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This is a report of bioengineering developments toward a cautery sys tem for laparoscopic sterilization in which current flow is limited between 2 electrically alive points and does not need to pass through the body toward a generally body-ground. The hazard of accidental bowel or skin injury may thus be reduced. The instrument may be introduced through a single puncture and if tubal division is shown unnecessary to achieve permanent occlusion the accompanying hazards of hermorrhage could also be avoided. Wiring diagrams and photographs comparing standard equipment and the new system are shown. In operations on sows the contained cautery required less coagulation current; gross and microscopic healing patterns of the 2 methods were the same. The coagulated tissue was absorbed in each case with occasional complete separation of the sections of the tube. Where the sows ovary had been purposely held next to the laparoscopic tube only adhesions occurred. No other damage was found. No instance of current leakage was encountered. In another series of tests 5 sows underwent minimal contained cautery destruction of tubal sections and subsequent fertility testing. No pregnancies occurred. Bilateral hydrosalpinx occurred in 1 animal in which each tube had been cauterized in 2 places indicating complete occlusion. The instrument is simpler to use and is considered safer than present standard equipment.

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1. 1. A simple, safe and, so far uniformly successful method of tubal sterilization is reviewed, sixty cases being analyzed as to morbidity and end-results. 2. 2. The operation should never be undertaken in the presence of any acute abdominopelvic infection, but subacute or chronic pathologic conditions can be removed at the same time without increasing the incidence of mortality or morbidity. 3. 3. The principle of the operation is based on the belief that preservation of tubal excretion prevents the possible formation of an aseptic hydrosalpinx. 4. 4. Ovarian function is not disturbed. 5. 5. On theoretical grounds the operation can be used as a temporary means of sterilization.

A histologic study of 9 hydrosalpinges and chemical analysis of their fluid content were performed. In most of the cases the wall was fibrotic; the epithelial lining in the main was impaired although in scattered areas it appeared normal and probably well functioning. Electrolyte values were similar to those found in the serum of the patients. Proteins and bicarbonate values were very low. Correlation between these low values and the functional potential of the hydrosalpinx should be considered, since it may be related to the degree of tubal damage. These aspects are discussed and the potential use of chemical study of hydrosalpinx fluid is reviewed. Consideration is given for use of the findings in evaluating functional prognosis prior to tuboplasty.

1. 1. It becomes apparent that the pyosalpinx associated with the tubal malignancy in this patient must have been the etiologic factor, precipitating her recurrent attacks of iritis. 2. 2. Early diagnosis must be stressed if our mortality is to be reduced. I believe the case reported herein was diagnosed and treated in its early asymptomatic stage, as it was discovered in a routine physical examination, and the patient is still in excellent physical condition after two years. 3. 3. Carcinoma of the fallopian tube is rarely diagnosed preoperatively. 4. 4. Early symptoms of carcinoma of the tubes are irregular vaginal bleeding or postmenopausal spotting and intermittent or continuous, watery vaginal discharge, often in gushes. 5. 5. The preoperative diagnosis, unfortunately, is usually benign tumor of the fallopian tube and, consequently, surgery may be delayed until pain occurs or until such time as the patient finds it convenient to be hospitalized. 6. 6. The disease is usually advanced when first seen or first diagnosed. The diagnosis is usually made at operation but may be missed even here, assuming the condition to be a hydrosalpinx. The specimen should be sectioned at operation. 7. 7. The disease usually affects women at or near the menopause. It occurs in approximately 0.1 to 0.3 per cent of all operations on the female genitalia. It is bilateral in approximately one-third of cases. 8. 8. The surgical treatment is frequently inadequate. These patients are rarely cured. 9. 9. There are probably many cases which have not been reported in the literature. 10. 10. In past years inflammation of the fallopian tubes has been very common, yet carcinoma has been extremely rare. It would seem that inflammation has no carcinogenic properties in this portion of the anatomy. 11. 11. In recent years we have added an excellent diagnostic aid, that of cytologic study. 12. 12. Treatment should be: (A) Total abdominal hysterectomy. (B) Bilateral salpingoovariectomy. (C) Wide resection of metastatic noted. (D) Postoperative roentgen therapy.

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Failure of tuboplasty may be caused by: 1) the presence of adenomyosis of the tunnel producing stricture of the interstitial part of the implanted tube; 1) premature softening of the ligatures resulting either in complete expulsion of the implanted portion or partial outward displacement with subsequent fibrosis of the inner part of the tunnel; 3) occlusion of the fimbrial end of the cornual opening due either to an ascending sepsis or to an allergic reaction to the material of the prosthesis; 4) presence of pathogenic organism inside the uterine cavity; 5) presence of undiagnosed subclinical tuberculous infection; 6) faults in technique; 7) difficulties resulting from the polyethylene tube or rod used to prevent contraction of the cornual opening. Possible complication include: 1) difficulty in removing prosthesis; 2) migration of the prosthesis into the peritoneal cavity; 3) ectopic gestation; 4) irregular vaginal bleeding; 5) endometriosis and 6) rupture of uterus. In the case of salpingostomy success of operation can be achieved if the following conditions are present: 1) tubal musculature is in a good condition and hydrosalpinx if present is small; 2) on performing a terminal salpingostomy the fimbria should be in a fairly good condition and capable of recovering from trauma of operating and 3) epithelium lining the tube is normal and free from adhesion. Laparotomy and post-sterilization techniques were briefly described.

