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To describe the observable MRI changes in the urogenital sinus during the second stage of labor and delivery by comparing the changes in the positions of the anatomical structures of the maternal perineum using MRI-based vector 3-D models. Seven pregnant women underwent 3-D MRI sequences using a Philips 1 T Panorama open MRI during the pre-labor period and during the second stage of labor. A 3-D vector reconstruction platform (BABYPROGRESS, France) enabled the transformation of volumes of 2-D images into finite element meshes. The polygonal meshes labeled with the principal components of the urogenital sinus were used as part of a biomechanical study of the pressure exerted on the perineum during fetal descent. The expansion of the urogenital sinus was observed in all patients. Qualitative stretching was observed toward the rear and bottom of the iliococcygeus, pubococcygeus, puborectalis and obturator internus muscles. Significant length differences were measured along the iliococcygeus and pubococcygeus muscles but not along the tendinous arch of the levator ani or the puborectalis muscle. The inversion of the levator ani muscle curvature was accompanied by the transmission of pressure generated during fetal descent to the pubic muscle insertions and the descent of the tendinous arch of the levator ani. Mechanical pressures responsible for the tensioning of the constituent muscles of the urogenital sinus were qualitatively identified during the second stage of labor. MRI-based vector 3-D models allow the quantitative assessment of levator ani muscle stretching during labor, but 2-D MRI is not sufficient for describing perineal expansion. Vector 3-D models from larger scale studies have the potential to aid in the calibration of a realistic simulation based on the consideration of the reaction of each muscular element. These models offer perspectives to enhance our knowledge regarding perineal expansion during childbirth as a risk factor for postpartum perineal defects.

To compare open and laparoscopic surgery in the management of non-epithelial ovarian malignancies.Retrospective study from University Hospital of Clermont-Ferrand, France, of 20 patients undergoing surgery for non-epithelial ovarian malignancies. We compared the outcome of 13 open surgeries and 7 laparoscopic surgeries. The main outcome measures were stage and size of the tumor, surgical procedure, hospital stay, adjuvant treatment, follow-up and fertility.The mean age of the patients and the type of tumor at the time of diagnosis were similar in the two groups but the tumor size was significantly larger in the laparotomy group (14.0cm vs. 6.7cm; p0.05). Treatment was conservative in 85.6% vs. 61.5% in the laparoscopy and laparotomy groups respectively. Tumor stages were not statistically different in the two groups. The hospital stay was shorter in the laparoscopy group (3.1 days vs. 6.9 days p=0.03) and there were no differences in terms of complications, surgical procedures, number of lymph nodes removed and adjuvant treatment.Laparoscopy respecting the usual oncologic principles appears to be a good alternative to laparotomy for the initial management of non-epithelial ovarian malignancies. The limiting factors of this technique remain the tumor size, the tumor stages and the surgeon's experience.

To demonstrate and describe fetal head molding and brain shape changes during delivery, we used three-dimensional (3D) magnetic resonance imaging (MRI) and 3D finite element mesh reconstructions to compare the fetal head between prelabor and the second stage of labor. A total of 27 pregnant women were examined with 3D MRI sequences before going into labor using a 1 Tesla open field MRI. Seven of these patients subsequently had another set of 3D MRI sequences during the second stage of labor. Volumes of 2D images were transformed into finite element 3D reconstructions. Polygonal meshes for each part of the fetal body were used to study fetal head molding and brain shape changes. Varying degrees of fetal head molding were present in the infants of all seven patients studied during the second phase of labor compared with the images acquired before birth. The cranial deformation, however, was no longer observed after birth in five out of the seven newborns, whose post-natal cranial parameters were identical to those measured before delivery. The changing shape of the fetal brain following the molding process and constraints on the brain tissue were observed in all the fetuses. Of the three fetuses presenting the greatest molding of the skull bones and brain shape deformation, two were delivered by cesarean-section (one after a forceps failure and one for engagement default), while the fetus presenting with the greatest skull molding and brain shape deformation was born physiologically. This study demonstrates the value of 3D MRI study with 3D finite element mesh reconstruction during the second stage of labor to reveal how the fetal brain is impacted by the molding of the cranial bones. Fetal head molding was systematically observed when the fetal head was engaged between the superior pelvic strait and the middle brim.

To assess the educational value of an ongoing interval practice laparoscopy training program among obstetrics and gynecology residents.Prospective cohort, multi-institutional recruitment study. We conducted structured laparoscopic training sessions for residents, using both inanimate and porcine models. The 6-day course was separated into two 3-day long modules conducted 2 months apart. A prospective evaluation of standardized tasks was performed using validated scales. Resident's performance was compared using the Student t test and Wilcoxon signed-rank test when appropriate.International Center of Endoscopic Surgery (CICE), Clermont-Ferrand, France.191 PGY2 or PGY3 residents from different institutions.Significant improvement in time and technical scores for both laparoscopic suturing and porcine nephrectomy was noted (p0.0001). After 2 months, we found no improvement in suturing time (p = 0.59) or technical scores (p = 0.62), and significant technical deterioration was observed for the right hand (p = 0.02). Porcine nephrectomy improvement remained significant after 2 months (p0.0001).Despite significant short-term educational value of interval practice in laparoscopic performance, some acquired skills seem to deteriorate faster than anticipated.

Objective To evaluate the feasibility of laparoscopic hysterectomy for uteri weighing more than 1000 g. Study design A retrospective study was conducted in a tertiary center of laparoscopic surgery including 38 women submitted to hysterectomy for uteri weighing more than 1000 g. Patients submitted to open hysterectomy were compared to those submitted to laparoscopic hysterectomy. The primary statistical endpoint was the complication rate. Secondary endpoints were operating time, estimated blood loss, length of hospital stay, and conversion to laparotomy. Results The patients’ mean age was 49.4 years and mean BMI was 25.2 kg/m2. The surgical intent was laparoscopic hysterectomy in 23 patients (60.5%) and laparotomy in 15 patients (39.5%). Conversion to open surgery was required in 4 patients (17.4%) due to inaccessibility of the pelvis at the beginning of surgery (n = 2), technical difficulties during surgery (n = 1), and intraoperative bleeding (n = 1). One patient in the laparotomy group had an intraoperative ureteral injury. Despite longer operative time (130 vs. 80 min, p = 0.002), laparoscopic surgery was associated with reduced length of hospital stay (3 vs. 6 days, p

This study was designed to compare the surgical outcomes of standard and reverse laparoscopic techniques for the treatment of rectovaginal endometriosis. A retrospective study was conducted in a teaching and research hospital (tertiary center), which included 75 women subjected to laparoscopic treatment of rectovaginal endometriosis that required both vaginal resection and rectal surgery. Standard and reverse laparoscopic techniques were compared in 35 and 40 women, respectively. Student’s t test, Mann–Whitney test, and Fisher’s exact test were performed to compare groups when needed; p

Our objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery.Human study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues.Human study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P.0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group.A low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO₂ pneumoperitoneum.

