Laparoscopy Today

JOURNAL WATCH: Fertil Steril Endometriosis

Laparoscopic Excision of Endometriosis: a Randomized, Placebo-Controlled Trial • Abbott J et al. 2004;82:878-884. Thirty-nine women were randomized to receive either a diagnostic procedure or full excisional surgery. Eighty percent of the women who received excisional surgery reported an improvement in symptoms whereas 32% of women in the placebo group reported an improvement. Those who underwent excisional surgery also reported significant improvement in quality of life.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Laparoscopy vs. Laparotomy in Pregnancy

UPDATE: LAPAROSCOPY FOR THE PREGNANT PATIENT

JAMES F. CARTER, MD, DAVID E. SOPER, MD

INTRODUCTION

The incidence of pelvic pain requiring surgery ranges from 1:440 to 1:1300 [1]. The incidence of surgery during pregnancies is approximately 0.75% [2]. One in 600 pregnancies are complicated by the presence of adnexal masses [3]. One must consider operative intervention when the mass persists or the patient develops symptoms of acute pelvic pain. The majority of these cases are still approached via laparotomy due to concern about injury during laparoscopic trocar insertion or about the high intraperitoneal pressures associated with pneumoperitoneum. A number of studies have documented the safety of laparoscopic cholecystectomy during pregnancy [4-8]. Conversely, 2 reports reveal that complications may occur while laparoscopy in pregnancy is being performed [6,9]. A growing body of evidence indicates that laparoscopy for gynecologic and obstetric indications can be performed safely during pregnancy [8-15].

Gurbuz [8] asked about the role of laparoscopy in pregnancy, while Hunter [10] gave us pressure numbers. Reedy [11,12] defined fetal outcomes and surveyed laparoscopic surgeons. Mazze [14] defined safety in appendectomies in pregnancy, and Carter [15] compared laparoscopy with laparotomy.

DISCUSSION

Reedy’s study, which used the Swedish Health Registry to analyze 5 fetal outcome parameters, showed that no difference existed in birth weight, gestational length, growth restriction, infant survival, or malformations when laparoscopy was compared with laparotomy. In a study that we performed comparing laparoscopy with laparotomy in pregnancy [15], age, gestational age at surgery, operating time, hospital stay, and complications of surgery were compared; and we found no statistical differences in outcomes except hospital stay: 1 day for our laparoscopic patients and 4.4 days for our laparotomy patients. All the laparoscopic patients delivered live-born infants, while 1 laparotomy patient had a spontaneous abortion 5 days postoperatively. During surgery, our laparotomy patients were placed in the dorsal supine position with a left ward tilt. All laparoscopy patients were placed supine with a leftward tilt and sequential compression devices. Placement of laparoscopic trocars must be modified depending on uterine size and gestational age. Trocar sizes (5 mm to 12 mm) should also be modified for gestational age. Our rule is to use the open technique for initial trocar placement. If the uterus is 18-weeks to 20-weeks size or greater, the initial trocar is placed above the umbilicus by using a 5-mm trocar via the open technique or radial dilatation (VersaStep) instruments. The remaining trocars are placed under direct visualization varying from 5 mm to 12 mm on the affected side. In no cases have we used more than 4 trocar sites, including the laparoscope. If the uterus is <18-week size, the initial trocar placement is in the umbilicus, not subumbilicus. Our initial trocars varied from 10 mm to 3 mm as our skills, comfort, and technology improved. Intraabdominal pressure was monitored in all patients and care was taken not to exceed 12-mm Hg pressure to ensure adequate venous return and minimize pressure on the inferior vena cava [8,13,16,17]. Using multiple graspers and manipulators, the abdominal contents were manipulated based on the location of the pelvic pathology. Uterine manipulation was kept to a minimum. Copious irrigation was used. Postoperatively, the patients were closely observed during labor and delivery for increased uterine activity. We used indomethacin in a one-time dose of 50 mg per rectum in greater than 12-weeks gestation. All laparotomy patients underwent general anesthesia and a midline abdominal incision with minimal manipulation of the uterus. Preoperatively, the fetus was monitored and postoperatively the patients were closely observed on labor and delivery for uterine activity and fetal heart tones.

STATISTICS

Discreet data were compared by using the chi-square test with Fisher’s exact test used where appropriate. The independent samples t test was used to analyze continuous variables.

The preoperative characteristics of pain or adnexal mass were similar in both the laparoscopic and laparotomy groups (Tables 1 and 2). Comparisons of the 2 groups were similar (Table 3 [p. 15]). The pathologies noted at the time of surgery are listed in Table 4. Pregnancy outcomes are noted in Table 5. One of 7 patients delivered prematurely (34 weeks vaginally) in our laparoscopically managed group compared with 3 of 9 (31 weeks for breech, 33 weeks for failed induction for chorioamnionitis, 35 weeks, 4 days for severe preeclampsia) managed by laparotomy. The difference was not statistically significant. All deliveries were remote from the index surgery, except for one spontaneous abortion following a laparotomy. All infants born preterm did well. The blood loss for laparoscopies was noted to be minimal. The blood loss for the laparotomies ranged from 50 mL to 300 mL.

Our work supports previous reports on the safety and effectiveness of operative laparoscopy in pregnancy. Until recently, laparoscopy was considered contraindicated in pregnancy. We show no increased mortality associated with laparoscopy in pregnancy, which confirms a landmark study by Reedy et al [9,10], showing that 413 laparoscopic procedures performed during pregnancy for general surgical and gynecologic indications had no higher fetal or maternal complications compared with complications in a population undergoing laparotomies. Fetal loss has been reported of 10% to 25% and a preterm delivery rate of approximately 20% in laparotomies [12-14].

CONCLUSION

In the hands of skilled laparoscopic surgeons, operative laparoscopy in pregnancy can be performed as safely as laparotomy in pregnancy can be with minimal hospital stay. Surgeons must recognize their limitations, know when to refer these patients, and leave their egos at the scrub sink. It is imperative to adhere to several technical aspects when performing laparoscopy in pregnancy. Safe laparoscopic access is paramount, and we feel that the Hasson technique is appropriate. Modification of trocar sites must be individualized ensuring an effective procedure with minimal uterine manipulation. The location of these trocars relative to the enlarged uterus is key to success. Smaller trocars (2 mm to 3 mm) should be used. Minimizing CO2 insufflation to maximize cardiac output, maternal hepatic flow, and minimize fetal acidosis is paramount, therefore 12-mm Hg pressure or less. Constant communication with the anesthetist combined with sequential compression devices, lateral tilting of the patient and routine Foley catheters is mandatory. When one adheres to these principles, skilled laparoscopic surgeons may perform these procedures with low morbidity. Though operating times are longer (Table 3), patients benefit with shorter hospital stays and subsequent successful pregnancies.

Figure 1. Dr. Soper and Dr. Bullard (Chief Resident) aspirating large ovarian cyst laparoscopically.

Figure 2. A. Large ovarian cyst removed laparoscopically. B. Dermoid cyst removed from abdomen via laparoscopy. C. Dermoid cyst removed laparoscopically-another view.

Address reprint requests to: James F. Carter, MD, Medical University of South Carolina, Dept of Ob/Gyn, 171 Ashley Ave, Ste 634, Charleston, SC 29425, USA. Tel: 843 792 4500, Fax: 843 792 0533, E-mail: carterja@musc.edu

James F. Carter, MD, is an Associate Professor of Obstetrics and Gynecology and the Director of Advanced Laparoscopy Laboratory, at the Medical University of South Carolina, Charleston, South Carolina, USA.

David E. Soper, MD, is Professor and Vice Chairman of Business Operations and Head, Division of Benign Gynecology at the Medical University of South Carolina, Charleston, South Carolina, USA.

