Complications of laparoscopy in gynecology]

In the field of surgery the development of operative laparoscopy has been one of the most important steps forward over the past fifteen years. This technique has become the surgical treatment of choice for a number of indications in gynaecology. The advantages of laparoscopy as compared with laparotomy are weil known, and assessment of the risk of complications is essential. A multicentric study was carried out in seven top French centres for laparoscopic gynaecological surgery. This series runs over a period of nine years and covers 29,966 diagnostic and operative laparoscopies. The risk of complications has been assessed according to the complexity of the laparoscopic procedure in question. The means of diagnosis and treatment of the complications have been analysed together with the importance of the surgeon's degree of experience. The mortality rate is 3.33 per hundred thousand laparoscopies. The overall complication rate is 4.64 per thousand laparoscopies (139 cases). The rate of complications requiring laparotomy is 3.20 per thousand (96 cases). The complication rate is significantly correlated with the complexity of the laparoscopic procedure (p = 0.0001). One out of three complications (34.1%; 43 cases) occurred while setting up for laparoscopy, and one out of four complications (28.6%) were not diagnosed during the operation. As new indications for laparoscopic surgery in gynaecology have appeared, there has been a parallel and statistically significant increase in the rate of urological complications (p = 0.001). Increased experience of the surgeons has had three consequences: a statistically significant drop in the number of bowel injuries (p = 0.0003), a drop in the rate of complications requiring laparotomy for those laparoscopic surgical procedures which are weil-defined (p = 0.01) and a change in the way complications are treated, with a significant increase in the proportion of incidents treated by laparoscopy (p = 0.0001). Laparoscopic surgery is a reliable technique. The risk of complications exists whatever the indication for laparoscopy. None of the phases in the operation must be neglected. The risk of accidents being overlooked means that the methods for postoperative follow-up must be adapted, bearing in mind the shorter hospital stay. The part played by the surgeon's experience raises the major problem of practitioner training.     

Perioperative morbidity of gynecological laparoscopy. A prospective monocenter observational study

BACKGROUND: To study the morbidity rate of gynecological laparoscopy and to the most influential variables. METHODS: We conducted a prospective observational study from January 1st 1992 to December 31st 1998 in a single tertiary care center. It concerned patients who underwent gynecological laparoscopic surgery performed by seniors and residents. We have prospectively recorded patients characteristics, indications for laparoscopy, leading diagnosis, main operative procedures, post-operative course, surgical and anesthetic incidents and accidents. Complications were defined as any event that would modify the usual course of laparoscopy or of the post-operative period. RESULTS: One thousand and thirty-three laparoscopies were included. 80.1% of the procedures were major or advanced laparoscopies. The overall complication rate was 3%, with a laparotomy rate of 1.2%. About half of those complications (54.8%) occurred during the installation of laparoscopy. Veress needle and first trocar insertion accounted for 23.5% of those accidents (0.3% of the procedures) and suprapubic trocar insertion for 76.5%. Hemorrhages constituted almost all of the complications occurring during the operative stage (80%). The risk increased with the level of surgery and decreased with surgeon's experience. Prior abdominal surgery had no significant effect on the overall morbidity rate. Post-operative and anesthetic complications were rare. The overall complication rate as well as the laparotomy rate were stable all along the course of the study. CONCLUSIONS: Complication rate of gynecological laparoscopy is not negligible. Efforts should be made to lower the complications induced by the installation of laparoscopy, especially for secondary trocars.     

Major complications of laparoscopy: a follow-up Finnish study.