Objective To describe different approaches for diagnosis and management of proximal ectopic pregnancies (PP) in general population. Design Observational population based-study. Setting Regional ectopic pregnancy registry. Patient(s) Eighty-six PP registered from 1992 to 2008. Intervention(s) Surgical (radical or conservative), medical, or combined therapies. Main Outcome Measure(s) Epidemiologic characteristics, clinical presentation, hCG level, treatments performed, failure rate, and recurrence. Result(s) Mean gestational age was 48.2 days. Estimated incidence of PP was 2.7%. Abdominal pain and vaginal bleeding were the commonest symptoms. Two patients were admitted in hypovolemic shock. Diagnostic modalities included transvaginal ultrasound, abdominal ultrasonography, and laparoscopy in 38 (44%), 7 (8%), and 39 (45%) cases, respectively. Mean hCG level was 10,759 IU/L. Thirty-four patients underwent primary cornual resection (39.5%) by laparoscopy (n = 32) or laparotomy (n = 2). Twenty-seven patients (31.4%) underwent primary conservative surgery by laparoscopy: cornuostomy (n = 18) or extended salpigostomy (n = 9). Primary medical treatment with methotrexate was attempted in 14 patients (16.3%). Expectant management was attempted in one case (1.2%). Eleven cases received combined therapies (11.6%). Failure rates for medical and surgical treatments were 35.7% and 28%, respectively. No failures were noted among patients who received combined therapies. Conclusion(s) Proximal ectopic pregnancy remains a life-threatening condition. Diagnosis is challenging and requires a high index of suspicion. Despite available conservative strategies, management of PP remains heterogeneous.

Animal experiments have suggested that the laparoscopic peritoneal environment is hypoxic. This study aimed to investigate whether peritoneal tissue is hypoxic on a cellular level during a carbon dioxide (CO(2)) pneumoperitoneum at different intraperitoneal pressures (IPPs) and to determine the short-term effects of surgical injury on the hypoxia status of peritoneal tissue in the injured peritoneum and the distant noninjured peritoneum at cellular and molecular levels.Experiment 1: Mice were divided into five groups according to the following treatments: anesthesia alone, laparotomy, and CO(2) pneumoperitoneum at IPPs of 2, 8, or 15 mmHg. Over the course of each experiment, the peritoneal tissue-oxygen tension (PitO(2)) was continuously monitored. Experiment 2: On the first day, the mice were divided into three groups according to the following treatments: CO(2) pneumoperitoneum at an IPP of either 2 or 8 mmHg or laparotomy. The bilateral caudal epigastric arteries and uterine horns then were coagulated using a bipolar cautery device. On day 7, peritoneal tissue samples were collected for real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. In both experiments, pimonidazole hydrochloride was used to detect tissue hypoxia at a cellular level.Experiment 1: Peritoneal hypoxia at both tissue and cellular levels was detected only in the groups treated with an IPP of 15 mmHg (PitO(2): 5.2 ± 1.0 mmHg, mean ± SEM). Experiment 2: The percentage of pimonidazole immunostained mesothelial and stromal cells from the distant noninjured peritoneum was significantly higher in the group treated with an IPP of 8 mmHg than in the other groups. Hypoxia-inducible factor 1 alpha subunit mRNA expression in the distant noninjured peritoneum of the group treated with an IPP of 8 mmHg was significantly higher than in the control group (anesthesia alone).The CO(2) pneumoperitoneum itself did not cause peritoneal hypoxia at either a tissue or a cellular level in a mouse model when a low IPP was used.

Objective To assess the feasibility of sentinel lymph node (SLN) biopsy in gynecologic malignancies using natural orifices transluminal endoscopic surgery (NOTES) in an animal model. Methods Ten female pigs were operated. Patent blue dye was injected in the paracervical region. The endoscope was introduced through a right lateral colpotomy. Internal iliac vessels were visualized followed by the identification of external iliac vessels. Bilateral dissection was performed to achieve visualization of the aorta and the vena cava. SLN colored in blue were bluntly dissected and then excised. Results Mean operative time was 56±16 minutes. The mean number of SLN retrieved was 1.75±1.28. All but one SLN were identified by NOTES procedure. No major complication was observed in this series. A total of 19 SLN were harvested, of which 11 from the left side and 8 from the right side. Fifteen lymph nodes were obtained from the iliac vessels or the promontory and 4 from the lateral aortic or preaortic region. Conclusions In this study, we confirmed the feasibility of the SLN technique by NOTES. It can be considered as a potential alternative to reduce morbidity during staging procedures for gynecologic malignancies. Prospective randomized series are necessary to establish the safety and the real benefits of this new technique.

The aim of this study was to investigate HOXA-10 expression in endometrium from infertile patients with different forms of endometriosis; with uterine fibromas, or with unexplained infertility and from normal fertile women.Expression levels of HOXA-10 mRNA and protein in endometrium were measured during the mid-secretory phase. This study utilized laser capture microdissection, real-time RT-PCR and immunohistochemistry.HOXA-10 mRNA and protein expression levels in endometrial stromal cells were significantly lower in infertile patients with different types of endometriosis (deep infiltrating endometriosis, ovarian endometriosis and superficial peritoneal endometriosis), with uterine myoma, and unexplained infertility patients as compared with healthy fertile controls. HOXA-10 mRNA expression levels of microdissected glandular epithelial cells were significantly lower than those of microdissected stromal cells, without significant differences among the different groups. No protein expression was detected in glandular epithelial cells. The percentage of patients with altered protein expression of HOXA-10 in stromal cells were significantly higher in patients with only superficial peritoneal endometriosis (100%, 20/20, P0.05) compared with the other infertile groups (deep infiltrating endometriosis: 72.7%, 16/22; ovarian endometriosis: 70.0%, 14/20; uterine myoma: 68.8%, 11/16; unexplained infertility: 55.6%, 5/9).The present findings suggested that altered expression of HOXA-10 in endometrial stromal cells during the window of implantation may be one of the potential molecular mechanisms of infertility in infertile patients, particularly in patients with only superficial peritoneal endometriosis. One of the underlying causes of infertility in patients with only superficial endometriosis may be altered expression of HOXA-10 in endometrial stromal cells.

The mechanisms promoting postoperative peritoneal tumor dissemination are unclear. This study aimed to investigate postoperative tumor dissemination over time on both tissue and molecular levels.For this study, C57BL6 mice were randomized into four groups: anesthesia alone (control), carbon dioxide (CO(2)) pneumoperitoneum at low (2 mmHg) or high (8 mmHg) intraperitoneal pressure (IPP), and laparotomy. A mouse ovarian cancer cell line (ID8) was injected intraperitoneally just before surgery. The groups were further subdivided into three groups, and a laparotomy was performed to evaluate tumor dissemination on postoperative day (POD) 7, 14, or 42.The incidence of cancer cell invasion into the muscle layers of the abdominal wall was significantly higher in the laparotomy and high-IPP groups than in the low-IPP and control groups on PODs 7 and 42. Expression levels of beta 1 integrin, cMet, urokinase-type plasminogen activator (uPA), urokinase-type plasminogen activator receptor (uPAR), and type-1 plasminogen activator inhibitor (PAI-1) mRNA in the disseminated nodules were not significantly different among the four groups on POD 7. However, the expression levels of all these genes in the disseminated nodules in the laparotomy group were significantly higher on POD 14 than on POD 7. They then returned to control levels on POD 42. There were no significant differences in the expression levels of any of these genes among the groups on POD 42.The current study suggests that the molecular mechanisms underlying postoperative peritoneal tumor dissemination may differ between a laparotomy and CO(2) pneumoperitoneum. Therefore, strategies targeting postoperative tumor dissemination likely will need to account for the surgical environment.

