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Background and Objectives: Laparoscopy is the standard method to visually identify endometriotic lesions under magnification within and outside the minor pelvis. The aim of this study was to analyze the accuracy of laparoscopic visualization in diagnosing the various endometriotic sites as confirmed histologically. Methods: Presumed endometriotic sites were observed in 164 patients operated on under the clinical suspicion of endometriosis. Targeted biopsies were performed for histologic corroboration, comparing the laparoscopic findings and diagnosis to the histological results. Results: The histological reports of the biopsies confirmed the presence of endometriosis in 138 patients (84.1%), but in 26 patients (15.9%), no evidence of endometriosis was observed. 100% of “red” lesions, 92% of “black” lesions, and 31% of “white” lesions turned out to be endometriosis. Of the 264 various suspected endometriotic sites observed, 142 (53.8%) were confirmed histologically. The most accurate diagnosis was in lesions on the parietal peritoneum of the pelvis, confirmed in 9/9 cases (100%); the ovarian fossa, confirmed in 8/12 cases (66.7%); and the uterosacral ligaments and posterior surface of the broad ligament, confirmed in 83/138 cases (60.1%). As for the other sites, the histologic confirmation rates in the ovarian surface, bowel serosa, and vesicouterine fold of the peritoneum were 48%, 40%, and 13%, respectively. Conclusions: Endometriosis has a multiple appearance, and the lesions may be confused with nonendometriotic lesions. It is clear that a nonhistology-based diagnosis may lead to unnecessary prolonged medical treatment and operations and may delay the proper treatment measures from being applied. Therefore, a meticulous histological confirmation should still be the first step in the laparoscopic diagnosis and treatment of suspected endometriosis.

In 1988 and 1989 176 patients underwent pelviscopy at the Kiel University Hospital of Gynaecology for primary or secondary sterility of at least 12 months duration. 120 patients (68%) filled in a questionnaire on the therapeutic results after 2 to 3 years. Following peripheral salpingostomy in 18 patient, an intrauterine pregnancy developed in 22% of these cases, while an ectopic pregnancy occurred in 11% of the cases. After fimbrioplasty in 37 cases, the intrauterine pregnancy rate amounted to 43%, whereas the rate was 50% following salpingoovariolysis. 4 patients with a subserous or intramural myoma, measuring 2.5 to 8 cm in diameter, but no other pathological signs of disturbed fertility, became pregnant after enucleation of the myoma. 2 patients delivered at full term, the other two miscarried. 5 out of a total of 10 patients became pregnant after endometriosis foci had been coagulated or endometriomas enucleated. In these cases, the adnexa did not require additional surgical treatment. Pelviscopy revealed an untreatable intratubal block in 9 cases. 10 patients could not be included in the study, either because of a successful in vitro fertilisation or a pregnancy following heterologous insemination or because a hysterectomy or tubectomy had been performed in the meantime. In cases, where inspection under magnification had shown at least one non-pathological adnexa and tubal patency of at least one of the tubes, 35% of the patients conceived after pelviscopy and chromopertubation within the follow-up period. The therapeutic action of the chromopertubation and the psychological effect of finding no pathological signs during the genital examination remains speculative.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1984 and 1989, 773 patients less than or equal to 45 years of age, presenting with a total of 809 ovarian cysts, underwent pelviscopy at the Department of Obstetrics and Gynecology of Kiel University. In 36 cases, cysts were bilateral. 678 cysts (84%) were treated by pelviscopy alone. Organ-preserving treatment was performed in 83%, oophorectomy or adnexectomy in only 17% of cases. Two stage Ia ovarian carcinomas (0.26% of all cysts) were operated on by pelviscopy before laparotomy. Sonography is particularly important in determining whether a pelviscopic approach is appropriate. Pelviscopic procedures are unacceptable in multilocular cysts measuring greater than or equal to 7 cm in diameter with echo-dense components. Special caution is required for any cyst measuring greater than 9 cm in diameter. The risk of opening a malignant cyst must be weighed against the advantages of pelviscopic surgery: minimal physical strain, better postoperative quality of life, and organ conservation. In doubtful cases, laparotomy is recommended.

