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Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg).The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.A randomised, controlled, double-blinded study.Private hospital in Denmark.Ninety-nine patients.Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg).Clinicaltrials.gov identifier: NCT01722097.

Establishment of sufficient muscle relaxation is essential in laparoscopic surgery. During laparoscopy, surgeons can experience abdominal contractions in their patients. Deep neuromuscular block (NMB) has the potential to prevent such episodes. In this study, we explored if deep NMB reduces the incidence of sudden abdominal contractions as compared with standard NMB.This was a pre-planned secondary analysis of a randomized, controlled study. A total of 110 patients scheduled for laparoscopic hysterectomy were randomized to either deep NMB and 8 mmHg pneumoperitoneum (deep NMB group) or single-bolus NMB and 12 mmHg pneumoperitoneum (standard NMB group). NMB was established with rocuronium and reversed with sugammadex. Two gynaecologists registered episodes of sudden abdominal contractions, alarms from the insufflator due to increased intraabdominal pressure and incidences with tightness of the abdominal wall.No sudden abdominal contractions were detected in the deep NMB group as compared with 12 episodes in the standard NMB group (p0.001). The insufflator alarmed in no versus ten procedures (p = 0.001) in the deep and standard NMB group, respectively. The gynaecologists registered increasing abdominal tensions in no versus eight procedures (p = 0.006) in the deep and standard NMB group, respectively.Deep NMB in combination with 8 mmHg pneumoperitoneum prevented sudden abdominal contractions during laparoscopic hysterectomy.This work was funded in part by a research grant from the Investigator Initiated Studies Program of Merck SharpDohme Corp, USA. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck SharpDohme Corp.The study was assigned with EudraCT number 2012-003787-51 and registered with clinicaltrials.gov (NCT01722097).

Design A 45-year-old woman with a symptomatic uterine myoma suffering from heavy menstrual bleeding, incontinence, and pain pressure received ulipristal acetate (UPA [Esmya; Gideon Richter, Budapest, Hungary]) for 6 months. Setting A Minimal Invasive Gynecology surgery Unit in Chopenhagen Denmark. Intervention Her symptoms were reduced; however, after 3 months on UPA, she was then admitted because of increased pain. A high level of C-reactive protein was found, and necrosis of the myoma was assumed to be the reason. In December 2015, she opted for a laparoscopic hysterectomy because of the increasing symptoms and lack of conviction that the medical therapy would be sufficient. Measurements and Main Results Ultrasound showed a 106 × 73 mm myoma with no abnormal blood flow or lacuna of fluid inside the myoma; there was no suspicion of malignancies. The video and the report have been approved by the local institutional review board. The weight of the contained morcellated uterus was 575 g, and pathology showed a malignant leiomyoma sarcoma. A postoperative positron emission tomographic scan showed 4 metastatic processes in the lungs. Conclusions The Food and Drug Administration has approved the PneumoLiner (Advanced Surgical Concepts, Dublin, Ireland); however, they also stress the point that the device “has not been proven to reduce the risk of spreading cancer.” In this case, the UPA treatment actually led to a delay in the diagnosis, potentially with a larger or even metastatic tumor as a consequence.

Background and Objectives: After the U. S. Food and Drug Administration's recommendation against the use of power morcellation for tissue extraction in minimally invasive hysterectomy, the number of procedures completed laparoscopically declined in favor of open surgery laparotomy. We conducted a retrospective cohort study comparing perioperative and long-term outcomes, including complications associated with laparoscopic hysterectomy before and after the FDA recommendation.Methods: We included procedures performed in Danish government hospitals (GHs) and a hospital specializing in minimally invasive gynecological surgery (MIGS). Different types of hysterectomy over the period from January 2011 through May 2016 were examined.Results: Hysterectomies were analyzed from GHs (n = 21,495) and from a hospital specializing in MIGS (n = 749). In the GHs, we found a decrease in open hysterectomy from 40% in 2011 to 20% in 2016. In the MIGS hospital, 4 of 749 (0.05%) open hysterectomies were performed during the 6 years; however, there was a change in operative technique. After the FDA recommendation, there was a shift from laparoscopic subtotal hysterectomy (LSH) to total laparoscopic hysterectomy (TLH) from 32% in 2011 to 82% by May 2016. Containment bags were used in LSH and large-uterus TLH after the 2014 advisory. Significantly more complications occurred in the GHs than in the MIGS hospital: 3224/21,495 (15%) vs 53/749 (7.0%), respectively.Conclusion: The rate of minimally invasive hysterectomies continues to increase. However, after 2014, many of the morcellation techniques have been replaced by a minilaparotomy to extract the uterus at the end of surgery, compared to the use of the contained morcellation in 100% of cases in the MIGS hospital. There was a major difference in complication rates between the hospitals that is partly explainable by the challenge in training residents and the low operative volume of surgeons in GHs.

Hypoestrogenism in postmenopausal women results in skin atrophy with a decrease in both elasticity and skin thickness. The fragility of the skin in aging women may be responsible for the reported 50% or more increase in major laparoscopic complications during the initial entry into the female abdomen. Several first-entry techniques in laparos- copy have been investigated to minimize entry-related complications. The Veress needle approach is the standard method used by most gynecologists. A promising new method is the direct optical access (DOA) which uses optically-guided trocars to provide visual guidance during entry. These 2 techniques have not been compared. The aim of this prospective randomized study was to evaluate the efficacy and safety of these 2 methods in postmenopausal women. The study was conducted at multiple European gynecology centers between 2004 and 2008. A total of 186 postmenopausal women scheduled to undergo laparoscopy for simple, persistent postmenopausal ovarian cysts were randomized to 2 groups: group I (n = 89) was assigned to surgical entry using DOA, and group 2 (n = 97) was assigned to entry using the Veress needle method. The 2 procedures were compared for the following parameters: the time needed for achieve adequate abdominal access, the occurrence of major and minor vascular and bowel injuries, and blood loss during laparoscopic access. The time needed to establish adequate abdominal access was significantly reduced in the DOA access group compared to the Veress group (65.7 ± 11.9 vs. 192.8 ± 5.6 minutes; P < 0.0001), but there were no significant differences between the two groups in the occurrence of major vascular and/or bowel injuries (P = NS). Although fewer minor vascular injuries were found with DOA method than the Veress technique (1 versus 3), the difference was not statistically significant. The findings of this small preliminary study suggest that use of the DOA technique may be a safe and less time-consuming approach to abdominal entry in postmenopausal women and may avoid the risks of blind access laparoscopy.