OBJECTIVE: To examine recent figures on major laparoscopic complications in Finland. METHODS: This was a nationwide record-linkage study from January 1995 through December 1996 including all Finnish hospitals performing gynecologic laparoscopies. Data files of the National Patient Insurance Association and the Finnish Hospital Discharge Register were used. Data were compared with previous results from 1990 to 1994. RESULTS: Among 32,205 gynecologic laparoscopies, 130 major complications were noted. The total complication rate was 4.0 per 1000 procedures: 0.6 per 1000 in diagnostic laparoscopies, 0.5 per 1000 in sterilization, and 12.6 per 1000 in operative laparoscopies. Intestinal injuries were reported in 0.7 per 1000, incisional hernias in 0.3 per 1000, urinary tract injuries in 2.5 per 1000, major vascular injuries in 0.1 per 1000, and other injuries in 0.5 per 1000 gynecologic laparoscopic procedures. Seventy-five percent (88 of 118) of the major complications in operative laparoscopies occurred during hysterectomies. The total major complication rate decreased from 4.9% in 1993 to 2.3% in 1996 (chi2 = 8.55, P = .003), but the incidence of ureteral injuries remained stable, at about 1% of laparoscopic hysterectomies. Ureteral injuries were most common in local hospitals (2.6%), followed by central (1.1%) and university hospitals (0.9%). From 1990 through 1996, the relative risk for ureteral injury in laparoscopic hysterectomies, compared with other operative laparoscopies was 29.0 (95% confidence interval [CI] 13.3, 63.0), for bladder injury 13.0 (95% CI 6.0, 28.2), for intestinal injury 1.3 (95% CI 0.6, 2.5), and for major vascular injury 0.4 (95% CI 0.1, 3.6). Compared with the figures for 1990-1994, all major complications in operative laparoscopies increased, from 0 per 1000 in 1990 to 14.0 per 1000 in 1996 (chi2 = 20.28, P<.001), but part of this increase was due to the increased proportion of laparoscopic hysterectomies. CONCLUSION: Laparoscopic hysterectomies are still associated with a stable 1% risk of ureteral injury, whereas other major complications were decreasing until 1996. Complications in other laparoscopic procedures generally are rare.     

Gynaecological laparoscopic injuries: a 10-year retrospective review at a District General Hospital NHS Trust

Worldwide, increasingly complex surgery is being performed laparoscopically; thus, laparoscopic complication rates may be increasing. Reported risks from all complications of laparoscopic surgery are between 1 and 12.5/1000 cases and serious complications in 1/1000 cases. Accurate complication rates of surgery are difficult to obtain as most data are from retrospective studies and may be incomplete. This paper is a 10-year retrospective review of gynaecological laparoscopic complications from 1 January 2003 to 31 December 2012. Data sources are SEMAHELIX Hospital Database, Gynaecology Complications Register, Clinical Governance Records, Complaints and Legal Cases. Recorded complications were classified as diagnostic, sterilisations and therapeutic laparoscopies. Further classifications are as follows: major complications and type of injury (bowel, urological, vascular, other), minor complications and failed sterilisations. Twenty-nine complications were identified from 5128 laparoscopies; total complication rate is 5.7/1000 procedures. Major complication rates are as follows: diagnostic, 2.2/1000; sterilisations, 3.3/1000; and therapeutic, 3.1/1000, subcategorised into bowel 1.4/1000, urological 0.2/1000 and vascular 1.2/1000. Our total complication rate lies within published national rates. Compared to published standards of major complications, diagnostic laparoscopy and laparoscopic sterilisation rates were comparable. Conversely, our therapeutic laparoscopy complication rate was much lower. The highest complication rate was in the failed sterilisation group; however, this rate is within published sterilisation failure rates. Bowel and vascular complications were comparable; minor complication rates were low in all groups.     

上海市10年妇科腹腔镜手术发展状况

目的 回顾性分析上海市7所医院1990年-1999年间腹腔镜手术资料,总结上海市妇产科腹腔镜手术10年的发展状况和发展趋势,探讨腹腔镜手术在妇科临床中应用前景。方法 以发卷询问形式对上海市开展腹腔镜手术医院的手术例数、手术适应证、手术范围及腹腔镜手术并发症进行调查。结果5所三级医院、2所区级医院给予了回答,回信率 70％。腹腔镜手术总例数9210例,其中5240例诊断性腹腔镜手术,3970例手术性腹腔镜手术。1990年～1997年间,诊断性腹腔镜手术呈平台走势,每年600例左右,1998年、1999年手术性腹腔镜明显增多,而诊断性腹腔镜明显减少。10年间腹腔镜手术的发展分为1990年-1994年和1995年～1999年两个阶段,两个阶段诊断性腹腔镜与手术性腹腔镜比例分别是3.8:1及1:4。所占妇科手术比例从1992年腹腔镜手术开始时的2.31％增加到1999年的30％。手术范围从输卵管切除、附件切除、全子宫切除到盆腔淋巴结切除。并发症89例,发生率0.97％。自1997年后,诊断性腹腔镜并发症几乎降为0,手术性并发症呈下降趋势,1999年手术性腹腔镜1290例中并发症仅6例,发生率0.47%(P<0.01)。结论 手术性腹腔镜手术有替代妇科大部分手术的趋势,并发症发生率随手术性腹腔镜技术的成熟呈下降趋势。     