In 969 patients, we observed 1016 ovarian cysts at pelviscopy between the years 1984-89. 36 of these were non-benign. On the basis of the pre- and intraoperative findings (palpation, sonography, inspection of the cyst surface under eye-glass magnification) we treated 827 cysts exclusively by pelviscopy, 189 cysts by laparotomy. Laparotomy was preceded by pelviscopic surgery on the cyst in 94 cases. None of the pre- and intraoperative findings completely eliminated the risk of performing pelviscopic surgery on a stage Ia carcinoma; indeed, this occurred in 2% (2/1016).

The fourth German pelviscopy/laparoscopy statistical report includes survey data on a total of 219,314 laparoscopies from 354 clinics and 40,892 laparoscopies from 161 private practices. Clinics' response rate was 44.7%; 98.9% of them reported performing laparoscopies; and the number of serious complications requiring laparotomy or control laparoscopy was 492 (2.2/1,000). For private practices, the comparable figures were 66%, 90.8% and 123 (3/1,000), respectively. Compared with data from the third laparoscopy statistical survey, the data show a slight increase in serious complications, most of which were mechanical lesions of blood vessels in the abdominal wall or in the mesosalpinx, followed by mechanical lesions of the intestine. As shown by the previous survey, 16.5% of the complications were burns. For tubal sterilization, bipolar techniques were still predominant; approximately equal numbers of departments used this method, with or without subsequent transsection of the tubes. Endocoagulation by the method of Semm was the second most popular procedure; the use of clips and rings was of little significance. Monopolar high-frequency (HF) current was still used with transsection by 4.1% of clinics (4.7% of private practices) and without transsection by 2.5% (5.3%). Sterilization failure rates remained the same as those previously reported (4.6/1,000 in clinics, 5.3/1,000 in private practices); the highest rates were observed after the use of monopolar HF techniques. Sixty-six percent of the clinics and 41% of the private practices reported their intention to increase the use of endoscopic operational methods.

The second set of statistics on pelviscopy in Germany included information on 269,603 pelviscopies done in 322 general hospitals, and 22,859 pelviscopies done in private clinics between 1978 and 1982. In general hospitals the rate of serious complications was 1.9% and in private clinics 2.0%. Injuries to large blood vessels headed the list of complications. The main technique for tubal sterilization was the bipolar high-frequency current method with 75% in general hospitals and 73.1% in private clinics, followed by the endocoagulation technique according to Semm (36.8%). Sterilization failures were reported in 2.6%. Most failures were reported after sterilization with the bipolar electrocoagulation technique, followed by the clip technique. The rate of post-sterilization ectopic pregnancies was 1.06%. The highest rate of ectopic pregnancies was reported after using the bipolar tubal sterilization method (1.4%).

Inspecting 200 patients with abdominal pain pelviscopically, we found adhesions and no other pathology in 62 (32%). Three groups were defined according to the extent of the adhesions. In 52 patients (84%), complete adhesiolysis was achieved pelviscopically. At discharge 3-5 days post-operatively, 38 of these patients (73%) were free from complaints; in 15%, the pain had lessened. 6 months after pelviscopy, the patients were again asked about their complaints. 39 (75%) of the patients with complete adhesiolysis answered the questionnaire. 15 (38%) were completely free from complaints after 6 months; in 8 others, the pain had lessened; in 60% of them, the abdominal pain had lasted for more than 6 months. Our results justify an attempt at complete adhesiolysis in all patients with abdominal pain, if adhesions are detected pelviscopically.

Adenomatous hyperplasia of the endometrium requires either gestagen treatment or hysterectomy, depending on the patient's age and grade of hyperplasia. 51 patients, in whom adenomatous hyperplasia of grade I-III had been ascertained by curettage, were hysterectomized not more than 4 weeks following diagnosis at the Kiel University Clinic of Obstetrics and Gynecology during the years 1985-1989. Only few of the patients received hormone treatment. For all grades of hyperplasia, histological findings from curettage and hysterectomy were identical in only 40% of the cases. In patients older than 40 years, 54% of 13 patients with adenomatous hyperplasia grade III in the curettage specimen had already developed a well differentiated adenocarcinoma, which was detected in the extirpated uterus. In our opinion, when adenomatous hyperplasia of grade II or III is present in a curettage specimen in the age group over 40 years women, hysterectomy should be recommended. For younger women and for adenomatous hyperplasia grade I, we recommend individual therapy.