Diagnostic and operative microlaparoscopy: a preliminary multicentre report

Assessment of Tubal Patency with Selective Chromopertubation at Office Hysteroscopy versus Modified Minilaparoscopy in Infertile Women

OBJECTIVES

Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.

MATERIALS AND METHODS

The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, "Visualizable flow" at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.

RESULTS

All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93-0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.

CONCLUSION

OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.

A mixture of 86% of CO2, 10% of N2O, and 4% of oxygen permits laparoscopy under local anesthesia: a pilot study

The aim of this study is to verify that 10 % of N₂O in CO₂ sufficiently reduces pain to permit laparoscopy under local anesthesia. In nine patients undergoing laparoscopy under local anesthesia for tubal sterilization, a mixture of 86 % of CO₂, 10 % of N₂O, and 4 % of oxygen (the Gas Mixture) was used for the pneumoperitoneum. For CO2, N₂O, and for the Gas Mixture, the pain when blowing over the tongue tip and the pH changes of saline and Hartmann’s solution were estimated. In all nine patients, discomfort was minimal and the intervention was well tolerated, similar to 100 % N₂O. Tongue tip pain (n = 15), on VAS scale, was lower with 86 % CO₂ + 10 % N₂O + 4 % O₂ (2.4 ± 1.4, P = 0.005) and much lower with 100 % N₂O (0.3 ± 0.6, P < 0.0007) than with pure CO₂ (3.6 ± 1.7). The pH of saline (n = 5) decreased from 7.00 ± 0.07 to 4.18 ± 0.04 (P = 0.001), 6.98 ± 0.08 (NS), and 4.28 ± 0.04 (P = 0.01) with 100 % CO₂, 100 % N₂O and the Gas Mixture_, respectively. The pH of Hartmann’s solution (n = 5) decreased similarly from 7.00 ± 0.07 to 5.18 ± 0.04 (P = 0.01), 7.02 ± 0.19 (NS), and 5.3 ± 0.4 (P = 0.01), respectively. These data demonstrate that a mixture with 10 % of N₂O and 4 % of O₂ in CO₂ permits laparoscopy under local anesthesia. This result cannot be explained by direct irritation estimated by tongue tip pain or by pH changes.

Office microlaparoscopic ovarian drilling (OMLOD) versus conventional laparoscopic ovarian drilling (LOD) for women with polycystic ovary syndrome

OBJECTIVE AND DESIGN

This was a prospective controlled study to compare the beneficial effects of office microlaparoscopic ovarian drilling (OMLOD) under augmented local anesthesia, as a new modality treatment option, compared to those following ovarian drilling with the conventional traditional 10-mm laparoscope (laparoscopic ovarian drilling, LOD) under general anesthesia.

METHODS

The study included 60 anovulatory women with polycystic ovary syndrome (PCOS) who underwent OMLOD (study group) and 60 anovulatory PCOS women, in whom conventional LOD using 10-mm laparoscope under general anesthesia was performed (comparison group). Transvaginal ultrasound scan and blood sampling to measure the serum concentrations of LH, FSH, testosterone and androstenedione were performed before and after the procedure. Intraoperative and postoperative pain scores in candidate women were evaluated during the office microlaparoscopic procedure, in addition to the number of candidates who needed extra analgesia.

RESULTS

Women undergoing OMLOD showed good intraoperative and postoperative pain scores. The number of patients discharged within 2 h after the office procedure was significantly higher, without the need for postoperative analgesia in most patients. The LH:FSH ratio, mean serum concentrations of LH and testosterone and free androgen index decreased significantly after both OMLOD and LOD. The mean ovarian volume decreased significantly (P < 0.05) a year after both OMLOD and LOD. There were no significant differences in those results after both procedures.

CONCLUSION

Intra- and postoperatively augmented local anesthesia allows outpatient bilateral ovarian drilling by microlaparoscopy without general anesthesia. The high pregnancy rate, the simplicity of the method and the faster discharge time offer a new option for patients with PCOS who are resistant to clomiphene citrate. Moreover, ovarian drilling could be performed simultaneously during the routine diagnostic microlaparoscopy and integrated into the fertility workup of these patients.

