Laparoscopic tubal anastomosis and reversal of sterilization.

Fallopian tube interruption is a common form of contraception worldwide. For a variety of reasons (e.g. change in marital status, wish for additional children, psychological factors), many of these women seek restoration of fertility. Laparoscopic tubal anastomosis is one of the newest of these procedures by which this can be achieved. Sixteen women underwent laparoscopic microsurgical anastomosis. We used a three-stitches technique with tubal cannulation adapted from methods described in the literature. Five pregnancies occurred, giving an overall pregnancy rate of 31.2%. Surgical outcome depends on the patient's age, the method of tube interruption and the length of Fallopian tube segments being anastomosed. In this study, the feasibility of laparoscopic tubal sterilization reversal is confirmed, as well as the benefits offered by laparoscopic procedures in terms of quality of life. Further improvement of surgical outcome will be achieved not only through better laparoscopic techniques but also through careful screening for surgical indications.     

Bilateral femoral neuropathy after microsurgical reversal of tubal sterilization: case report and analysis of contributing factors

A case of bilateral femoral neumpathy after micranrrgical tubopiastyfor reversal of sterilization is reported. Although the prognosisis favourable and full recovery is usually observed, the disablingeffect of the newpathy may last for several months. This reportis an attempt to alert fertility surgeons to the possible occurrenceof such a complication disturbing to bdh patient and physician,by analysing the mechanisms of injury and possible ways of itsprevention.     

Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24 046 patients

BACKGROUND: Gynaecological laparotomies are associated with considerable adhesion-related burdens; however, few data are available concerning laparoscopic surgery. This study evaluated the epidemiology of adhesion-related readmissions following open and laparoscopic procedures. METHODS: Records from 24,046 patients undergoing gynaecological surgery in Scottish National Health Service hospitals during 1996 were assessed retrospectively. Cohorts comprised 15,197 patients undergoing laparoscopic surgery and 8849 patients undergoing laparotomies. Adhesion-related readmission episodes (directly and possibly related) were assessed over 4 years following initial surgery and were expressed as percentages of the number of initial procedures. RESULTS: Directly adhesion-related readmissions 1 year after initial laparoscopic surgery were: in the high-risk group (adhesiolysis and cyst drainage) 1.3%; medium-risk (therapeutic and diagnostic procedures not categorized as high- or low-risk) 1.5%; and low-risk (Fallopian tube sterilizations) 0.2%. Readmissions for laparotomy following surgery on the Fallopian tubes were 0.9%, ovaries 2.1%, uterus 0.6% and vagina 0%. Readmissions occurred at reduced rates in the second, third and fourth years after surgery. Exclusion of patients who underwent surgery within the previous 5 years resulted in reduced readmission rates following laparotomy and high-risk laparoscopy. CONCLUSIONS: With the exception of laparoscopic sterilizations, open and laparoscopic gynaecological surgery are associated with comparable risks of adhesion-related readmissions.     

Hysteroscopic sterilization using a micro-insert device: results of a multicentre Phase II study

BACKGROUND: Unlike laparoscopic surgery for interval tubal sterilization, a hysteroscopic approach obviates surgical incision and requires only local anaesthesia or intravenous sedation. The safety, tolerability and efficacy of an hysteroscopically placed micro-insert device was evaluated. METHODS: A cohort of 227 previously fertile women participated in this prospective international multicentre trial. Micro-inserts were placed bilaterally into the proximal Fallopian tube lumens under hysteroscopic visualization in outpatient procedures. RESULTS: Successful bilateral micro-insert placement was achieved in 88% of women. The majority of women reported that intraprocedural pain was less than or equal to that expected, and 90% rated tolerance of the device placement procedure as good to excellent. Most women could be discharged in an ambulatory state within 1-2 h. Adverse events occurred in 7% of the women, but none was serious. Correct device placement was confirmed in 97% of cases at 3 months. Over 24 months follow-up, 98% of study participants rated their tolerance of the micro-insert as very good to excellent. After 6015 woman-months of exposure to intercourse, no pregnancies have been recorded. CONCLUSIONS: Hysteroscopic sterilization resulted in rapid patient recovery without unacceptable post-procedure pain, as well as high long-term patient tolerability, satisfaction and effective permanent contraception.     