Objective To compare three types of equipment during hysteroscopic resection. Design A randomized study. Setting Women's clinic at Ullevaal University Hospital, Oslo, Norway. Patient(s) Two hundred premenopausal women with menorrhagia caused by dysfunctional bleedings, fibroids, or polyps. Intervention(s) Hysteroscopic resection was performed either with monopolar electrodes using glycine 1.5% as irrigant or with two different types of bipolar electrodes (TCRis; Olympus, Hamburg, Germany and Versapoint; Gynecare, Menlo Park, CA) using saline as irrigant. Main Outcome Measure(s) Change in serum sodium as a result of irrigant consumption, operating time, and amount of tissue removed. Result(s) A statistically significant reduction in mean serum sodium from 138.7 mmol/L to 133.8 mmol/L was seen in the monopolar group, compared with the case of the saline groups with no reduction. The amount of resected tissue in the monopolar and TCRis group was approximately 1.00 g/min, compared with 0.65 g/min in the Versapoint group. Loss of fluid during the procedure was significantly higher in the two bipolar groups. Conclusion(s) Bipolar electrodes appear to have a safer profile compared with monopolar electrodes because of the unchanged serum sodium. Irrigant consumption was significantly higher in the two bipolar groups, without any side effects during or after the procedure. Furthermore, the TCRis loop appears to be superior to the Versapoint loop, as regards operating time and amount of tissue removed.

Objectives To evaluate whether assessment of blood flow by transvaginal color Doppler and three-dimensional power Doppler imaging, enhanced by intravenous contrast, may be useful in the differentiation between benign endometrial polyps and endometrial cancer. Methods A prospective study was performed comparing 17 women with benign endometrial polyps and 17 women with endometrial cancer. Transvaginal color Doppler and three-dimensional power Doppler angiography were performed before and after injection of intravenous contrast. The pulsatility index (PI) and the resistance index (RI) of the polyp feeding vessel or central vessel in malignant lesions, as well as the power Doppler endometrial flow indices vascularization index (VI), flow index (FI) and vascularization flow index (VFI), were calculated before and after enhancement by contrast, and compared between the two groups of women. Results PI (mean difference ± SD, 0.68 ± 0.22; 95% CI, 0.23–1.13; P = 0.004) and RI (mean difference ± SD, 0.16 ± 0.08; 95% CI, 0.00–0.32; P = 0.045) were significantly lower in vessels of malignant tumors than in those of benign endometrial polyps after enhancement by intravenous contrast. No significant differences in PI, RI, VI, FI or VFI before enhancement by contrast, or in VI, FI or VFI after enhancement by contrast, were detected between women with endometrial polyps and those with endometrial cancer. Conclusions Transvaginal color Doppler examination enhanced by intravenous contrast may help to discriminate between benign endometrial polyps and cancer. Larger studies are required to confirm these findings. Copyright © 2008 ISUOG. Published by John Wiley & Sons, Ltd.

The objective of this pilot study was to evaluate the feasibility of a transvaginal clamp prototype used for temporary uterine artery occlusion as a treatment for myomas. In particular, we aimed to evaluate technical aspects of successful occlusion with angiography and magnetic resonance imaging (MRI) and to evaluate possible ureter occlusion with pyelography. Ten premenopausal women aged 34 to 37 years with menorrhagia and myomas were treated with a temporary uterine artery occlusion for 6 hours. Five patients did not complete the clamping procedure because of unsuccessful clamping. While the clamp was in position, angiographic examination of the uterine arteries and pyelography were performed in 8 of the patients. The clamps occluded both uterine arteries in 4 patients and 1 side in another 2. Two procedures occluded the ureter unilaterally. MRI with contrast was done before, the day after, and 3 months after the procedure. Three of 5 patients who completed the clamp treatment had reduced or no contrast enhancement at MRI afterward. Clinical effects were obtained in 3 patients. Difficulties with application of the vaginal clamp were related to initial learning and size of the myomas. Our initial experience shows that the treatment is feasible in some patients with symptomatic myomas. However, improvement of the technique and equipment is needed. Care with regard to the ureters is required during further studies aimed at evaluating this approach.

Study objective To estimate the occurrence of malignancy and atypical hyperplasia in endometrial polyps in patients with and without symptoms. Design Retrospective registration of all patients who underwent hysteroscopic resection of endometrial polyps. Age, menopausal status, presence or absence of symptoms, any use of hormonal medication, as well as histologic diagnosis, complications, and eventual repeated surgery were documented (Canadian Task Force classification II-3). Setting Ullevaal University Hospital, Department of Gynecology. Patients All patients who underwent hysteroscopic resection of an endometrial polyp in our department from January 1, 2001 through March 1, 2005. Interventions Hysteroscopic resection of endometrial polyps. Measurements and main results Four hundred eleven patients were included. One hundred twenty-nine patients (31.4%) had no symptoms. The prevalence of malignancy or atypical hyperplasia was 3.2% in women with symptoms and 3.9% in those without symptoms. Conclusion The prevalence of malignancy and atypical hyperplasia was found to be relatively high, indicating that symptomatic, as well as asymptomatic, endometrial polyps should be removed.

Study objective To elucidate the safety and patient satisfaction with laparoscopic supracervical hysterectomy (LSH) performed in an outpatient setting. Design Prospective case study (Canadian Task Force classification II-2). Setting Public hospital. Patients Forty-three women. Intervention Outpatient LSH performed by lap-loop. Measurements and main results The procedure was recommened by 41 out of 43 patients. Three patients (7%) were admitted to the hospital due to complications after the surgery. One patient was admitted because of a vasovagal reaction after anesthesia; she recovered quickly and was discharged after a few hours of observation. One patient was admitted because of postoperative pain and discharged the next day; she had a prolonged postoperative recovery with pain and subfebrile temperature. One patient underwent laparotomy due to major intraabdominal bleeding. Postoperative complications occurred in another five patients (12%) without need for hospitalization (infected intra-abdominal hematoma, urine retention, cystitis, cystitis combined with wound infection, and pneumonia). Conclusion Laparoscopic supracervical hysterectomy as an outpatient procedure is a safe and highly acceptable treatment.

OBJECTIVE: The purpose of this study was to compare the long-term efficacy of the levonorgestrel intrauterine system and transcervical resection of the endometrium in the treatment of menorrhagia. METHODS: This study was an open, randomized 3-year trial. Patients with menorrhagia were assigned randomly to either the levonorgestrel intrauterine system (n = 30) or endometrial resection (n = 29). Pictorial blood loss assessment charts were used to measure menstrual blood loss. A pictorial blood-loss assessment chart score exceeding 75 (representing menstrual blood loss >/=60 mL) was used to diagnosis the patient as having menorrhagia. Discontinuations and cases requiring repeat operations were evaluated. RESULTS: Pictorial blood loss scores decreased from a baseline median of 261.5 (range, 60-1503) to 7 (range, 0-101; P < .001) for the levonorgestrel intrauterine system and from 311 (range, 81-2506) to 4 (range, 0-182; P < .001) for transcervical resection of the endometrium. Nineteen women of 30 using the levonorgestrel intrauterine system completed the 3-year follow-up compared with 22 of 29 for transcervical resection of the endometrium. CONCLUSION: Both treatments efficiently reduced menstrual bleeding. The high continuation rate suggests that the levonorgestrel intrauterine system is comparable with transcervical resection of the endometrium.

