Management of adnexal cystic masses with unexpected intracystic vegetations detected during laparoscopy

STUDY OBJECTIVE

To evaluate a prospective series of consecutive patients with unexpected intracystic vegetations detected during operative laparoscopy for adnexal masses.

DESIGN

Prospective series of consecutive patients (Canadian Task Force classification: II-2).

SETTING

Tertiary care university hospitals.

PATIENTS

Consecutive patients found during surgery to have unexpected intracystic vegetations and treated by operative laparoscopy, out of a total series of 667 patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillarities, or solid components.

INTERVENTIONS

Operative laparoscopy and follow-up.

MEASUREMENTS AND MAIN RESULTS

Thirty-five (5.2%) of 667 patients were found at surgery to have unexpected intracystic vegetations. A frozen section was sent for pathologic analysis in all 35 patients. Frozen section diagnosis was benign in 32 patients and borderline in 3 patients. Final pathology diagnosis was borderline ovarian tumor in five of the 35 patients (14.3%), and benign in 30 patients (85.7%). No case of invasive carcinoma was diagnosed either at frozen section or at final pathology examination. The patients with borderline tumors are alive with no evidence of disease after a mean follow-up of 60 months.

CONCLUSIONS

In the present series, with accurate preoperative selection, the rate of adnexal cysts with unexpected intracystic vegetations was 5%, of which 14% were borderline tumors. The laparoscopic management of these adnexal masses did not adversely affect the prognosis.

Laparoscopic Excision of Adnexal Masses

STUDY OBJECTIVE

The purpose of the present study was to evaluate a prospective series of consecutive patients with adnexal masses selected with strict preoperative clinical and ultrasonographic criteria.

DESIGN

Prospective series of consecutive patients (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospitals.

PATIENTS

Six hundred and eighty-three consecutive patients under 40 years of age with ultrasonographic evidence of an adnexal cystic mass without thick septa, internal wall papillation, or solid components, except for sonographic pattern suggestive of dermoid.

INTERVENTIONS

Operative laparoscopy and follow-up.

MEASUREMENTS AND MAIN RESULTS

After initial diagnostic laparoscopy in 13 patients with stage 4 endometriosis and extensive bowel adhesions, in 2 patients with large-volume dermoids, and in 1 patient with suspect ovarian and peritoneal implants, the procedure was converted to laparotomy. Therefore, 667 patients were completely managed by laparoscopy. There were 1069 cysts excised. Histologic diagnosis was endometrioma in 57% of the excised cysts, serous cyst in 13%, dermoid in 12%, paratubal in 8%, mucinous cysts in 5.3%, functional cyst in 2.8%, other benign histotypes in 1.1%, and ovarian malignancies (seven borderline tumors and one endometrioma with a microfocus of G1 endometrioid carcinoma) in 0.7% of the cysts and 1.2% of the patients. These last patients are alive with no evidence of disease after a mean follow-up of 62 months.

CONCLUSIONS

In the present series, with accurate preoperative and intraoperative selection, the rate of unexpected borderline or focally invasive malignancies was 1.2% of the patients, and the laparoscopic management of these adnexal masses did not adversely impact on prognosis.

Salpingoscopy

PURPOSE OF REVIEW

Salpingoscopy is an endoscopic technique that allows direct evaluation of the ampullary tubal mucosa at the time of laparoscopy. It has been reported that the presence of ampullary mucosal adhesions can negatively affect reproductive outcome and increase the risk of ectopic tubal pregnancy. Various studies have suggested that the extent of intra-luminal adhesions may not correlate with the nature and extent of periadnexal adhesions.

RECENT FINDINGS

Further studies on salpingoscopic and laparoscopic correlations with regard to fertility outcome have been reported in the literature. Recently microsalpingoscopy has been introduced, with the number of nuclei stained by methylene blue dye employed as a prognostic factor of conception in women with infertility. As an alternative to salpingoscopy performed during laparoscopy, which requires hospitalization and general anesthesia, two groups have described salpingoscopy as an office procedure performed during transvaginal hydrolaparoscopy or in conjunction with fertiloscopy.

