and continue to be treated by laparotomy. This is mainly due to technical difficulties and the possibility of malignancy. We describe four patients in whom laparoscopy was used to remove large ovarian cysts. Laparoscopic guided aspiration was performed, followed by extra-abdominal excision of the cyst. This approach has the advantages of minimising the risk of spillage of cyst fluid, a smaller incision compared to laparotomy, as well as faster recovery. We advocate this method for large unilocular benign cysts.

Materials and Methods:

A literature review was performed using Springerlink, Pubmed, Highwire press,   search engines like Google, and Yahoo. the following terms were used :ovarian tumors,cystic teratomas, endometriosis . Selected papers were screened for further references.

Key words :

Bordline ovarian tumors cystectomy fertility recurrence surgery

Conclusion :

With proper patient selection, the size of an ovarian cyst is not necessarily a contraindication for laparoscopic surgery

Introduction

Ovarian endometrioma is a common disease lesion among women with endometriosis. Regardless of its symptoms, surgery is most frequently chosen for its treatment because medical treatment alone is inadequate (Jones and Sutton, 2000). In addition, a likelihood of malignant change in this disease is not negligible (Nishida et al ., 2000), and European Society of Human Reproduction and Embryology (ESHRE) guidelines recommend that histology should be obtained to exclude malignancy in cases of endometrioma of more than 3 cm in diameter (Kennedy et al ., 2005) Because this disorder is commonly diagnosed in women of reproductive age (Giudice and Kao, 2004), laparoscopic excision of endometrioma, instead of oophorectomy, is applied for most cases. When it is done in infertile woman, laparoscopic excision is also known to improve fertility (Beretta et al ., 1998). One of the most frustrating aspects of treating endometrioma with laparoscopic excision is disease recurrence after surgery (Busacca et al ., 1999). When planning a laparoscopy, gynaecologists should be aware of each individual’s expected likelihood of recurrence as well as her symptoms and desire for current or future fertility. By having information about factors that may be related to a recurrence of ovarian endometrioma, gynaecologists will be able to distinguish patients at risk, optimize the timing of laparoscopy and plan pre- and post-operative management properly. However, little study has been done to analyse various variants that may have impacts on a recurrence of endometrioma after laparoscopic excision. To date, recurrence of ovarian endometrioma after laparoscopy has always been discussed focusing on a single factor, such as the effect of post-operative (Muzii et al ., 2000) or preoperative (Muzii et al , 1996) medication, the method of laparoscopic treatment (Saleh and Tulandi, 1999) and the anatomical location (Ghezzi et al ., 2001). There is only one multivariate analysis that analysed six variables on the recurrence of K.Koga et al . 2172 endometrioma by Busacca et al . (1999). To analyse risk factors that might influence the recurrence of endometrioma after laparoscopic excision, we retrospectively evaluated 14 variables to assess their independent effects on the recurrence.

The borderline ovarian tumours (BOTs), also referred to as low malignant potential tumours, are a subgroup of epithelial ovarian tumours accounting for 10–15% of all ovarian tumours, which are characterized by histologic features of malignant tumours without identifiable destructive stromal invasion (Acs, 2005 ).

Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the gold standard treatment for BOTs in peri- or post-menopausal women, patients who have completed childbearing or those who have no desire to preserve their fertility (Tinelli et al ., 2006 ) . Because BOTs are characterized by common presentation during the childbearing years at an early stage and by an excellent long-term survival, fertility preservation becomes an important issue in their management (Morice et al ., 2003 ) . In this regard, a fertility-sparing surgical treatment, consisting of uterine preservation and at least a part of one ovary, has been proposed to patients with early-stage BOTs who want to preserve their childbearing potential, and, over the years, this treatment has become a pivotal and well-consolidated approach for patients with BOTs who want to preserve their fertility (Morice et al ., 2003 ; Tinelli et al ., 2006 ) .

Even if obtained in a retrospective fashion, in a non-selected population after laparotomy, the available data suggest that in patients with BOTs, cystectomy is related to a higher recurrence rate compared with oophorectomy (Morice et al ., 2003 ; Tinelli et al ., 2006 ) . For these reasons, salpingo-oophorectomy has been widely used to reduce recurrence and to preserve good reproductive capabilities in patients with unilateral BOTs (Morice et al ., 2003 ) .