Is Single-Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes

Objective. This study aimed to compare postoperative pain and surgical outcomes after transumbilical single-port access (SPA) and conventional multiport laparoscopic surgery for adnexal lesions. Methods. A retrospective case–control study was conducted matched by age, body mass index, and frequency of previous abdominal surgery. A total of 110 SPA laparoscopy patients (cases) were matched with a cohort of 107 patients who underwent conventional laparoscopy (controls) for benign adnexal lesions. SPA system consisted of a wound retractor, surgical glove, two 5-mm trocars, and one 11-mm trocar. Postoperative pain scores were measured immediately after surgery and at 6, 24, and 48 hours postsurgery using the numerical rating scale. Results. Postoperative pain scores did not differ between the 2 groups ( P = .552). However, higher number of painkiller administrations was observed in the SPA laparoscopy group (median 3 vs 1, P < .001). The type of surgery and intraoperative blood loss were the significant factors influencing the number of painkiller administrations after controlling for other parameters by linear regression ( P < .0001). The SPA laparoscopy group had less intraoperative blood loss (45.3 vs 87.5 mL, P < .001) and shorter hospital stay (2.1 ± 0.8 vs 2.7 ± 1.0 days, P < .001) compared with the conventional laparoscopy group. Operative time and perioperative complications did not differ between groups. Conclusions. There was no difference in pain intensity between the SPA and conventional laparoscopic group in this study. Future trials are warranted to better define the benefits of SPA surgery in terms of postoperative pain.

Minimizing ancillary ports size in gynecologic laparoscopy: a randomized trial

STUDY OBJECTIVE

To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm.

DESIGN

Randomized, controlled trial (Canadian Task Force classification I).

SETTING

Gynecologic department of a university hospital

PATIENTS

A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n=52) or 3-mm instruments (n=50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria.

INTERVENTIONS

Laparoscopic procedures for the treatment of benign adnexal masses.

MEASUREMENTS AND MAIN RESULTS

Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p=.49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15-175 min] vs 50 min [range 20-150 min], p=.89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0-60] vs 32.5 [range 0-80], p=.04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups.

CONCLUSION

Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon's ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

Canine model of surgical stress response comparing standard laparoscopic, microlaparoscopic, and hand-assisted laparoscopic nephrectomy

OBJECTIVES

To compare the postoperative stress induced by standard laparoscopic, microlaparoscopic, and hand-assisted laparoscopic (HALS) nephrectomy in an animal model.

METHODS

A total of 39 dogs underwent standard laparoscopic (n = 19), microlaparoscopic (n = 11), or HALS (n = 9) left nephrectomy. The serum cortisol levels were measured preoperatively, at skin closure, and 2, 4, and 6 hours postoperatively.

RESULTS

Compared with the preoperative level, a sharp rise was noted in the serum cortisol taken at skin closure that correlated with both operative time (P = 0.003) and method (P = 0.009 for HALS versus microlaparoscopy and P = 0.02 for HALS versus standard). HALS had the lowest cortisol increase and shortest operative time, and microlaparoscopy had the greatest cortisol increase and longest operative time (P = 0.03 for cortisol increase, HALS versus microlaparoscopy). Two hours postoperatively, HALS was the only method associated with a continuing increase in cortisol levels (P = 0.01 and P = 0.02 compared with the other methods) and had the greatest cortisol level relative to baseline. The cortisol level decreased at all postoperative points in the other groups. By 4 hours, all methods were associated with similar and falling cortisol levels.

CONCLUSIONS

HALS nephrectomy was associated with a greater operative stress response in the first 2 postoperative hours in dogs compared with standard laparoscopic and microlaparoscopic nephrectomy that was partially ameliorated by the lower intraoperative cortisol production in the more rapid HALS procedure. Microlaparoscopy provided no benefit in terms of reduced surgical stress. The stress differences among the techniques were insignificant by 4 hours postoperatively.