Transvaginal hydrolaparoscopy compared with laparoscopy for the evaluation of infertile women: a prospective comparative blind study

Standard diagnostic laparoscopy is considered the gold standard to investigate tubo-peritoneal infertility. It requires general anaesthesia and full operative facilities. Due to the risk of complications, laparoscopy is frequently postponed to the final stage of infertility evaluation or even after treatment trials have failed. Transvaginal hydrolaparoscopy (THL) is based on vaginal access using a needle puncture technique and saline for distention. THL can be performed on an outpatient basis under local anaesthesia. However, little data exist concerning the accuracy of THL in comparison with laparoscopy. We conducted a prospective comparative blind trial to assess the feasibility and accuracy of THL compared with diagnostic laparoscopy in infertile women. Sixty women were assigned to undergo THL immediately prior to laparoscopy. Different operators evaluated the findings of the two procedures. In order to evaluate the accuracy of THL, findings in terms of tubal pathology, endometriosis and adhesions were analysed. The success rate of accessing the pouch of Douglas was 90.2%. Complication rate was 1.6%. THL diagnosis was correlated with that of laparoscopy in 92.3% of cases. In cases of abnormal findings by THL, there were no normal laparoscopies. Our pilot study suggests that THL is a safe and reproducible method. Retroverted uterus should be considered as a relative contraindication to THL. When a complete evaluation by THL is available, it is a highly accurate technique in comparison with the laparoscopy.     

The role of laparoscopy in intrauterine insemination: a prospective randomized reallocation study

BACKGROUND: We questioned whether a laparoscopy should be performed after a normal hysterosalpingography before starting intrauterine inseminations (IUI) in order to detect further pelvic pathology and whether a postponed procedure after six unsuccessful cycles of IUI yields a higher number of abnormal findings. METHODS: In a randomized controlled trial, the accuracy of a standard laparoscopy prior to IUI was compared with a laparoscopy performed after six unsuccessful cycles of IUI. The major end-point was the number of diagnostic laparoscopies revealing pelvic pathology with consequence for further treatment such as laparoscopic surgical intervention, IVF or secondary surgery. Patients were couples with medical grounds for IUI such as idiopathic subfertility, mild male infertility and cervical hostility. RESULTS: Seventy-seven patients were randomized into the diagnostic laparoscopy first (DLSF) group and the same number was randomized into the IUI first (IUIF) group. The laparoscopy was performed on 64 patients in the DLSF group, 10 patients withdrew their consent from participation and three patients (3%) became pregnant prior to laparoscopy. In the IUIF group, 23 patients remained for laparoscopy because pregnancy did not occur after six cycles of IUI. From the original 77 randomized patients, 38 patients became pregnant and 16 patients dropped out. Abnormal findings during laparoscopy with therapeutic consequences were the same in both groups: in the DLSF group, 31 cases (48%) versus 13 cases (56%) in the IUIF group, P = 0.63; odds ratio (OR) = 1.4; 95% confidence interval (CI): 0.5-3.6. The ongoing pregnancy rate in the DLSF group was 34 out of 77 patients (44%) versus 38 out of 77 patients (49%) in the IUIF group (P = 0.63; OR = 1.2; 95% CI: 0.7-2.3). CONCLUSIONS:Laparoscopy performed after six cycles of unsuccessful IUI did not detect more abnormalities with clinical consequences compared with those performed prior to IUI treatment. Our data suggest that the impact of the detection and the laparoscopic treatment of observed pelvic pathology prior to IUI seems negligible in terms of IUI outcome. Therefore, we seriously question the value of routinely performing a diagnostic and/or therapeutic laparoscopy prior to IUI treatment. Further prospective studies could be performed to determine the effect of laparoscopic interventions on the success rate of IUI treatment in order to rule out completely the laparoscopy from the diagnostic route prior to IUI.     