The determination of patency of fallopian tubes has hitherto been possible only by direct inspection and palpation obtained by laparotomy. Physician examination was wholly inadequate because it still left the question of patency a matter of speculation. This is especially true when, as in certain intances, the tubes are sealed tight at their fimbriated end, although no distention of the lumen is present. In other instances it is hard to diagnose occlusion of the tube due to hydrosalpinx when the walls are flaccid. Some tubes are closed by adhesions secondary to a peritonitis that arises outside of the gynecologic domain. No matter how clear the history, the question as to whether such a tube is patent or not is always a matter of doubt. The same holds true in cases in which the tube may be occluded by a tumor. It is often not possible to distinguish whether a mass

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It is certain that we here had to deal with an old salpingitis, which suddenly became strangulated by torsion of the pedicle. The tube was club shaped and the fimbriated end was closed by dense, old organized adhesions which completely obliterated the fimbriae. This pathologic condition could not have occurred in the three days elapsing between the attack and the operation. In a number of the previously reported cases the tube was normal before the torsion. The differential diagnosis of this case is rather interesting. An acute appendiceal inflammation could be eliminated at once, due principally to the lack of temperature, normal leucocyte count and the general good, nonseptic, condition of the patient. This excellent general condition has been emphasized strongly as constant in many of the cases reported, in spite of severe local symptoms and terrible pain. The main difficulty in this case was the elimination of an acute kidney condition, particularly obstructing renal calculus. The onset of the symptoms was so suggestive of renal colic that ureteral catheterization was contemplated. The absence of pus in the catheterized urine, the development of a palpable mass and the localization of symptoms clarified the diagnosis, and made a pelvic operative condition certain. The findings at the operation show how necessary it is in this condition to arrive at a correct diagnosis at the earliest possible moment. The bluish, discolored, strangulated salpinx, distended with blood almost to bursting, the walls showing early gangrenous areas, leaves no doubt as to what would have happened if this condition had been unrecognized for any considerable time.

Diverticulosis of the Fallopian tubes is uncommon, but is nine times as common in Negro women of Jamaican origin as in Caucasian women living in Bristol. 58 examples were encountered in 918 hysterosalpingograms done in Kingston, Jamaica (426) and in Bristol (492) from 1968 to 1972. In 41 cases (72%) diverticulosis was bilateral. There are several possible predisposing clauses, of which infection, including tuberculosis, is the most important. The radiological appearances are distinctive, but, with the possible exception of tuberculosis, do not give any indication of the cause. Infertility was the commonest clinical association of diverticulosis. Among infertile patients, hydrosalpinx and tubal obstruction were slightly commoner in the presence of diverticulosis, and the significance of this is discussed. Ectopic pregnancy is the most important associated condition and diverticulosis predisposes to its occurrence. Hysterosalpingography is indicated following ectopic pregnancy to show whether there is diverticulosis of the contralateral tube, as this may influence prognosis and management.

Pelvic lesions which require surgical treatment are primarily inflammatory, neo-plastic or mechanical, or a combination of any of these types. Surgery is recommended for conditions such as certain benign ovarian tumors, hydrosalpinx, ectopic pregnancy, large uterine fibroids, etc. Surgery is not advisable in such conditions as corpus luteum cysts and acute salpingitis or postabortal inflammatory disease.

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Six hundred and fifty-four patients with an ectopic pregnancy seen during a 21 year span were surveyed. The ratio of ectopic pregnancies to deliveries was 1 to 87, the largest number occurring in multiparous patients in the 26 to 30 year age bracket. Abdominal pain (100 per cent), amenorrhea (84 per cent), and irregular vaginal bleeding (80 per cent) were the presenting symptoms, the most significant physical finding being abdominal or rebound tenderness associated with adnexal or cul-de-sac fullness. The diagnosis was initiated by culdocentesis in the majority of patients. Eighty per cent of the tubal pregnancies were ruptured and therapy consisted, primarily, of a total salpingectomy. A small percentage of pregnancies were in rare anatomic sites, i.e., abdominal (1.4 per cent), uterine (0.7 per cent) and ovarian (0.15 per cent). There were three maternal deaths in this series. Etiologically, a histopathologic survey of 320 Fallopian tubes revealed varying degrees of inflammatory change consisting primarily of follicular salpingitis (18 per cent), interstitial salpingitis (16 per cent), and hydrosalpinx (8 per cent). The need for continuing early diagnosis was stressed, for from 1959 to 1963, 505 women in the United States died from an ectopic pregnancy. In the state of New Jersey alone there were, in a 9 year period, 38 maternal deaths due to ectopic pregnancy, 23 patients never receiving therapy.

