Publications

Results and role of rectal endoscopic ultrasonography for patients with deep pelvic endometriosis.

The objective of this work was to assess the advantages and the role of rectal endoscopic ultrasonography (EUS) when establishing evidence of infiltration of the rectal wall in patients with proven deep pelvic endometriosis. To this end we performed a retrospective study between July 1993 and December 1996 of a continuous series of 38 patients who presented with deep pelvic endometriosis which was confirmed histologically. The EUS results were considered normal in nine cases (23.7%). In 12 cases (31.6%) EUS revealed an image compatible with infiltration of the uterosacral ligaments and/or the rectovaginal septum without any associated bowel infiltration. In 17 cases (44.7%) EUS revealed an image compatible with deep infiltration of the intestinal wall. Sixteen of these 17 patients underwent laparotomy with bowel resection. The histological results confirmed in each of these 16 patients (100%) that there was deep infiltration of the intestinal wall by endometriotic lesions. The seventeenth patient refused such major surgery by laparotomy, and underwent partial laparoscopy due to the risk of bowel injury. For the 21 patients with no EUS evidence of rectal infiltration complete laparoscopic surgical exeresis was achieved in every case (100%) without broaching the intestinal wall. These preliminary results enable us to state that EUS, which is a simple and non-invasive technique, provides a reliable indication as to the presence of deep bowel infiltration in patients with retroperitoneal endometriotic lesions. EUS used pre-operatively enables patients to be selected for treatment via laparotomy or by laparoscopic surgery.

[Uterus and diethylstilbestrol: which examinations, which antecedents for an active management? Which treatments?].

Diethylstilbestrol (DES) was widely prescribed to pregnant women from 1946 to 1977. This resulted in multiple abnormalities of the genital tract. Many studies show an increased incidence of infertility, ectopic pregnancy, spontaneous abortions and premature delivery. For women with certain abnormalities such as a construction of the upper uterine cavity, with or without a T configuration of the uterus, hysteroscopic metroplasty is feasible with good anatomic and functional results.

A French survey on gynaecological laparoscopy.

[Extra-uterine pregnancy. Etiology, diagnosis, course of disease, treatment].

326. Rev Prat. 1998 May 1;48(9):1037-9. [Extra-uterine pregnancy. Etiology, diagnosis, course of disease, treatment]. Dubuisson JB, Chapron C.

Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 29,966 cases.

A multicentre study was carried out in seven top French centres for laparoscopic gynaecological surgery. This series covers a period of 9 years, in which 29,966 diagnostic and operative laparoscopic operations were performed. 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 was 3.33 per 100,000 laparoscopies. The overall complication rate was 4.64 per 1000 laparoscopies (n = 139). The rate of complications requiring laparotomy was 3.20 per 1000 (n = 96). The complication rate was significantly correlated with the complexity of the laparoscopic procedure (P = 0.0001). One in three complications (34.1%; n = 43) occurred while setting up for laparoscopy, and one in four (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 by 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 that are well 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 management of organic ovarian cysts: is there a place for frozen section diagnosis?

Only benign ovarian cysts can be treated by laparoscopic surgery. Although clinical examination and the results of pre-operative work-up do make a real contribution in indicating the benign or malignant nature of cysts, only histology can provide the absolute diagnosis. In this context, the goal of this study was to establish whether there is any advantage in performing frozen section during laparoscopic surgical management of organic ovarian cysts. Between January 1989 and March 1996, 228 patients underwent an adnexectomy for an ovarian mass. After the pre-operative work-up and the diagnostic phase of laparoscopy, 26 patients (11.4%) presented with suspected signs of malignancy restricted purely to the ovary. These 26 patients underwent a laparoscopic adnexectomy with extraction of the excised tissues using an endoscopic bag, followed by frozen section. For all these patients the results of the frozen section concluded that the lesion was benign. In every case the definitive histological results confirmed the frozen section findings. This strategy enabled us to avoid laparotomy, especially for the nine post-menopausal patients whose adnexal masses appeared to be complex by ultrasound. These encouraging preliminary results need to be confirmed by a larger series of patients, so as to specify the place of frozen section in the laparoscopic surgical management of organic ovarian cysts.

[Total hysterectomy for benign pathologies. Laparoscopic surgery does not seem to increase the risk of complications].

OBJECTIVE: To assess the risk of complications of total laparoscopic hysterectomy (TLH). SETTING: University Hospital, Surgical Gynecological team. DESIGN: Retrospective study of 313 patients. For all the patients a total laparoscopic hysterectomy was performed. Every part of the operation was carried out via laparoscopy, from the adnexal phase (conservative or radical) to the colpotomy. All hemostasis was carried out by electrosurgery (bipolar coagulation). All the instruments are reusable. RESULTS: The rate of conversion to laparotomy was 6.7% (21 patients). For the patients who underwent a TLH (292 cases; 92.3%) the overall complication rate was 9.95% (29 patients). The rate of patients presented a complication which required a further operation was 1.4% (4 patients). The rate of patients presented a complication which required a re-hospitalization was 2.0% (6 patients). The rate of major urinary injury was 2.5% (6 cases): bladder injury (4 patients; 1.35%); vesico-vaginal fistula (1 case; 0.35%); ureteral complication (1 case; 0.35%). The rate of postoperative febrile morbidity was 5.8% (17 patients). CONCLUSIONS: These encouraging results mean that, provided the surgeons are experienced in laparoscopic surgery, total laparoscopic hysterectomy technique would appear not to have a higher rate of complications than hysterectomy via laparotomy or the vaginal route.

Complications of laparoscopy: a prospective multicentre observational study.

379. Br J Obstet Gynaecol. 1997 Dec;104(12):1419-20. doi: 10.1111/j.1471-0528.1997.tb11017.x. Complications of laparoscopy: a prospective multicentre observational study. Chapron C, Dubuisson JB, Querleu D, Pierre F.

Appropriate treatment for tubal pregnancy?

381. Fertil Steril. 1997 Nov;68(5):945-7. doi: 10.1016/s0015-0282(97)90362-9. Appropriate treatment for tubal pregnancy? Chapron C, Dubuisson JB.

Major vascular injuries during gynecologic laparoscopy.

BACKGROUND: This study was undertaken to report our experience with major vascular injuries in gynecologic laparoscopy in order to specify the circumstances under which they occurred, the means of diagnosis, the risk factors, and the means for prevention. STUDY DESIGN: Retrospective case review study. RESULTS: Seventeen patients with 21 major vascular injuries were identified. The average age of the patients was 33.8 +/- 11.6 years, and the mean body index mass was 21.6 +/- 3.08 kg/m2. Three of four of the accidents occurred during the set-up phase of laparoscopy (13 cases; 76.5%), and in 4 cases (23.5%) the accident occurred during the laparoscopic surgery procedure. Eleven (84.6%) of the complications occurring during the set-up phase were secondary to insertion of the umbilical trocar and 2 (15.4%) to insertion of the needle used to create the pneumoperitoneum (P-needle). Half (6 cases; 54.5%) of the major vascular injuries secondary to insertion of the umbilical trocar were observed when reusable trocars were used. In every case, the diagnosis was made during the operation. Two patients died, and two others presented a serious complication (phlebitis; acute ischemia requiring reoperation). CONCLUSIONS: Major vascular injuries are rare but serious complications of laparoscopic surgery. Prevention of these accidents relies on the surgeon's experience and scrupulous respect of the safety rules. In the vast majority of cases, it is necessary to convert to laparotomy immediately, calling in a vascular surgeon.