References

1.    Kort B, Katz VI, Watson WJ. Effect of non-obstetric operation during pregnancy. Surg Gynecol Obstet. 1993;177:371-376.

2.    Mazze RI, Kallen B. Reproductive outcome after anesthesia and operation during pregnancy: a registry study of 5,405 cases. Am J Obstet Gynecol. 1989;161:1178-1185.

3.    Kohler MF. The adnexal mass in pregnancy. Postgrad Obstet Gynecol. 1994;14:1-5.

4.    Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy during pregnancy-a case series and review of the literature. Obstet Gynecol Surv. 1998;53:566-574.

5.    Amos JD, Schorr SJ, Norman PF, et al. Laparoscopic surgery during pregnancy. Am J Surg. 1996:171:435-437.

6.    Eichenberg BJ, Vanderlinden J, Miguel C, et al. Laparoscopic cholecystectomy in the third trimester of pregnancy. Am Surg. 1996;62:874-877.

7.    Lanzafame RJ. Laparoscopic cholecystectomy during pregnancy. Surgery. 1995;118:627-633.

8.    Gurbuz AT, Peetz ME. The acute abdomen in the pregnant patient: is there a role for laparoscopy? Surg Endosc. 1997;11:98-102.

9.    Reedy M, Kim U, Thompson E, Rayburn WL, Laparoscopy during pregnancy. A safe alternative to laparotomy? Contemp Ob Gyn. 1998:75-91.

10.    Hunter JG, Swanstrom L, Thornberg K. Carbon dioxide pneumoperitoneum induces fetal acidosis in a pregnant ewe model. Surg Endosc. 1995;9:272-279.

11.    Reedy MB, Galan HL, Richards WE, Preece CK, Wetter PA, Kuehl TJ. Laparoscopy during pregnancy, a survey of laparoendoscopic surgeons. J Reprod Med. 1997;42:33-38.

12.    Reedy MB, Kallen B, Kuehl TJ. Laparoscopy during pregnancy: a study of five fetal outcome parameters with use of the Swedish Health Registry. Am J Obstet Gynecol. 1997;177:673-680.

13.    Duncan PG, Pope WDB, Cohen MM, et al. Fetal risk of anesthesia and surgery during pregnancy. Anesthesiology. 1986;64:790-794.

14.    Mazze RI, Kallen B. Appendectomy during pregnancy-A Swedish Registry study of 778 cases. Obstet Gynecol. 1991;77:835-840.

15.    Carter JF, Soper DE. Laparoscopy in pregnancy. JSLS. 2004;8:57-60.

16.    Iafrati MD, Yarnell R, Schwaitzbergs. Gasless laparoscopic cholecystectomy in pregnancy. J Laparoendosc Surg. 1995;5:127-130.

17.    Carter J, Chang E, Haynes G, Scardo J. Hemodynamic Effects of pneumoperitoneum during gynecologic laparoscopic surgery. J Gynecol Surg. 1997;13:169-173.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS De Novo Adhesions

Prevention of De Novo Adhesions by Ferric Hyaluronate Gel After Laparoscopic Surgery in an Animal Model • Detchev R, Bazot M, Soriano D, Daraï E. 2004;8:263-268. Results obtained with a rabbit model suggest that routine intraperitoneal application of hyaluronate gel does not prevent adhesion formation after laparoscopic surgery.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Hernias in Women: Uncommon or Unrecognized?

CHRONIC PELVIC PAIN

DEBORAH A. METZGER, PhD, MD

Considering the perceived rarity of hernias in women [1], the association between chronic pelvic pain and occult hernias is not generally considered when evaluating women with chronic pelvic pain [2]. However, based on a review of the literature and personal experience, nonpalpable, or occult hernias are a common source of chronic pelvic pain in women.

Most gynecologists and general surgeons are unaware of occult hernias and many do not believe that they exist; and therefore, they are controversial. However, Nyhus [3] described a spectrum of hernias differentiated by size, presence or absence of a sac, and the degree of deformity of anatomy. Type III hernias are more common in men, whereas Type I and II hernias (occult hernias) appear to be more common in women. Type I and II hernias, often referred to as occult inguinal hernias, have been reported to be associated with groin pain in men, women, and athletes [4].

Except for a mass in the groin, pain is the most common symptom of a hernia [5]. Pain is more common in the incipient stages of hernia, when the tissues are being stretched [6], and is by far the most common sole initial symptom caused by hernia. The pain is often sharp and may even be of the neuralgic type [7]. Symptoms may develop long before a palpable hernia develops. Thus, in women with chronic pelvic pain, it would be anticipated that the earlier, nonpalpable stages of hernias would predominate.

Because a variety of organ systems are involved in the spectrum of presentations of occult inguinal hernias, the diagnosis can be confusing. The primary symptom is groin pain that the patient may describe as “ovarian pain” (Figures 1 and 2). Other symptoms, such as pain with bowel movements, full bladder, or with intercourse, are related to exacerbation of the pain with increased intraabdominal pressure. Back pain, either uni- or bilateral, appears to be due to piriformis muscle spasm as this muscle is often quite tender on vaginal examination. Likewise, sciatica may be due to the stretch of the sciatic nerve as it passes over the tensed piriformis muscle. The exacerbation of groin pain with menses, which patients describe as different from cramps, is not readily explained, but commonly observed. Ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal neuralgia symptoms may predominate, and the patient may complain of sharp, shooting pains up the vagina, around the hip and back, into the flank, down the thighs, and into the labia. These secondary problems make it more difficult to make the diagnosis of inguinal hernia especially since the patient may see a variety of specialists who may not connect all of the symptoms. Thus, the patient may have been diagnosed with lumbar disc problems, pelvic floor tension myalgia, sacroiliac instability, interstitial cystitis, endometriosis, abdominal wall trigger points, neuropathy, pudendal neuralgia, orthopedic problems of the hip, or psychosomatic problems.

Diagnosis of nonpalpable hernias in women relies almost exclusively on clinical examination. The small size of these hernias and the presence of incarcerated fat make it difficult to obtain useful information from ultrasound, computed tomography, magnetic resonance imaging, or herniography.

Examination of the abdomen in a supine position with the abdominal wall tensed may reveal tenderness over the course of the ilioinguinal or iliohypogastric nerves, or both. Abdominal examination in a standing position sometimes reveals a subtle bulge associated with the external inguinal canal. More often, however, there may be tenderness of the ring reproducing a component of the patient’s pain. The best predictor of an occult hernia is the vaginal examination. Often the pelvic floor muscles are tense and tender. Likewise, the ischial spines may be tender. Most telling is a reproduction of the patient’s pain by palpation of the internal inguinal area. The positive predictive value of this latter sign approaches 100% [8].

Oral medications that specifically target nerve pain, such as gabapentin, amitriptyline, and tramadol, are often helpful. Antiinflammatory medications, such as ibuprofen, naprosyn, and the cox-2 inhibitors, can be helpful. Narcotic medications in general are not particularly helpful for nerve-related pain. Topical medications, such as Lidoderm, 10% ketoprofen, 5% amitriptyline, 5% lidocaine, and/or 10% gabapentin, may reduce pain.

Myofascial release performed by a physical therapist trained in internal manual methods can sometimes be helpful in alleviating some of the muscle spasms. Nerve blocks may produce temporary relief, but the pain invariably returns.

Surgery is considered only when a patient has tried the medical treatments described above and still has a level of pain that interferes with her quality of life. Hernias are generally not visible at the time of laparoscopy and thus are usually missed by prior surgeons. To make the diagnosis, inguinal exploration of the affected side(s) is performed using a laparoscopic approach. A transverse incision is made in the peritoneum, and a careful exploration is performed to look for incarcerated fat or dilation of the indirect inguinal, direct inguinal, femoral, and obturator spaces. All 4 spaces are explored because it is common to find more than one type of hernia [8]. The incarcerated fat is removed, and a soft mesh is placed over the hernias. We do not use staples or tacs to hold the mesh in place because these fixation devices can cause pain and require additional surgery to remove them [9]. The peritoneum is then closed with an absorbable suture.