Objective To evaluate the effect of protein kinase C inhibition on surgically induced endometriosis in mice. Design Prospective, randomized study. Setting Academic facility. Animals Sixty adult female C57BJ6 mice. Intervention(s) On day −7, oral gavage of a vehicle alone or of a protein kinase C inhibitor (100 mg/kg/day, once a day) was started and continued for 1 week in donor groups A and B, respectively. On day 0, uterine fragments from donor group A were implanted into recipient mice. Recipient mice were divided randomly into two groups: group 1 (vehicle) and group 2 (protein kinase C inhibitor). Uterine fragments from donor group B were implanted into recipient mice, and they were divided randomly into two groups: group 3 (vehicle) and group 4 (protein kinase C inhibitor). Oral gavage of a protein kinase C inhibitor (100 mg/kg/day, once a day) or vehicle was continued for 1 week. Main Outcome Measure(s) Presence and number of ectopic implants. Result(s) The number of mice that developed ectopic implants was significantly lower in groups 3 (40%) and 4 (30%) than in group 1 (100%). The number of ectopic implants was significantly lower in groups 2, 3, and 4 than in group 1. Conclusion(s) Protein kinase C inhibitor use partially prevented the development of ectopic implants in a mouse model of endometriosis.

BACKGROUND: Post-operative adhesion formation is a major clinical problem. Tissue oxygenation is one of the most important determinants in adhesion formation. The objective of this study was to investigate whether supplemental perioperative oxygen could reduce post-operative adhesion formation through increasing the peritoneal tissue oxygen tension (PitO 2 ) in a mouse model. METHODS: Adult C57BJ6 mice were randomly assigned to two groups: Group 1 (n = 20), Fraction of Inspired Oxygen (FiO 2 ): 0.21; Group 2 (n = 20), FiO 2 : 0.80. On day 0, over the course of the 90 min procedure including the 60 min of laparotomy, PitO 2 was continuously monitored. On day 7, a second laparotomy was performed to assess abdominal wound adhesions. Real-time RT-PCR was performed to measure expression levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues. RESULTS: The PitO 2 levels in Group 2 were significantly higher compared to Group 1 (P < 0.001) and controls (P < 0.003). There was no significant difference in the incidence of abdominal wound adhesions; however, the severity of adhesions was significantly reduced in Group 2 compared to Group 1 (P < 0.03). A significantly higher tPA/PAI-1 mRNA ratio was detected in Group 2 and the controls compared to Group 1 (P < 0.02 and P < 0.002, respectively). CONCLUSIONS: Supplemental perioperative oxygen may help to reduce post-operative adhesion formation.

Objective To investigate whether WT1 protein expression is altered in eutopic endometrium of endometriosis patients. Design Prospective study. Setting University hospital. Patient(s) Patients with endometriosis and fertile women with macroscopically normal pelvic cavities. Intervention(s) During surgery, endometrial tissues were obtained from 59 patients with deep infiltrating endometriosis, ovarian endometriosis, or only superficial peritoneal endometriosis. Control endometrial tissue samples were obtained from 40 fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Main Outcome Measure(s) The percentage of nuclear surface positively immunostained for WT1 (PI) and WT1-positive microvessel density. Result(s) The PI was significantly lower in endometrial stromal cells from patients with deep infiltrating endometriosis than in stroma from control subjects during the midsecretory phase, whereas there was no significant difference between the two populations during the proliferative, early secretory, and late secretory phases. The PI was also significantly lower during the midsecretory phase in endometrial stromal cells from patients with ovarian endometriosis and superficial peritoneal endometriosis compared with control subjects. Conclusion(s) During the midsecretory phase, PI in endometrial stromal cells is down-regulated in patients with deep infiltrating endometriosis, ovarian endometriosis, and superficial peritoneal endometriosis compared with endometrium from healthy control subjects.

Objective To investigate differentially expressed genes in epithelial and stromal cells of eutopic endometrium from patients with deep endometriosis and women with normal pelvic cavities using laser capture microdissection and complementary DNA microarrays. Design Prospective study. Setting University hospital. Patient(s) Patients with deep endometriosis and fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Intervention(s) Endometrial tissue biopsies during the late proliferative phase and early, mid-, and late secretory phases. Main Outcome Measure(s) Genes that were regulated with a change greater than threefold were selected as differentially expressed genes. Validation was performed with real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Result(s) Microarray analysis identified up-regulation during the late secretory phase (patients with endometriosis vs. controls) of several genes in two important signaling pathways: RAS/RAF/MAPK and PI3K. This included the genes RON, SOS, 14-3-3 protein eta, and uPAR in epithelial cells and KSR and PI3K p85 regulatory subunit alpha in stromal cells; real-time RT-PCR analysis validated up-regulation of all six genes. Conclusion(s) The RAS/RAF/MAPK and PI3K pathways may be involved in initial development of endometriosis.

Study Objective To discover the prevalence of adnexal torsion after laparoscopic hysterectomy Design Retrospective analysis (Canadian Task Force classification II-3). Setting A tertiary referral hospital. Patients One thousand thirty-three women underwent laparoscopic hysterectomies between the years 1995 and 2002. The mean age (± SD) of the women at the time of hysterectomy was 43.87 ± 4.28 years. Intervention Laparoscopic hysterectomy in which at least one adnexa was left intact. Measurements and Main Results The files of all women with adnexal torsion diagnosed by laparoscopy from 1995 to 2003 were retrospectively reviewed. In seven women, adnexal torsion occurred after laparoscopic hysterectomy. Torsion occurred 2.64 (± 1.79) years (mean ± SD) after hysterectomy. Torsion was treated by laparoscopy in all of the women; either oophorectomy or detorsion and ovariopexy was performed. We calculated the prevalence of this complication to be 7.91/1000. Conclusion Adnexal torsion can occur after laparoscopic hysterectomy.

The incidence of the spread of ovarian cancer after laparoscopic surgery is difficult to establish from the current literature. The prognosis incidence of a trocar site metastasis without peritoneal dissemination is not known. Data from general surgeons in prospective studies from a single institution suggested that in colon cancer the risk is low, whereas it seems to be much higher in multicentric studies of undiagnosed gallbladder cancer. Experimental studies suggested that laparoscopy has advantages and disadvantages. However, the risk of dissemination is high when a large number of malignant cells and a carbon dioxide pneumoperitoneum are present, a situation encountered when managing adnexal tumours with large vegetations. Animal studies will allow the development of a peritoneal environment adapted to the treatment of cancer. The ovary is an intraperitoneal organ and ovarian cancer a peritoneal disease, so the risk of peritoneal spread may be higher in ovarian cancer than in other gynecological cancers. A careful preoperative evaluation appears to be the best way to prevent these risks. It should also be used to choose which patient should be operated by which surgical team. The second step is a careful and cautious laparoscopic diagnosis, so that more than 98% of ovarian cancers encountered can be treated immediately and effectively. The laparoscopic management of ovarian cancer remains controversial; it should be performed only in prospective clinical trials. Until the results of such studies become available, an immediate vertical midline laparotomy remains the gold standard if a cancer is encountered.