Progress in transvaginal hydrolaparoscopy

Reproductive performance is now more than ever determining the choice of treatment for each individual couple. The easy access to ART treatments, their financial benefits, and the relative high success rate per cycle are at the basis of a liberal referral to these treatments without an accurate diagnosis. The easy and comprehensive investigation by a transvaginal endoscopy as a first-line diagnostic procedure allows for an accurate diagnosis and the choice of the most appropriate treatment.

"Needlescopic" heller myotomy

MIS continues to evolve with the introduction of new techniques and technology. This report discusses the use of "needlescopic" technology in the surgical management of achalasia. Heller myotomy procedures performed between January 1, 1997, and July 1, 2000, were analyzed and the results of 14 needlescopic procedures were compared with 15 laparoscopic procedures. Demographic and short-term outcome data were compared for each group using chi2, Fisher exact, and Student t tests where appropriate. Both groups were similar in age and gender. However, the needlescopic group weighed less (72.2 vs. 83.5 kg; P = 0.05). Intraoperatively, the needlescopic procedures were shorter (98.2 vs. 131.9 minutes; P = 0.03). There were no conversions to open surgery or differences in the number of intraoperative complications for either group. Postoperatively, the groups had similar complications, time to normal diet, and analgesia requirements. Nonetheless, the needlescopic group had a shorter length of stay in hospital (1.1 vs. 2.0 days; P = 0.04). Needlescopic Heller myotomy appears to be a safe treatment option, resulting in a decreased length of stay and improved wound cosmesis.

Comparison of microlaparoscopy and conventional laparoscopy for tubal sterilization under local anesthesia with mild sedation

STUDY OBJECTIVE

To compare tubal sterilization performed by microlaparoscopy and conventional laparoscopy.

DESIGN

Prospective, randomized trial (Canadian Task Force classification I).

SETTING

Gazi University School of Medicine.

PATIENTS

Twenty women undergoing surgical sterilization.

INTERVENTION

Ten sterilizations by conventional laparoscopy and 10 by microlaparoscopy.

MEASUREMENTS AND MAIN RESULTS

The techniques were comparable in quality of visualization, operating time, amount of drugs used for sedation and local anesthesia, and intraoperative pain scores. However, the postoperative analgesic requirement was significantly less in women treated by by microlaparoscopy.

CONCLUSION

Tubal sterilization by microlaparoscopy does not differ greatly from conventional laparoscopic sterilization.

Operative culdolaparoscopy: a new approach combining operative culdoscopy and minilaparoscopy

The tendency is to use small cannulas for operative laparoscopy; however, working with these cannulas may have technical limitations. We developed a technique for performing appendectomy combining culdoscopy and minilaparoscopy. It uses 3- or 5-mm abdominal cannulas, and the large 10- or 12-mm cannula is inserted into the posterior vaginal fornix under laparoscopic surveillance. The vaginal port is used to introduce operative instruments and extract specimens, and for vision. Culdolaparoscopy avoids additional or large abdominal ports, thus overcoming limitations of small cannulas.

Microlaparoscopy in gynecology: analysis of 16 cases and review of literature

Microlaparoscopy represents the development of endoscopic surgery towards a minimally invasive surgical procedure. The advantages include fewer surgical complications, faster return to daily activities, more comfortable postoperative recovery, and satisfactory aesthetic results. The possibility of performing surgery under sedation may result in shorter hospitalization, lower hospital costs, and easier anesthetic procedures. The authors report their preliminary experience with the use of microlaparoscopy, using optics and 2mm instruments, as well as a review of the literature since the introduction of this new technique. The report of these 16 cases demonstrates that microlaparoscopy is a feasible technique with satisfactory results. On the other hand, this new technique requires precise indications and a training period for the development of the skills necessary for performing these surgeries.