As with any type of laparoscopic surgery, risks are associated with hernia repair. Bleeding from vessels in the inguinal area, permanent damage to nerves, infection, adhesions, and continued pain are all potential risks. Postoperative pain is somewhat greater than with other types of laparoscopic procedures and should be treated with appropriate narcotics. Neuropathy may initially resolve and then reappear within 1 to 3 weeks following surgery and last 2 to 3 weeks before it spontaneously resolves. Some women require a series of nerve blocks to completely resolve the nerve pain. Overall, 80% to 85% of women obtain complete or significant pain relief from surgery for occult hernias [10].

The treatment of chronic pelvic pain has been limited by our ability to specifically diagnose and treat the cause(s) of pain. Because occult hernias are not generally apparent on laparoscopic evaluation, they should be considered in chronic pelvic pain patients with negative laparoscopy results or where the observed pathology is insufficient to explain the degree and type of pain.

Figure 1. Location of the ovarian point.

Figure 2. Patterns of pain in the presence of occult hernias. The pain can be unilateral or bilateral.

Address reprint requests: Deborah A. Metzger, PhD, MD, Harmony Women’s Health, 851 Fremont Ave, Ste 104, Los Altos, CA 94024, USA. Tel: 650 229 1010, Fax: 650 229 1011, E-mail: DrDebMetz@pol.net

Deborah A. Metzger, PhD, MD, is a gynecologic surgeon and reproductive endocrinologist whose major interest is the integrated treatment of women with chronic pelvic pain. After graduating from college (SUNY at Buffalo, 1973), she obtained a PhD in molecular endocrinology from Baylor College of Medicine in Houston, Texas (1979). She attended medical school at the University of Texas Medical School at Houston (1982) and completed her residency in Obstetrics and Gynecology (1986) and a fellowship in Reproductive Endocrinology and Infertility (1988) at Duke University in North Carolina. She has served on the medical school faculties of the University of Connecticut, Yale, and Stanford. Currently, she is Medical Director of Harmony Women’s Health in Los Altos, California.

She is recognized as one of the leading authorities in the treatment of endometriosis and chronic pelvic pain. In addition to her involvement in many professional societies, she is a founding member and past-President of the International Pelvic Pain Society. She has lectured extensively throughout the world, published widely in peer-reviewed journals and textbooks, and is one of the editors of Chronic Pelvic Pain: An Integrated Approach, the first book on the subject.

References

1.    Spangen L. Nonpalpable inguinal hernia in women. In: Hernia Fourth Edition. Nyhus LM, Condon RE, eds. Philadelphia: JB Lippincott Co; 1995:87-90.

2.    Kavic MS. Chronic pelvic pain, hernias and the general surgeon [editorial]. JSLS. 1999;3:89-90.

3.    Nyhus LM. Individualization of hernia repair: a new era. Surgery. 1993;114:1-2.

4.    Harris K, Davies K, Dumont S, Stephenson BM. A pain in the groin. Lancet. 1997;350:334.

5.    Roos H, Smedberg S. Symptomatic non-palpable inguinal hernias. Postgrad Gen Surg. 1992;4:131.

6.    Lichtenstein IL. Hernia repair without disability. St Louis, MO: CV Mosby; 1970.

7.    Ljungdahl I. Inguinal and femoral hernia. An investigation of 502 own operated cases. Acta Chir Scand. 1973;439:1-81.

8.    Metzger DA, Daoud I. Occult hernias in women with chronic pelvic pain. Plenary abstract presented at: International Congress of Gynecologic Endoscopy, American Association of Gynecologic Laparoscopists 26th Annual Meeting; September 24-28, 1997, Seattle, WA.

9.    Metzger DA. Groin pain in women. Presented at: 12th International Congress and Endo Expo, SLS Annual Meeting; September 22-25, 2003, Las Vegas, NV.

10.    Metzger DA, Daoud I. Occult hernias in women with chronic pelvic pain. Plenary abstract presented at: International Congress of Gynecologic Endoscopy, American Association of Gynecologic Laparoscopists Annual Meeting; November 14-16, 2000; Orlando, FL.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

When to Operate on Patients With Adhesions as a Cause of Pain

LAPAROSCOPIC ADHESIOLYSIS

Jay A. Redan, MD

Determining the cause of abdominal and pelvic pain can be very difficult. Often the workup for abdominal pain, including endoscopy, radiologic tests, and physical examination, yields negative or inconclusive results, leaving the physician and patient with no diagnosis and a treatment consisting only of pain control.

Through the work of Harold Ellis, we know that over 90% of patients who undergo open abdominal surgery develop adhesions [1,2]. We also know from the recent Surgical and Clinical Adhesions Research (SCAR) Study in Scotland [3] that of the patients who underwent an open abdominal hysterectomy during their lifetime, 50% developed an adhesion-related complication requiring hospitalization. It is from studies such as these that we know adhesions are a very common cause of abdominal pathology and chronic pain.

The use of laparoscopy with photography and pathologic examination can often show the cause of the patient’s pain, and treatment can be performed then and there laparoscopically. Recently, many articles [4-7] have appeared in the literature showing the utility of laparoscopy for such a purpose. Additionally, a laparoscopy that is negative for pathologic findings can also prompt the primary care physician to explore other disciplines for treatment of patients with subjective chronic abdominal pain, sometimes psychological counseling being the treatment of choice.

We have devised guidelines to help with triage when patients have abdominal pain. Patients are first divided into 2 categories: prior surgery and no prior surgery. In patients with prior surgery, we further divide them into obstructed or not obstructed. Certainly, some patients who present with a bowel obstruction require surgery; those who are not obstructed and have had prior surgery should first undergo simple radiologic tests to evaluate for an underlying malignancy or other serious abdominal pathology. If any of the test results are positive, the patient proceeds to the appropriate treatment; however, negative test results would warrant a laparoscopic examination to evaluate for the presence of an adhesion-related disease.

Patients with no prior surgery first require radiologic evaluation of the abdomen and pelvis, endoscopy, and a medical workup. If the results of these tests are all negative, then a diagnostic laparoscopy should be performed to evaluate for any additional intraabdominal pathology.

Several questions now exist. Which adhesions cause pain? Do adhesions cause constipation, which in turn can lead to pain? When do adhesions lead to partial or complete small bowel obstruction? Will laparoscopic adhesiolysis cure pain? How long will adhesions remain asymptomatic, and how do health care providers differentiate people complaining of adhesion-related disease from people who are purely seeking pain medication? How do we design a study to assess the efficacy of laparoscopic adhesiolysis for pain? How much skill is needed to perform a successful adhesiolysis? Does an adhesiolysis procedure need to be performed by a surgeon and gynecologist?

First, which adhesions cause pain? The best way to answer this is with the use of patient directed laparoscopy as documented by Larry Demco [8]. Advantages of this treatment modality are obvious; however, this clinical pathway is not suited for everyone. If a patient were able to tolerate direct laparoscopy under intravenous sedation, you would, no doubt, find the cause of that patient’s abdominal pain. However, many patients are not able to tolerate an “awake” laparoscopy, and often a patient’s adhesion disease is so extensive their treatment requires a long general anesthetic.

Adhesions are classified as abdominal wall, inter loop, and pelvic. Abdominal wall adhesions certainly cause pulling and tugging sensations due to the parietal peritoneal innervation. Most patients who have these adhesions lysed have immediate relief of their pain and almost certainly remain pain free unless these adhesions return.