A 43-year-old woman with menorrhagia, dysmenorrhea, and pelvic pain of several years' duration had a uterus enlarged by myomas to the size of a 16-week pregnancy. Her uterine arteries were noninvasively transvaginally identified and occluded for 6 hours with a clamp that was guided by audible Doppler ultrasound. Following removal of the clamp, blood flow in the uterine arteries returned immediately. Menorrhagia symptoms diminished. Three months following treatment, uterine volume decreased by 48.9%, and dominant myoma volume decreased by 77.2%.

Objective Our purpose was to evaluate the effects of laparoscopic occlusion of uterine vessels in treating symptomatic fibroids and compare with embolization of the uterine arteries. Study design We studied 46 premenopausal women, aged 43 (34-51) years with symptomatic uterine fibroids, undergoing radiologic embolization (n = 24) and laparoscopy closure of the uterine arteries (n = 22). Results The laparascopic technique reduced picture blood assessment score after 6 months by 50% from an initial value of 345 (±288). Uterus volume was reduced by 37% (±18%), and the dominant fibroid was reduced by 36% (±31%). Postoperative pain and use of pain relief differed significantly, requiring more pain medication after embolization: ketobemidon 38 mg compared with 16 mg in the laparoscopic group (P = .008). Specific complications to the laparascopic technique were temporary damage to the obturator nerve in three patients. Conclusion Laparoscopic occlusion of uterine vessels is a promising new method for treating fibroid-related symptoms, with less postoperative pain than embolization and comparable effects on symptoms.

Udgivelsesdato: 2001-Aug OBJECTIVE: Treatment of menorrhagia with levonorgestrel intrauterine system (LNG IUS) and transcervical resection. DESIGN: An open, therapeutic, randomized study. SETTING: Central county hospital specializing in hysteroscopy. PATIENT(S): Two parallel groups of 30 subjects each. INTERVENTION(S): Thirty patients had a LNG IUS inserted within the first 7 days of menses; 29 patients underwent endometrial resection. MAIN OUTCOME MEASURE(S): A 12-month follow-up of menstrual blood loss and adverse events were evaluated. RESULT(S): LNG IUS group: 13 patients reported one or more pelvic adverse events, bleeding disorders (n = 6), abdominal pain (n = 4), breast tenderness (n = 3), headache, acne (n = 2), and mood changes (n = 1). Six patients discontinued treatment because of irregular bleeding (n = 3), pain (n = 2), and acne (n = 1). In both groups, general feeling of genital health increased with Visual Analogue Scale score. Nine patients reported adverse events. This included pelvic pain indicating inflammation (n = 4), bleeding (n = 3), vaginitis (n = 1), and ulceration (n = 1). Treatment success at 12 months was achieved in 20 (67%) of the 30 patients in the LNG IUS group and in 26 (90%) of the 29 patients in the transcervical resection group. Adverse events were more often reported in the LNG IUS group. CONCLUSION(S): Both treatments effectively reduced the menstrual blood loss. Furthermore, the LNG IUS treatment is reversible and has no operative hazards.

In our department, laparoscopic supracervical hysterectomy has gradually replaced hysterectomy by laparotomy in patients with a benign condition and no history of cervical dysplasia. During the last year, we experienced serious complications in two patients because of inadequate removal of the tissue in the morcellator procedure. These cases are presented and discussed in this case report.

Shoulder pain is a commonly reported symptom following laparoscopic procedures such as myomectomy or hysterectomy, and recent studies have shown that lowering the insufflation pressure during surgery may reduce the risk of post-operative pain. In this pilot study, a method is presented for measuring the intra-abdominal space available to the surgeon during laproscopy, in order to examine whether the relaxation produced by deep neuromuscular blockade can increase the working surgical space sufficiently to permit a reduction in the CO2 insufflation pressure. Using the laproscopic grasper, the distance from the promontory to the skin is measured at two different insufflation pressures: 8 mm Hg and 12 mm Hg. After the initial measurements, a neuromuscular blocking agent (rocuronium) is administered to the patient and the intra-abdominal volume is measured again. Pilot data collected from 15 patients shows that the intra-abdominal space at 8 mm Hg with blockade is comparable to the intra-abdominal space measured at 12 mm Hg without blockade. The impact of neuromuscular blockade was not correlated with patient height, weight, BMI, and age. Thus, using neuromuscular blockade to maintain a steady volume while reducing insufflation pressure may produce improved patient outcomes.

Objective To determine if women who have undergone transcervical resection of the endometrium can be treated safely with estrogens alone. Methods Sixty-two postmenopausal women who had undergone endometrial resection were recruited into a double-blind, randomized study. Twenty-one had menopausal symptoms at the primary operation and were recruited at the time of the surgery, and 38 were recruited an average of 20 months (range 8–42) after the primary endometrial resection and underwent a second resection to remove any residual endometrium before entering the study. Three patients were excluded from the study. Subjects were allocated randomly to one of two hormone replacement therapy (HRT) regimens: 17-β-estradiol 2 mg alone or combined with norethisterone 1 mg. Clinical and ultrasound data were collected every 3 months. Hysteroscopically standardized endometrial biopsies were taken after 1 year. Results In the single-agent therapy group, endometrial hyperplasia without atypia was found in six subjects and proliferative endometrium in eight after 1 year. No such cases occurred among women receiving combined therapy. Endometrial thickness and menstrual bleeding were significantly greater in the single-agent therapy group than in those receiving combined therapy. These differences between single-agent and combined therapy were statistically significant. Conclusion Fostmenopausal HRT in patients who have undergone transcervical resection of the endometrium should include progestagen for protection of the endometrium.

To evaluate the value of transcervical resection of endometrium and fibroids in clinical practice.A retrospective review of operative details of 412 transcervical resections of endometrium and fibroids and clinical outcome from 387 procedures performed over five years is reported.Patients referred due to bleeding disturbance, treated with a standard urological resectoscopes, controlled after 6 and 12 months. Subsequent follow up was performed by questionnaire and patient bleeding diary.Operative complications (perforation, hemorrhage, absorption and more than 1500 ml glycine irrigating fluid) arose in 72 patients (18%). In 52 (14.4%) of 366 patients the outcome was not considered acceptable by either ourselves or the patients. This led to a repeat resection procedure being performed in 31 cases (9.0%) with favorable result in 21 (68%) of these cases. Twenty-one patients (6.1%) underwent a hysterectomy because of a persistently poor outcome. A favorable outcome was then reported in subsequent follow up of 335 patients (91%). In addition, pain associated with menstruation was reduced after the procedure and correlates with achieved result on bleeding intensity.Endometrial resection is safe and acceptable treatment option for both menorrhagia and metrorrhagia associated with dysmenorrhoea.