Two hundred and eighty-six patients between the ages of 16 and 48 with a cystic adnexal mass were treated with estrogen and progesterone for 6 weeks. Persistence of the adnexal mass occurred in 81 patients and surgical exploration was done. All patients explored with an ovarian enlargement had an ovarian neoplasm causing the enlargement. There were 7 patients with normal-sized ovaries but an associated paraovarian cyst or unilateral hydrosalpinx was found. No patient was subjected to surgical exploration with the finding of a physiologic cyst causing the adnexal mass. In this series suppression of the pituitary gonadotropins for 6 weeks was long enough to cause all significant physiologic cysts to regress. It would seem that menstruating women with a cystic adnexal mass and a differential diagnosis that includes a physiologic cyst should not be subjected to operation without a trial of pituitary suppression. Also, the use of pituitary suppression with estrogen and progestogen removes the indecision as to how long a physiologic cyst will remain before undergoing regression.

A rare case of congenital association of an imperforate anus with hydrocolpos, hydrometra and hydrosalpinx is reported. This is the first case of its kind reported in this country.

I believe that hydrosalpinx with twisted pedicle has not been given the attention as a definite surgical condition which is its due. Ovarian cyst with twisted pedicle receives definite consideration in every differential diagnosis in which an acute pelvic lesion with tumor arises, yet hydrosalpinx with twisted pedicle is not mentioned in some of our textbooks of differential diagnosis, and others merely mention the possibility. I have encountered two such cases within a brief space of time, and feel that they should be reported. Both of these patients suffered the sudden, severe seizure which is characteristic of the same accident with ovarian cyst, and in each instance a complete twist of the broad ligament was found beneath a tremendously dilated fallopian tube. The tumor mass was in each instance from blue to black, and the fallopian tube contained blood. The lesion found in each was a hematosalpinx, and should be

Anyone who takes the trouble to investigate this subject carefully will be surprised at the frequency of a postoperative exudate as a sequel to surgical procedures for the relief of the various pathologic conditions which may be found within the female pelvis, due to past or present inflammation. Let these conditions be what they may—pyosalpinx, hydrosalpinx, or hematosalpinx, ovarian cystomata, hematomata or abscesses, neoplasms of the uterus or periuterine structures associated with degenerative or inflammatory changes—if they produce an exudation which results in the formation of abnormal adhesions, if they bring about hyperplastic changes in the pelvic connective tissue structures, or if they are responsible for an embarrassed pelvic circulation with passive hyperemia, edema or venous varicosity, they may easily lay the foundation for future postoperative exudates. Although theoretically recognizing the possibility of postoperative pelvic exudates, the question had not assumed practical importance to me until three years ago, when

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By the term "hydrops tubae profluens" or "intermittent hydrosalpinx" we understand a condition of the fallopian tube in which the abdominal ostium is closed by inflammatory adhesions, while the uterine opening remains patulous. In consequence of this condition, the tube fills with serum as in ordinary hydrosalpinx; but when the pressure of this fluid inside of the tube rises to a sufficient degree, the fluid escapes through the uterine ostium and the tube becomes collapsed. Another explanation of this curious intermittent condition is that the uterine end of the tube is kinked, occluding the communication between the tube and the uterus; but as the tube distends with fluid, the kink becomes straightened, allowing the tubal lumen to become patulous again, following which, the tubal contents may escape into the uterus. The clinical appearance of such a case is one of intermittent pain in the region of the tube which is

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Volvulus of the fallopian tube is a rather infrequent and interesting condition. A survey of the literature for the last twenty-five years reveals that while torsion of the fallopian tube is not a medical curiosity, it is exceedingly rare and only infrequently reported. Smith and Butler 1 thoroughly reviewed the literature up to 1921, and report a case of their own occurring in a girl 9 years of age. They classify the different types of adnexal disease into two main divisions: Those occurring in pathologic adnexa. Those occurring in normal adnexa. These are further subdivided as follows: Pathologic Adnexa. Torsion of ovarian tumors. Before puberty. After puberty. In the nonpregnant state. During pregnancy and the puerperium. Torsion of tubal tumors, including hydrosalpinx, hematosalpinx, and pyosalpinx. Normal Adnexa. Within the abdomen. In the nonpregnant state. During pregnancy. Within a hernial sac (not simple strangulation). Torsion of the uterine adnexa is