Inter loop adhesions tend to cause more partial obstructive symptoms due to the kinking and twisting of the bowel.

Pelvic adhesions are most common in females and are correlated with dyspareunia and chronic pelvic pain in the posthysterectomy patient. Should there be adhesions to the adnexal structures or vaginal cuff, evaluation for endometriosis and ovarian remnants is most important.

The relationship of constipation and adhesions has long been debated. Many patients have a pseudo obstruction type or motility disorder. Most are female status posthysterectomy. Many have endometriosis relating to either an “N” or a “W”-shaped rectum. Subjectively, it is a common complaint among those with adhesion-related disease. Objectively, however, more study is required to definitively show that adhesions cause constipation [9,10].

Many patients who undergo a laparoscopy for abdominal pain, in the face of a workup with negative results, have a placebo effect for relief of their pain. This was emphasized in a current study by Swank et al [11,12] in which 50% of their patients who underwent a laparoscopy for pain in the control group had relief of their pain although they had undergone a procedure with no adhesiolysis. Additionally, patients who undergo a successful adhesiolysis may still have chronic pain; a neurological cause may be responsible for the patient’s continued pain, which may need to be addressed in conjunction with adhesiolysis [13].

Next, the area that certainly causes most questions among patients is “how long will the adhesions remain asymptomatic?” We do know that 90% of people who undergo an open procedure will have their adhesions return as documented by Harold Ellis [2]. However, the recurrence rate of laparoscopic lysis of adhesions has not yet been widely established. Drs Swank [11,12], Reich [14,15], and Khaitain [16] all consistently reported that an average of 75% of their patients have a cure of their pain after a laparoscopic adhesiolysis.

Many formulations for adhesion prevention are commercially available and in trial for either intestinal adhesions or gynecologic/infertility adhesions. The caveat, however promising, is that results of trials for these products have a wide standard deviation in success and have not been consistently reproducible [17-21].

To provide adequate evidence-based medicine, the question of how to design a study to assess the efficacy of laparoscopic adhesiolysis for pain is quite difficult. To match patients in a prospective manner minimizing the variables from patient to patient while maintaining the same level of skill by the surgical operator and the ability to randomize the patients into either a controlled/no treatment group versus a “standardized” laparoscopic lysis of adhesions is virtually impossible. And finally, if not most importantly, to operate on a patient with pain and visible adhesions and to not perform an adhesiolysis because they have been randomized into this group would be at the least questionably unethical if not legally challengeable. Therefore, a prospective study, while valuable, is not feasible; we are forced to rely on retrospective data as our “standard of care.” Unfortunately, this adds an additional skewed variable in any summary of studies that are performed on this topic.

Finally, for any surgeon or gynecologist who has a patient with chronic abdominal pain, chronic pelvic pain, or both, where an adhesion related disorder is suspected, we ask that you keep in mind this minimally invasive diagnostic and most therapeutic tool as an option to offer these patients.

Address reprint requests to: Jay A. Redan, MD, c/o Celebration Health, 400 Celebration Pl, Ste B-200, Celebration, FL 34747. Tel: 407 303 4602, Fax: 407 303 4603, E-mail: jarlap@aol.com

Jay A. Redan has been performing laparoscopic and thoracoscopic procedures since the infancy of this specialty. Starting with laparoscopic cholecystectomy and diagnostic laparoscopy for trauma in 1989, he has participated in the growth of the specialty as it has evolved to a true general surgical specialty that now encompasses all abdominal (general and gynecologic) and thoracic surgery. Dr Redan has also been involved with the development of Hand-Assisted Laparoscopic Surgery (HALS) as well as teaching and preceptoring surgeons and students throughout the world.

An area of great interest has been the diagnosis and treatment of acute and chronic abdominal and pelvic pain. Dr Redan strongly believes in the liberal use of laparoscopy to provide patients with “photodiagnostics” that allow them to see exactly what the problem inside their abdomen is or is not.

Dr Redan is now the Medical Director of the Surgical Training Institute for General Surgery at Florida Hospital—Celebration Health.

Laparoscopic lysis of adhesions. Jay A. Redan, MD, and Mary Lou DePietro, LPN.

References

1.    Holmadahl L, Risberg B, Beck DE, et al. Adhesions: pathogenesis and prevention-panel discussion and summary. Eur J Surg Suppl. 1997;577:56-62.

2.    Ellis H. Medicolegal consequences of postoperative intraabdominal adhesions. J R Soc Med. 2001;94:331-332.

3.    Lower AM, Hawthorn RJ, Ellis H, et al. The impact of adhesions on hospital readmissions over 10 years after 8849 open gynecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. BJOG. 2000;107(7):855-862.

4.    Onders RP, Mittendorf EA. Utility of laparoscopy in chronic abdominal pain. Surgery. 2003;134(4):549-552.

5.    Reissman P, Spira RM. Laparoscopy for adhesions. Semin Laparopsc Surg. 2004;10(4):185-190.

6.    Nezhat FR, Crystal RA, Nezhat CH, et al. Laparoscopic adhesiolysis and relief of chronic abdominal pain. JSLS. 2000;4(4):281-285.

7.    Carter JE. Surgical treatment for chronic pelvic pain. JSLS. 1999;2(2):129-139.

8.    Demco LA. Effect on negative laparoscopy rate in chronic pelvic pain patients using patient assisted laparoscopy. JSLS. 1999;1(4):319-321.

9.    Duepree HJ, Senagore AJ, Delaney CP, et al. Laparoscopic resection of deep pelvic endometriosis with rectosigmoid involvement. J Am Coll Surg. 2002;195(6):754-758.

10.    Perry CP. Relationship of gynecologic surgery to constipation. J Am Assoc Gynecol Laparosc. 1999;6(1):75-78.

11.    Swank DJ, Swank-Bordewijk SC, Hop WC, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomized controlled multi-center trial. Lancet. 2003;361(9536):1247-1251.

12.    Swank DJ, Van Erp WF, Repelaer Van Driel OJ, et al. A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Laparosc Endosc Perc Tech. 2003;13(2)88-94.

13.    Holden JE, Pizzi JA. The challenge of chronic pain. Adv Drug Deliv Rev. 2003;55(8):935-948.

14.    Reich HR, Roberts LM, Redan JA. Laparoscopic surgery for adhesions. In: Pasic R, Levine RL, eds. A Practical Manual of Laparoscopy: A Clinical Cookbook. New York, NY: The Parthenon Publishing Group; 2002:127-156.

15.    Reich HR, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med. 1991;36(7):516-522.

16.    Khaitan L, Scholz S, Houston HL, et al. Results after laparoscopic lysis of adhesions and placement of Seprafilm for intractable abdominal pain. Surg Endosc. 2002;17(2)247-253.

17.    Swank DJ, Bonjer HJ Jeekel J. Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissection. A prospective study. Surg Endosc. 2002;16(12):1796-1801.

18.    Di Lorenzo N, Coscarella G, Lirosi F, et al. Impact of laparoscopic surgery in the treatment of chronic abdominal pain syndrome. Chir Ital. 2002;54(3):367-378.

19.    Ferland R, Mulani D, Campbell PK. Evaluation of a sprayable polyethylene glycol adhesion barrier in a porcine efficacy model. Hum Reprod. 2001;16(12):2718-2723.

20.    Mettler L, Audebert A, Lehmann-Willenbrock E, et al. Prospective clinical trial of spray gel as a barrier to adhesion formation: An interim analysis. J Am Gynecol Laparosc. 2003;10(3):339-344.