LESS, or laparo-endoscopic single site surgery, is a promising new method in minimally invasive surgery. An increasing number of surgical procedures are being performed using this technique; however, its large-scale adoption awaits results of prospective randomized controlled studies confirming potential benefits. Theoretically, cosmetic outcomes, postoperative pain and complication rates could be improved with use of single site surgery. This study describes introduction of the method in a private hospital in Denmark in which 40 women were treated for benign gynecologic conditions. Although the operations described are the first of their kind reported in Denmark, favorable operating times and very low complication rates are seen. It is the authors' opinion that in addition to being feasible for hysterectomy, single port laparoscopy may become the preferred method for many simple gynecological procedures.

Case reports for uterine rupture subsequent to laparoscopic myomectomy were reviewed to determine whether common causal factors could be identified. Published cases were identified via electronic searches of PubMed, Google Scholar, and hand searches of references, and unpublished cases were obtained via E-mail queries to the AAGL membership and AAGL Listserve participants. Nineteen cases of uterine rupture after laparoscopic myomectomy were identified. The removed myomas ranged in size from 1 through 11 cm (mean, 4.5 cm). Only 3 cases involved multilayered closure of uterine defects. Electrosurgery was used for hemostasis in all but 2 cases. No plausible contributing factor could be found in one case [corrected]. It seems reasonable for surgeons to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. Nevertheless, individual wound healing characteristics may predispose to uterine rupture.

We report 2 cases of laparoscopic gynecologic procedures, complicated by small bowel obstruction possibly related to use of a hemostatic agent. The cause was most likely from excess material not incorporated in the hemostatic clot at the site of application. Gentle irrigation and removal of excess material from the site of application is recommended by the manufacturer of FloSeal and may reduce the risk of postoperative adhesion formation and small bowel obstruction.

Study Objective To estimate the clinical effectiveness of transcervical resection of endometrial polyps. Design Randomized controlled trial (Canadian Task Force classification I). Setting University teaching hospital. Patients One hundred fifty premenopausal women with endometrial polyps. Interventions Either transcervical resection of the polyp or observation for 6 months. Measurements and Main Results There was no difference in periodic blood loss measured using the Pictorial Blood Assessment Chart between the study groups at 6-month follow-up. A significant difference between the groups was observed in favor of the intervention group for 2 secondary outcome measures: mean difference of periodic blood loss measured using a visual analog scale (score, 0.7; 95% confidence interval, 0.11–1.30; p = .02) and occurrence of gynecologic symptoms at follow-up (7 of 75 patients [9.3%] vs 28 of 75 [37.3%]; p Conclusion Transcervical resection of endometrial polyps seems to have minimal effect on periodic blood loss; however, the procedure seems to relieve symptoms such as intermenstrual bleeding in most premenopausal women.

More than 50% of major laparoscopic complications occur during the initial entry into the abdomen. We investigated the efficacy and the safety of two laparoscopic access techniques: the direct optical access (DOA) versus the classical open entry, as described by Hasson.Two hundred and two premenopausal women, homogeneous in age, parity, and body mass index undergoing laparoscopic surgery for simple ovarian cysts, were prospectively, randomly assigned to either open or DOA abdominal entry for laparoscopic surgery. The following parameters were compared: duration of access for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. The results were analyzed by using SAS software (SAS Institute, Inc., Cary, NC), considering a P-value of0.05 as significant.No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques. However, time for establishment of abdominal entry was significantly reduced in the DOA group, as was the blood loss (P0.05).The results of this preliminary comparison on the DOA and the Hasson methods, commonly used by general surgeons and less frequently by gynecologists, suggest that the visual entry system confers a little statistical advantage over the traditional Hasson entry, in terms of safety, minimal time saving, and in reducing blood loss, allowing a safe, fast, visually guided entry.

To compare long-term symptom recurrence and 6-month magnetic resonance (MR) imaging results after two different treatments for uterine leiomyomas.Sixty-six women with uterine leiomyomas were randomized to undergo uterine artery embolization (UAE) or laparoscopic bilateral occlusion of uterine arteries. Contrast-enhanced MR imaging was performed before treatment and after 6 months.Fifty-eight patients received treatment. Median follow-up time was 48 months (range, 8-73 months). Clinical failure and symptom recurrence occurred in 14 patients after laparoscopy (48%) and in five after UAE (17%; P = .02, log-rank test). Hysterectomy was performed in two patients after UAE (7%) and in eight after laparoscopy (28%; P = .041). Six-month MR imaging results were available for 26 patients treated with UAE and 22 treated with laparoscopy. The mean uterine volume was reduced by 51% (range, 16%-86%) after UAE treatment, compared with 33% (range, 6%-77%) after laparoscopy (P = .001). Complete leiomyoma infarction was seen in all 26 patients in the UAE group and in only five patients in the laparoscopy group (P.001). Eleven patients experienced symptom recurrence later than 6 months. Uterine volume reduction at 6 months was 24% in this group, compared with 48% in the 37 patients with no recurrence (P = .004). Incomplete infarction of leiomyomas was seen in eight of the 11 cases of recurrence (73%) versus nine of 37 cases without recurrence (24%; P = .009).Recurrence rate was significantly lower after UAE than after laparoscopic treatment. Larger volume reduction and more complete devascularization of leiomyomas were found after UAE treatment and among patients with no recurrence.

Hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous fibroids, polyps, hyperplasia and cancer. However, there are still problems and complications connected to hysteroscopy. Fluid overload of 1-2l occurs in approximately 5.2% and >2l in 1% of cases. This article discusses the physiology, implications and treatment of these cases. Uterine perforation is encountered in nearly 1% of cases. We describe the precautions to avoid this perforation and the methods to treat it. The article also discusses excessive bleeding, which occurs in 3% of operative hysteroscopies and describes strategies to avoid and to deal with this complication. Emergency hysterectomy and other surgical interventions are rarely indicated and are seen in 2% of cases. Finally, death due to septicaemia or fluid overload has been reported only very rarely (0.1%). These different complications are discussed in detail.