Objective: To compare tumor growth, intraperitoneal implantation, and abdominal wall metastasis after laparotomy and CO2 pneumoperitoneum in a rat ovarian cancer model. Methods: To mimic intraoperative rupture of an ovarian tumor in a syngenic rat ovarian carcinoma model, 105 malignant cells were injected intraperitoneally after a 5-cm vertical midline laparotomy or after the insufflation of a CO2 pneumoperitoneum achieved with 4 mmHg or 10 mmHg intra-abdominal pressure. Two weeks later, the intraperitoneal tumor growth and the tumor dissemination were evaluated semiquantitatively with a scoring system. The scores attributed to each organ were added to calculate the dissemination score of each animal. Results: The mean (± SD) dissemination score was 83.4 ± 12 in the laparotomy group and 67.3 ± 16 and 71.9 ± 17 in the 4 and 10 mmHg CO2 pneumoperitoneum groups, respectively (P < .01). The scores for the peritoneum were 21.8 ± 3.8 in the 10 mmHg pneumoperitoneum group and 18 ± 2.4 in the laparotomy group (P < .01). In the laparotomy group, the implant found along the midline scar accounted for a mean of 62.6 ± 15% of the peritoneal score, whereas the trocar site metastases did not influence the peritoneal score in the pneumoperitoneum groups. The incidence of wound metastasis was 96% in the laparotomy group and 55% and 54% in the 4 mmHg and 10 mmHg pneumoperitoneum groups, respectively. Conclusion: In this model, tumor growth was greater after laparotomy than after laparoscopy, but peritoneal tumor dissemination was more severe after CO2 pneumoperitoneum.

Objective: To evaluate the laparoscopic management of adnexal masses suspicious at ultrasound. Methods: In a prospective study, adnexal masses suspicious at ultrasound were managed by laparoscopy. Indications for laparotomy included general contraindications to laparoscopy, obviously disseminated ovarian cancer, and technically impossible laparoscopic treatment. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Results: Over a 3-year period, 247 of the 599 adnexal masses (41.2%) treated in our department were suspicious or solid at ultrasound. Seventeen patients were evaluated by laparotomy and 230 by laparoscopy. Overall, 204 women (82.6%) were treated by laparoscopy, including seven of the 37 malignant tumors (18.9%) and 197 of the 210 benign masses (93.8%). One case of tumor dissemination occurred after a laparoscopic adnexectomy and morcellation of a grade 1 immature teratoma. Conclusion: Laparoscopic diagnosis of adnexal masses suspicious at ultrasound avoids many laparotomies for the treatment of benign masses and allows an improved inspection of the upper abdomen. The laparoscopic treatment of adnexal masses suspicious at surgery should be evaluated further in carefully designed prospective studies.

From their experience and from data in the literature, the authors try to define the respective place of the different treatments for endometriosis, especially those of operative laparoscopy. In cases of endometriosis-associated infertility, operative laparoscopy is the first line treatment and assisted reproductive technology (ART) the second one. Gonadotrophin-releasing hormone (GnRH) analogues are only useful in cases of extensive endometriosis to render surgery easier, and for ART. The average pregnancy rate following laparoscopic treatment is approximately 50% (range 34-80%). It is poorly related to the type of endometriosis except in cases of large adhesions and tubal involvement. However, duration of infertility, age and sperm quality have a direct influence on it. Therefore the authors propose a scheme for the management of endometriosis-associated infertility. In cases of pain, laparoscopic surgery can also be used; however, drugs have a more important role in these cases, to avoid recurrent surgery.

To evaluate the impact of obesity in the safety of laparoscopic hysterectomy.A retrospective study was conducted using a database of 2271 women undergoing laparoscopic hysterectomy for benign diseases between January 1995 and December 2008 at the Centre Hospitalier Universitaire Estaing (Clermont-Ferrand, France). Patients were divided into two groups according to the body mass index:30 kg/m(2) (n=2088) and ≥ 30 kg/m(2) (n=183). Primary outcomes were differences in conversion rates, operating time, estimated blood loss, intraoperative complications, and early postoperative complications.There was no difference in the operative time (121.3 versus 122.5 minutes; P=.71), in the difference between pre- and postoperative hemoglobin levels (1.8 versus 1.6 g/dL; P=.28), and in the conversion rate (4.6% versus 5.5%; P=.62) comparing the two groups. The overall intraoperative complication rate was 14.03% (n=293) and 13.66% (n=25) for nonobese and obese patients (P=.89), respectively. The overall postoperative complication rate was 8.81% (n=184) and 7.65% (n=14), respectively.Obesity does not have an adverse effect on the feasibility and safety of laparoscopic hysterectomy in experienced hands.

To compare surgical outcomes of laparoscopic hysterectomy for benign diseases according to the uterine weight.Retrospective study (Canadian Task Force classification II-3).Teaching and research hospital, a tertiary center.Women undergoing laparoscopic hysterectomy for benign diseases.Patients were divided into three groups according to the uterine weight:250 g (n = 1300), 250 to 500 g (n = 614), and500 g (n = 178).Primary outcomes were differences in conversion rates, operating time, and blood loss. Secondary outcomes were differences in length of hospital stay, time to first bowel movement, time of bladder catheterization, and complications. Operating time increased according to the uterine weight (116.5 vs 124.1 vs 133 minutes; p.001). The rate of conversion was statistically higher only for patients with uteri500 g (3.3% vs 5% vs 13.5%; p.001). However, the difference between preoperative and postoperative hemoglobin levels was equivalent for the three groups, as well as the overall rates of minor and major intraoperative complications. There was no difference in the time of bladder catheterization, time to first bowel movement, length of hospital stay, and incidence of minor and major postoperative complications among the three groups.Despite longer operating time, there is no increase in the intraoperative or postoperative complication rates in those patients with enlarged uteri undergoing laparoscopic hysterectomy. Only conversion is higher in patients with uteri500 g.

Context: Only a few, small, human studies on E-cadherin and β-catenin expression in normal cycling human endometrium have been reported. It remains unclear whether expression of these molecules might be altered in the endometrium of infertile patients with endometriosis. Objectives: The aim of the present study was to investigate E-cadherin and β-catenin expression in the endometrium of infertile patients with endometriosis, those with uterine fibromas, and patients with unexplained infertility. Design: Expression levels of E-cadherin and β-catenin mRNA and/or protein in the endometrium of infertile patients with endometriosis (n = 151), those with uterine fibromas (n = 41), patients with unexplained infertility (n = 9), as well as healthy fertile controls (n = 57) were measured. This study utilized laser capture microdissection, real-time RT-PCR, and immunohistochemistry. Results: No significant differences in E-cadherin or β-catenin mRNA expression in microdissected epithelial cells were observed among the different groups throughout the menstrual cycle. However, very low or no protein expression of E-cadherin, total β-catenin, or dephosphorylated β-catenin in luminal and glandular epithelial cells was detected in the mid-secretory endometrium of healthy fertile controls. E-cadherin, total β-catenin, and dephosphorylated β-catenin protein expression in the mid-secretory endometrium of infertile patients with endometriosis or unexplained infertility was significantly higher compared to that of healthy fertile controls in both luminal and glandular epithelial cells. Conclusions: These findings suggest that impaired down-regulation of E-cadherin and β-catenin protein expression, along with Wnt/β-catenin signaling pathway activation during the window of implantation, might be one of the potential molecular mechanisms of infertility in patients with endometriosis.

