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47 patients out of the IVF-program of the Department of Obstetrics and Gynecology University of Kiel, who demonstrated in previous stimulation cycles premature LH surges, were treated in two modalities with a down regulation applying the GnRN-analogue decapeptyl (DTRP-6 LH/RH) and a concomitant HMG- or FSH-stimulation. The down-regulation was started after ovulation up to a negative LH/RH test followed by a concomitant gonadotropin stimulation in group 1. In group 2 a parallel treatment with decapeptyl and HMG or FSH was performed from day 2 of the cycle. 10 husbands of the punctured patients had pathological sperm. In both groups 6 patients were discarded from of the stimulation protocol as their oestradiol responses were not adequate, sperm contamination was detected late in one case, and in one patient a premature LH surge occurred once again. In 36 patients vaginal follicular punctures were performed. With respect to pregnancies group 1 revealed a much higher pregnancy rate than group 2. It seemed better to start the down-regulation with the GnRH-analogue decapeptyl in the luteal phase of the previous cycle. The treatment with decapeptyl should not only be applied in patients with previous LH surges but also in order to establish a synchronous follicular maturation in ovulating patients treated for in-vitro fertilization, or gamete-intra-Falloppian-tube-transfer.

In der rechtsmedizinischen Sektionspraxis findet sich Verbluten als Todesursache in 5–10% der Falle. Im vorliegenden Fall wurde ein signifikanter Blutverlust in den Magen und in das Duodenum festgestellt. Das Blut im Duodenum und sich anschliesenden Dunndarmanteilen war geronnen und glich einem Ausgusspraparat der Darmschleimhaut, sodass von einer Sickerblutung ausgegangen wurde. Bei der Suche nach der Blutungsquelle fand sich ein intraduodenaler Verlauf eines aortobifemoralen Bypasses bei arteriosklerotisch bedingtem Verschluss beider Beckenschlagadern. Das Material des Bypasses war aufgrund der Einwirkung der Verdauungssafte verfarbt und stark bruchig; als Blutungsquelle fand sich ein Einriss der Gefasprothese. Da sich am Ubergang der Prothese zur Darmschleimhaut Nahtmaterial befand, wurde zunachst von einem arztlichen Kunstfehler ausgegangen. Bei dem intraduodenalen Verlauf des Bypasses handelte es sich jedoch um eine aortoenterale Fistel, eine seltene, jedoch ernste Komplikation der Aortenchirurgie.

Laparoscopy was developed by Kalk of Germany in 1929 as a routine procedure in internal medicine for diagnosis of liver diseases. Air was insufflated to create the pneumoperitoneum, and an electric lamp was placed at the end of the laparoscope to provide illumination of the abdominal cavity. Entrance into the peritoneal cavity was in the upper abdomen two finger breadths under the ribs. The danger of damaging the bowel by burning, etc. was very low. Previously laparotomized patients were considered an absolute contraindication for Laparoscopy. In 1946 Palmer, France turned the laparoscope from the upper abdomen to look into the lower abdomen. He called this technique Coelioscopy. It was used as for a diagnostic procedure mainly for the sterility patient in Gynecology. For coelioscopy Palmer used the same instruments as were used for Laparoscopy. The danger of burning bowel increased enormously as the protector of the upper abdomen, the omentum, was missing in the lower abdomen.

Comparison of Different Surgical Methods: The cardinal question of this prospective longitudinal study was whether different surgical methods of hysterectomy correlate with differences in adaptation and in respect of psychological as well as sexual consequences. A total of 83 patients were investigated immediately prior to surgery as well as 6 weeks later. 61 resp. 58 patients participated in follow-up investigations 6 months and 1 year following surgery. Total hysterectomy was performed vaginally in 16 females, abdominally in 22 patients. 23 patients underwent subtotal C.I.S.H. hysterectomy. 23 females indicated for myoma enucleation formed another group of this study. Besides several psychological variables of potential influence such as personality characteristics, coping, sexual attitudes and partner satisfaction, the study covered psychological as well as physical complaints, life satisfaction and differential characteristics of sexual experiences and behaviour longitudinally. The results indicate that single subgroups differ from each other in several respects. There were no indications of different psychological as well as sexual consequences depending on the surgical method. These findings support the view that consequences of hysterectomies are more likely to be predicted on the basis of psychological traits that existed before the operation, rather than from a medico-technical point of view.

