Only benign adnexal masses are suitable for treatment by operative laparoscopy. Ovarian cancer must always be managed by midline laparotomy. In our experience the preoperative workup (clinical examination, study of past history, trans vaginal ultrasonography, doppler, tumoral markers etc.) together with the diagnostic phase of laparoscopy provide a sensitivity value of 100%, a positive predictive value of 50% and a negative predictive value of 100% for diagnosis of malignancy. Provided a strict selection, laparoscopy is reliable both for the diagnosis and the management of benign ovarian masses.
Total hysterectomy via laparoscopy is a recently developed technique. Assessment of a new surgical technique, once the operation has been shown to be feasible, requires an evaluation of the risks of complications. Here we report our cumulative 3 year experience with laparoscopic hysterectomy in a total of 222 patients. The overall complication rate was 10.0%. We did not observe any haemorrhage complications requiring another operation. Four patients (1.8%) were re-admitted to hospital but only two of them (0.9%) had to be operated upon again (one vesico-vaginal fistula and one vaginal cuff wound separation). 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.
The great majority of hysterectomies in nulliparous patients have been carried out via laparotomy. The purpose of this study was to establish whether laparoscopic surgery can be of use in an attempt to reduce the number of laparotomies when hysterectomy is indicated in patients without previous vaginal delivery. A retrospective study was carried out on 66 women who had not had a previous vaginal delivery who underwent hysterectomy from January 1993 to May 1995. Laparotomy was required for only 19.7% of cases (13 patients). For the 53 patients (80.3%) who underwent laparoscopic hysterectomy, the average duration of the operation was 152.24 +/- 45.7 min, and the average weight of the uterus was 238.3 +/- 154.1 g. The duration of the laparoscopic operation was correlated in a statistically significant fashion with the weight of the uterus (P = 0.0005), the necessity of associated procedures during the hysterectomy (P = 0.01) and the surgeons' experience (P = 0.01). These results demonstrated that laparoscopic surgery decreases the number of laparotomies necessary for patients with no previous vaginal delivery who require hysterectomy. When vaginal access is poor, simple laparoscopic preparation is inadequate and the only possibility of avoiding laparotomy is to carry out the hysterectomy entirely via the laparoscopic route.
In the field of gynaecological surgery, the past few years have been significant due to the development of operative laparoscopy. Originally recommended for the diagnosis of female infertility, over the past 15 years laparoscopy has acquired the standing of a surgical discipline in its own right. Laparoscopic surgical treatment of ovarian cysts, whether conservative or radical, has now been completely standardized. The aim of this work is to specify the indications, procedures and risks involved with this surgery as applied to organic ovarian cysts. Only benign ovarian cysts are suitable for treatment by laparoscopic surgery; ovarian cancer must always be handled by classic surgery using a mid-line laparotomy. Given that clinical and other pre-operative investigations can give only an indication, ovarian lesions require surgical investigation to diagnose the histological type. Laparoscopy appears to be as reliable as laparotomy when assessing whether an ovarian tumour is malignant. The risk of parietal contamination and peritoneal dissemination if a malignancy is not recognized means that, if there are no signs of extra-ovarian extension, adnexectomy is mandatory whenever there is the slightest doubt. This adnexectomy must obey two important rules: it must be accomplished without rupturing the cyst, and the cyst must be placed, intact, inside an endoscopic bag before being extracted. Provided that all stages of the procedure, from pre-operative work-up to the initial diagnostic phase of the laparoscopy, are carried out meticulously, laparoscopic surgery is reliable for both the diagnosis and the management of benign organic-ovarian cysts.
400. Am J Obstet Gynecol. 1996 Jul;175(1):234-5. doi: 10.1016/s0002-9378(96)70290-9. Laparoscopic treatment of ovarian dermoid cysts. Chapron C, Dubuisson JB.
The aim of this study was to assess the fertility outcome after ectopic pregnancy (EP) treated by laparoscopic salpingectomy. Among the 375 patients who underwent this operation between January 1983 and December 1993, there were 145 patients who desired pregnancy and whose contralateral tube was not obstructed. The overall rate of intrauterine pregnancy (IUP) was 50.3%, with an EP rate of 15.2%. These results were analysed according to the patients' past history together with the condition of the contralateral tube at the time of the laparoscopy. We defined two groups. Group 1 included patients who had no previous history of tubal surgery and whose contralateral tube was normal. Group 2 comprised those patients who had a previous history of tubal surgery and/or those whose tube was pathological, but not obstructed. Postoperative fertility of the patients in group 1 was significantly higher than that of the patients in group 2, with IUP rates of 75 and 36.6% respectively (P < 0.001), and a risk of EP recurrence of 9.6 and 18.3% respectively. In group 1, the actuarial IUP rate at 24 months was significantly higher than that for the patients in group 2 (66.7 versus 36.9%; P < 0.001). The patient's past history and the condition of the contralateral tube were the two major factors related to fertility outcome after laparoscopic salpingectomy for EP. In patients with no past history of tubal surgery or infertility and whose contralateral tube was normal, the fertility results after laparoscopic salpingectomy appeared comparable to those observed after conservative laparoscopic treatment.
The aim of this work was to clarify the value and application of operative laparoscopic treatment for adnexal torsion. We included in our study all patients (n = 27) who presented with an intra-operative diagnosis of torsion of the adnexa between January 1989 and May 1995. A total of 28 adnexal torsions were treated. Treatment was carried out by laparoscopic surgery in 75% of cases (21 torsions): in one-half of the cases (14 torsions) it was possible to achieve conservative laparoscopic treatment. The nature of the lesions and the experience of the surgeons are two factors which closely govern the outcome of surgical treatment. For those patients presenting a benign pathology, laparoscopic surgery was used to treat 84% of cases in the series. All the patients presenting a benign pathology and operated upon since 1993 have received laparoscopic surgical treatment. No major complications (peritonitis, thrombotic emboli, coagulation problems) were observed after conservative laparoscopic surgery. These results demonstrate that, provided the surgeons are sufficiently experienced, treatment by conservative laparoscopic surgery for adnexal torsion is both safe and reliable. In the years to come more work must be done to assess the vitality of the adnexa so that as many patients as possible can benefit from conservative treatment.
The goal of this study was to assess the efficiency of laparoscopic surgical treatment of pain for patients presenting deep endometriosis located on the uterosacral ligaments. To this end we analysed a continuous series of 21 patients treated by laparoscopic surgery between January 1993 and June 1994. In all these cases treatment consisted of resection of all the uterosacral ligament(s) presenting deep endometriotic lesions together with exercise of all other endometriotic lesions. No complications were observed per- or postoperatively. The results were assessed for all the patients with a minimum follow-up of one year. The efficiency of the treatment varied according to the symptoms. Patients who presented dysmenorrhoea (19 cases) improved in 84.2% of cases (16 patients). Out of the 17 patients who presented deep dyspareunia, improvement was evident for 94.1% of cases (16 patients). The chronic pelvic pain suffered improved in seven out of nine cases (77.7%). Patients who benefited from an improvement rated it excellent or satisfactory in over 80% of cases. These results demonstrate that, provided the surgeon is highly skilled in laparoscopy, laparoscopic surgery is efficient for the treatment of patients presenting painful symptoms related to deep endometriotic implants located on the uterosacral ligaments.