BOTs are bilateral in 25 –50% and in 5 –10% of the serous and mucinous histotypes, respectively (Acs, 2005 ; Tinelli et al ., 2006 ) . In these cases, the standard fertility-sparing surgery consists of salpingo-oophorectomy plus controlateral cystectomy (Morice et al ., 2003 ) . At present, it is not known whether patients with bilateral BOTs of reproductive age could benefit by a more minimally invasive approach, such as a bilateral cystectomy. During the last few years, laparoscopic treatment of adnexal masses has proved to be a useful diagnostic and therapeutic tool (Pejovic and Nezhat, 2001 ) . In terms of reproductive outcomes, the laparoscopic approach also seems to be safer than laparotomy in reproductive age patients (Pejovic and Nezhat, 2001 )

The purpose of the present study was to compare the effects of two laparoscopic fertility-sparing surgical procedures, that is, oophorectomy plus controlateral cystectomy versus bilateral cystectomy, on the safety and fertility in young women who desire to conceive as soon as possible and are affected by bilateral BOTs.

Teratomas are neoplasms containing tissue from all three germ cell layers. Most are mature cystic teratomas (MCT) with predominantly ectodermal derivatives such as hair and teeth. Collectively, teratomas constitute half of all ovarian neoplasms in children (Azizkhan and Caty, 1996 ) and 1% of these are malignant immature teratomas (O’Connor, 1996 ) . Traditional management of children with MCT has been oophorectomy via laparotomy (Carney, 1972; Mahour et al ., 1976 ; Azizkhan and Caty, 1996 ) . However, acceptable management in adults is ovarian cystectomy approached by laparoscopy, with laparotomy generally reserved for cases of large MCT tumours or those suspected of malignancy (Bollen et al ., 1992 ; Canis et al ., 1994; Lin et al. , 1995 ). The aim of this study was to examine the contemporary surgical management of MCT in children and adolescents.

Benign cystic teratomas (‘dermoid cysts’) of the ovary constitute some 10–13% of all ovarian tumours and represent the most common benign ovarian germ cell tumours (Peterson et al. , 1955; Peterson, 1956; Woodruff et al. , 1968; Caruso et al. , 1971). Typically these tumours are discovered during Child-bearing age. The spectrum of clinical presentation of these tumours ranges from incidental finding in some cases to chemical peritonitis in others, but usually consists of some form of abdominal pain reaching extreme intensity when ovarian torsion occurs (Cunanan et al. , 1983). Up to 12% of cases involve both ovaries, which in the past has led some authorities to recommend routine contralateral ovarian biopsy (DiSaia, 1994). The advisability of this routine in the absence of obvious involvement may be challenged on the basis of 1% malignant transformation which is specifically rare in the young (Gallion et al. , 1983). 1810 © European Society for Human Reproduction and Embryology Notwithstanding this, any surgical approach to dermoid cysts should take into account the possibility of both chemical peritonitis and malignancy. In addition, maximal ovarian conservation and minimal abrasive tissue handling are advocated when future fertility is of importance. Therefore, laparoscopic surgery emerges as a specifically tailored technique to tackle these demands (Reich et al. , 1989; Nezhat et al. , 1989; Shalev and Peleg, 1993), provided that the chances for chemical peritonitis due to spillage are minimized. We present here our experience with 84 cases, treated laparoscopically. This can serve to delineate the clinical scope of this pathology and the safety and feasibility of its treatment in the era of laparoscopic surgery.

Management of ovarian cysts

Depends on age, menopausal status, and the size and structure of the cyst Ovarian cyst s are present in 6% of asymptomatic postmenopausal women. Most of these cyst s are benign or functional, and the physician’s role is largely to exclude cancer, which has a prevalence of 61 per 100 000 in women aged 68 years. Needle aspiration of ovarian cyst s has been proposed as an alternative to laparoscopic and conventional surgical excision , especially when the cyst is believed on clinical grounds to be benign. Needle aspiration has the important advantage over surgical excision that it can be performed under local anaesthetic and does not require admission to hospital. Nevertheless, there are several important questions concerning needle aspiration of ovarian cyst s.

Firstly, how easy is it to predict whether a cyst is benign or malignant? Clinical examination, ultrasonography, and serum concentrations of CA 125 are the main approaches available. Clinical examination is of ten disappointing, with 30-65% of ovarian tumours (in particular those less then 40-50 mm in diameter) being overlooked. Vaginal ultrasonography is more accurate, predicting the benign nature of a tumour in 96% of cases by showing the presence or not of vegetations. Finkler et al calculated a negative predictive value of 71% in postmenopausal women. None the less, analysis of six screening programmes covering 7476 patients showed a false positive rate of 13.3%. (The false negative rate may be calculated only by performing surgical exploration.) Doppler studies of ovarian cyst s have a sensitivity of 92% and a specificity of 52%, with higher predictive values when combined with transvaginal ultrasonography.