21.    Wiseman DM, Trout JR, Franklin RR, Diamond MP. Metaanalysis of safety and efficacy of an absorbable adhesion barrier (INTERCEED TC7) in laparotomy. J Reprod Med. 1999;44:325-331.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Uterine Fibroids and Bleeding

UPDATE

HERBERT A. GOLDFARB, MD

The approach to the gynecological patient with abnormal bleeding requires specific diagnosis prior to any consideration of specific therapy. The first intervention after a thorough pelvic and rectovaginal examination should be an endovaginal pelvic ultrasound. Should the uterus be quite large, an abdominal ultrasound may be performed. The endometrial cavity can be best visualized by saline infusion ultrasound. In the absence of fibroids or endometrial polyps, an endometrial biopsy will differentiate anovulatory or dysfunctional bleeding that can be treated with cyclic progesterone. Ovulatory metrorrhagia (secretory) that is recurrent is best treated with an endometrial ablation procedure.

GLOBAL ENDOMETRIAL ABLATION PROCEDURES

The first technique described in 1985 by Goldrath [1] used a bare Nd:Yag laser fiber dragged along the endometrium to destroy the entire lining. Vancaille [2] subsequently described a rollerball electrode via the hysteroscopic resectoscope. Later variants of the procedure utilized a loop electrode to resect the endometrium with the distinct advantage of obtaining tissue for evaluation, and finally some operators finished off the procedure with the grooved electrode at a high power to finely sculpture the cavity.

ThermaChoice. Neuwirth [3] developed a balloon (latex–silicon) device that expanded inside a basically normal (<10 cm) cavity filled with up to 30 cc of D5w pressurized to 160 to 180 mm Hg and heated to 87°C. Distortion of the cavity due to fibroids is a contraindication. This procedure is approved for premenopausal women with menorrhagia due to benign causes for whom childbearing is complete [4].

Novasure. This procedure consists of an impedance–controlled bipolar grid and moisture transfer with controlled and contoured tissue ablation. Treatment time averages 90 seconds. This self-
terminating procedure is based on tissue impedance. Amenorrhea rates of 47% to 58% result. It is approved for patients with polyps and submucous fibroids <2 cm [5,6].

Her Option. A 5.5-mm cryoprobe is placed in the endometrial cavity, and by using abdominal ultrasound guidance, the probe is cooled to -90°C. A 3.5- to 5-cm elliptical ice ball forms. A temp is reached of -20°C 1.5 cm from the edge of the ice ball. The procedure requires 10 to 20 minutes to complete. The bladder is filled to help monitor the procedure via abdominal ultrasound. Inclusion criteria are a cavity <10 cm and uterine volume <300 cc. This procedure is not approved for use with cavitary myomas [7].

Microsulis Microwave. This procedure, recently approved by the FDA, is a non-contact system that uses a microwave generator to develop radiant heat and destroy tissue. Anderson, the lead investigator, has shown that the radiant energy is not limited by cavitary distortion. The uterus is sounded, the radiant wand is placed in the cavity and the intrauterine temperature monitored. The wand is oscillated manually and slowly withdrawn until the endometrium is completely ablated. Results are comparable to those achieved with electrosurgical ablations [8].

Hydrothermablation. Hot water is delivered into the uterine cavity and the process is monitored using a hysteroscope. The cavity should be <10 cm. Fibroids and polyps can be treated with this method. The procedure is microprocessor controlled with visual control of low-pressure gravity fed saline heated to 90°C for 10 minutes. An insulated hysteroscopic sheath 7.8 mm accepts a 3-mm hysteroscope. Results are 54% amenorrhea: 23% oligo, and 14% eumenorrhea [9].

The downside to all these methods is cost, which is approximately $700 to $900 per case, requiring an approved facility for reimbursement, which is at the mercy of the third party carrier. All of the described procedures are effective, with the operative hysteroscopic technique requiring the greatest learning curve.

Uterine Artery Embolization. First reported in 1995 by Ravina [10], uterine artery embolization is a temporizing method in a hemorrhaging patient awaiting a hysterectomy. More than 20 000 procedures have been performed since 1997. Speis [11] reported on 200 patients with fibroids and menorrhagia with improvement in 87% to 91%. Bulk symptoms were improved in 90%. Hospitalization was required in 10.5% of patients. Complications include misplaced polyvinyl particles. Immediate menopause secondary to uterine ovarian anastomosis was experienced by 10% to 15% of patients. Submucosal myomas often prolapse and require hysteroscopic surgery. Other complications include infection, necrosis, pulmonary embolus, and readmission for severe pain. Volume reduction is reported to be 40% to 60%. Volumetric reduction of 10x10x10 cm with a 40% reduction will result in a size of 8x8x8 cm. Therefore, 7 to 8 cm should be a rational size limit for uterine artery embolization.

FIBROID SOLUTIONS

Large multinodular myomatous uteri require surgical intervention. The diagnostic insight provided by magnetic resonance imaging (MRI) can help the clinician make the decision as to what course to recommend. Myomectomy should not only be offered to women wishing to be pregnant. Preserving the uterus for many women has very significant psychological implications. Myomectomy can be performed laparoscopically, and Miller [12,13] has reported on a large series of cases. Most very large myomatous uteri can be made whole with mini-laparoscopic techniques.

Myolysis and Variants. Goldfarb [14] performed Nd:Yag laser myolysis in 1990 and subsequently converted to bipolar electromyolysis, developing sturdy 5-cm needles for the procedure. The present technique was described in the journal of the AAGL in 1995 and subsequently in the Society of Laparoendoscopic Surgeons’ journal in 1999 [15]. The procedure involves undermining identifiable myomas with electrified bipolar needles using the endpoint of cyanosis. Pretreatment with GnRh analog allows a therapeutic trial. Symptoms should abate prior to definitive therapy. Pelvic ultrasound, (MRI), and endometrial biopsy are performed preoperatively. Average volume reduction was 72%. Hysterectomy was avoided in 93.5% of cases. Complications of myolysis (<1%) were minimal. Fibroid degeneration was rare as was infection. Hysterectomy in the myolsis and ablation group was 2.5% in cavities <9 cm.

Cryomyolysis. A cryoprobe is placed laparoscopically into a fibroid via a 5-mm trocar, and an ice ball is created that can extend to 5 cm causing myoma cells necrose. The downside is the expense of the equipment, ranging up to $35000 plus $750 per case. Cryomyolysis has also been described as an MRI-guided procedure. If you add the expense of an MRI to that of the cryoprobe, then you have a procedure whose expense cannot be justified. Electrobipolar myolysis needles sell for about $750 and can be used for years [16,17].

Radiofrequency Myolysis Technique (RITA). After initial puncture, a StarBurst-type probe is advanced into a myoma and with RF coagulation 45D to 50D results in protein denaturation. Cost is similar to that of cryo [18].

Myolysis is effective in select cases of moderate-sized myomas 5-cm to 7-cm after a therapeutic trial with a GnRh agonist. All systems described are effective but cannot compete with Bipolar electromyolysis in price and ease of performance.

OTHER NEW TECHNIQUES

Intravaginal occlusion of the uterine artery described by Istre [19] and Lichtinger utilizes a specialized clamp placed in the uterine fornix. The uterine blood vessels lie within 1 cm to 3 cm from the fornix. A Doppler is attached to the clamp and identifies the occlusion of uterine blood flow. Vessels are pinched for 6 hours. Studies have shown that even after uterine embolization, uterine reperfusion takes place after 6 hours. Postprocedure MRIs have revealed fibroid microcirculation clotting confirming myoma death.

CONCLUSION

Multiple techniques have been described in the ongoing attempt to offer women alternatives to hysterectomy. All have been presented at major meetings and most have been published in refereed journals. It is important to differentiate what we can do from what is cost effective and appropriate for our patients. When all other factors are equal, cost is an important factor. Patients need to be educated and share in their health care decisions.