SUMMARY

The prognostic value of salpingoscopy during operative laparoscopy for tubal factor infertility in terms of reproductive outcome has been confirmed. The prognostic significance of microsalpingoscopy needs further validation in large-scale clinical trials. Transvaginal hydrolaparoscopy and fertiloscopy appear to be an alternative to hysterosalpingography as a first line procedure to investigate female infertility.

Current practical application of office endoscopy

Outpatient hysteroscopy has shown good correlation of findings compared with inpatient hysteroscopy, but one limitation is pain and discomfort in some women, and vasovagal reaction. Various forms of local anaesthesia have been evaluated in the past year, with controversial results, and a narrow 3.5 mm sheath hysteroscope has been introduced. Transvaginal hydrolaparoscopy as an outpatient procedure has been further investigated.

Fallopian tube disease: the cobblestone pattern as a radiographic sign

PURPOSE

To identify radiographic signs of mucosal damage by comparing hysterosalpingography with salpingoscopy in a prospective study.

MATERIALS AND METHODS

Forty-one candidates for laparoscopy underwent hysterosalpingography and peroperative salpingoscopy; at both, tubal patency was noted. Radiographic criteria for mucosal abnormality were rounded filling defects (ie, the cobblestone pattern) and the absence of longitudinal radiolucent bands in the ampullary tract. At salpingoscopy, tubal mucosa was categorized by means of inspection into five classes of fold pattern: classes I and II, normal; classes III-V, abnormal. Hysterosalpingographic and salpingoscopic results were compared by means of a two-by-two table and kappa statistics.

RESULTS

Seventy-four tubes were evaluated. At hysterosalpingography, 31 tubes were distally nonpatent. Of these, 26 showed a distal obstruction at salpingoscopy. None of the patent tubes at hysterosalpingography showed obstruction at salpingoscopy. The agreement between hysterosalpingography and salpingoscopy in detecting abnormal mucosal pattern was 89.2% (kappa, 0.73; P: <.001). The cobblestone pattern always corresponded to intraluminal adhesions at salpingoscopy. The absence of radiolucent bands corresponded to abnormal mucosa at salpingoscopy in four of six cases. The cobblestone pattern was found only in hydrosalpinges and never in patent tubes. Six normal patent tubes at hysterosalpingography showed intraluminal adhesions at salpingoscopy.

CONCLUSION

Results indicate that the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges and suggest that intraluminal disease in patent tubes might not always be excluded on normal hysterosalpingograms.

Improvement of hysterosalpingographic accuracy in the diagnosis of peritubal adhesions

OBJECTIVE

Our purpose was to compare hysterosalpingography with laparoscopy in the diagnosis of peritubal adhesions and to verify whether a combination of radiographic signs improves hysterosalpingographic accuracy.

SUBJECTS AND METHODS

Thirty candidates for laparoscopy underwent hysterosalpingography before surgery. Two radiologists evaluated the presence or absence and types of radiographic signs of peritubal adhesions (convoluted tubes, vertical tubes, loculation of contrast medium in peritoneum, halo effect, and fixed laterodeviation of the uterus) using two different criteria for normality or abnormality: no sign means a normal result, one or more signs mean an abnormal result (first criterion); no sign or one sign means a normal result, two or more signs mean an abnormal result (second criterion). Interpretation discrepancies were resolved by consensus. Peritubal and periovarian adhesions were evaluated by a single operating surgeon during laparoscopy (recorded on S-VHS videotape) and by a different surgeon reviewing the videotape. The radiographic results obtained using the two criteria in radiologically patent as well as in distally nonpatent tubes were compared with corresponding laparoscopic results by 2 x 2 tables and were statistically analyzed (kappa statistics).

RESULTS

The first criterion displayed poor diagnostic accuracy. The correlation with laparoscopy was not statistically significant in either radiologically patent or distally nonpatent tubes. The second criterion greatly improved the agreement with laparoscopy, but only in patent tubes (kappa = 0.7789; p<0.001).