The role of surgery in the treatment of patients with invasive cervical cancer is undisputed, but how radical the surgery should be is discussed. Every case requires detailed knowledge of the development and spread of cervical cancer. Tumour volume is the most important diagnostic factor in cervical cancer and also correlates with vascular invasion and lymph node involvement. In cervical cancer radical hysterectomy also requires an easily performable lymphadenectomy together with resection of parametria and skeletonization of ureters. In order to do this we have started to treat endometrial cancer in a combined laparoscopic and vaginal approach. In patients with the suspicion of stage I endometrial cancer prior to the laparoscopic staging, the prerequisites histological grading with ploidy and measurement of monoclonal antibodies were performed. All patients underwent a general check with radiography, computer tomography, liver scan, bone scan and lymphography. The performance of lymphadenectomy in cases ...

A novel way of performing endoscopic intrafascial supracervical hysterectomy is presented. By using the endoscopic approach for dissection as well as uterine extraction using the serrated-edged macro-morcellator, we avoid giving the patient a colpotomy incision and its inherent post-operative discomfort. A further modification involves nearly complete excision (95%) of uterocervical mucosa using a calibrated resection tool, thus eliminating the possible subsequent development of cervical stump neoplasia. Sparing of the cardinal ligament insertion provides support to the cervical stump. Hemorrhage and genitourinary complications are prevented by avoiding dissection of the parametrium at the level of endocervix. Comparison of data of the pelviscopic CISH procedure with the laparotomy approach in our preliminary series (n = 190) confirms our claims as to its safety. Data on long-term postoperative evaluation are ongoing, but the initial reports deny any postoperative discomfort. Larger randomized studies are required to prove its value compared with the existing techniques. We believe that with its multitude of benefits, the classic intrafascial serrated-edged macro-morcellated (SEMM) hysterectomy (= CISH) may emerge as an attractive alternative to conventional hysterectomy.

As the use of endoscopic surgery in gynaecology develops, endoscopic techniques represent a larger proportion of the practised surgical techniques. Therefore there is a need for good training and regulation in endoscopic surgery for the benefit and well-being of our patients (Semm and Mettler, 1980; Semm, 1982; Ruckdeschel and Semm, 1988). Gynaecological endoscopic surgery (pelviscopy) has been the pacesetter for the change from the mainly organ-resecting gynaecological laparotomy to organ-preserving operative surgery. This stands for general surgical technologies as well. Minimally invasive surgery is still at the very beginning of its development as the major surgical technique practised and requires special training and regulation. Although we gynaecological have performed these surgical procedures for 20 years, we still lack guidelines for training and regulation of standards. Every patient requiring an endoscopic surgical procedure is prepared for a laparotomy and has to sign a consent form for a possible change from laparoscopy to laparotomy; if she wakes up with a laparotomy, she will understand that in her case laparotomy was the best procedure. Under these premises, this chapter tries to provoke the establishment of training and regulation in all countries.