Address reprint requests to: Herbert A. Goldfarb, MD, 35 Delwick Ln, Short Hills, NJ, 07078, USA.
Tel: 973 744 7470, Fax: 973 744 1274, E-mail: HGoldfarb@NoHysterectomy.com

Herbert A. Goldfarb, MD, is an Assistant Clinical Professor of Ob-Gyn at the New York University School of Medicine and the Director of Gynecological Endoscopy at NYU Downtown Medical Center. In 1986, Dr Goldfarb performed the first video laser laparoscopic surgery in the New York metropolitan area and the first Nd:YAG laser hysteroscopic ablation of the endometrium. In 1990, he pioneered the myoma coagulation (myolysis) procedure, and developed bipolar needles designed to make the procedure easier to perform. Dr Goldfarb, an advocate of alternative solutions to hysterectomy, has authored two books and several scientific articles and book chapters. The No-Hysterectomy Option was written in 1990, with a second edition published in 1997 and Overcoming Fertility was published in 1995.

References

1.    Goldrath MH, Fuller FA, Segal S. Laser photovaporization of the endometrium for the treatment of menorrhagia. Am J Obstet Gynecol. 1981;140:14-19.

2.    Vancaille T. Electrocoagulation with a ball and resectoscope. Obstet Gynecol. 1989;74:425.

3.    Neuwirth RS. Cost effective management of heavy uterine bleeding: ablative methods versus hysterectomy. Curr Opin Obstet Gynecol. 2001;13(4):407-410.

4.    Vilos GA, Vilos EC, Pendley L. Endometrial Ablation with a thermal balloon for the treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 1996;3:383-387.

5.    Busund B, Erno LE, Gronmark A, Istre O. Endometrial ablation with NovaSure GEA, a pilot study. Acta Obstet Gynecol Scand. 2003;82(1):65-68.

6.    Gallinat A, Nugent W, Novasure impedance-controlled system for endometrial ablation. J Am Assoc Gynecol Laparosc. 2002;9(93):283-289.

7.    Rutherford TJ, Zreik TG, Troiano RN, et al. Endometrial cryoablation, A minimally invasive procedure for abnormal bleeding. J Am Assoc Gynecol Laparosc. 1998;5(1):23-28.

8.    Kanaoka Y, Hirai K, Ishiko O, Ogita S. Microwave endometrial ablation at a frequency of 2.455 GHz. A pilot study. J Reprod Med. 2001;46(6):559-563.

9.    Corson SL. A multicenter evaluation of endometrial ablation by Hydro Thermablator and rollerball for treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2001;8(3):359-367.

10.    Ravina J, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolization to treat uterine myomata. Lancet. 1995;346:671-672.

11.    Speis J, Ascher SA, Roth AR, Kim J, Levy EB. Uterine artery embolization for leiomyomata. Obstet Gynecol. 2001;98:29-34.

12.    Miller CE. Contemporary approach to laparoscopic myomectomy. Oper Tech Gynecol Surg. 2000:5(2):1-11.

13.    Miller CE. Myomectomy: comparison of open and laparoscopic techniques. Obstet Gynecol Clin North Am. 2000;27(2):407-420.

14.    Goldfarb HA, Myoma coagulation (Myolysis). Obstet Gynecol Clin North Am. 2000;27(2):421-430.

15.    Goldfarb HA. Combining Myoma Coagulation with endometrial ablation/resection reduces subsequent surgery rates. JSLS. 1999;3(4):253-260.

16.    Olive DL, Rutherford T, Zreik T, Palter S. Cryomyolysis in the Conservative Treatment of Uterine Fibroids. J Am Assoc Gynecol Laparosc. 1996;3(4 suppl):S36.

17.    Zreik TG, Rutherford TJ, Palter SF, et al. Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids. J Am Assoc Gynecol Laparosc. 1998;5(1):33-38.

18.    Lee BB. Radiofrequency ablation of uterine fibroids; A new minimally invasive hysterectomy alternative. Obstet Gynecol. 2002;99(suppl):9S.

19.    Istre O. New approaches to uterine artery occlusion, vaginal technique. Presented at: The Contemporary Management of Uterine Fibroids. April 2003; Santa Fe Springs, CA.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Adhesions and Adhesiolysis

Adhesions and Adhesiolysis: The Role of Laparoscopy • Kavic SM, Kavic SM. JSLS(2002)6:99-109. Postoperative abdominal adhesions may result in intestinal obstruction, infertility, and chronic pain, or may complicate subsequent operative procedures. Laparoscopic access may reduce postoperative adhesions; however, additional adjuvant materials are available that should result in clinically relevant reductions in adhesion formation.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Laparoscopy in the Management of the Patient with Right Lower Quadrant Abdominal Pain

NEW APPROACHES: RLQ PAIN

RAYMOND J. LANZAFAME, MD, MBA, FACS

Diagnostic laparoscopy was once the province of some gynecologists and a few surgeons in the pre-lap chole era. The medical literature nowadays has numerous articles describing the use of laparoscopy under local anesthesia, with nitrous oxide insufflation, in office-based and emergency department venues in order to evaluate the acute abdomen in trauma and other indications. Such applications may become more commonplace in the future, but are beyond the capacity of many facilities due to logistical and technical concerns.

The patient with acute abdominal pain is more likely to be evaluated by clinical and laboratory examination, followed by a CT scan, an ultrasound examination, or both. Proponents of the triple contrast CT and ultrasound evaluations often cite the ability of these modalities to simultaneously evaluate a number of organ systems and to reduce the incidence of negative laparotomy. Recent studies, however, indicate that these modalities do not reduce the misdiagnosis of appendicitis and can result in delayed diagnosis and treatment [1-4]. Anecdotal evidence from my own institution, where the emergency room physicians order scans and ultrasounds seemingly routinely prior to obtaining a surgical or gynecological consultation, supports this thesis. The following case is presented to demonstrate the utility of laparoscopy in the diagnosis and treatment of the acute abdomen:

Case 1: A 23 year-old, sexually active female, G0 P0, LMP 3 weeks PTA, with daily spotting, presented with abrupt onset of RLQ abdominal pain 15 hours ago. The pain was described as constant, persistent and severe, and was associated with anorexia. She had changed OCPs 3 weeks previously and used an Advair® inhaler bid for asthma. On exam, the patient was quite uncomfortable, lying very still in bed. Abdominal exam demonstrated hypoactive bowel sounds, with marked RLQ tenderness and guarding, mild LLQ tenderness and an equivocal Rovsing’s. Rectal exam was negative and GYN exam was negative, except for a small amount of blood in the vaginal vault. Labs demonstrated HCT 40, WBC 18,000, with 83 SEGS and 4 BANDS. Urinalysis was unremarkable and ßHCG was negative. A triple contrast CT scan ordered by the Emergency Room physician demonstrated “inflammation” in the area of the cecum, with “fullness” in the area of the right ovary. The appendix was not visualized. Laparoscopy demonstrated a small amount of bloody fluid in the pelvis and an enlarged and grossly hemorrhagic right salpinx (Figure 1), with a fibrotic, normal-appearing retrocecal appendix. (Figure 2). A partial salpingectomy was performed after intraoperative GYN consultation. Incidental appendectomy was not performed. Histology demonstrated acute inflammation, edema and hemorrhage. No placental or fetal tissue was identified. The patient’s postoperative course was uneventful.

Discussion: This case illustrates several points relative to the management of the young female with right lower quadrant abdominal pain. The patient had findings on physical examination and an elevated white count with a left shift that were indicative of an acute abdomen. Gynecologic examination was not helpful in distinguishing between a tubovarian or bowel process and the CT scan similarly failed to establish the diagnosis, and resulted in a delay in definitive surgical therapy. Sarfati, et al [5] reviewed the preoperative evaluation and outcomes for 203 patients undergoing appendectomy. They concluded that routine use of adjunctive testing was not helpful and that outcomes were improved by early surgical intervention.