Major complications of operative gynecologic laparoscopy in southern Taiwan: a follow-up study

STUDY OBJECTIVES: This follow-up study examined the major complications among 4307 operative gynecologic laparoscopies. The overall complication rate and each individual category were compared with those of our previous study period. The clinical outcome and salvage procedures were correlated with the time of recognition and the severity of initial procedures in the individual injury type. DESIGN: Retrospective, comparative study based on medical record reviewing (Canadian Task Force classification II-3). SETTING: Tertiary teaching hospital, Chi Mei Foundation Hospital in southern Taiwan. PATIENTS: Records of women (n = 4307) aged 40.5 +/- 11.7 years (mean +/- SD [95% CI 40.1-40.5]) who underwent operative gynecologic laparoscopies from January 2000 through February 2006 were reviewed in this study. The complications were compared with those of our previous study based on 1507 laparoscopies performed between December 1992 and November 1999 for follow-up comparison. INTERVENTIONS: Gynecologic laparoscopic surgeries. MEASUREMENTS AND MAIN RESULTS: Thirty-four complications occurred in 31 patients requiring repair procedures, 3 of whom had multiple complications, with an overall complication rate of 0.72% (31/4307). There were 13 bladder injuries (0.30%), 7 bowel injuries (0.16%), 3 cases of internal bleeding (0.07%), 4 vaginal stump hematomas or abscesses (0.09%), 3 ureteral injuries (0.07%), 3 major vessel injuries (0.07%), and 1 trocar site hematoma (0.02%). In addition, there were 125 (2.88%) postoperative blood transfusions without additional operative intervention. The major complication rate decreased compared with that of the previous study (0.72% [95% CI 0.51%-1.02%] vs 1.59% [95% CI 1.07%-2.36%]; p = .005). The overall complication rates were not significantly different between laparoscopic hysterectomy (LH) group and non-LH group. However, bladder injury happened more frequently in the LH group, whereas bowel injury was more common in the non-LH group. In addition, the severity of the original injury, timing of recognition, and accompanying salvage procedures correlated with the clinical outcomes. CONCLUSION: The significantly decreased major complication rate, as compared with that of our previous study period, confirms the importance of experience accumulation and use of preventive maneuvers in reducing the complication rate. There were no significant differences among the individual injury category during these 2 study periods. The manifestations of bowel injury were highly variable and individualized. The accumulation of surgical experience with the aid of preventive maneuvers is helpful to reduce the complication rate significantly.     

腹腔镜手术并发症34例分析

目的 探讨腹腔镜手术的并发症及其相关因素。方法 回顾性分析北京协和医院妇产科近6扑的1769例腹腔镜手术病例及34例出现并发症的病例情况。手术包括附件手术1421例，子宫肌瘤剔除术52例，腹腔镜辅助的阴式子宫切除术296例，并发症指术中出现的需额外处理或术后出现的因手术术身引起需行再次手术或保守治疗的情况。结果 并发症发生率为1.9%，需开腹手术处理者6例（0.3%)。附件手术、肌瘤剔除术及阴式子宫切除术的并发症发生率分别为0.9%、1.9%及6.8%。与穿刺及气腹有关的并发症12例（35.3%)，包括腹壁血管、大网膜血管损伤及严重的皮下气肿；术中并发症5例（14.7%)，其中大出血3例，膀胱破裂1例，均改开腹手术，另1例为负极板放置处大腿皮肤烧伤；术后并发症17例（50.0%)，其中2例术后腹腔内出血再次开腹止血，术后并发症还包括肠道并发症、神经麻痹及发热。结论 妇科腹腔镜手术的并发症不容忽视，并发症的发生与手术的难度有关。阴式子宫切除术并发症的发生远高于附件手术及子宫肌瘤剔除手术。     