Serum concentrations of CA 125 were normal in 97% of women presenting with benign cyst s and were raised (over 35 UI ml) in 80% of women over the age of 50 presenting with malignant lesions. 5 However, only 50% of women presenting with a stage I ovarian cancer (the most difficult to diagnose) had raised serum concentrations of CA 125. Secondly, is ovarian cytology reliable? Provided that de Brux’s conditions are met (immediate fixation to avoid uninterpretable cells, double centrifugation, personal experience in excess of 200 to 300 analyses), the answer seems to be yes. Of 1632 cases in which cytology was verified, only 19 were unsuspected malignancies and two false negative results. Thirdly, what are the consequences of aspirating a malignant cyst ? Data collected from studies of the risk of dissemination after aspiration of a malignant ovarian cyst show survival rates at five and 10 years that were no worse than the rates for non-aspirated cyst s (76% for poorly or moderately differentiated epithelial cancers classified as stage I or IIA).

Discussion

Many previous studies discussed the recurrence of ovarian endometrioma after laparoscopic excision, in view of requirements of reoperation (Busacca et al ., 1999; Saleh and Tulandi, 1999; Abbott et al ., 2003) or pain recurrence (Busacca et al ., 1999; Abbott et al ., 2003). In this study, we focused on the mechanism of ovarian endometrioma recurrence per se and used a definition of the recurrence as the presence of cysts more than 2 cm in diameter by ultrasonography, which might be rather objective and cover minimum lesions. Under this definition, we observed a recurrence rate of 30.4%. The patient’s age, presence of infertility and pain did not significantly influence the recurrence. The presence of neither uterine myoma nor adenomyosis was significant. As for the characteristics of endometrioma, single or multiple cysts and unilateral or bilateral ovarian involvement were not significant, whereas patients with larger ndometrioma had higher probability of recurrence, which agrees with the finding of earlier studies (Busacca et al ., 1999; Saleh and Tulandi, 1999). Because most ovarian endometrioma are associated with extra ovarian endometriosis (Redwine, 1999), we evaluated revised ASRM score and co-existence of deep endometriosis. Revised ASRM score did not independently correlate the recurrence.

Co-existence of deep endometriosis did not influence the recurrence either. A new observation demonstrated in this study was that previous medical treatment of endometriosis was a significant factor that was associated with higher recurrence, whereas previous surgery of ovarian endometrioma was not. The less-favourable prognosis for women who have already had medical treatment may be explained by two possible reasons. The first is that the medication may mask endometriotic lesions and allow them to escape from removal at operations. Because more than half of the women who were categorized into previous medical treatment group had continued their medication until the time of operation, it may be possible that the medication might yield latent lesions that remain and recur after the operation. Our findings may also support the study of Muzii et al . (1996), which suggests that pre-operative GnRH agonist treatment does not seem to offer any advantage in terms of surgical performance based on various parameters including recurrence rates. The second possible reason for negative impact of medical treatment on endometrioma recurrence is that hormonal suppressive therapy may alter some genomic characteristics of endometriotic lesions. As for malignant transformation of endometriosis, it is proposed that hormonal ablative treatments may cause negative selection, suppress the normal, eukaryotic cells more than aneuploid cells bearing chromosomal aberrations and increase the rate of dyskaryotic cells in the endometriotic implants (Blumenfeld, 2004). We suppose that the ‘negative selection’ may also contribute to the recurrence of disease, making the lesion more active, progressive and prone to recurrence. Patient with post-operative pregnancy had a much lower rate of recurrence, which indicates that subsequent pregnancy may have a protective effect on endometrioma recurrence. On the contrary, laparoscopic excision of endometrioma is known to improve fertility, when it is done in infertile women (Beretta et al ., 1998). Taken together, gynaecologists should optimize the timing of laparoscopy according to the patient’s desire for current and future pregnancy. Our study was in line with previous observations that postoperative medical treatment did not significantly influence disease recurrence (Bianchi et al ., 1999; Muzii et al ., 2000; Busacca et al ., 2001). Three-month GnRH analogue (Busacca et al , 2001) or danazol (Bianchi et al ., 1999) therapy after laparoscopy was demonstrated to provide no significant advantage in preventing disease recurrence. Post-operative administration of low-dose cyclic oral contraceptives for 6 months had also no significant effect on the long-term recurrence rate of endometrioma (Muzii et al ., 2000). However, the treatment period of these studies, and also ours, was less than 1 year, and there is no information about the effect of longer period of treatment. It is therefore possible that medical treatments longer than 1 year may have an effect to prevent endometrioma recurrence. Further studies, e.g. randomized controlled trials, are needed to determine the effectiveness of these therapies. Table III. Univariate and logistic regression analysis of factors related to the recurrence of ovarian endometrioma ASRM, American Society for Reproductive Medicine Factors Univariate analysis