Prompt surgical consultation followed by diagnostic and therapeutic laparoscopy would have facilitated patient care in a cost effective and efficient fashion. Several authors have documented the utility of diagnostic laparoscopy in the evaluation and management of patients with acute abdominal pain [6-10]. However, laparoscopic appendectomy remains controversial despite a growing body of evidence demonstrating outcomes that are equivalent or superior to laparotomy [11-13]. Conversion to an open procedure is reported in approximately 10% of cases and is usually determined by intraoperative findings, skill and experience of the surgical team, and patient anatomy [14].

Management of the normal appendix is equally controversial [11]. Some authors have advocated routine removal of the appendix regardless of the absence of clinical evidence of acute inflammation. Advocates of routine appendectomy often cite the same arguments used to justify appendectomy during open surgery for presumed appendicitis. Others have argued that a clinically normal appendix has a low probability of subsequently becoming acutely inflamed and that one of the advantages of laparoscopy is the ability to avoid unnecessary procedures. Our patient clearly demonstrated an acute gynecologic process and had a normal, fibrotic appendix. The decision to leave the appendix in-situ was based on the fact that this anatomy should preclude the development elevated intraluminal pressure and subsequent vascular compromise.

Our case also demonstrates the benefits of collaboration between surgical and gynecological laparoscopists in the management of patients with an unclear presentation or intraoperative findings deserving of intraoperative consultation and dialog. Collegiality and cooperation facilitate high quality patient care.

Figure 1. A grossly hemorrhagic right salpinx was visualized. The ovaries and uterus were normal. A small amount of bloody ascites was present in the pelvis.

Figure 2. A fibrotic, normal appearing retrocecal appendix was visualized.

Address reprint requests to: Raymond J. Lanzafame, MD, MBA, FACS, Director, Laser Center, Assoc. Professor of Surgery, Via Health, Rochester General Hospital, 1445 Portland Ave Ste 202, Rochester, NY 14621, Telephone: 585 922 4505, Fax: 585 544 8761, E-mail: Raymond.Lanzafame@viahealth.org

Dr Lanzafame is a member of 27 organizations including the Society of Laparoendoscopic Surgeons where he serves on the Board of Trustees. He is Editor-in-Chief of the Journal of Clinical Laser Medicine and Surgery, is Consulting Editor of the Biomedical Optics Newsletter, and is on the Editorial Board of several other publications. Dr Lanzafame is Associate Professor of Surgery and Director of the Laser Center at RGH and is Director of Continuing Medical Education for the American Society for Laser Medicine and Surgery (ASLMS). He has served as president of ASLMS and the American College of Surgeons.

References

1.    Flum DR, Morris A, Koepsell T, Dellinger EP. Has misdiagnosis of appendicitis decreased over time? A population-based analysis. JAMA. 2001;286:1748-1753.

2.    Wilson EB, Cole JC, Nipper ML, Cooney DR, Smith RW. Computed tomography and ultrasonography in the diagnosis of appendicitis: When are they indicated? Arch Surg. 2001;136:670-675.

3.    Lee SL, Walsh AJ, Ho HS. Computed tomography and ultrasonography do not improve and may delay the diagnosis and treatment of acute appendicitis. Arch Surg. 2001;136:556-562.

4.    Rozycki GS, Tremblay L, Feliciano DV, Joseph R, deDelva P, Nicholas JM, Cava RA, Ansley JD, Ingram WL. Three hundred consecutive emergent celio-tomies in general surgery patients Influence of advanced diagnostic imaging techniques and procedures on diagnosis. Ann Surg. 2002;235(5):681-689.

5.    Sarfati MR, Hunter GC, Witzke B, Bebb GG, Smythe SH, Boyan S, Rappaport WD. Impact of adjunctive testing on the diagnosis and clinical course of patients with acute appendicitis. Am J Surg. 1993;166(12):660-665.

6.    Schwaitzberg SD. Diagnostic Laparoscopy. Semin Laparosc Surg. 2002;9(1):10-23.

7.    Memon MA, Fitzgibbons RJ. The role of minimal access surgery in the acute abdomen. Surg Clin N Amer. 1197;77(6):1333-1353.

8.    Gaitan H, Angel E, Sanchez J, Gomez I, Sanchez L, Aguldelo C. Laparoscopic diagnosis of acute lower abdominal pain in women of reproductive age. Intl J Gyn Obstet. 2002;76(2);149-158.

9.    Cohen SB, Weisz B, Seidman DS, Masiach S, Lidor AL, Goldenberg M. Accuracy of the preoperative diagnosis in 100 emergency laparoscopies performed due to acute abdomen in nonpregnant women. J Am Assoc Gynecol Laparosc. 2001;8(1):92-94.

10.    Sozuer EM, Bedirli A, Ulusal M, Kayhan E, Yilmaz Z. Laparoscopy for diagnosis and treatment of acute abdominal pain. J Laproendosc & Adv Surg Tech. 2000;10(4):203-207.

11.    Fischer CP, Castanada A, Moore F. Laparoscopic appendectomy: Indications and controversies. Semin Laparosc Surg. 2002;9(1):32-39.

12.    Long KH, Bannon MP, Zeitlow SP, Helgeson ER, Harmsen WS, Smith CD, Ilstrup DM, Baerga-Varela Y, Sarr MG. Laparoscopic appendectomy interest group. A prospective randomized comparison of laparoscopic and open appendectomy: clinical and economic analyses. Surgery. 2001;129: 390-400.

13.    Greason KL, Rappold JF, Liberman MA. Incidental appendectomy for acute right lower quadrant abdominal pain. Its time has come. Surg Endosc. 1998;12(3):223-225.

14. Shiuh-Inn L, Siewet B, Raptopoulos V, Hodin RA. Factors associated with conversion to laparotomy in patients undergoing laparoscopic appendectomy. J Am Coll Surg. 2002;194:298-305.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Musculoskeletal Causes of Pelvic Pain: Hernias

PELVIC PAIN AND HERNIAS

JAMES E. CARTER, MD, PhD, FACOG

Introduction: Hernia has been defined as a protrusion of organs or parts thereof from their natural place in a cavity through an abnormal opening. However, it is the hernial defect, the opening through which a protrusion may occur, that characterizes hernias, not the protrusion of a viscus. Consistent with this, the designation of various hernias uses not the protruded viscus but the location or region in which a hernia can take place [1]. Hernias can occur in the following locations: 1) Hernias of the pelvic wall, perineum, and pelvic floor (sciatic hernia, obturator hernia, perineal hernia); 2) Groin hernias (direct inguinal hernia, indirect inguinal hernia, femoral hernia); 3) Hernias of the abdominal wall (epigastric hernia, umbilical hernia, Spigelian hernia, incisional hernia); 4) Internal abdominal hernia (internal supra-vesical hernia and hernia through broad ligaments) 5) Sports hernias; 6) Pelvic floor support defects. Each of these hernias has characteristic symptoms and signs [2]. Of these three will be discussed: incisional hernias, groin hernias, and sciatic hernias.

Incisional Hernias: An incisional hernia is the abnormal protrusion of peritoneum through a separation of the edges of a musculoaponeurotic wound. They are common after open abdominal procedures and occur in 0.5% to 14% of abdominal operative procedures. Seventy percent occur within the first year and 97% within 5 years of surgery [3]. Incisional hernias occur after laparoscopy with risk of herniation through a 12 mm trocar site (3.1%) approximately 13-fold greater than that for a 10 mm trocar site (0.23%) [4]. Laparoscopic incisional hernias can be prevented, however, by mass closure of the fascia and peritoneal layers under direct laparoscopic vision [5].