Study Objective To describe our experience in diagnosing and managing parasitic myomas developing as an unexpected late complication of laparoscopic morcellation. Design Observational study (Canadian Task Force classification II-3). Setting University hospital. Patients Retrospective chart review of all patients found to have parasitic myomas that developed after previous morcellation. Intervention Laparoscopic morcellation. Review of the recent literature correlated with clinical, surgical, and pathologic features of our cases. Measurements and Main Results Four patients had heterogeneous pelvic masses after morcellation. In 3 patients, symptoms developed between 2 and 16 years after the primary surgery. One patient had no symptoms, and was referred because of a suspect pelvic mass. Vaginal examination revealed painful pelvic masses in the pouch of Douglas in 2 patients, and painless masses fixed to the vaginal vault and anterior vaginal wall, respectively, in the other 2 patients. Laparoscopic examination confirmed the presence of parasitic masses in 3 patients. In 1 patient, the mass was excised vaginally. Histologic analysis confirmed leiomyoma fragments in all patients. A well-differentiated endometrial carcinoma was incidentally found in 1 patient after hysterectomy. Conclusion These masses probably resulted from growth of missed fragments of uterine tissue after previous morcellation, culminating in development of symptomatic iatrogenic parasitic myomas. If morcellation is anticipated or required, exclusion of malignancy is mandatory. Meticulous inspection of the abdominal cavity is necessary after morcellation. In patients with a history of morcellation who have pelvic masses, iatrogenic parasitic myomas should be considered in the differential diagnosis.

Endometriosis, a common gynecological disorder responsible for infertility and pelvic pain, is defined as the presence of endometrial glands and stroma within extra-uterine sites. Gene expression studies performed on endometriotic tissue homogenates have yielded results reflecting mRNA abundance in a mixture of cell types (including epithelial cells, stromal cells, fibrotic tissue, and muscle tissue). Therefore, a method for quantifying gene expression separately in individual cell populations is essential for identifying genetic markers. Laser capture microdissection is a technique for obtaining pure populations of cells from heterogeneous tissues. This chapter provides methods to obtain high-quality RNA suitable for a variety of different down stream applications from frozen endometrial and endometriotic tissues for laser capture microdissection, using the Arcturus PixCell II system.

Total laparoscopic radical hysterectomy (TLRH) has been reported since the early 1990 s. Although the acceptance of TLRH had been slow over the past 15 years, several teams throughout the world have recently reported promising results in the treatment of early cervical cancer with this procedure. Several modifications of the originally described technique have also been reported. From the currently existing data, these is no doubt that TLRH is technically feasible. Its operative safety profile is comparable to that of radical abdominal hysterectomy (RAH), and there exist sufficient data to suggest that the histopathologic outcome is also similar in terms of local radicality and lymph node yield. The duration of the procedure has become acceptable but remains still longer in comparison to RAH, in most series. It is now evident that with increasing experience, repetition, standardization, and incorporation of technological advances, duration can be reduced considerably and become similar to that of RAH. Total laparoscopic radical hysterectomy is associated with less blood loss, faster recovery and return of bowel function, reduced febrile morbidity, and a better cosmetic result. Nevertheless, shorter hospitalization in comparison to that observed after RAH is not consistently reported, and return of normal bladder activity is similar to that observed after RAH. It is also true that the currently existing recurrence and survival data are still immature to draw safe conclusions on its long-term oncological safety. Probably, the time has come for a multicenter randomized study between TLRH and RAH with participation of the institutions with significant experience in this procedure.

Background The aim of this study was to identify risk factors for the removal of normal ovarian tissue during laparoscopic cystectomy for endometriosis. Methods A total of 121 patients who had histologically confirmed ovarian endometriosis and 56 control patients who had other histologically confirmed benign cysts were included for the present analysis. The blocks of removed tissue were sectioned at 120 microm intervals and a total of five sections were analyzed for each ovarian cyst. Eight variables (age, pre-operative medical treatment, previous surgery for ovarian endometriosis, single or multiple cysts, size of the largest cyst, side of cyst, co-existence of deep endometriosis, revised American Society for Reproductive Medicine classification) were evaluated using a generalized linear modeling analysis to identify major factors associated with the removal of normal ovarian tissue. Results Normal ovarian tissue adjacent to the cyst wall was detected in 71 patients (58.7%) with endometriosis, whereas normal ovarian tissue was removed from only three patients (5.4%) with other benign cysts. A significant factor that was independently associated with the removal of normal ovarian tissue with ovarian endometriosis was pre-operative medical treatment. Conclusions The present retrospective, controlled study suggests that pre-operative medical treatment might be a risk factor for the removal of normal ovarian tissue during laparoscopic cystectomy for ovarian endometriosis.

Objective To evaluate fertility results after laparoscopic distal tuboplasty and to compare these results with those obtained previously with microsurgery. Design Retrospective, nonrandomized. Setting Department of Obstetrics and Gynecology at the University Hospital of Clermont-Ferrand, France. Patients All the distal tuboplasties performed between October 1985 and June 1989 were included. Adnexal damage was assessed using tubal and adhesions scoring systems described previously. Tuboplasty was carried out bilaterally except when one tube was absent or severely damaged (tubal stage III or IV and/or with severe adhesions). Patients with bilateral severe adnexal damages were treated only if they refused to undergo in vitro fertilization. Laparoscopic tuboplasty was performed either with the C0 2 laser or with conventional instruments. Main Outcome Measure Fertility after laparoscopic treatment was evaluated using simple and cumulative pregnancy rates (PRs) according to the adnexal damage and compared with the micro-surgical results using PRs according to the adnexal damage. Results The overall intrauterine and extrauterine PRs were 33.3% and 6.9%, respectively. Twenty-six of the 29 intrauterine pregnancies were obtained within the 1st postoperative year. According to tubal and adhesion stages, the results of laparoscopic distal tuboplasty are similar to those obtained using microsurgery. Conclusion We conclude that laparoscopic distal tuboplasty, when performed by experienced surgical laparoscopists, represents an effective alternative to microsurgery.

Background We recently demonstrated that a CO2 pneumoperitoneum at either a high or low IPP has few if any short term effects on peritoneal dissemination when tumors are well established before surgery. The objective of the present study was to evaluate the impact of the surgical peritoneal environment on pre-implanted tumors on a molecular level. Materials and Methods On day 7, C57BJ6 mice received an intraperitoneal inoculation of a mouse ovarian cancer cell line (ID8). On day 0, mice were randomized into four groups: anesthesia alone, CO2 pneumoperitoneum at a low (2 mm Hg) or high (8 mm Hg) IPP, or laparotomy. Groups were further subdivided into four groups and a laparotomy was performed to collect pre-implanted tumors on POD 1, 2, 7, or 14. Expression levels of β-1 integrin, cMet, uPA, uPAR, and PAI-1 mRNA in pre-implanted nodules were measured using real-time PCR. Results Expression levels of uPA, uPAR, and cMet mRNA were significantly higher in the laparotomy group than in the control group on POD 1. We detected significantly higher expression levels of uPAR and cMet in the laparotomy group than in the control group on PODs 2 and 7. There were no significant differences in the expression levels of any genes examined among the low IPP, anesthesia alone, and control groups on POD 1, 2, 7, or 14. Conclusion The impact of a CO2 pneumoperitoneum at a low IPP on gene expression levels of pre-implanted tumors might be minimal until POD 14 in the present mouse model.