In summary, this study demonstrated significant factors that were independently associated with a higher or lower recurrence of endometrioma after laparoscopic excision. An important finding of the present study was the significant increase in basal FSH value detected after oophorectomy plus controlateral cystectomy. Although no difference in menstrual cyclicity was observed between groups, it could be suggested that the loss of a considerable part of ovarian tissue after oophorectomy plus controlateral cystectomy with subsequent reduction of ovarian reserve could be the explanation. On the contrary, bilateral cystectomy seems to preserve a more intact pituitary–ovary axis, with beneficial effects on the reproductive function. On the basis of these considerations, patients with BOTs who should be undergoing ovarian hyperstimulation and IVF for tubal and or male factor infertility could benefit from an extremely conservative surgical approach.

In conclusion, our findings, although obtained on a small population, demonstrate that laparoscopic bilateral cystectomy followed by non-conservative treatment performed at the first recurrence after childbearing completion is an effective surgical strategy in terms of reproductive outcomes for patients with bilateral early stage BOTs who desire to conceive as soon as possible and accept to undergo a radical treatment. Powered studies on a wider sample are needed to draw definitive conclusions on the safety of this ultra-conservative treatment. Conservative ovarian surgery in childhood and adolescence is important for the development of normal puberty and future fertility. Mature cystic teratomas constitute half of the benign ovarian masses in this population (Azizkhan and Caty, 1996 ) making the appropriate management of this tumour a vital concern to surgeons caring for patients in this age group.

Pre-operative and intraoperative criteria that have been historically used to predict malignancy in adnexal cystic masses include: adnexal masses with extra-ovarian spread, ultrasonically suspicious masses >8 cm in diameter, a thick cyst wall, a lengthened utero-ovarian ligament or numerous vessels starting from the mesovarium with a comb-like pattern, peritoneal metastases and external ovarian or intracystic vegetations (Canis et al ., 1994). Taken together, these criteria have 100% sensitivity for predicting malignancy but result in a 4% rate of unnecessary laparotomy (Canis et al ., 1994). After careful exclusion of an obvious malignancy, ovarian cystectomy has become an accepted option for MCT in adults. If the surgeon is endoscopically experienced, a laparoscopic approach may be considered (Lin et al ., 1995 ). However, there has been concern about the impact of laparoscopy on the incidence of intraoperative MCT spill with the subsequent risk of chemical peritonitis and adhesion formation (Nezhat et al ., 1999 ). In children with an MCT, oophorectomy has traditionally been performed due to concern about occult germ cell malignancy along with the viability of ovarian tissue and potential for MCT recurrence after cystectomy. At present, experience with a laparoscopic approach in children with MCT is limited to case reports (Cohen et al ., 1996 ; Garcia et al ., 1996 ; Jawad, 1998; Liu et al ., 1998 ). The aim here was to address some of these management concerns in children and adolescents.

The results show that abdominal pain and torsion as presenting symptoms were more common among young girls. Adolescent tumours were more likely to be detected on pelvic examination. Ultrasound was the most commonly used diagnostic test and this is appropriate given that the positive predictive ability of ultrasound approaches 100% when two or more characteristic findings for MCT, such as shadowing echodensity and regionally bright echodensity are present (Patel et al ., 1998 ).

A laparoscopic approach to the management of MCT in adults has now become accepted practice among many surgeons (Luxman et al ., 1996 ; Yuen et al ., 1997 ; Morgante et al ., 1998 ) . A consistent benefit to the patient is a shorter hospital stay (Howard, 1995 ; Lin et al ., 1995 ; Morgante et al ., 1998 ; Zanetta et al ., 1999 ). A shorter hospital stay was also demonstrated among our patients approached laparoscopically, suggesting that the benefit afforded adults is also applicable to children. Until recently, inadequate instrumentation made this approach difficult in children and this is reflected in our series where laparoscopy was confined almost entirely to the more recent time period. Among our patients, surgeon type was predictive of operative approach. This may be explained by the greater experience of gynaecologists with laparoscopic adnexal surgery. Our results suggest that young patients particularly suited to a laparoscopic approach are those with smaller tumours (all 8 cm, mean 5.5 cm in our series).