Study Ojective To estimate the prevalence, 1-year regression rate, and clinical significance of endometrial polyps in women aged 45 to 50 years. Design Cross-sectional study (Canadian Task Force II-2). Setting University teaching hospital. Patients Two hundred fifty-seven of 1000 randomly selected women aged 45 to 50 years. Interventions Transvaginal ultrasonography and saline infusion sonography were performed in all study participants and were repeated in women with endometrial polyps after 12 months. Polyps present at follow-up were removed by hysteroscopic polyp resection. Measurements and Main Results Endometrial polyps were diagnosed in 31 women (12.1%). At 1 year, the polyp regression rate was 27%. Myomas occurred more often in women with endometrial polyps, and women with polyps experienced significantly heavier periodic bleeding compared with women without polyps. Conclusion Our study findings suggest that endometrial polyps are common in women aged 45 to 50 years and that women with such polyps experience heavier periodic bleeding. Although some polyps seem to regress spontaneously during 1-year follow-up, most seem to persist.

Objective : Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. Study design : 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p -value Results : No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. Conclusions : The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.

Objective To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo on preoperative cervical ripening after pre-treatment with estradiol vaginal tablets at home in postmenopausal women prior to day-care operative hysteroscopy. Design Randomised double-blind placebo-controlled sequential trial. The boundaries for the sequential trial were calculated on the primary outcomes of a difference of cervical dilatation ≥1 millimetre, with the assumption of a type 1 error of 0.05 and a power of 0.95. Setting Norwegian university teaching hospital. Population Postmenopausal women referred for day-care operative hysteroscopy. Methods The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before day-care operative hysteroscopy. All women had administered a 25-microgram vaginal estradiol tablet daily for 14 days prior to the operation. Main outcome measures Preoperative cervical dilatation (difference between misoprostol and placebo group, primary outcome), difference in dilatation before and after administration of misoprostol or placebo, number of women who achieve a preoperative cervical dilatation ≥5 millimetres, acceptability, complications and side effects (secondary outcomes). Results Intra-operative findings and distribution of cervical dilatation in the two treatment groups: values are given as median (range) or n (%). Difference in dilatation before and after administration of misoprostol and placebo: values are given as median (range) of intraindividual differences. Percentage of women who achieve a cervical dilatation of ≥5 mm, percentage of women who were difficult to dilate. Acceptability in the two treatment groups: values are given as completely acceptable n (%), fairly acceptable n (%), fairly unacceptable n (%), completely unacceptable n (%). Pain in the two treatment groups: pain was measured with a visual analogue scale ranging from 0 (no pain) to 10 (unbearable pain): values are given as median (range). Occurrence of side effects in the two treatment groups. Values are given as n (%). Complications given as n (%). Funding sources No pharmaceutical company was involved in this study. A research grant from the regional research board of Northern Norway has been awarded to finance Dr K.S.O.’s leave from Hammerfest hospital as well as travel expenses between Hammerfest and Oslo, and research courses. The research grant from Prof B.I.N. (Helse Ost) funded the purchase of estradiol tablets, the manufacturing costs of misoprostol and placebo capsules from the hospital pharmacy, as well as the costs incurred for preparing the randomisation schedule and distribution of containers containing capsules to hospital. Prof B.I.N.’s research grant also funded insurance for the study participants. Conclusions Estimated completion date 31 December 2008.

The objective of this study was to evaluate the performance and safety of a modified unipolar electrode developed for excision of the endocervix in a reverse cone pattern during laparoscopic supracervical hysterectomy (LSH) to reduce the occurrence of persistent vaginal bleeding after the procedure. The study is a prospective pilot trial performed at a Norwegian university teaching hospital. Excision of the endocervix was performed with the unipolar electrode immediately after the amputation of the cervix during LSH in 23 consecutive women referred to the department for hysterectomy on the basis of a benign condition. The mean duration of the inverse conization was 61.9 seconds (SD 24.7). The excision of the endocervix in a reverse cone pattern was reported to be without technical problems in 22 procedures (96%). The results of this pilot study indicate that the modified device is safe, technically easy to use, and prolongs the duration of the LSH procedure insignificantly. Long-term effects of the device will be evaluated in a prospective randomized trial.

Objective To compare the impact of 1000 micrograms of self-administered vaginal misoprostol versus self-administered vaginal placebo at home on preoperative cervical ripening in both premenopausal and postmenopausal women before operative hysteroscopy. Design Two separate but identical parallel, randomised, double-blind, placebo-controlled sequential trials, one in premenopausal women and one in postmenopausal women. The boundaries for the sequential trials were calculated on the primary outcomes of a difference of cervical dilatation ≥1 mm, with the assumption of a type 1 error of 0.05 and a power of 0.95. Setting Norwegian university teaching hospital. Sample Eighty-six women referred to outpatient operative hysteroscopy. Methods The women were randomised to either 1000 micrograms of self-administered vaginal misoprostol or self-administered vaginal placebo the evening before outpatient operative hysteroscopy. Main outcome measures Preoperative cervical dilatation (primary outcome), number of women who achieve a preoperative cervical dilatation ≥5 mm, acceptability, complications and adverse effects (secondary outcomes). Results In premenopausal women, the mean cervical dilatation was 6.4 mm (SD 2.4) in the misoprostol group and 4.8 mm (SD 2.0) in the placebo group, the mean difference in cervical dilatation being 1.6 mm (95% CI 0.5–2.7). Among the premenopausal women receiving misoprostol, 88% achieved a cervical dilatation of ≥5 mm compared with 65% in the placebo group. Twelve percent of the women who received misoprostol were difficult to dilate compared with 32% who received placebo. Dilatation was also quicker in the misoprostol group. Misoprostol had no effect on cervical ripening in postmenopausal women compared with placebo, and 43% of the women were difficult to dilate. The trials were terminated after analysis of 21 postmenopausal women and 65 premenopausal women after reaching a conclusion on the primary outcome with only 28% of the number of women needed in a fixed sample size trial. Three of 45 women who received misoprostol experienced severe lower abdominal pain, and there was an increased occurrence of light preoperative bleeding in the misoprostol group. Most women did not experience misoprostol-related adverse effects. The majority (83% of premenopausal and 76% of postmenopausal women) found self-administered vaginal misoprostol at home to be acceptable. There were two serious complications in the premenopausal misoprostol group: uterine perforation with subsequent peritonitis and heavy postoperative bleeding requiring blood transfusion, but these were not judged to be misoprostol related. Complications were otherwise comparatively minor and distributed equally between the two dosage groups. Conclusions One thousand micrograms of self-administered vaginal misoprostol 12 hours prior to operative hysteroscopy has a significant cervical ripening effect compared with placebo in premenopausal but not in postmenopausal women. Self-administered vaginal misoprostol of 1000 micrograms at home the evening before operative hysteroscopy is safe and highly acceptable, although a small proportion of women experienced severe lower abdominal pain. There is a risk of lower abdominal pain and light preoperative bleeding with this regimen, which is very cheap and easy to use. Please cite this paper as: Oppegaard K, Nesheim B, Istre O, Qvigstad E. Comparison of self-administered vaginal misoprostol versus placebo for cervical ripening prior to operative hysteroscopy using a sequential trial design. BJOG 2008;115:663–e9.