上海市14所医院近10年妇科内镜手术并发症的分析

目的　探讨妇科内镜手术并发症发生的规律。方法　回顾性调查分析上海市 9所三级医院和 5所二级医院近 10年妇科内镜手术 (腹腔镜和宫腔镜手术 )并发症发生情况。结果　 14所医院共进行妇科手术性腹腔镜手术 10 2 63例 ,并发症 15 5例 ,发生率 1 5 1% ;宫腔镜手术 183 0 6例 ,并发症16例 ,发生率为 0 0 9%。腹腔镜手术最常见的并发症是出血性并发症 ,70例 ,发生率 0 68% ,占并发症总数的 45 2 % (70 / 15 5 ) ,其他主要并发症为感染性并发症 18例、脏器损伤性并发症 12例 ,发生率各为 0 18%、0 12 % ;主要并发症在非经验者中的发生率为有经验者的 6倍 (P <0 0 1) ;从 1992～ 2 0 0 1年 ,并发症发生率由 7 2 5 %下降至 0 90 %。宫腔镜手术并发症为子宫穿孔 6例 ,液体超负荷 3例 ,心脑综合征 2例 ,术后出血 3例 ,内脏损伤 1例 ,死亡 1例 ,死亡率 0 0 0 5 % ;并发症年发生率为 0 0 4%～0 2 0 %。进行宫腔镜手术不到 10 0 0例医院的并发症发生率为手术超过 10 0 0例医院的 16倍 (P<0 0 1)。结论　内镜手术并发症发生呈逐年下降趋势。随手术范围的扩大 ,出血性并发症、脏器损伤性并发症有所增加 ,并发症的发生与手术者的手术经验有关。要降低妇科内镜手术并发症发生率 ,应重视适应证的选择、内镜     

Laparoscopy: is it replacing clinical acumen?

One thousand sixty-one laparoscopic procedures (80% for diagnostic indications and 20% for therapeutic indications) performed during a 51-month period were reviewed to assess the effectiveness of laparoscopy in improving clinical diagnosis and avoiding major surgery. The error in preoperative clinical assessment as compared to postlaparoscopic diagnosis was approximately 50%: disease was suspected more often than found. Pelvic inflammatory disease, endometriosis, and ovarian cyst were the entities most often confused. Tubal coagulation was the most common procedure performed for therapeutic reasons. The complication rate for all laparoscopies and associated procedures was 2.6%.     

Analysis of Failed and Complicated Laparoscopy on a Gynecologic Oncology Service

OBJECTIVE: To assess the incidence of and factors that predict failed or complicated operative laparoscopy on a gynecologic oncology service. METHODS: Two hundred four consecutive operative laparoscopies were reviewed. Procedures converted to laparotomy or associated with major operative or postoperative complications were compared with uncomplicated laparoscopies with respect to patient characteristics, details of operative procedure, and length of hospitalization. The influence of patient characteristics, operative findings, and specific procedures on the risk of failed or complicated laparoscopies was estimated. RESULTS: Twenty-five (12. 3%) procedures were either converted to laparotomy or associated with major operative or postoperative complications. Women with failed or complicated laparoscopies had significantly more previous laparotomies and adhesions, greater blood loss, and longer hospital stay than those with uncomplicated laparoscopies (60.0% vs 35.7%, P = 0.03, 68.0% vs 37.4%, P<0.001, 275 ml vs. 132 ml, P = 0.03; and 5. 9 days vs 0.98 days, P< 0.001, respectively). Age, body mass index, parity, menopausal status, preoperative CA-125, appearance of adnexal masses, and complexity of the procedure had no significant influence on failed or complicated laparoscopies. In univariate analysis, history of laparotomy and presence of adhesions and in multivariate analysis only presence of adhesions were predictive of failed or complicated laparoscopies (P = 0.03, <0.001, and 0.006, respectively). CONCLUSIONS: The incidence of failed and complicated laparoscopy is low on a gynecologic oncology service. Presence of adhesions is the only significant independent risk factor predictive of failed or complicated laparoscopy.     