The diagnosis of chemical peritonitis is suspected in the presence of postoperative fever and ileus associated with granulomatous deposits on the abdominal peritoneum and adhesion formation (Huss et al ., 1996 ). This concern has been addressed in the adult literature and chemical peritonitis has been found to occur with an estimated incidence of 0.2% following laparoscopic excision of an MCT (Nezhat et al ., 1999 ) if spillage is managed by immediate copious lavage (Zanetta et al ., 1999 ). In our series, there were no cases of chemical peritonitis, confirming that spill in children can be managed in the same way as adults with similar expectations for a successful outcome.

Intraoperative tumour spillage also raises the concern of postoperative adhesion formation. This issue is confounded in adults because few patients have had second-look procedures. Also, many patients undergoing MCT removal have had concurrent reproductive surgery, including resection of endometriosis, tubal adhesiolysis or myomectomy (Nezhat et al ., 1989 ; Bollen et al ., 1992 ) all of which may themselves promote adhesion formation. Concurrent surgery among our patients was almost entirely elective appendectomy (85.7%) and this has been shown not to affect future fertility (Andersson et al ., 1999 ) . In our series, postoperative intrauterine pregnancy occurred in seven (20.6%) patients, four of whom had intraoperative spill of MCT contents and six who had additional surgery at the time of MCT removal. As in adults (Canis et al ., 1992 ) , this suggests that even if tumour spillage does promote adhesion formation, future fertility is possible.

Biopsy of the contralateral ovary was performed in 12 patients, typically by gynaecologists in the earlier time period. This was likely to be due to concerns about the presence of MCT in the contralateral ovary. However, ovarian wedge biopsy is not without complication and may result in haemorrhage, infection, and adhesion formation (Toaff et al ., 1976 ) . It is unlikely to be positive if the contralateral ovary is normal in appearance since the chance of an occult MCT is 1.1% (Doss et al ., 1977 ; Ayhan et al ., 1991 ) . Therefore, since ultrasound is a good predictor of MCT presence, preoperative ultrasound in combination with careful inspection of the contralateral ovary at the time of surgery offers a safe alternative to wedge biopsy (Commerci et al ., 1994 ) .

In adults, the reported incidence of recurrent MCT following cystectomy is 3–4% (Anteby et al ., 1994 ; Chapron et al ., 1994 ) and usually occurs in patients under 40 years of age (Anteby et al ., 1994 ) . Also, in younger patients with multiple or bilateral MCT there is a 2–3% incidence of the subsequent development of germ cell tumours (Borenstein et al ., 1982 ; Yanai-Inbar and Scully, 1987 ; Anteby et al ., 1994). In our series there were no reported cases of recurrence among the 19 patients (of a total of 25) managed with cystectomy in whom follow-up data were available. However, this may be due to insufficient follow-up time since recurrences and germ cell tumours may occur months to many years following surgery (Chapron et al ., 1994 ) .

This study demonstrates that some of the conclusions regarding the contemporary management of MCT in adults are applicable to children and adolescents. In particular, the benefit of shorter hospital stay achieved in adults with a MCT approached laparoscopically extends to our population. Chemical peritonitis may be avoided and future fertility is possible if intraoperative MCT spill is managed with copious saline irrigation.

In the absence of specific literature investigating MCT recurrence in children, recommendations for postoperative surveillance are empirical. Given the sensitivity of ultrasound in the detection of MCT, annual imaging in prepubertal and young adolescents followed by annual pelvic examinations in older adolescents seems appropriate

Conclusion

We report a prospective pilot study which evaluated the feasibility of combined ultrasonographically guided drainage and laparoscopic excision after pre-operative administration of a gonadotrophin-releasing hormone analogue for 3 months in the management of ovarian endometriotic cysts >5 cm. Ten patients with an ultrasonographic diagnosis of large unilateral or bilateral ovarian endometriotic cysts received an intramuscular injection of leuprorelinum acetate 3.75 every 4 weeks for 12 weeks. After 4 weeks of medical treatment, the endometrioma was carefully drained transabdominally under ultrasonographic control. Within 8 weeks since the last injection, the patients were submitted to a second ultrasonography, and laparoscopy-guided stripping of the endometrioma was performed. A videotape review was undertaken to evaluate duration and complexity of the different phases of surgery. Stripping of endometriomas with preservation of residual ovarian parenchymas was obtained in all cases; adhesiolysis was complete in 6 cases. There were neither intra-operative complications nor conversions in laparotomy. In conclusion, gonadotrophin-releasing hormone analogue and cyst drainage seem to permit an easy laparoscopic approach of large endometriomas; the findings of our pilot phase seem to justify a randomized trial to better define the effectiveness of this approach with respect to standard procedures

References