Heavy menstrual bleeding is the predominant complaint in women with abnormal uterine bleeding. Treatment options are drug therapy, and first- and second-generation endometrial resection. Many women will subsequently have a hysterectomy. Uterine fibroids are the most common solid pelvic tumours in women, and although many fibroids seem to cause no symptoms, they can have serious adverse effects and impact on quality of life. As women postpone having children, gynaecologists will have to manage fibroids and polyps in a conservative manner. The past decade has witnessed the development of highly sophisticated diagnostic and therapeutic technology for women suffering from menorrhagia, fibroids and polyps, including minimally invasive uterine therapy. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. This chapter reviews the evidence-based approach and minimally invasive therapy.

To compare clinical outcome 6 months after treatment with bilateral laparoscopic occlusion of the uterine artery versus uterine leiomyoma embolization.Sixty-six premenopausal women with symptomatic uterine leiomyomata were randomized to treatment with either laparoscopic occlusion of uterine arteries or uterine leiomyoma embolization. The primary outcome was reduction of blood loss from pretreatment to 6 months postoperatively, measured by a Pictorial Bleeding Assessment Chart. Secondary outcomes included patients' own assessment of symptom reduction, postoperative pain assessed using visual analog scales, ketobemidone used postoperatively, complications, secondary interventions, and failures.Fifty-eight women were included; 6-month follow-up data were available for 28 participants in each group. The percentage reduction in Pictorial Bleeding Assessment Chart scores did not differ between the treatment groups (52% after uterine leiomyoma embolization and 53% after laparoscopy, P=.96). The study had 52% power to detect a 20% difference on the Pictorial Bleeding Assessment Chart. Fewer participants in the group treated with uterine leiomyoma embolization complained of heavy bleeding after 6 months (4% compared with 21%, P=.044). The postoperative use of ketobemidone was higher after uterine leiomyoma embolization (46 mg compared with 12 mg, P.001).Both laparoscopic occlusion of uterine vessels and embolizaton of uterine leiomyoma improved clinical symptoms in the majority of patients. Participants with the laparoscopic procedure had less postoperative pain but heavier menstrual bleeding 6 months after treatment. A larger study and longer follow-up is necessary before a definite conclusion can be made regarding the most effective treatment.(www.ClinicalTrials.gov), NCT00277680I.

Study objective To evaluate the change in hysterectomy technique. Design Retrospective study (Canadian Task Force classification XXX). Setting University tertiary referring center in Norway. Patients A total of 1963 women treated with hysterectomy over a 5-year period in Oslo. Interventions The operative records and techniques were investigated in all treated patients. Measurements and main results A total of 1963 hysterectomies were performed from 2001 through 2005. The operative patient records were investigated with the main focus on indication for surgery and the technique used in the operative procedure. In 2001, 62 (17.7%) laparoscopic hysterectomies were performed, while 256 (73.1%) of the hysterectomies were done with laparotomy. The operative technique has gradually changed during the last 5 years. In 2005, 220 (53.5%) of the surgical procedures were laparoscopic, 177 (43.1%) were done by laparotomy, while the vaginal approach in all these years was less than 10%. Conclusion From 2001 to 2005, a trend shift of the operative technique has been observed in Oslo, increasing the endoscopic hysterectomy rate from approximately 18% to 54%. During the same time, enlarged uteri with myomas equivalent to 10 to 12 weeks’ gestation and endometrial cancer were more often treated by laparoscopic hysterectomy instead of open abdominal hysterectomy. With modern equipment and trained staff, more routine hysterectomies can be managed with laparoscopy.

To study the feasibility, complications and symptom relief of laparoscopic treatment in patients with deep infiltrating endometriosis.From January 2004 to March 2005, 24 patients with deep infiltrating endometriosis were treated with laparoscopic techniques. Preoperative symptoms, staging, involvement of the disease, and surgical procedures were recorded. Operating time and perioperative complications were also registered, as well as follow-up of the patients.The surgical treatment was individualized with removal of deep infiltrating endometriosis in all 24 patients, additional bladder resection in five patients and colorectal resection in eight patients. In two cases laparoconversion was performed, and one patient had a temporary loop ileostomy. We observed no major peri- or postoperative complications. Median operating time was 3.4 h (range 1.4-8.0 h). All patients with bladder involvement were relieved of their urinary dysfunction, while all except three patients were successfully treated for their pain problems, and also these three patients had symptom relief.Patients with deep infiltrating endometriosis represent a challenge to surgical procedures. Our results show that radical laparoscopic surgery including colorectal and bladder resection is feasible, safe, and effective in almost all patients.

Objective To evaluate the incidence of tubal patency as well as the shape of the endometrial cavity after transcervical resection of the endometrium. Design An open observational trial. Setting The obstetrics and gynecology unit at a district hospital in Norway. Patients Fifty consecutive patients who had undergone treatment for menorrhagia and metrorrhagia by resection of the endometrium and coagulation of the tubal ostium were included in the study. Intervention A hysterosalpingogram was performed with a semistiff catheter and injection of 20mL contrast dye 5 to 12months after transcervical resection of the endometrium and fibroids. Main Outcome Measures Tubal patency and uterine cavity morphology. Results Forty-four patients showed total occlusion of the fallopian tubes, and the uterine cavity showed fibrosis and narrowing of the cavity. Three patients showed bilateral and three patients unilateral tubal patency. Conclusion Shrinkage and fibrosis of the uterine cavity occur after endometrial resection. A significant number of women after transcervical resection of the endometrium have patient tubes (13%) despite coagulation of the tubal ostia.

Myomectomy is performed frequently to preserve or increase fertility, although the risk of future uterine rupture is a major concern of any surgery of the uterus. A 36-year-old woman underwent laparoscopic removal of a pendunculated myoma, and 6 weeks later she conceived after IVF. At 35.5 weeks' gestation she was admitted to the hospital because of abdominal pain. Cesarean section revealed rupture of the uterine wall at the site of the myoma. This and similar case reports indicate that inadequate laparoscopic suturing is not the only factor involved in rupture of the uterine wall during pregnancy after laparoscopic myomectomy.