We recently demonstrated that CO(2) pneumoperitoneum at low intraperitoneal pressure (IPP) had few if any short-term effects on peritoneal dissemination when an ovarian cancer cell line was inoculated just prior to surgery. The objective of the present study was to evaluate the impact of surgical peritoneal environment on postoperative tumor growth and dissemination over time when tumors were present before surgery.On day-7, C57BJ6 mice received an intraperitoneal inoculation of a mouse ovarian cancer cell line (ID8). On day 0, mice were randomized into four groups: anesthesia alone, CO(2) pneumoperitoneum at a low (2 mmHg) or high (8 mmHg) IPP, or laparotomy. Groups were further subdivided into four groups of eight animals each and a laparotomy was performed to evaluate dissemination on postoperative day (POD) 1, 2, 7 or 14.Peritoneal dissemination score was significantly higher in the laparotomy group compared with in the remaining three groups on PODs 2 and 7. We detected no significant differences in the peritoneal dissemination scores among the low-IPP, high-IPP, and anesthesia groups on PODs 2 and 7. However, there were no significant differences in the peritoneal dissemination score among the three surgical groups on POD 14. Histopathological examination demonstrated that the incidence of invasion of cancer cells into the muscle layers was significantly higher in the laparotomy group than in the low-IPP and anesthesia groups on POD 14. There were no significant differences in tumor growth among the four groups.The present findings suggest that CO(2) pneumoperitoneum at either high or low IPP has few if any short-term effects on peritoneal dissemination when tumors are well established before surgery.

To investigate postoperative peritoneal dissemination of ovarian cancer cells in a syngenic mouse model with and without controlled respiratory support (CRS).Randomized controlled trial (Canadian Task Force classification I).Academic facility.Sixty-four female C57BJ6 mice.Mice were randomly divided into 4 surgical groups: anesthesia alone group; 2 carbon-dioxide pneumoperitoneum groups, 1 with low (2 mm Hg) and 1 with high (8 mm Hg) intraperitoneal pressure (IPP); and finally the laparotomy group. Each of the 4 groups was then subdivided into one group with CRS and the other without. Mouse ovarian cancer cells were injected intraperitoneally just before surgery.A laparotomy was performed to evaluate postoperative peritoneal dissemination of ovarian cancer cells on postoperative day 14. A computerized analysis system was then used to evaluate peritoneal dissemination. In the groups with CRS, the peritoneal dissemination score was significantly higher in the laparotomy and high IPP groups compared with anesthesia alone (p.0001 vs laparotomy, p.002 vs high IPP) and low IPP (p.0002 vs laparotomy, p.004 vs high IPP) groups. No significant difference was detected between the low IPP and anesthesia alone groups.Postoperative peritoneal dissemination of ovarian cancer cells is not promoted by a carbon-dioxide pneumoperitoneum with a low IPP in a mouse model with CRS when assessed on postoperative day 14.

Study Objective We sought to study laparotomy (conversion and initial) and complication rates among patients who underwent hysterectomy initially performed laparoscopically whenever feasible. Design A retrospective cohort study (Canadian Task Force classification II-3). Setting University hospital. Patients A continuous series of 680 patients, operated on between January 1, 2000, and December 31, 2003, was analyzed. Patients with malignancy and prolapse were excluded. Interventions Hysterectomy. Measurements and Main Results Overall, 7.2% of patients underwent laparotomy. In all, 27 (3.9%) patients were treated by initial laparotomy and 22 procedures were converted to laparotomy, 13 to laparoscopic-assisted vaginal hysterectomy (1.9%). Intraoperative and postoperative bladder complication rates were 0.8% and 0.4%, respectively. Ureteric complications were 0.3% and 0.4%, respectively, and bowel complications (bowel occlusion, peritonitis) were 0.4% and 0.4%, respectively. Three patients received blood transfusion. Of 19 patients who had repeated surgery for early or late postoperative complications, 13 were treated by laparoscopy and/or vaginally. Conclusion Including management of complications, laparotomy was necessary in 8.1% of cases. Laparoscopic hysterectomy may be safely used in most patients.

Study Objective Whether, after laparoscopic hysterectomy (LH), selected patients may be safely and comfortably discharged on postoperative day 1 (day after surgery) using specific anesthesia and analgesia protocols that included Post Anesthetic Discharge Scoring System. Design A prospective feasibility pilot study (Canadian Task Force classification II-3). Setting A French tertiary care hospital. Patients A total of 35 patients who underwent total LH were selected using preestablished criteria based on age, surgical history, place of residence, and capacity to follow instructions. Interventions All patients had a telephone call the second and seventh day after surgery. Measurements and Main Results Of 35 patients, 34 (97.1%) left the hospital the day after surgery. One patient was not discharged on surgeon’s instructions, because of technical difficulties during the procedure. Two patients (6.7%) required readmission because of complications. The first patient required hospitalization for vesicovaginal fistula at day 10 and had to undergo laparoscopic treatment of the fistula. The second consulted for hyperthermia at day 4 with suggestion of cuff cellulitis, and was discharged after 2 days of antibiotic treatment. Of 35 women, 34 (97.1%) were satisfied with the procedure and all would recommend it to other patients. Conclusion Using our protocol for analgesia, anesthesia, and early discharge (24 hours after surgery) may be safely proposed after total LH in selected patients. Satisfaction rate of patients on postoperative days 7 and 30 was very high.

Study objective To evaluate feasibility and anatomic and functional results of complete laparoscopic treatment of genital prolapse with meshes. Design Retrospective monocentric study (Canadian Task Force classification II-2). Setting Centre Hospitalier Universitaire de Clermont-Ferrand, Polyclinique Hotel Dieu, France. Patients One hundred thirty-eight consecutive patients operated from January 1, 1998, through December 31, 2003. Interventions Laparoscopic promontofixation using meshes placed anteriorly in the vesicovaginal space and posteriorly to the levator ani muscles and in the prerectal space. In the space of Retzius, the anterior compartment was treated with paravaginal repair, Burch colposuspension, or both. Measurements and main results Mean follow-up was 33.7 months, with 7 patients lost to follow-up. Mean operating time was 190 minutes without any conversion to laparotomy or major perioperative complications. In all, 98% of patients were satisfied with the operation. Anatomic recurrence rate was 11%, and functional recurrence rate was 12%, with maximum delay of 40 months. A total of 57 patients (46%) had postoperative stress urinary incontinence (grade 1 or 2 in most cases), including 9 who did not receive any perioperative treatment for stress urinary incontinence. Seven patients (5%) had vaginal erosion, and for 2 of them (1%), meshes had to be removed because of infectious complications. Conclusion Complete laparoscopic treatment of prolapse including promontofixation appears to be an efficient and viable technique. Treatment of stress urinary incontinence as a consequence of surgery should be improved. Laparoscopic placement of meshes induced few complications.