Needlescopic urology: current status

Technological miniaturization is an emerging trend that encompasses virtually all surgical subspecialties. Minimization of surgical trauma while maximizing surgical cure through gradual progression from maximally invasive to minimally invasive to ultimately noninvasive technologies must be the goal. Needlescopic techniques represent a natural evolution and sophistication of conventional laparoscopy. At the author's center, needlescopic techniques have been used to particular advantage in four specific clinical applications: adrenalectomy, pediatric orchiopexy, detaching the bladder cuff during laparoscopic nephroureterectomy, and as an adjunctive needlescopic port for retraction purposes during conventional laparoscopic surgery. Given the urologist's natural facility with small-diameter endoscopes, the specialty is uniquely positioned to take a leadership position in this emerging field. Increased experience and careful comparisons with conventional laparoscopy will determine the true role of needlescopic technology in the armamentarium of the urologic surgeon.

Female sterilization. Evidence

The literature review herein reveals substantial information regarding the safety, efficacy, short-term complications, long-term complications, and noncontraceptive benefits of sterilization. This information should be helpful for providers and potential sterilization candidates. The review also reveals areas where the data are unclear. Points to keep in mind during counseling include the following: The vast majority of women are satisfied with the decision to undergo sterilization. The fact that regret occurs underscores the importance of counseling and adequate individual deliberation before the procedure. In addition to the difficulty and expense associated with sterilization reversal, the woman should thoroughly understand the permanence of the procedure. Although failure is a rare event, it can occur many years after the procedure. Although evidence suggests that hysterectomy rates are higher in sterilized women aged less than 30 to 35 years, it is unlikely that there is a plausible biologic effect of sterilization on hysterectomy risk. An association between tubal sterilization and menstrual cycle changes does not seem valid for changes noted up to 2 years after the procedure. Data are unclear and inconsistent among studies observing women more than 2 years after the procedure. Evidence consistently shows that sterilization is associated with a reduced incidence of ovarian cancer and pelvic inflammatory diseases. Most studies show no effect or improvement of sexual satisfaction after sterilization. Complications during and postprocedure are rare. Sterilization provides no protection against the acquisition of sexually transmitted disease. Patients and their physicians should recognize that sterilized women may need more targeted preventive efforts for health screening and to reduce high-risk behavior than women who use other contraceptive methods. The surgeon's experience and the woman's preferences should govern the ultimate decision regarding the approach and occlusion method. Level II-2 evidence indicates comparable safety between interval laparoscopy and minilaparotomy. Data consistently show that in experienced trained hands, tubal sterilization is safe and highly effective regardless of the approach or occlusive method. Attention to the subtleties of technique seems to be most important in ensuring procedure safety and efficacy. Reanalysis of the CREST data shows that the cumulative failure rate of bipolar coagulation is comparable with the failure rate of unipolar coagulation if a substantial length of tube is adequately coagulated. The data discussed herein can be used to guide management decisions that may increase accessibility and reduce cost of the procedure. Low-resource settings and office settings have maintained an excellent safety record for this procedure through performance of sterilization under local anesthesia. The use of local anesthesia enables a change in procedure location from an inpatient operating room to a free-standing surgical clinic or adequately equipped office. Local anesthesia, with or without preoperative medication, is an excellent option associated with a lower complication risk, reduced cost, and shorter, easier recovery. The surgeon should have specific training in the effective use of local anesthetics, preoperative medications, and management of rare complications in low-resource settings. Little additional research is needed regarding the safety and efficacy of standard sterilization approaches and occlusion methods. There is a need for continued development of nonsurgical methods of sterilization, microlaparoscopic approaches performed in the office setting, and the feasibility and acceptance of service provision by nonspecialist health care providers. The evidence indicates that female sterilization can be performed safely in a variety of resource settings ranging from rural sterilization camps in developing countries to high-tech, resource-rich operating rooms in developed c

Renal surgery in the new millennium

In the not too distant future, the minimally invasive renal surgeon will be able to practice an operation on a difficult case on a three-dimensional virtual reality simulator, providing all attributes of the real procedure. The patient's imaging studies will be imported into the simulator to better mimic particular anatomy. When confident enough of his or her skills, the surgeon will start operating on the patient using the same virtual reality simulator/telepresence surgery console system, which will permit the live surgery to be conducted by robots hundreds of miles away. The robots will manipulate miniature endoscopes or control minimally or noninvasive ablative technologies. Endoscopic/laparoscopic footage of the surgical procedure will be stored digitally in optical disks to be used later in telementoring of a surgery resident. All this and more will be possible in the not so distant third millennium.