The first reported abdominal (supracervical) hysterectomy was performed by Wilhelm Alexander Freund in 1878 in Breslau (Freund, 1878, 1879). From then on, supracervical hysterectomy was the leading technique in gynaecological surgery for over 80 years. Later a shift to total hysterectomy, performed either vaginally or abdominally, occurred because of the danger of cervical stump cancer (Tervilfi, 1963). Tervil~i (1963) reported the danger of cervical cancer to be 0.3-1.9% following supracervical hysterectomy. At the beginning of this century the Viennese and the Berlin schools carefully described the technique of hysterectomy in cancer cases. From about 1963 till 1990, all hysterectomies carried out in our department were total hysterectomies. In 1982, Semm began performing the laparoscopically assisted vaginal hysterectomy (LAVH), which he published details of in 1984 (Semm, 1984). In the Department of Obstetrics and Gynaecology, University of Kiel, the number of vaginal hysterectomies has increased over the last 10 years, with pelviscopy preceding vaginal hysterectomy in cases with many previous laparotomies, severe adhesions or benign adnexal tumours. However, we supported the use of vaginal hysterectomy performed with anterior colpotomy to allow the adnexa to be separated from the pelvic wall. Dissection of the uterine arteries was never performed pelviscopically, as it is easily done during the vaginal hysterectomy. The international acceptance of this technique occurred in 1989 after Reich published details of the LAVH with dissection of the ureter and uterine arteries via laparoscopy. In 1991 this was followed by the classic intrafascial supracervical hysterectomy (CISH) without colpotomy (Semm, 1991). The advantages of the CISH technique, which can be performed via pelviscopy, laparotomy or vaginal surgery, are: 1. Partial preservation of the integrity of the pelvic floor and no colpotomy, with the exception of an anterior colpotomy in an intrafascial vaginal hysterectomy. 2. Preservation of full blood supply to the pelvic floor. 3. Continuation of normal sexual function. 4. Protection against cervical cancer by coring out the transformation zone. Bailli~re's Clinical Obstetrics and G ynaecology

During 1990-1991, 626 cystic ovarian tumours measuring > 3 cm diameter were treated endoscopically at the Department of Obstetrics and Gynaecology at the University of Kiel. In 97 patients, either ovariectomy or adnexectomy, and in 529 cases, an ovarian cyst enucleation was performed. In every case, we considered clinical laboratory, pre-examinations as well as a vaginal ultrasound examination to be of extreme importance for our decision. In 1990, we changed 18 times from pelviscopy to laparotomy and in 1991 7 times under the visual impression of an ovarian malignant tumour. The diagnosis was verified 8 times in 1990 and 3 times in 1991. 10 times in 1990 and 4 times in 1991, the patients were laparotomised with benign ovarian tumours, whose form and motility did not indicate laparotomy at the beginning. No case of ovarian cancer was endoscopically biopsied in 1990-1991. Details on the treatment of patients, their brief hospitalisation period and quick reintegration into family and professional life speak for the applied operation technique.

Die laparoskopische Diagnostik einer Appendizitis ist der bisherigen klinischen, exspektativen Methode weit uberlegen. Die endoskopische Appendixentfernung mit Nadel und Faden sollte neuen Methoden mit Hochfrequenzstrom oder Laser vorgezogen werden. Jede Anwendung von unkontrollierter Warme im Abdominal-, d. h. Darmbereich zu Blutstillungszwecken impliziert unkalkulierbare Risiken, in erster Linie Schmerzen. Auch das Einblasen von kaltem CO2-Gas erzeugt eine schmerzhafte Hypothermie. Es ist daher die WISAP®-CO2-Gas-Flow-Therme zu empfehlen. Die periappendizitische Peritonealendometriose kann nur laparoskopisch diagnostiziert und therapiert werden. Die laparoskopische Appendixchirurgie reduziert die Operationsbelastung fur den Patienten auf ein Minimum, vermeidet postoperative Verwachsungsbauche (bei Frauen Sterilitat) und verbessert die Lebensqualitat.

Coagulation and vaporization of tissue are techniques applied in pelviscopic surgery in order to achieve hemostasis as well as cut and destroy endometriotic implants. An animal experimental study was devised to show if there is a difference in the incidence of adhesions after vaporization of equal-sized areas of the anterior abdominal wall of the rat compared to coagulation of equal-sized areas. A similar depth of the lesions was achieved by repeating the vaporization procedure. The rate of adhesions was significantly lower (P less than 0.001, Chi2-test) post-coagulation, using a biopolar high frequency current or post-endocoagulation than post-vaporization. The surface vaporization of tissue, for example endometriotic implants, as produced by laser is to be viewed critically as regards the higher incidence of adhesions after vaporization compared with coagulation.