Etiology: Infection, obesity, postoperative strain, inadequate suture material, and nerve injury are some of the etiological factors of incisional hernias.

Symptoms and History: Patients may complain of intermittent pain or dragging sensation. They may also complain of distention and severe abdominal pain if they have herniated small bowel.

Physical Examination: Palpation of the wound site may identify separation and tenderness in the area of the separation without a small bulge being present. When the patient is asked to cough, a small bulge may be seen or a pulsation felt by the examining finger.

Diagnostic Studies: The diagnosis of herniation into an incision site can be made by CT scan or ultrasonography. If only the separation is present without the protrusion of tissue, the diagnosis may be difficult without exploration. However, the defect can frequently be palpated and is a source of pain.

Treatment: The treatment of the incisional hernia is surgical placement of graft material of an appropriate size for the hernia present.

Groin Hernias: Groin hernias include direct inguinal, indirect inguinal, and external supravesical which emerge through the abdominal wall by way of the external inguinal ring above the inguinal ligament and femoral hernia that emerges beneath the inguinal ligament by way of the femoral canal. The incidence of inguinal hernias is 10% to 15%. Indirect inguinal hernias are congenital, and direct inguinal and femoral hernias are considered acquired [3].

Etiology: The processus vaginalis is a diverticulum of the peritoneal cavity which is patent in 80% of 90% of newborns, but which closes until at adulthood 15% to 30% have a patent processus vaginalis. Many women with patent processus vaginalis remain asymptomatic. However, this is held to be a prime cause of indirect inguinal hernia. Three factors are involved in generating inguinal hernias: the presence of a preformed sac, repeated elevation in the intraabdominal pressure, and weakening of the body muscles and tissues with time. Raised intraabdominal pressure, such as that which occurs during pregnancy, can make a hernia appear for the first time. The cause of hernia is multifactorial. In the case of indirect hernia, a performed sac (patent processus vaginalis), is present, but bowel is prevented from entering by efficient muscular action. A sudden and unusually high increase in intraabdominal pressure may be sufficient to overcome this protective mechanism and a hernia may quite suddenly appear. In direct hernia there is no performed sac; in fact there is no real peritoneal sac at all. The protective mechanisms fail. The weakened transversalis fascia, on its own, cannot withstand the repeatedly raised intraabdominal pressure and stretches or simply tears.

Symptoms or History: The primary symptoms are pain, and in the case of an acute event, ecchymosis of the inguinal region. The patient may feel some discomfort in the groin and notice a small bulge when coughing or straining that immediately subsides.

Physical Examination: Physical examination reveals tenderness along the edges of separation, or a bulge that increases in size with coughing that can usually be reduced. When the patient stands, a cough impulse can be felt at the tip of the finger after introducing it into the inguinal canal through the external ring by invagination.

Diagnostic Studies: Herniography can be performed for the diagnosis of inguinal hernia. Laparoscopically an indirect inguinal hernia is evident as an opening adjacent to the round ligament. A direct or femoral hernia may not be clearly seen until the peritoneum is open [6].

Surgical Treatment: A sheet of prosthetic mesh is used to reconstruct the inguinal floor. These procedures can be performed laparoscopically and the prosthesis used to cover and overlap all potential defects in the myopectineal orifice [6].

Femoral Hernia: Femoral hernia is a protrusion of preperitoneal fat or intraperitoneal viscus through a weak transversalis fascia into the femoral ring and the femoral canal. It is not unusual for individuals to develop a femoral hernia who have had a previous repair of an inguinal hernia.

Etiology: Natural weakness of the tissues and loss of elasticity is the basic cause. They are more common in multiparous women.

Symptoms or History: The patient may notice a small reducible lump in the medial aspect of the groin.

Physical Examination: The diagnosis can usually be made on finding a soft tumor at the femoral fossa.

Diagnostic Studies: If suspected by symptoms, a gentle push with a blunt instrument at the time of laparoscopy will reveal weakness in the peritoneum.

Surgical Treatment: Non-absorbable mesh is placed appropriately to occlude the orifice.

Sciatic Hernia: A sciatic hernia is a protrusion of a peritoneal sac and its contents through the greater or lesser sciatic foramen. In one study of women with CPP diagnosed and treated during laparoscopy, sciatic hernia was diagnosed in 20 of 1100. This gives an incidence of 1.8% in women with Chronic Pelvic Pain (CPP) requiring laparoscopic intervention [7].

Symptoms or History: Sciatic hernias present with pain originating in the pelvis. Patients may report ipsilateral posterior thigh or buttocks pain or both. Compression of the sciatic nerve may occur, causing pain to radiate down the posterior thigh that is aggravated by dorsiflexion.

Physical Examination: Sciatic hernias pass downward and may present under the lower border of the gluteus maximus muscle in the posterior medial aspect of the thigh. Sciatic hernias, however, are only rarely evident on physical examination. If the ureter herniates into the sciatic foramen it may give rise to a urographic appearance of a redundant, horizontally oriented ureter within a hernia sac that has been called a “curlicue” ureter. Laparoscopically a sciatic hernia may be found to be filled with the ipsilateral ovary or fallopian tube. A prior history of laparoscopic evaluation may not preclude the need for reevaluation.

Surgical Therapy: When the sciatic hernia is approached laparoscopically, its contents are reduced and the peritoneum overlying the sciatic hernia is elevated and transected transversely with scissors. Mesh is then placed in the space created by the atrophic piriformis muscle. A second piece of mesh is trimmed to the size of the peritoneal defect and placed over the folding mesh. This overlying mesh is secured to the obturator internus fascia laterally and the coccygeus medially. The peritoneum is then closed over the mesh [2].

Address reprint requests to: James E. Carter, MD, PhD, FACOG, Mission Hospital Reg. Med. Ctr., 26732 Crown Valley Pkwy #541, Mission Viejo, CA 92691,
Telephone: 949 364 5802, Fax: 949 364 2871, E-mail: drjamescarter@cox.net

Dr Carter, a clinical associate professor in the Department of Obstetrics and Gynecology at the University of California, Irvine College of Medicine, has researched and applies techniques that assist in diagnosis and treatment of chronic pelvic pain, osteoporosis, polycystic ovary disease and insulin resistance, stress urinary incontinence and pelvic floor support defects, and avoidance of complications in advanced laparoscopic procedures. Dr Carter’s published works include two chapters in Prevention and Management of Laparoendoscopic Surgical Complications, and he co-authored Pelvic Pain: Diagnosis and Management. He has served as President of the Society of Laparoendoscopic Surgeons and the International Pelvic Pain Society.

References

1.    Netter FH, Iason AH, Pansky B. Hernias. In: Oppenheimer E, ed. The CIBA Collection of Medical Illustrations. Summit, NJ: CIBA; 1962:204-230.

2.    Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, El-Minawi AM. Pelvic Pain: Diagnosis and Management. New York, NY: Lippincott Williams and Wilkins; 2000:385-413.

3.    Abrahamson J. Hernias. In: Zinner MJ, Schwartz SI, Ellis H, eds. Maingot’s abdominal operation. Stanford, CT: Appleton & Lange; 1997:479-580.

4.    Kadar N, Reich H, Liu CY, et al. Incisional hernias after major laparoscopic gynecologic procedures. Am J Obstet Gynecol. 1993; 168:1493-1495.

5.    Carter JE. A new technique of fascial closure for laparoscopic incisions. J Laparoscop Endoscop Surg. 1994;4:143-148.

6.    Kavic MS. Laparoscopic Hernia Repair. The Netherlands: Harwood Academic Publishers; 1997.

7.    Miklos JR, O’Riley MJ, Saye WB. Sciatic hernias as a cause of chronic pelvic pain in women. Obstet Gynecol. 1998; 91: 998-1001.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source