Needlescopic surgery for cryptorchidism: the initial series

PURPOSE

The aim of this study is to report the initial experience with needlescopic surgery (2-mm optics and instrumentation exclusively) for the cryptorchid testicle.

METHODS

Ten patients (age 8 months to 37 years) underwent 12 needlescopic procedures: orchiopexy (n = 8), orchiectomy (n = 2), and diagnostic exploration with attempted excision of testicular remnant (n = 2). Two patients underwent bilateral needlescopic orchiopexy. Needlescopic (2 mm) optics and instrumentation were used exclusively in the pediatric patients.

RESULTS

All procedures were completed successfully by needlescopic techniques. Mean surgical time was 110 minutes (range, 60 to 180 minutes), and blood loss was 6 mL (range, 0 to 20 mL). There were no intraoperative complications. All procedures were performed on an outpatient basis. In all 8 orchidopexies, the testis was successfully brought to a scrotal position.

CONCLUSIONS

Needlescopic techniques allow safe performance of various procedures for a cryptorchid testicle. The cosmetic result is excellent.

Microlaparoscopy for an intact ectopic pregnancy and endometriosis with the use of a diode laser: case report

Microlaparoscopy is a development of endoscopic surgery which further reduces invasiveness of surgical procedures. The use of a diode laser in microlaparoscopy for the treatment of a patient with an intact ectopic pregnancy and endometriosis is described for the first time. As the diode laser has easy management and widely recognized precision, its use could be highly advantageous in such situations. The success achieved in this case contributes to the wider use of micro-endoscopic procedures.

Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion

OBJECTIVE

To determine the frequency of peritoneal and visceral adhesions to the umbilical region according to past surgical history and to estimate the risk of bowel injury with blind insertion of the principal trocar-cannula.

DESIGN

Prospective, unicentric study by a single operator.

SETTING

Clinique Saint-Sernin and Polyclinique de Bordeaux, Bordeaux, France.

PATIENT(S)

Eight hundred fourteen patients undergoing diagnostic or operative laparoscopy were classified into four groups based on their history of abdominal surgery: group I (n = 469), no previous abdominal surgery; group II (n = 125), prior laparoscopic surgery; group III (n = 131), previous laparotomy with a horizontal supra-pubic incision; group IV (n = 89), previous laparotomy with a midline incision.

INTERVENTION(S)

Initial microlaparoscopy performed through the left upper quadrant of the abdomen, inspection of the anterior abdominal wall and particularly the umbilical area for the presence of adhesions. Patients who had adhesions were assessed as to whether or not they were at significant risk of injury from blind insertion of the principal trocar.

MAIN OUTCOME MEASURE(S)

Incidence of umbilical adhesions and the potential risk of bowel injury with blind insertion of the umbilical (principal) trocar.

RESULT(S)

Umbilical adhesions were found in 9.82% of the 814 cases. The rates of umbilical adhesions were as follows: group I, 0.68%; group II, 1.6%; group III, 19.8%; and group IV, 51.7%. Severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar in the four groups were 0.42%, 0.80%, 6.87%, and 31.46%, respectively.

CONCLUSION(S)

Women with previous laparotomy have a higher incidence of umbilical adhesions, especially in case of midline incision. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended for patients at risk for adhesions to reduce complications associated with insertion of the principal (umbilical) trocar.

Adhesion formation after microlaparoscopic and laparoscopic ovarian coagulation for polycystic ovary disease

STUDY OBJECTIVE

To compare the effects of microlaparoscopy and decreased CO2 exposure on peritoneal microcirculation and potential adhesion formation after ovarian surgery with those of conventional operative laparoscopy.

DESIGN

Prospective, randomized study (Canadian Task Force classification I).

SETTING

Teaching hospital.

PATIENTS

Eighteen women with polycystic ovary disease.