From 1977-1989, 298 ectopic pregnancies were treated pelviscopically at the Dept. of Gynaecology Hospital of the University of Kiel. 26 tubes were already ruptured. In 251 patients (84%), organ preserving treatment was possible, 205 treatment by longitudinal salpingotomy. 46 tubal abortions were extracted. In 47 patients (16%), who did not wish to augment their family any further, or in whom recurrence of tubal pregnancy occurred on the same side, salpingectomy was performed. Complications required re-pelviscopy in 5% and laparotomy in another 1%. The intrauterine pregnancy rate in 143 patients desiring pregnancy was 58%. Abortions occurred in 8%. A recurrence of ectopic pregnancy in the ipsilateral tube occurred in 10%, in the contralateral tube in 6%. 9 patients desiring pregnancy had already undergone salpingectomy on the contralateral side or were treated pelviscopically by longitudinal salpingotomy because of ectopic pregnancy on both sides. Three of them gave birth to healthy infants.

SummaryWhen compared to the classic operative therapy of appendicitis the advantages of endoscopic therapy are evident. The operative steps have been simplified over the past 10 years of development. The operation time is short and does not exceed the time required to perform the same procedure by laparotomy. The post-operative therapy, which is dependent on the severity of appendix inflammation, is standardized. Reduction in the length of hospital stay is from 1–4 days and convalescence requiring days instead of weeks are two great advantages of such a minimally invasive technique when compared to laparotomy. The only contraindication to the endoscopic appendectomy is advanced gangrenous appendicitis. However, even this indication in the modern medical era is perhaps no longer an absolute contraindication.

Between 1983 and 1988, we treated 66 patients with pelvic abscesses. Twenty-five patients required laparotomy and 41 underwent pelviscopy for treatment. The choice of the operative procedure, laparotomy or pelviscopy, depended on the age of the patient, the clinical presentation and the operative findings. The two collectives demonstrated no differences in the duration of hospitalization and in-patient treatment with antibiotics. A conservative, organ-preserving procedure could be performed in 80% of patients operated pelviscopically. In follow-up examinations 1-2 years after operation, 27% of the patients treated per pelviscopy complained of chronic abdominal pain as compared to 37% of those treated per laparotomy. In young patients, pelviscopic treatment of pelvic abscesses is a valuable alternative to laparotomy.Physicians at Christian Albrecht University Hospital in Keil, West Germany treated 66 women with pelvic abscesses between 1983-1986. Pelviscopically treated patients were younger than laparotomy treated patients and IUD usage occurred 17% vs. 20% respectively. They 1st treated many patients with ampicillin and metronidazole or ampicillin and clavulanic acid. They were able to perform pelviscopy on 25 of the 33 patients with inflamed Fallopian tubes. 9 of these women experienced either a uni- or bilateral salpingectomy or salpingo-oophorectomy. They were able to do an organ preserving procedure designed to preserve fertility in 80% of the women, especially pelviscopically treated patients (81% vs. 16% laparotomy patients). They performed a laparotomy on the 6 patients with bilateral total abdominal tuboovarian abscesses. Of the 25 women who underwent a laparotomy, 20 required only a uni- or bilateral salpingectomy or salpingo-oophorectomy and 5 required a total hysterectomy and bilateral salpingectomy. No differences existed between pelviscopically and laparotomy patients in number of days in the hospital and duration of inpatient antibiotic therapy. Even though more laparotomy treated patients (37%) experienced chronic abdominal pain following treatment than pelviscopically treated patients (27%), the laparotomy patients initially experienced more severe and extensive infections than did pelviscopically treated patients. Of the 45 patients who were able to be examined 1-2 years after surgery, only 3 experienced recurrent pelvic inflammatory disease (8% of pelviscopically treated patients and 5% of laparotomy patients) which the physicians found encouraging since pregnancies may occur. In conclusion, to preserve fertility, they advocated pelviscopy along with organ preservation for patients in their reproductive years.