腹腔镜与传统开腹术治疗直肠癌的手术并发症比较

目的分析腹腔镜下全系膜切除术(TME)与开腹TME手术治疗直肠癌在并发症发生率方面的差别。方法回顾43例腹腔镜和50例传统开腹手术治疗直肠癌患者的临床资料,分析并发症的发生原因及其发生率。结果腹腔镜治疗组较传统开腹组在术后肠功能恢复、早期下床活动、住院时间等方面均占优势。在术中损伤吻合口瘘、术后性功能保护、排尿功能障碍、局部复发和切口转移上与传统开腹组均无明显差别。结论腹腔镜下TME治疗直肠癌的效果同传统开腹术,术后患者自觉症状较开腹手术良好。     

Early outcome of myomectomy by laparotomy, minilaparotomy and laparoscopically assisted minilaparotomy. A randomized prospective study

BACKGROUND: To compare in the first 7 days after surgery the outcome of myomectomy performed by three laparotomic approaches: laparotomy (LT), minilaparotomy (MLT) and laparoscopically assisted minilaparotomy (LA-MLT). METHODS: Fifty-one women with 5-15 cm total myoma diameter were randomized blindly using a computer randomization list, to LT (n = 17), MLT (n = 17) or LA-MLT (n = 17). RESULTS: Mean operation length was similar in the three groups. Mean (+/- SEM) time of paralytic ileus (55.0 +/- 4.5 versus 33.4 +/- 3.4 h; P < 0.01) and discharge (141.6 +/- 5.2 versus 81.5 +/- 8.2 h; P < 0.01) was longer in LT than LA-MLT or even MLT. In comparison with LA-MLT, LT induced a greater haemoglobin decline (-3.07 +/- 0.3 versus -1.8 +/- 0.15 mg/dl; P < 0.025), and a greater post-operative stress, as documented by increased prolactin (+15.1 +/- 3.8 versus +0.16 +/- 4.5 ng/ml; P < 0.03) and decreased insulin sensitivity (fasting glucose/insulin; -7.5 +/- 2.6 versus -0.7 +/- 2.1; P < 0.02). Seven days after surgery, abdominal pain (P < 0.05) was higher after LT (3.0 +/- 0.6) than MLT (0.5 +/- 0.2) and LA-MLT (0.9 +/- 0.4). CONCLUSIONS: In selected cases, myomectomy by LA-MLT offers some advantages versus LT and, to a smaller extent, MLT.     

Doppler colour flow analysis of uterine and ovarian arteries prior to and after surgery for tubal sterilization: a prospective study

Female sterilization by tubal ligation is a very common methodof birth control. A relationship between tubal sterilizationand subsequent development of menstrual disorders has been describedin the literature but a biological mechanism explaining suchan association has not yet been demonstrated. The aim of thisstudy was to evaluate the influence of tubal ligation by thePomeroy technique on ovarian and uterine artery blood flow usingpre- and post-surgical Doppler assessments. We studied prospectively20 patients undergoing laparotomy for tubal ligation. All patientshad a Doppler blood flow assessment before and after surgery,conducted in the mid-foUicular phase of their cycle. The pulsatilityindex (PI) of the right uterine artery ranged from 1.44 to 3.86(mean 2.23) when measured prior to surgery and from 136 to 2.85(mean 2.13) when measured after surgery. In the left uterineartery, the PI ranged from 1.67 to 3.17 (mean 2.17) and from1.69 to 2.88 (mean 2.22) before and after surgery respectively.The difference was not statistically significant The PI of theright ovarian artery ranged from 138 to 3.48 (mean 2.41) priorto surgery and from 1.48 to 3.23 (mean 2.29) after surgery.In the left ovarian artery, the PI ranged from 1.36 to 3.62(mean 234) and from 1.85 to 4.00 (mean 2.61) before and aftersurgery respectively. Again, the difference was not statisticallysignificant Our results suggest that tubal sterilization performedby Pomeroy‘s technique does not induce immediate alterationsin the vascular flow of either ovarian or uterine arteries.     

Transfundal insertion of a Veress needle in laparoscopy of obese subjects: a practical alternative.