Objective To investigate whether genes that had been found to be differentially expressed in deep-infiltrating endometriosis and matched eutopic endometrium in our previous complementary DNA microarray study also are differentially expressed in ovarian endometriosis and matched eutopic endometrium. Design Prospective study. Setting University hospital in France. Patient(s) Patients with ovarian endometriosis. Intervention(s) During surgery, paired samples of tissue representing ovarian endometriosis and eutopic endometrium were obtained from 12 patients. Main outcome measure(s) Expression levels of messenger RNA for heat shock protein 90 alpha (HSP90A), chicken ovalbumin upstream promoter transcription factor 2 (COUP-TF2), prostaglandin E(2) receptor subtype EP3 (PGE(2)EP3), tyrosine kinase receptor B (TrKB), and 17beta-hydroxysteroid dehydrogenase type 2 (17betaHSD2; epithelial cells) and of platelet-derived growth factor receptor alpha (PDGFRA), protein kinase C beta 1 (PKCbeta1), Janus kinase 1 (JAK1), mitogen-activated protein kinase kinase (MKK7), Sprouty2, mu-opioid receptor (MOR), and 5HTT (stromal cells) from ovarian endometriosis and matched eutopic endometrium were determined by using laser capture microdissection and real-time reverse-transcription polymerase chain reaction (RT-PCR) techniques. Result(s) Expression of PDGFRA, PKCbeta1, JAK1, HSP90A, COUP-TF2, MOR, and 17betaHSD2 was significantly higher in ovarian endometriosis than in eutopic endometrium, whereas that of Sprouty2 and PGE(2)EP3 was significantly lower. There was no significant difference in mitochondrial RNA expression of MKK 7, TrKB, and 5HTT. Conclusion(s) Ovarian endometriosis might share several common molecules with deep-infiltrating endometriosis that act to sustain endometriotic lesions, whereas molecules involved in local endocrine control might be different between these two types of endometriosis.

Objective To investigate mRNA expression of aromatase and 17β-hydroxysteroid dehydrogenase type 2 (17βHSD2) in epithelial and stromal cells from eutopic and ectopic endometrium of patients with deep endometriosis. Design Prospective study. Setting University hospital. Patient(s) Patients with deep endometriosis and fertile women with macroscopically normal pelvic cavities. Intervention(s) During surgery, 30 endometrial and 16 endometriotic samples were obtained from 30 patients with deep endometriosis. Control endometrial samples were obtained from 24 fertile women with macroscopically normal pelvic cavities who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Epithelial cells and stromal cells from endometrial or endometriotic tissues were microdissected using laser capture microdissection. Main Outcome Measure(s) Expression levels of aromatase and 17βHSD2 mRNA in microdissected epithelial and stromal cells were determined using quantitative real-time reverse transcriptase polymerase chain reaction. Result(s) Aromatase mRNA expression was significantly higher in epithelial cells than in stromal cells in both eutopic and ectopic endometrium obtained from endometriosis patients. In the ectopic endometrium of 8 patients (8/16, 50%), 17βHSD2 expression was not detected in either epithelial or stromal cells. In eutopic endometrium from endometriosis patients, 17βHSD2 expression in epithelial cells was significantly increased during the early, middle, and late secretory phases compared with the late proliferative phase, whereas no significant cyclical difference was detected in control endometrium. Conclusion(s) Local estrogen concentration may be much higher in epithelial cells than in stromal cells in deep endometriotic tissue.

Study Objective To study the usefulness of and applications for frozen section in the laparoscopic management of adnexal masses. Design Historical prospective study (Canadian Task Force classification II-3). Setting Large tertiary care hospital with university affiliation. Patients One hundred forty-one women undergoing laparoscopy for a suspicious adnexal mass. Intervention Adnexal masses suspicious on ultrasound were managed by laparoscopy. After laparoscopic diagnosis, frozen sections were used to confirm a diagnosis of malignancy. Treatment was performed by laparoscopy whenever feasible. Measurements and Main Results The results of frozen section were compared with the results of permanent sections, and the consequences of the intraoperative diagnosis on the surgical management were evaluated. The frozen section diagnosis was correct in 125 of the 141 patients (88.7%). In one patient, the result was false negative. Specifically, frozen section diagnosis was correct in 96.8% of cases when a cyst or biopsy was sent for pathologic examination and in 86.4% when the whole adnexa was sent. It was correct in 93% of the cases involving tumors smaller than 100 mm and in 74% of larger tumors. It was correct in 92.3% of the women younger than 50 years and in 81.6% of women older than age 50. Intraoperative pathologic diagnosis was correct in 95.5% of benign tumors, 77.8% of low-malignancy tumors, and 75% of cancer cases. Conclusion Frozen section is a useful examination for surgical management decision making; however, the limitations and the difficulties should be taken into account.

Objective To compare the antiadhesion efficacy of three agents (4% icodextrin, ferric hyaluronate gel, and Ringer's lactate) in severe peritoneal trauma caused by bipolar coagulation in a laparoscopic rat model. Design Prospective, randomized, blinded experimental study. Setting International Laparoscopic Surgery Centre, Clermont-Ferrand, France. Animal(s) Female Sprague-Dawley rats. Interventions Animals were prospectively randomized to receive one of the three agents or to be controls. Coagulation of the parietal peritoneum was performed using a bipolar 40-W current followed by administration of an antiadhesion agent. Postoperative adhesion assessment was carried out on day 7 in 42 rats. Main Outcome Measure(s) Adhesions were scored according to their extent and severity. Result(s) Adhesions occurred in all rats, however, adhesion and vascular adhesion rate scores were significantly higher in controls compared with treated groups. Adhesions were more likely to be filmy and easily separable in the 4% icodextrin group compared with the Ringer's lactate solution group. Conclusion(s) Adhesion scores were decreased by the use of antiadherent agents. However, no rats were found to be free of adhesions after severe peritoneal trauma induced by 40-W bipolar coagulation of the peritoneum.

Objective To evaluate Cox-2 inhibition on surgically induced endometriosis in rats. Design Prospective, randomized study Setting Academic facility. Animal(s) Seventy adult female Sprague-Dawley rats. Intervention(s) Uterine fragments were implanted into abdominal peritoneum with suture (site A), and/or into the pelvic cavity without suture (site B). Oral gavage of Cox-2 inhibitor (5 mg/kg/day, twice/day) was started 4 weeks postimplantation (protocol-1), after implantation (protocol-2), or beforehand (protocol-3). Controls received vehicle. Immunohistochemistry evaluated Cox-2 expression after treatment. Main outcome measurement(s) Presence and size of ectopic implants after treatment. Result(s) Protocol-1: After 4 weeks' treatment, size of ectopic implants (site A) was significantly reduced compared with pretreatment size. After 8 weeks' treatment, no ectopic implants were detected in 2 (40%, site A) and 3 (60%, site B) rats. Protocol-2: After 2 weeks' treatment, no ectopic implants were detected in 3 (50%, site A) and 2 (33%, site B) rats. After 4 weeks' treatment, no ectopic implants were detected in 3 (50%, site A) and 3 (50%, site B) rats. Protocol-3: After 2 or 4 weeks' vehicle-only treatment, ectopic implants were in all rats (site B). Conclusion(s) Cox-2 selective inhibition was effective in a rat model of endometriosis, particularly in prevention of ectopic implants.

Objective To quantify the expression of transforming growth factor β1 in nerve fibers in endometriotic lesions and to correlate it with dysmenorrhea and appearance of endometriotic implants. Design Prospective comparative study. Setting University hospital. Patient(s) Peritoneal endometriotic specimens obtained from 35 patients diagnosed with endometriosis were compared with biopsies of normal peritoneum from 10 patients without endometriosis. Intervention(s) Endometriosis-associated dysmenorrhea for each patient was evaluated before surgery using a 10-point visual analog scale, which was followed by a laparoscopic staging of the patient's endometriosis. Main outcome measure(s) Immunohistochemical analysis of the peritoneal endometriotic specimens evaluated the maximal intensity of staining (INTMMAX) of TGFβ1, defined as higher staining intensity found within a selected structure. Result(s) When the nerve fibers of endometriotic lesions were compared with those of normal peritoneum, statistically significant differences were found in the INTMMAX of TGFβ1. Greater TGFβ1 INTMMAX was found in red lesions and deep endometriotic foci than in black lesions and normal peritoneum. A statistically significant relationship was found between the TGFβ1 INTMMAX score and dysmenorrhea; a relationship also was found to the color of the lesions. Conclusion(s) The physical appearance of endometriotic implants and the severity of dysmenorrhea appear to be related to the expression of TGFβ1 in nerve fibers.