A retrospective analysis undertaken at the University of Kiel by the Department of Obstetrics and Gynaecology, consisted of a 3-year study of cases of tubal surgery with operative pelviscopy (laparoscopy). In the period from 1987 to 1989, 529 patients underwent selective operative laparoscopy specifically because of a tubal factor of infertility. The type of surgery performed was aimed at the conservation and salvaging of the tubes whenever possible, according to the principles of 'Minimally Invasive Surgery'.

The incidence of tubal pregnancy has been increasing in recent years. The improvement in diagnostic procedures leads to an early detection of tubal pregnancies. As a result, conservative treatment modalities are more feasible today. In this study, we compared the treatment of tubal pregnancy by means of locally applied prostaglandin with pelviscopic surgery. 75 patients with an early tubal pregnancy were included in each group. The comparison between the two groups showed, that prostaglandin treatment has a higher failure rate, than treatment by pelviscopic surgery. However, postoperative fertility indicated better results in the prostaglandin treated patients.

Between 1993 and 1994, 368 women underwent hysterectomy for benign disorders at the University of Kiel. Of these operations, 58.7% were performed either by pelviscopic or by laparotomic Classic Intrafascial Supracervical Hysterectomy, subtotal hysterectomy with coring of the inner cervix. Of the remainder, 14.8% were performed by total abdominal hysterectomy, 13.6% by Intrafascial Vaginal Hysterectomy, 12.2% by vaginal hysterectomy, and only 0.05% by Laparoscopic Assisted Vaginal Hysterectomy. Comparative data of these six surgical techniques concerning patients' characteristics, indications for operation, histological features, blood loss, operating time, hospital stay, uterine weights and postoperatively used analgesics are described.

Das Seminar sollte dem Dialog von Wissenschaft (Labor) und Klinik (Praxis) dienen und sollte auch und vor allem auf die notwendige Kommunikation zwischen Praxis (Anamnese, Diagnostik) und gynakologischer Histopathologie (unter Einschlus neuerer molekularbiologischer Verfahren) hinweisen.

The CISH-technique per laparotomiam, vaginam, or pelviscopiam which sometimes may be limited to a TUMA procedure should replace classic total hysterectomy is approximately 80% of the cases. Where hysterectomy is indicated CISH and TUMA reduce the feeling of disfiguration many women feel after total hysterectomy. The uterine artery is not ligated as is routinely performed at total hysterectomy where, thereafter, the vagina is supplied by collateral branches only. Atrophic tissue in the pelvic floor results. The CISH-technique preserves the full blood supply to the lower pelvis, and this is particularly important for older patients. Perhaps this is the first step in the prophylaxis against prolapse. With TUMA not only the sexual function of the vagina remains intact but through the preservation of the genital blood supply the endocrinological function of the ovaries remains unchanged. We are at the beginning of a new era of minimal invasive operative techniques in gynecology. This new era of surgery limits itself to removing only the diseased part of the affected organ. Radical operations such as oophorectomy, salpingectomy, hysterectomy etc. are reduced to a minimum and indicated only in cases of malignant disease in these organs. Experience will show whether IVH is the least physically traumatic hysterectomy technique or not. At the present IVH is the most minimally invasive hysterectomy technique.