Because induction of artificial pneumoperitoneum through the infra-umbilical route is associated with complications in laparoscopic procedures, especially in obese patients, we performed a prospective randomized study comparing the conventional infra-umbilical route with a transfundal route, in which the Veress needle is inserted into the peritoneal cavity through the uterine fundus. One hundred obese subjects (body mass index >/=25 kg/m(2)) scheduled for laparoscopic sterilization were randomized into two groups. In the infra-umbilical group pneumoperitoneum was achieved at a ratio (punctures/pneumoperitoneum) of 56/49 (1.14). There was one failure in this group. In the transfundal group the ratio was 53/51 (1.04). There was no clinically significant bleeding in either of the groups; nor were there any major complications. One subject in whom the infra-umbilical route failed was moved to the transfundal group. This subject also underwent dilatation and curettage at the time of laparoscopy. Postoperatively she contracted chlamydial pelvic inflammatory disease. No other infections were detected postoperatively in either of the groups. In conclusion, the transfundal route of inducing artificial pneumoperitoneum proved to be easy, safe and effective.     

Gamete intra-Fallopian transfer combined with diagnostic laparoscopy: a treatment for infertility in a district hospital

Gamete intra-Fallopian transfer (GIFT) was combined with a diagnosticlaparoscopy on a routine operating list in a district generalhospital. The equipment used was entirely portable. Operationswere programmed 6–12 weeks in advance using a fixed ovarianstimulation regimen. Of 47 patients treated, 38 (81%) respondedappropriately to stimulation. Of these, 23 had partners withnormal semen parameters and 5 of 21 (24%) who had GIFT conceived.Two others were found to have tubal damage. Their eggs weretransported to an in-vitro fertilization unit at another hospital.Both conceived after embryo transfer. In 15 couples, the semenwas found to be sub-optimal and none of these became pregnant.GIFT can be performed in a district hospital, on a fixed schedulein conjuction with a diagnostic laparoscopy. The technique appearsunsuitable for patients with sub–optimal semen and thebacking of an in-vitro fertilization unit increases pregnancyrates.     

Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe

BACKGROUND: Commonly used adhesion prevention devices either cannot be applied or are difficult to use via laparoscopy. A viscoelastic gel was developed specifically for adhesion prophylaxis during minimally invasive surgery. METHODS: Randomized, third party-blinded, parallel-group design conducted at four centres. Patients (18-46 years old) underwent laparoscopic surgery with second look 6-10 weeks later. Viscoelastic gel coated adnexa and adjacent tissues. Blinded reviews of videotapes were quantified by American Fertility Society (AFS) adhesion scores. RESULTS: In 25 treatment patients, surgery was performed on 45 adnexa. Coverage of surgical sites at risk for adhesions was typically accomplished with approximately 15 ml of viscoelastic gel which was delivered in approximately 90 s. In 24 control patients, surgery alone was performed on 41 adnexa. Treated adnexa showed a decrease in AFS score (11.9-9.1). In contrast, control adnexa showed an increase in AFS score (8.8-15.8). This difference in second-look AFS scores (42% reduction) is significant (P<0.01). Ninety-three per cent of treated adnexa did not have a worse adhesion score in contrast to 56% of control adnexa. Combining scores into prognostic categories also show significant treatment effect of the viscoelastic gel (P<0.01). CONCLUSION: Viscoelastic gel was easy to use via laparoscopy and produced significant reduction in adnexal adhesions. It provides benefits to patients undergoing gynaecological surgery.     

Surgery: Laparoscopic myomectomy of large symptomatic leiomyoma using airlift gasless laparoscopy: a preliminary report