Study Objective To assess the efficacy of repeat transcervical resection of the endometrium (TCRE) in patients with dysfunctional uterine bleeding and myomas in whom primary resection failed. Design Retrospective analysis (Canadian Task Force classification III). Setting University hospital endoscopic unit. Patients Six hundred sixty-eight women. Intervention Repeat TCRE or transcervical resection of a myoma (TCRM). Measurements and Main Results Of 668 patients, 118 (17%) required repeat resection for the following reasons: pain (52, 44%), menorrhagia (39, 31%), myomas (15, 13%), perforation at the primary TCRE (6, 5%), and large fluid deficit during the procedure (6, 5%). Of 118 women undergoing repeat TCRE or TCRM, 33 (28%) eventually required hysterectomy due to pain (17, 48%), persistent bleeding (7, 27%), pain and bleeding (3, 10%), regrowth of myomas (3, 14%), and other reasons (3, 14%). Conclusion Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate.

A prospective, single-arm, multicenter, controlled, observational pilot study to assess the safety and efficacy of the NovaSure Global Endometrial Ablation (NovaSure GEA) system in women with severe menorrhagia secondary to dysfunctional uterine bleeding (DUB).University tertiary referring center and central hospital.Forty-six premenopausal women aged 41.3 years with menorrhagia secondary to DUB unresponsive to medical therapy, who had completed childbearing, with non-distorted uterine cavities were included in the study.Bleeding score was recorded before, 6 and 12 months after treatment. All patients received the treatment under intravenous sedation with para-cervical block and were treated with Nova Sure endometrial ablation for mean 94 s at the day surgery unit.No serious intraoperative complications were observed. Treatment time averaged 94 s. Forty-six patients have completed 6-months of follow-up and 45 patients completed the 12-months follow-up. 50% of the patients were amenorrheic at 6 months follow-up and 58% had complete cessation of uterine bleeding (amenorrhea) at 12 months follow-up.Preliminary results indicates that the NovaSure GEA System is an effective treatment for DUB, achieving 58% amenorrhea after 12 months.

We wanted to evaluate initial results and feasibility of laparoscopic surgery in patients with stage I endometrial cancer.51 women with presumed endometrial cancer stage I were operated February 2000 to February 2001. Without prior randomisation, 27 patients (median age 64.5 years) were operated with a laparoscopic approach and 24 (median age 71.3 years) with laparotomy. Follow-up time was 6-18 months.The laparoscopic operation was feasible in all 27 patients. Conversion to laparotomy was done in one patient due to damage to the bladder. Mean operative time was 143 minutes in the laparoscopy group and 86 minutes in the laparotomy group (p0.001); mean hospital stay 4.3 days and 6.6 days, respectively, and the number of lymph nodes removed 155 and 111. In the laparoscopy group, one patient was converted to laparotomy due to a bladder perforation, and laparotomy was done in one patient due to septicaemia. In the laparotomy group, one patient developed a wound dehiscence and one a vesicovaginal fistula requiring a secondary repair. Perioperative blood transfusions were needed in two patients, both in the laparotomy group.The laparoscopic approach is feasible and may obtain an important place in the treatment of early endometrial cancer.

To evaluate the diagnostic accuracy of transvaginal ultrasonography, sonohysterography and hysteroscopy in patients presenting with abnormal uterine bleeding.Prospective, blind, comparative study.Outpatient clinic and day surgery unit of a district hospital specializing in operative hysteroscopy.One hundred consecutive patients referred with abnormal uterine bleeding (AUB).Transvaginal ultrasonography and sonohysterography were performed in the outpatient clinic. Within 1 week, all patients underwent operative hysteroscopy.All diagnoses established by transvaginal ultrasonography, and sonohysterography were compared to the appearance of the cavity using hysteroscopy as well as the histological diagnosis from removed tissues.In 88 patients information suitable for analysis was obtained by all methods. The detection rate of focal intrauterine pathology using sonohysterography was (94.1%), but was significantly lower with transvaginal ultrasonography (23.5%). In about 75% of all cases none of the methods used was able to correctly detect endometrial hyperplasia.Sonohysterography was significantly better than transvaginal ultrasonography in detecting focal intrauterine pathology. Visual examination at operative hysteroscopy yielded no additional information to the detection or exclusion of focal lesions than was obtained at outpatient sonohysterography. All methods performed equally in assessing endometrial pathology. We conclude that sonohysterography may replace diagnostic hysteroscopy in many patients with AUB.

Background. Transcervical resection of endometrial polyps is usually performed in order to exclude atypic and/or malignant endometrial changes, to relieve abnormal uterine bleeding or to improve infertility. Objective. To systematically explore the rationale of transcervical polyp resection. Search strategy. Electronic searches of MEDLINE, EMBASE and The Cochrane Library. Selection criteria. Studies reporting the prevalence of premalignant and/or malignant tissue changes within endometrial polyps, as well as outcomes of endometrial polyp removal in terms of symptom relief and improved fertility were included. Main results. 46 studies met the criteria for inclusion (malignancy: 20 studies including 9,266 women, symptom relief: 15 studies including 1,034 women, infertility: 11 studies including 935 women). Most studies were uncontrolled retrospective case series. Only two randomized controlled trials were identified. The prevalence of premalignant and malignant tissue changes within endometrial polyps varied in the included studies, 0.2–23.8% and 0–12.9%, respectively. Postmenopausal symptomatic women appeared to have the highest risk of premalignant and malignant tissue changes. The effect of polypectomy on periodic blood loss appeared to be questionable, but all studies measuring the effect of polypectomy by general terms such as improved/not improved reported a favorable outcome (75–100% success rate). Polypectomy appears to have a favorable outcome in infertile women. Conclusions. The evidence which substantiates the removal of endometrial polyps is limited, and future research evaluating the outcome of this common procedure is required. Based on the available evidence, however, we provide recommendations for treatment of women with endometrial polyps.

OBJECTIVE: Transcervical resection of the endometrium with the use of 1.5% glycine for irrigation is associated with postoperative nausea in some patients. This could be because of hyponatremia or toxic effects of glycine and its metabolites. Moreover, 1.5% glycine is hypoosmolar, and hemolysis and fibrinolysis are possible. Changes in plasma factors related to these potential complications of transcervical resection of the endometrium were measured. STUDY DESIGN: In 101 patients undergoing transcervical resection of the endometrium sodium, ammonium, and coagulation factors were measured preoperatively and postoperatively at intervals. In the initial 30 patients glycine and 28 other amino acids were measured at the same intervals. The results were correlated with the patients' clinical status and operative parameters. RESULTS: Glycine and nine other amino acids and ammonia showed increased postoperative plasma levels; these changes were correlated with the absorption of the irrigating glycine solution and the development of hyponatremia. Minor activation of fibrinolysis and hemolysis was also seen. CONCLUSION: Nausea after transcervical resection of the endometrium with 1.5% glycine for irrigation may be partly explained by toxic effects of glycine and its secondary metabolites in addition to the effects of water intoxication and hyponatremia. Minor, clinically insignificant changes in the coagulation system may also occur. Studies on alternatives to glycine for creation of near-isotonic irrigating solutions are encouraged.