Comparison of Different Surgical Methods: The cardinal question of this prospective longitudinal study was whether different surgical methods of hysterectomy correlate with differences in adaptation and in respect of psychological as well as sexual consequences. A total of 83 patients were investigated immediately prior to surgery as well as 6 weeks later. 61 resp. 58 patients participated in follow-up investigations 6 months and 1 year following surgery. Total hysterectomy was performed vaginally in 16 females, abdominally in 22 patients. 23 patients underwent subtotal C.I.S.H. hysterectomy. 23 females indicated for myoma enucleation formed another group of this study. Besides several psychological variables of potential influence such as personality characteristics, coping, sexual attitudes and partner satisfaction, the study covered psychological as well as physical complaints, life satisfaction and differential characteristics of sexual experiences and behaviour longitudinally. The results indicate that single subgroups differ from each other in several respects. There were no indications of different psychological as well as sexual consequences depending on the surgical method. These findings support the view that consequences of hysterectomies are more likely to be predicted on the basis of psychological traits that existed before the operation, rather than from a medico-technical point of view.

Of more than 800 women with uterine myomas, 60% underwent endoscopic myomectomy with uterine preservation and 40% conventional hysterectomy. Before endoscopic myomectomy, 3% of women were treated with gonadotropin-releasing hormone analogs for 3 to 6 months. Operating time was 30 to 60 minutes. No complications occurred. Histologically, the majority of myomas were fibromyomas.

In order to determine the diagnostic value of various methods for placental insufficiency, the following parameters were obtained from 108 patients with intrauterine growth retardation (IUGR) as the only risk factor: A/B-ratio, resistence index (RI), pulsatility index (PI) of the umbilical artery (UA) and descending fetal aorta (FA), maternal serum estriol, grading of the placental maturity according to Grannum, amount of amniotic fluid, and fetal heart rate tracings. All Doppler indices showed the same efficacy as regards prediction of neonatal growth retardation. With a value of 8.0 for the A/B ratio of the FA and 4.5 for the UA neonatal dystrophy may be recognized with a precision of 72.2% (sensitivity 65.2%, specificity 77.4%). Maternal serum estriol has an accuracy of 64% (sensitivity 50%, specificity 74%), fetal heart rate tracings are able to predict neonatal growth retardation with a precision of 63% (sensitivity 43.5%, specificity 77.4%) determination of the amount of amniotic fluid has an accuracy of 58% (sensitivity 69%, specificity 50%) and grading of placental maturity 61% (sensitivity 17%, specificity 95%). The parameters combined yield in an accuracy of 75% (sensitivity 72%, specificity 74%). The fetal outcome of neonates with preceeding pathologic Doppler indices differed significantly from those with normal Doppler indices as regards indication for cesarean section, necessity of therapy in the intensive care unit, and preterm labor rate (chi square test, p0.05). This result could be improved to 2-4% by obtaining additional parameters. Pulsed Doppler sonography of fetal vessels is an additional tool in diagnosing intrauterine growth retardation.

In many surgical centers the intra-abdominal morcellation of IS-cm myomas' or freely dissected organs such as krdrieys" has become routine. A prerequisite is the availability of a macro-morcellator which re- duces the tissue bulk to a small enough size that it may be removed through the standard abdominal tro- cars in a reasonable amount of time.

Anfangs dienten optische Systeme in der Gynokologie nur diagnostischen Zwecken, so z.B. die Kolposkopie zur Diagnose des Portio-Karzinoms mit dem Ansinnen, damit ursprunglich die Messerbiopsie an der Portio bzw. Spater die Konisation zu erubrigen. Selbst die Mikrokolposkopie von Antoine und Grunberger mit Transparentmachen der Portio-Haut brachte jedoch keine Erfolge und wurde letztendlich von der Screening-Methode nach Papanikolaou abgelost.

Anfangs diente die Coelioskopie (Kelling, 1901) und Laparoskopie (Jakobaeus, 1910) (weitere Namensgebungen s. Semm, 1974) ausschlieslich der Diagnostik in der inneren Medizin. Inauguriert von Palmer (1942) und spater von Frangenheim und Schwalm bemuhte man diese Technik in der Gynakologie hauptsachlich zur Sterilitatsdiagnostik. Anfang der 60er Jahre war aber (Abb. 1) die Laparoskopie in der Gynakologie obsolet. Wegen Zwischenfallen wurde der Laparotomie, auch in diagnostischen Fragen der Sterilitat, absolut der Vorzug gegeben. Durch „Entscharfung” der Technik der Laparoskopie in der Gynakologie durch die Einfuhrung von Kaltlicht, der CO2-Pneu-Automatik und eines praktikablen 5 mm Instrumentariums incl. 5 mm Pelviskop (s. bei Semm 1974) wurde die Laparoskopie unter dem Namen Pelviskopie in der Gynakologie in Deutschland akzeptiert.