INTERVENTIONS

Microlaparoscopic or laparoscopic ovarian coagulation of the ovaries.

MEASUREMENTS AND MAIN RESULTS

Approximately 10 to 12 coagulation points were applied to each ovary. Two to 3 weeks after the initial surgery second-look microlaparoscopy was performed to determine the extent of adhesions in both groups. The frequency of adhesion formation and changes in glutathione peroxidase (GSH-Px), superoxide dismutase (SOD), catalase (CAT), and glutathione (GSH) levels were studied in homogenized peritoneal tissues obtained during surgery in each group.

RESULTS

Clinical profiles were similar between groups. Mean exposure, amount, and pressure of CO2 were significantly less in the microlaparoscopy group (p <0.05). The laparoscopy group had significantly more adhesions than the microlaproscopy group (24% vs 48%, p <0.05). The GSH-Px, SOD, CAT, and GSH levels were significantly lower in the laparoscopy group (0. 425 micromol, 1.2 ng, 37.55 micromol, and 0.9 nmol vs 0.755 micromol, 2.l ng, 625 micromol, and 2.6 nmol, respectively).

CONCLUSION

Reduced exposure to and amount of CO2 during microlaparoscopy may result in decreased adhesion formation compared with conventional laparoscopy. This effect may possibly be due to lack of or minimal adverse effects on peritoneal microcirculation and cell-protective systems, which are proposed mechanisms for adhesion formation and closely related to peritoneal injury. In addition, microlaparoscopy may be a cost-effective alternative to conventional laparoscopy. (J Am Assoc Gynecol Laparosc 6(2):159-163, 1999)

Laparoscopic tubal sterilization. Methods, effectiveness, and sequelae

The following statements summarize the material presented herein. 1. Although laparoscopic tubal ligation remains an effective and widely available form of birth control throughout the world, cumulative failure rates may be higher than previously reported, and patients should be appropriately counseled, with special attention to younger women. 2. Proper surgical technique is important in reducing failure rates, particularly with regard to applying clips or using bipolar cautery. Teaching institutions should employ strict guidelines for instructing residents in the most effective techniques. 3. Although overall rates of ectopic pregnancy are lower after tubal ligation (as is true with any form of birth control), should pregnancy ensure from a failed procedure, there is a 30% to 80% chance of ectopic pregnancy. Consideration should be given to earlier ultrasound and documentation of the location of the pregnancy. 4. There is little evidence to support PTLS from a biologic standpoint. The data on increased hysterectomies in post-tubal patients may be a result of multiple factors, particularly for women aged less than 30 years at the time of occlusion. 5. Although the majority of women report satisfaction with sterilization, thorough counseling for all women cannot be overemphasized. Women aged less than 30 years should be completely aware of all alternatives and possibly encouraged to try another method prior to permanent sterilization.

Needlescopic urology: incorporating 2-mm instruments in laparoscopic surgery

OBJECTIVES

To report the initial experience with incorporation of needlescopic (2 mm) instruments and optics in various therapeutic minimally invasive urologic procedures.

METHODS

Needlescopic techniques were used to successfully perform a variety of urologic surgeries including adrenalectomy, nephrectomy, renal cyst marsupialization, orchiopexy, lymphocele marsupialization, and pelvic lymph node dissection.

RESULTS

To date we have performed 42 needlescopic procedures in 39 patients (14 female and 25 male) ranging in age from 8 months to 87 years (mean 46.6 years). Three procedures were converted to conventional laparoscopy and one to open surgery, yielding a needlescopic success rate of 90.5%. Surgical times averaged 132 minutes and blood loss averaged 67 mL. Procedures were performed on an outpatient basis in 33.3% of cases, and 94.9% of patients were discharged home within 23 hours. The overall complication and conversion rate was 14.3% and there was no mortality.

CONCLUSIONS

Our initial experience is quite promising. In select patients, needlescopic urologic surgery is feasible and safe, and may reduce postoperative pain, hospital stay, and recovery time, and improve cosmesis. Further evaluation of, and improvement in, 2-mm instrumentation and optical technology is needed.