Major complications arising from 1265 operative laparoscopic cases: a prospective review from a single center

STUDY OBJECTIVE: To identify the volume and type of laparoscopic surgery being performed. To review the incidence, nature of associated complications, and reasons for conversion to laparotomy. DESIGN: A multicenter, prospective case load analysis and chart review, identifying operations performed by 6 advanced laparoscopic surgeons over a 12-month period (1/1/05 to 12/31/05). SETTING: Surgical cases were performed in 5 hospitals in Sydney, New South Wales. PATIENTS: One thousand two hundred sixty-five women underwent a variety of major and advanced operative procedures. MEASUREMENTS AND MAIN RESULTS: A total of 1265 major and advanced laparoscopic procedures were performed. Laparoscopic hysterectomy accounted for 364 cases (28.8%), pelvic floor repair and Burch colposuspension 280 cases (22.2%), excisional endometriosis surgery 354 cases (28%), adnexal surgery 177 cases (13.9%), adhesiolysis 75 cases (5.9%), and miscellaneous cases 15 (1.2%). Overall major complications in terms of bowel, urologic, or major vessel injuries accounted for 8 cases (0.6%). There were 4 injuries of the bowel, 2 injuries to the bladder, and 2 injuries to ureters. There were no major vessel injuries. There were no injuries associated with primary trocar or Veres needle insertion. The most common perioperative morbidity reported was the requirement for blood transfusion (11 cases [0.9%]), and the second most common was venous thromboembolism (4 patients [0.3%]). Six (0.5%) cases were converted to laparotomy, 2 as a result of a complication and 4 for technical reasons. Six of the 8 complications were managed laparoscopically, and a multidisciplinary input was sought only in 4 of the 8 complications. CONCLUSIONS: Despite the advanced nature of laparoscopic procedures performed by our group, the complication rate and conversion to laparotomy remain low. There is an increasing feasibility to perform traditional open operations laparoscopically. An increasing number of these complications are now being managed laparoscopically by the gynecologist.     

妇科腹腔镜手术并发症相关因素的分析

目的:探讨腹腔镜手术的并发症及其相关因素。方法:回顾性分析我院7 年中2946例腹腔镜手术病例及25例出现并发症的患者相关因素。结果:腹腔镜手术并发症的发生率为0.85%(25/2946)。因并发症而需要中转开腹手术者6例(0.2%),子宫切除术、肌瘤剔除术、附件手术及其他手术的并发症发生率分别为5.3%(7/133)、2.0%(5/246)、0.50%(11/2189)及0.53%(2/378)。穿刺及气腹有关的并发症11例(0.37%);术中并发症6例(0.28%);术后并发症8例(0.2%)。子宫切除术并发症的发生率远高于子宫肌瘤剔除手术及附件手术(P<0.01)。结论:妇科腹腔镜手术的并发症不容忽视,其并发症的发生与手术的难度有关。     

Minilaparoscopy and open laparoscopy: prevention of laparoscopic complications

BACKGROUND: The study aimed to compare laparoscopy, open-laparoscopy and mini-laparoscopy and to correlate the results of each technique with the respective percentages of laparotomic conversion. METHODS: A total of 101 laparoscopies were performed between November 1997 and April 1999: 18.8% were diagnostic and 81.2% operative. The latter included 54 traditional laparoscopies (65.9%), 18 open-laparoscopies (21.9%) and 10 minilaparoscopies (12.2%). RESULTS: Laparotomic conversion was required in 5.5% of laparoscopies. No laparotomic conversion was necessary for the open-laparoscoples and for mini-laparoscopies. CONCLUSIONS: The possibility of resorting to open-laparoscopy and mini-laparoscopy may represent a valid tool when the patient has previously undergone laparoscopic or laparotomic surgery, with the supposition of pelvo-abdominal adherences that would increase the risk of traditional laparoscopy.     