Auf dem 47. Kongres der Deutschen Gesellschaft fur Gynakologie und Geburtshilfe in Munchen veairteilte Herr Kindermann die von mir vorgetragene pelviskopische Ovarialchirurgie mit der apodiktischen Feststellung, das bei jeder Eroffnung der Ovarialkapsel im Falle eines Karzinoms aus dem FIGO-Stadium la ein solches der Gruppe Ic entsteht. Herr Professor Kindermann leitete daraus die Berechtigung ab, in 500 Fallen,auch bei jugendlichen Frauen, lieber eine Ovarialgeschwulst in toto per laparotomian zu entfernen als ein einziges Mal ein Ia in Ic zu verwandeln.

To date the pneumoperitoneum has been passively created by instrumentally monitored introduction of a gas, such as carbon dioxide gas. The abdominal cavity expander ACE developed already in 1991 produces an active pneumoperitoneum by suctioning air into the abdominal cavity; this is achieved by a modified and automated form of the ACE. A modified myoma drill elevates the abdominal wall for primary aspiration of air into the abdominal cavity by means of a Veress needle.

The history of development in laparoscopy shows that the dilemma involving blind insertion of the trocar has not changed in over 100 years. Perforation of the abdominal wall with the cutting trocar is no longer necessary with today's anatomical and technical possibilities. The cutting trocar with its four cutting surfaces has a great disadvantage compared to the conical trocar with regard to safety. The linea alba should not be disrupted, and perforation of the abdominal wall should be performed in an area where the fascia is weaker and muscle is more abundant. The "z"-track method of trocar insertion prevents intestinal or omental herniation. For perforation and stretching of the muscle, a conical trocar with a blunt tip is recommended. After inserting the conical trocar down to the layer of subcutaneous fat or muscle, further advancement is performed under visual control using a normal straight endoscope and by rotating the bevelled end of the trocar sheath. Perforation of the abdominal wall with a conical trocar using the "z"-track incision under endoscopic control prevents incisional herniation of intestine or omentum.

From 1987 until 1993 a total of 337 patients underwent a therapy for tubal pregnancy at the Department of Gynaecology and Obstetrics of the University of Kiel. The percentage of cases treated by tubal-preserving pelviscopic linear salpingotomy and subsequent extraction of the conceptus, increased from 59% in 1987 to 88% in 1993. In 6.5% a second look pelviscopy was performed for suspected remnants of trophoblastic tissue. Remaining trophoblastic cells can be recognised by serial determination of serum beta-hCG titers postoperatively. However, the interval of the postoperative beta-hCG decline reveals considerable interindividual variation. A regression following the "Cox Proportional Hazard" model shows that the period of the beta-hCG decline depends on the initial titer. The Kaplan Meier curve obtained via beta-hCG determination in 98 patients following pelviscopic linear salpingotomy until values reached 20 mIU/ml or less, shows that 50% of the patients had to be controlled for more than 7 days, 10% for more than 28 days and individual patients even for more than 70 days. The relative beta-hCG titers differ significantly from the unresolved group compared to the group with resolved ectopic pregnancy starting at postoperative day 2 (p0.01). At postoperative day 3/4 10% of the initial beta-hCG value is attained in 50% of cases. Even then a serial beta-hCG follow-up should be obtained down to the detection limit to ensure complete resolution of viable trophoblastic cells.