Despite the expanding role of laparoscopic surgery in many gynaecologicalfields, some discrepancies still exist regarding the efficacyof laparoscopic myomectomy in treating patients with large symptomaticleiomyoma. in this report,, a better operative procedure andthe results of treatment are evaluated. Patients (n = 14) presentingwith infertility, menorrhagia, pressure symptoms or pelvic massassociated with a large leiomyoma were managed with laparoscopicmyomectomy using airlift gasless laparoscopy. Uterine size rangedfrom 14 to 24 weeks gestational age and the weight of the myomaranged from 246 to 669 g (mean 454); operatIve time ranged from78 to 165 mm (mean 104) and blood loss from 90 to 580 ml (mean201). No major complication occurred during the operation orfollow-up. All except one patient were discharged within 72h of the operation and resumed normal activity within 1 week.When myomectomy is Indicated, the airlift gasless laparoscopicapproach appears to offer a better alternative to abdominalor pneumoperitoneum laparoscopic surgery in selected cases.Airlift gasless laparoscopy has several advantages: (i) smallabdominal incisions and minimal endoscopic equipment are required;(ii) the excised leiomy omata mass can be easily cut into stripsand removed through the small abdominal incision; (iii) theuterine defect can be more efficiently repaired using easilyper formed suture techniques; (iv) high-pressure irrigationand large-volume suction devices can be used without fear ofdecompressing the pneumoperitonewn; and (v) the poten tial riskof metabolic and haemodynamic derangements during pneumoperitoneumlaparoscopy are obviated. Gasless laparoscopy also has somedisadvantages. The exposure obtained with gasless laparoscopyis not as good, under some circumstances, as that achieved bypneumoperi toneum. For patients who are thin, and even thosewith moderate obesity, the exposure obtained with airlift mechanicalsuspension is adequate however, morbidly obese patients andpatients with previous abdominal sur gery with suspected pelvicadhesions can incur some prob lems during the operation becauseof a poor operative field.     

Total laparoscopic hysterectomy versus total abdominal hysterectomy: an assessment of the learning curve in a prospective randomized study

The present randomized study was undertaken in order to compare the short-term results between total laparoscopic hysterectomy and abdominal hysterectomy in a centre with experience in laparoscopic surgery. From January 1997 to September 1998 inclusive, 102 women aged 44-71 years were randomly assigned to either total laparoscopic hysterectomy (n = 51 patients) or abdominal hysterectomy (n = 51 patients). The patients' demographic characteristics were similar in both groups. Average intra-operative blood loss was lower in laparoscopic hysterectomy than in abdominal hysterectomy (P 相似文献   

Pregnancy: A comparison of methotrexate versus laparoscopic surgery for the treatment of ectopic pregnancy: a cost analysis

This study was a cost analysis of direct medical costs of themethotrexate management versus laparoscopic surgery in the treatmentof ectopic pregnancy. A total of 40 patients treated from January1991 to October 1994 with methotrexate were compared with another40 patients treated at the same hospital by laparoscopy fromApril 1986 to June 1994. Medical records for all these patientswere received and hospital databases were used to retrieve informationon cost Treatment cost included the primary treatment, hospitalizationand outpatient follow-up necessitated by treatment, complicationsand secondary treatment in cases of treatment failure. The costrelated to diagnosis was excluded. The direct medical costsfor methotrexate and laparoscopy groups were based on successrates of 72.5 and 95% respectively. The total cost of methotrexatetreatment was Canadian $35 180 compared with Canadian $73 440for the laparoscopic treatment. The mean ± SE cost perpatient was Canadian $880 ± 160 in the methotrexate groupcompared with Canadian $1840 ± 150 in the laparoscopicgroup (P 0.001). The mean ± SE cost per patient withmethotrexate success was Canadian $330 ± 67 comparedwith Canadian $2330 ± 220 per patient with methotrexatefailure (P = 0.001). A complete assessment of methotrexate treatment,including cost-benefit and cost-effectiveness, is warranted.     

Routine use of hysterosalpingography prior to laparoscopy in the fertility workup: a multicentre randomized controlled trial

BACKGROUND: A multicentre randomized controlled trial with orwithout hysterosalpingography (HSG) was conducted to assessthe usefulness of HSG as a routine investigation in the fertilityworkup prior to laparoscopy and dye. METHODS: From 1 April 1997to 1 April 2002, subfertile women were allocated by a computer–based1 : 1 ratio randomization procedure, either for an HSG followedby laparoscopy and dye (the intervention group) of for laparoscopyand dye only (the control group) as a part of their fertilityworkup. Cumulative pregnancy rate (CPR) within 18 months afterrandomization was the primary outcome of interest. RESULTS:344 women were randomized to the intervention group (n = 169)and the control group (n = 175). There was no significant differencein CPR at 18 months in the intervention group (49.1%) [95% confidenceinterval (CI) 41.6 to 56.6] and the control group (50.3%) (95%CI 42.8 to 57.8), a difference of –1.2% (95% CI –11.8%to 9.5%). CONCLUSION: The routine use of HSG at an early stagein the fertility workup prior to laparoscopy and dye does notinfluence CPR, compared with the routine use of laparoscopyand dye without HSG.     