Reevaluation of hysterosalpingography in infertility investigation

The hysterosalpingogram has been extensively used in infertility investigations to assess tubal patency, however, the diagnostic reliability of this technique is not known. Two hundred thirty-one consecutive hysterosalpingograms were retrospectively evaluated. Sixty-two percent (143) of the patients subsequently underwent laparoscopy. Comparison of hysterosalpingogram and laparoscopic findings revealed a 15.9% false positive tubal patency rate and a 14.9% false negative tubal patency rate. Seventy-six percent of laparoscopies revealed previously undiagnosed intraperitoneal disease. Seventeen percent of hysterosalpingograms demonstrated intrauterine pathology. There was a 0.9% major complication rate with hysterosalpingograms due to two cases of acute pelvic inflammatory disease. No significant laparoscopic complications were noted. The results suggest that laparoscopy provides a more accurate assessment of tubal patency and peritoneal factors than hysterosalpingogram in the investigation of infertility.     

Tolterodine reduces the number of urge incontinence episodes in patients with an overactive bladder

OBJECTIVE: To evaluate the feasability of transvaginal hydrolaparoscopy in infertile patients undergoing basic infertility investigations, and to determine its usefulness in comparison with standard laparoscopy. MATERIALS AND METHODS: Twenty-three unexplained infertile women were prospectively included. Selected patients had no history of pelvic disease or previous pelvic surgery and had normal findings on gynecological examination and vaginal sonography. The patients received general anesthesia and underwent the transvaginal hydrolaparoscopy immediately prior to a standard laparoscopy by a different operator. The main outcome measures were the rate of successful access to the pouch of Douglas, the duration of the procedure, and the rate of complications. In order to compare the accuracy of the transvaginal hydrolaparoscopy to the standard laparoscopy, findings in terms of tubal pathology, endometriosis, and adhesions were analyzed. RESULTS: The successful rate of access to the pouch of Douglas was 95.7%. The rate of complications was 4.3%. The mean duration of the transvaginal hydrolaparoscopy procedure was 8 min. The concordance between transvaginal hydrolaparoscopy and laparoscopy for pelvic cavity examination was statistically significant (k=0.57, P=0.02). In 40.9% of cases, the transvaginal hydrolaparoscopy procedure has shown a normal pelvic examination confirmed by laparoscopic diagnosis. According to the findings by laparoscopy, transvaginal hydrolaparoscopic diagnosis was correlated well in 81.8% of cases. When transvaginal hydrolaparoscopy showed pathological findings, there were no normal laparoscopies. Pathological laparoscopies were found in 18.2% of the normal transvaginal hydrolaparoscopies. CONCLUSION: The transvaginal hydrolaparoscopy is a reproducible and safe method to investigate the pelvis and its structures. The diagnostic accuracy of the transvaginal hydrolaparoscopy suggests that more than 40% of standard laparoscopies for unexplained infertility could be avoided.     

The learning curve of total laparoscopic hysterectomy: comparative analysis of 1647 cases

STUDY OBJECTIVE: To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them. DESIGN: Retrospective, comparative study (Canadian Task Force classification II-2). SETTING: University tertiary referral center for endoscopic surgery. PATIENTS: During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology. INTERVENTION: Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005). CONCLUSION: Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.     

Major complications of operative gynecologic laparoscopy in southern Taiwan

STUDY OBJECTIVE: To describe our experience with major complications in gynecologic laparoscopy compared with literature reports. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Two regional teaching hospitals in southern Taiwan. Patients. One thousand five hundred seven women. INTERVENTION: Gynecologic laparoscopy. MEASUREMENTS AND MAIN RESULTS: The overall number of major complications in 1507 laparoscopies was 24 (1.6%): 6 bladder injuries, 5 bowel injuries, 4 ureteral injuries, 3 cases of delayed vaginal stump bleeding, 2 cases of postoperative ileus, 2 abscesses, 1 vessel injury, and 1 umbilical hernia. Complication rates were analyzed by type of surgery-laparoscopic-assisted vaginal hysterectomy (LAVH) versus non-LAVH. We correlated clinical outcome with time of recognition and treatment of complications. Our complication rates were similar to those reported in the literature and were not significantly different between LAVH and non-LAVH. CONCLUSION: Early recognition of injuries, preferably intraoperatively, with immediate appropriate treatment is crucial. It is also important to be alert to early manifestations of complications in the postoperative observation period. (J Am Assoc Gynecol Laparosc 8(1):61-67, 2001)     