Objective To identify any relationship between cyclooxygenase-2 expression and the intensity of severe, endometriosis-related dysmenorrhea. Design Prospective study. Setting University hospital. Patient(s) Patients with deep endometriosis. Intervention(s) During surgery, paired samples of tissue representing deep endometriosis and eutopic endometrium were obtained from 46 patients. Control endometrial tissue samples were obtained from 34 fertile women who underwent laparoscopic tubal ligation or reversal of tubal sterilization. Pain assessment for dysmenorrhea was done with a 10-point linear analogue scale. Main outcome measure(s) The percentage of surface immunostained for Cox-2 was determined by an immunohistochemical technique. Relationships between pain score for dysmenorrhea and Cox-2 expression were analyzed. Result(s) Cox-2 expression was significantly higher in eutopic endometrial stromal cells from patients with deep endometriosis than in stroma from controls during the early, mid, and late secretory phases. In endometriosis patients, Cox-2 expression in eutopic endometrial stromal cells was significantly higher in women with more severe dysmenorrhea (pain score ≥7 vs. Conclusion(s) Elevated Cox-2 expression in stromal cells in eutopic endometrium from patients with deep endometriosis may play a role in severe, endometriosis-related dysmenorrhea.

Purpose of review To review recent literature on the laparoscopic management of adnexal masses, when this approach may be considered as a gold standard. Recent findings Cyst rupture was recently demonstrated to be a significant prognostic factor in stage I invasive epithelial carcinoma, and it was recommended to restrict the laparoscopic approach to patients with preoperative evidence that the cyst was benign. The laparoscopic approach is still highly controversial in masses suspicious at ultrasound. The limits of the laparoscopic approach are discussed reviewing recent literature and our experience. The laparoscopic management of adnexal masses appears to be safe in most hospitals even in developing countries. This approach is being used with increasing frequency in unusual indications such as newborns, children, adolescents and pregnant women. The learning curve for endoscopic surgery appears to be longer than expected. Many patients with benign adnexal masses, such as ovarian endometrioma, are still treated by laparotomy or with an inadequate endoscopic technique. Several studies have suggested that the stripping technique is a tissue-sparing procedure. Summary The laparoscopic puncture of malignant ovarian tumours confined to the ovaries is uncommon, and should be avoided whenever possible. The teaching of endoscopy is essential to promote adequate procedures performed according to the principles of microsurgery and to preserve postoperative ovarian physiology.

Dermoid cysts are usually treated by ovarian cystectomy or oophorectomy. Less invasive laparoscopic treatment of dermoid cysts has replaced traditional laparotomy as the preferred surgical approach, but has been associated with a greater likelihood of accidental cyst rupture, intraperitoneal spillage of contents, and subsequent granulomatous (chemical) peritonitis. In the early 1990s, the use of an endoscopic retrieval bag placed under the cyst during surgery was introduced to minimize spillage into the peritoneal cavity. This retrospective study investigated whether use of the endoscopic bag among a population of patients undergoing laparoscopic surgery for ovarian dermoid cysts could prevent intraperitoneal spillage of cyst contents and postoperative granulomatous peritonitis. The study was conducted between 1982 and 2003 in 314 women with ovarian dermatoid cysts confirmed by histology as benign cystic teratomas. Data were analyzed from 2 groups of women: group 1 was comprised of 174 patients in whom endoscopic bags were not used (1983-1992), and group 2 consisted of 140 patients in whom endoscopic bags were used (1992-2003). The primary study endpoints were the incidence of cyst rupture with intraperitoneal spillage of contents and rate of postoperative granulomatous peritonitis in each group. Routine use of the bag during laparoscopy reduced the frequency of accidental cyst rupture compared to a total laparoscopic approach (group 1, no bag: 26/174 or 15% versus group 2, bag: 39/140 or 28%; P = 0.005). In group 1, the incidence of granulomatous peritonitis after intraperitoneal spillage was 8% (2/26). No cases of granulomatous peritonitis were reported in group 2. These findings demonstrate that routine use of an endoscopic retrieval bag during laparoscopic removal of ovarian dermoid cysts can minimize the risk of granulomatous peritonitis.

Objective: To review the experimental studies on laparoscopy and cancer and to propose guidelines for the clinical management of gynecologic cancer. Methods: The literature in MEDLINE was searched from January 1992 to December 1998 using the terms ‘cancer’, ‘laparoscopy’ and ‘experimental or animal study’. Cross-referencing identified additional publications. Abstracts and letters to the editor were excluded. All the relevant papers were reviewed. Results: Depending on the model used, controversial results have been reported on the incidence of trocar site metastasis when comparing CO 2 laparoscopy and laparotomy. In contrast, the following conclusions can be proposed: (i) tumour growth after laparotomy is greater than after endoscopy; (ii) tumour dissemination is worse after CO 2 laparoscopy than after laparotomy; (iii) some of the disadvantages of CO 2 laparoscopy may be treated using local or intravenous treatments or avoided using other endoscopic exposure methods, such as gasless laparoscopy. Conclusions: The laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages, and may only be performed in prospective clinical trials. The risk of dissemination appears high when a large number of malignant cells are present. Adnexal tumours with external vegetations, and bulky lymph nodes should be considered as contra-indications to CO 2 laparoscopy.

The minimum distance between the vaginal mucosal epithelium and the endometriotic glands was1,000 microm in 30 patients (49.2%),2,000 microm in 44 patients (72.1%), and5,000 microm in 60 patients (98.4%). Our findings provided histologic evidence that excision of the posterior vaginal fornix was necessary to completely remove large rectovaginal endometriotic nodules.

Objective To study fertility of patients with adnexal abscesses treated by laparoscopy, antibiotic therapy, and second-look laparoscopy. Design A retrospective clinical study. Setting Department of Obstetrics Gynecology and Reproductive Medicine, University of Auvergne, University Hospital of Clermont Ferrand, France. Patient(s) Thirty-nine patients treated for adnexal abscesses between January 1983 and December 1992. Intervention(s) Laparoscopic drainage of adnexal abscesses was performed in all patients; 35 patients underwent a second laparoscopy 3 to 6 months later. Main Outcome Measure(s) Immediate and long-term clinical results, anatomical data obtained at second-look laparoscopy, spontaneous fertility. Result(s) No immediate reoperation was necessary within the first 2 months after the initial laparoscopic surgery. At second-look laparoscopy, an adhesiolysis was necessary in all cases. A distal tuboplasty was performed in 17 patients and 6 patients were referred to IVF-ET. Subsequently, 12 of 19 patients not using any contraception obtained a spontaneous intrauterine pregnancy (63%). Conclusion(s) This study confirms that laparoscopic surgery is a safe and efficient technique for treating adnexal abscesses. Anatomical results observed at second-look laparoscopy suggest that this second surgical step is essential for patients desiring future pregnancy.