Indications for the 346 hysterectomies performed in the Department of Obstetrics and Gynecology University of Kiel in the years 1991 till 1994 were myomas with pain, hypermenorrhoea, menorrhagia, recurrent bleedings and endometriosis. The applied hysterectomy technique consisted of supercervical hysterectomy without colpotomy including the resection of the transcervical and transuterine mucosa by laparotomy and via laparoscopy (pelviscopy). Histologically results were divided between fibromas, leiomyomas, adenomyosis and adenomatous hyperplasia. 42 patients where pretreated with hormones and showed a significantly reduced blood loss compared to the non treated patients during surgery. Intra- and postoperative complications were very low. The CISH-technique is an alternate method for vaginal and abdominal total hysterectomy via laparotomy or via laparoscopy. Gynecological indications for hysterectomies presents the following advantages. 1. CISH via pelviscopy: Prophylaxis against the development of cervical cancer, preservation of the pelvic floor, preservation of the pericervical vascular and nerve tissue and especially, avoiding the danger zone of the uterine arteria and ureter, reduced physical stress, short hospitalisation and recovery time of the patients. 2. CISH via laparotomy: Prophylaxes against cervical cancer, preservation of the pelvic floor, reduction of the pelvic trauma, simple technique. 3. CISH via vagina: The advances of the intrafascial vaginal hysterectomy are the same as those for laparoscopic intrafascial hysterectomy without colpotomy, no separation of cardinalia and sacrouterina ligaments, no cervical amputation. No search for the uterine artery, no change in sexual life. Ideal conditions for the preservation of pelvic floor to regain stability. 4. During the resection of the transcervical and transuterine mucosa the technique of mucosa ablation emerged, indications are dysfunctional bleeding.

From 1987 to 1990 pelvioscopic distal salpingostomy was performed in 47 patients at the University Hospital of Kiel. The tubal mucosa was everted and fixed with 4/0 PDS sutures. 35 patients (74%) responded to a questionnaire 2-4 years after surgery. A bilateral salpingostomy had been performed in 16 of these 35 cases, while the contralateral tube was either absent or intramurally occluded in 19 cases. Eight patients (23%) postoperatively had an intrauterine pregnancy, five patients gave birth to a healthy child, one patient was pregnant at time of follow-up. Three patients had abortions and three experienced a tubal pregnancy of one or both sides. Compared to the endoscopic procedure with the CO2 laser pelvioscopic salpingostomy with an everted suture represents an equally suited alternative.

The first statistical report on pelvioscopy/laparoscopy of total Germany covers a five years period from 1989, 01.01 to 1993 31.12. It includes a total of 461,568 pelvioscopies/laparoscopies from 374 hospitals and 52,861 pelvioscopies/laparoscopies from 116 medical practitioners. Hospitals' response rate was 43% with 99.2% reporting pelvioscopy/laparoscopy. The response rate of medical practitioners was 41% with 97.4% performing same methods. During the five year period of survey, hospitals reported a total of 2095 serious complications requiring laparotomy or control laparoscopy (complication rate = 4.5/1000). Medical practitioners reported a total of 197 serious complications (complication rate = 3.7/1000). Compared with the data of the fourth statistical survey of laparoscopy (1986 to 1988) there is a remarkable increase in serious complications. Most of them are mechanical lesions of blood vessels in the abdominal wall or in the mesosalpinx, followed by mechanical lesions of the intestine. Also remarkable is the observation that pelvioscopy/laparoscopy as surgical method is continuously increasing. As shown in previous statistics on pelvioscopy for tubal sterilization the bipolar technique is the most popular one for both hospitals and medical practitioners. It is followed by endocoagulation after Semm whereas mechanical techniques are of little importance. The monopolar high frequency current is still used in 9.6% by hospitals and 8.8% by medical practitioners, with and without transsection. Sterilization failure rate remains nearly at the same levels as it was reported previously: 1.6/1000 in hospitals and 3.7/1000 in private practices. The highest failure rate was observed after the use of monopolar HF-techniques. 82.5% of the hospitals and 65% of the medical practitioners reported tendency in performing endoscopy by surgery is continuously increasing.