A case of laparoscopic reversal of tubal sterilization is reported. The patient was a 38 year old woman sterilized by bipolar diathermia two years earlier. Refertilization was performed by laparoscopic end to end anastomosis of one tube. Postoperatively, the patient had one menstruation and then achieved an intrauterine pregnancy. The laparoscopic method of refertilization saves expensive hospitalization costs.A 38-year-old woman, who had a normal delivery at age 29 and a Cesarean section at age 35, underwent laparoscopic adhesiolysis the next year because of pain. Later that year, a laparotomy was performed to remove the left adnex because of a hemorrhagic corpus luteum. During this operation, she underwent sterilization by bipolar coagulation and division of the right tube. 6 months later, her 2-year-old daughter died of hemophilus meningitis. The next year, she was admitted to the hospital several times because of pain in her lower abdomen. She decided to undergo refertilization. The operative technique involved insertion of a Foley catheter into the uterine cavity. Laparoscopic adhesiolysis was performed, and blue dye was flushed through the catheter. The medial end of the right tube was cut off in thin slices until dye passed through the lumen. The lateral part of the tube was then cut, and hemostasis was secured by point monopolar diathermia. The portions of the tube were mobilized slightly and adapted by 2 sutures in the muscularis and 1 in the serosa. Blue dye was flushed through the tube to demonstrate patency. The pelvic cavity was rinsed with Ringer's solution, with about 300 ml left in the abdomen. No antibiotics or steroids were administered. The operation took 90 minutes, and the patient left the hospital the next day. She was able to return to work without using any sick leave. 22 days after the operation, she had a normal menstruation and she achieved an intrauterine pregnancy in the following cycle. A lack of funds in the Norwegian public health service has led to a debate about the necessity of providing the so-called "luxury" procedures of refertilization and infertility surgery. The traditional operative methods are expensive and require between 5 and 7 days of hospitalization. In order to determine whether traditional laparotomy with microsurgical end-to-end anastomosis of the tube or laparoscopic refertilization is more effective, a comparative, randomized study will be necessary.

Transcervical resection of endometrium--and of submucous fibroids when present--seems to represent a new alternative to hysterectomy for patients with uncontrolled bleeding disorders. In the present study, we report our initial experience with the first 20 patients treated with a standard, rigid urological resectoscope. Resection of endometrium--and of fibroids when present--was carried out under general anesthesia. The uterine cavity was distended and irrigated with glycine 1.5%. Two perforations occurred, but damage to neighboring organs was not seen. In one patient, copious bleeding was encountered and hysterectomy became necessary the following day. Clinical signs of postoperative infection occurred in 3 patients. Otherwise, no major morbidity was seen during or after the procedure. In 2 patients with persistent metrorrhagia, re-resection was performed after 2-3 months and satisfactory bleeding control achieved. At the 3-month follow-up, 2 further patients complained of persistent bleeding and had an abdominal hysterectomy performed. In the remaining patients, satisfactory bleeding control was reported at the 6-month follow-up. Although large series are needed to assess the complications associated transcervical resection of the endometrium, the technique may be applied in departments with experience in routine hysteroscopy, and the approach seems to represent an attractive alternative to hysterectomy.

Absorption of irrigating solution may involve serious complications during hysteroscopic surgery. This absorption occurs mainly into the vessels opened during the procedure. Careful perioperative monitoring of the deficit of collected irrigating medium during transcervical surgery is mandatory. Significant absorption seems to be connected with the development of discrete cerebral oedema and nausea, secondary to dilutional hyponatraemia and elevation of several amino acids.

Twenty-five women with complete perineal rupture were compared with a control group of 25 women, with regard to risk factors and possible long-term sequelae as a consequence of perineal damage. Following an average period of 78 months (52-123), all women received a questionnaire and were invited to a clinical follow-up, which included perineal inspection and measurement of the anal pressure profile. Vacuum extraction was more frequent in the rupture group than among controls (p less than 0.002). Eighty percent of the women in the rupture group were primiparae, compared with an overall rate of 40% (p less than 0.02). Forty-two percent of the women in the rupture group reported anal incontinence, compared with none in the control group (p less than 0.01). Most of these women reported stress-provoked incontinence regarding flatus and loose stools. Measurement of the anal pressure profile showed markedly reduced sphincter pressure, with maximum squeeze in the rupture group, but no differences were found regarding maximum anal pressure at rest. Sphincter length was reduced both at rest and with maximal squeeze in the rupture group. It is concluded that complete perineal rupture is a condition with possible long-term consequences such as reduced sphincter strength and partial anal incontinence.

The acute tissue effects of transcervical endometrial resection (TCRE) with a standard Iglesias resectoscope using glycine 1.5% for irrigation were studied in 8 women prior to hysterectomy. Combinations of 80 or 120 W cutting current with blend 1 or 2 were applied for endometrial resection, preceded by cornual endometrial coagulation with the roller ball electrode with a coagulation effect of 40 or 60 W. The temperature was measured at the uterine vessels, ovarian ligaments and serosal surface. The increase in temperature at the serosal surface was 2.0 degrees C during cornual coagulation and 0.3 degrees C during endometrial resection, independent of the current effect applied. The maximum depth of tissue damage was 1.7 mm. No change in temperature was found at the uterine vessels or ovarian ligaments. The tissue destruction and the increase in temperature of the uterine surface are minimal, and TCRE offers excellent histological material. Careful coagulation/resection in the cornual and isthmus regions is recommended.

Absorption of irrigating solution during transcervical resection of endometrium can cause dilutional hyponatraemia, nausea, and cerebral oedema. We studied 6 patients who absorbed more than 1500 mL of 1.5% glycine, and 14 patients who absorbed less. Cerebral oedema was diagnosed by blinded, paired comparison of computed tomography (CT) scans 3-6 hours and 3-6 days after operation. The absorbed volume of irrigating glycine solution was correlated with peroperative decrease in serum sodium. 10 patients who absorbed 500 mL of glycine or more had postoperative nausea, with cerebral oedema suspected in 9. None of the 10 patients who absorbed less than 500 mL had nausea; changes on CT scan suggestive of cerebral odema were found in 1. 8 patients who absorbed 1000 mL or more had a decrease in serum sodium of 10 mmol/L or more, nausea, and cerebral oedema on CT scan. Cerebral oedema may contribute to the development of postoperative nausea in patients undergoing transcervical surgery who absorb more than 500 mL of 1.5% glycine irrigating solution.