Gynaecological laparoscopy: 'see and treat' should be the gold standard

PURPOSE OF REVIEW: Two hundred and fifty thousand gynaecological laparoscopies are performed yearly in the UK, many of them diagnostic. Unless a patient has major endometriosis and needs advanced surgery, the Royal College of Obstetricians and Gynaecologists suggest a 'see and treat' policy. Thus, gynaecologists who undertake laparoscopy should be competent at performing intermediate level laparoscopic surgery, including excision of endometriosis, adhesions and benign ovarian tumours, rather than converting to laparotomy or referring patients to another unit. In order to reduce operative risk and make best use of resources, preoperative assessment should triage patients into those with unlikely pelvic pathology who do not require laparoscopy in the first instance, those with severe endometriosis, who need referral to a specialist centre and the intermediate group who is best served with a 'see and treat' policy. RECENT FINDINGS: Appraisal of alternatives to diagnostic laparoscopy in infertility assessment and recent reports of modified ultrasound scanning improve the predictive value and will help to avoid unnecessary laparoscopies. Preoperative predictors for severe endometriosis can determine who needs specialist referral. 'See and treat' laparoscopies require adequate education, and workable training methods are under investigation. SUMMARY: Negative laparoscopies should be avoided and 'see and treat' laparoscopy should replace diagnostic procedures. Thorough preoperative assessment helps to identify women suitable for 'see and treat' laparoscopy.     

妇科腹腔镜手术3993例并发症分析

目的探讨妇科腹腔镜手术并发症的相关情况,寻求有效预防和减少并发症的方法,降低并发症危害。方法对首都医科大学附属北京朝阳医院妇科1995年2月至2008年12月3993例腹腔镜手术术中及术后并发症的发生情况进行回顾性分析。结果 3993例妇科腹腔镜手术中,并发症发生率为1.65%(66/3993),其中轻度并发症41例,发生率为1.03%;重度并发症25例,发生率为0.63%。手术并发症与医师的手术经验明显相关,从事腹腔镜手术时间不足1年者,并发症发生率明显升高,尤其是与穿刺及气腹有关的并发症;手术并发症与腹部手术史有相关性,有腹部手术史患者并发症发生率较无手术史者增高。结论腹腔镜手术并发症与手术难度、腹部手术史及医师手术经验有关。提高临床医生的内镜手术技能和手术技巧,进行正规手术操作训练可减少并发症的发生。     

Complicaciones en la laparoscopia

AimTo determine the incidence of complications of laparoscopic surgical techniquesDesignRetrospective observational studyMethodThe gynecological history of patients undergoing laparoscopic surgery between January 1991 and December 1999 were reviewed, including the type of surgical intervention and nature of the complication. Complications were considered to be any unexpected intraoperative or postoperative event requiring subsequent treatmentResultsA total of 3,504 laparoscopic procedures were carried out. Of these, 2,135 (60.7%) were surgical laparoscopies, 1,026 (20.2%) were diagnostic and 343 (9.8%) were tubule sterilizations. Total morbidity was 8.56% (30 complications). No deaths occurred. The percentage of complications was 13.58% (29) in laparoscopic surgery and 0.28% (1) in diagnostic laparoscopy. In 10 patients, surgical complications required conversion to laparoscopy (2.85%), the main cause being intestinal lesions. Four patients (1.14%) underwent reoperation, three for intestinal lesions and one for ureteral lesionsConclusionsLaparoscopy is not a risk-free technique. Most complications occur during surgery. The diversity of surgeons and residents' training programs increases the percentage of complications, mainly in the pneumoperitoneum due to the insertion of a Veress needle or the first trocar needle. Consequently, laparoscopic techniques should be standardized and patients should be selected to identify those most at risk in order to maximize precautions and prevent surgical complications