Ceftriaxone versus ampicillin for the treatment of community-acquired pneumonia. A propensity matched cohort study

ObjectivesCeftriaxone is recommended as first-line antibiotic treatment (with the addition of macrolide) for hospitalised adults with community acquired pneumonia (CAP). Narrower-spectrum β-lactam as ampicillin, may be associated with comparable clinical outcomes, with less emergence of resistant pathogens or Clostridioides difficile infection (CDI). We aimed to examine whether ampicillin and ceftriaxone (with the addition of macrolides for both arms) are comparable for the treatment of hospitalized adults due to CAP.MethodsThis was a single center, observational cohort study. We included adult patients who were hospitalized in internal medicine wards due to CAP and were treated with either ceftriaxone or ampicillin with the addition of macrolide. A propensity-score model was used. The primary outcome was 30-day all-cause mortality. A multivariable logistic regression analysis and Kaplan-Meier survival analysis was performed. We performed subgroup analyses for the main outcome based on CURB-65 score and age.ResultsA total of 1586 patients fulfilled the inclusion criteria. There was no difference in 30-day mortality rate in the total cohort (28/233 vs. 208/1353 in ampicillin and ceftriaxone arm, respectively; p = 0.184). In the propensity matched cohort (197 in ampicillin and 394 in ceftriaxone arm), there was no significant difference in 30-day all-cause mortality between treatment groups in multivariable analysis of the main model (OR 0.67, 95% CI, 0.37–1.2; p = 0.189) and Kaplan-Meier survival analysis (p = 0.108). Thirty-day mortality rate was (19/197 vs. 57/394, in ampicillin and ceftriaxone arms, respectively; p = 0.108) Patients who were treated with ampicillin experienced significantly lower rates of CDI (0/197, 0% vs. 8/394, 2%; p = 0.044).DiscussionAmpicillin was associated with comparable clinical outcomes in comparison to ceftriaxone for patients who were hospitalized due to CAP. Ampicillin was associated with significantly lower rate of CDI. Results need to be confirmed by more robust study designs.     

Effects of 3 month therapy with danazol after laparoscopic surgery for stage III/IV endometriosis: a randomized study.

The effect of treatment with danazol was evaluated with respect to expectant management after laparoscopic conservative surgery. All patients conservatively operated at laparoscopy for stage III-IV endometriosis from July 1994 to October 1996 were requested to enter the study. Patients who underwent surgery for recurrent endometriosis were excluded from the study, as well as patients who had taken hormonal therapies before laparoscopy. Informed consent was obtained from 77 women who were randomized after surgery to treatment with danazol 600 mg daily for 3 months (n = 36) or to expectant management (n = 41). All patients were regularly followed up every 6 months for evaluation of fertility, recurrence of pain symptoms and disease. During the follow-up, six (55%) of the 11 infertile women allocated to danazol and eight (50%) of the 16 given no treatment became pregnant (not significant). Moderate/severe pelvic pain recurred during follow-up in seven (23%) of the 31 women with pelvic pain allocated to the danazol group and nine (31%) of the 29 allocated to no treatment; the respective cumulative pain recurrence rates at 12 months were 26 and 34% (log rank test, not significant). Three women (8.3%) treated with danazol and six (15%) who received no treatment had disease recurrence as demonstrated by gynaecological examination and/or pelvic ultrasonography (not significant). Our results do not demonstrate a significant advantage of 3 month danazol therapy after laparoscopic surgery for stage III-IV endometriosis with respect to postoperative expectant management.