CONCLUSION

Hysterosalpingographic accuracy in peritubal adhesion diagnosis can be improved in patent tubes by taking into account more than one of the reported radiographic signs.

Postoperative administration of monophasic combined oral contraceptives after laparoscopic treatment of ovarian endometriomas: a prospective, randomized trial

OBJECTIVE

We sought to evaluate the efficacy of postoperative administration of monophasic, combined, low-dose oral contraceptives on endometrioma recurrence and on persistence-recurrence of associated pain symptoms after laparoscopic treatment of moderate-to-severe endometriosis.

STUDY DESIGN

In a prospective, randomized trial 70 patients who were not attempting to conceive, aged 20 to 35 years, underwent laparoscopic excision of ovarian endometriomas, followed by either postoperative administration of low-dose cyclic oral contraceptives for 6 months or no treatment on the basis of a computer-generated sequence. At 3 and 6 months after surgery and then at 6-month intervals, both groups underwent ultrasonographic examination for possible evidence of endometrioma recurrence and for evaluation of the absence, persistence, or recurrence of pain symptoms.

RESULTS

Two patients in the oral contraceptive group did not complete the study. After a mean follow-up of 22 months (range, 12-48 months), there were 2 (6.1%) endometrioma recurrences in the 33 patients who received postoperative oral contraceptives versus 1 (2.9%) recurrence in the 35 patients in the control group (not significant). The moderate-to-severe pain recurrence rate was 9.1% in the oral contraceptive group versus 17.1% in the control group (not significant). The mean time to recurrence of either symptoms or endometriomas was 18.2 months in the oral contraceptive group versus 12.7 months in the control group. The 12-month cumulative recurrence rate at life-table analysis was significantly lower for patients receiving oral contraceptives versus control subjects, whereas no significant difference was evident at 24 and 36 months.

CONCLUSION

Postoperative administration of low-dose cyclic oral contraceptives does not significantly affect the long-term recurrence rate of endometriosis after surgical treatment. A delay in recurrence is evident at life-table analysis.

Stress responses to endoscopic surgery

Growing evidence in the literature suggests that laparoscopic surgery should be performed instead of laparotomy for the treatment of pelvic benign diseases whenever feasible, as it results in a lower stress response on the part of the patient and possibly a shorter recovery time.

The prognostic role of salpingoscopy in laparoscopic tubal surgery

The present study was designed to evaluate the prognostic value of salpingoscopy in patients undergoing tubal laparoscopic surgery for infertility due to periadnexal adhesion or distal tubal occlusion. In addition, the clinical value of salpingoscopy was compared with a current classification system of adnexal adhesions and distal tubal occlusion. A total of 51 patients with either adnexal adhesions (24 patients) or hydrosalpinx (27 patients) were prospectively evaluated. Salpingoscopy was performed concomitantly with salpingo-ovariolysis or salpingoneostomy at the time of operative laparoscopy. There was no significant correlation between salpingoscopic classes and the classification system used for both the salpingo-ovariolysis and the salpingoneostomy groups of patients. The patients had a mean follow-up of 33 months. Patients with a normal tubal mucosa (salpingoscopic classes I and II) had a 71% cumulative term pregnancy rate in the salpingo-ovariolysis group and a 64% cumulative term pregnancy rate in the salpingoneostomy group. No intrauterine pregnancies were obtained in patients with intratubal damage (salpingoscopic classes III to V). There was a statistically significant correlation between the occurrence of a term pregnancy and the salpingoscopic classes, but not with the classification system used. These results suggest that patients with tubal infertility should be offered operative laparoscopy with salpingoscopy as the first step of treatment.

Laparoscopically assisted vaginal hysterectomy versus total abdominal hysterectomy: a prospective, randomized, multicenter study

OBJECTIVE

The objective of this study was to evaluate short-term results of laparoscopically assisted vaginal hysterectomy with those of total abdominal hysterectomy in a prospective, randomized, multicenter study.

STUDY DESIGN

One hundred sixteen patients referred for abdominal hysterectomy were randomized to either laparoscopically assisted vaginal hysterectomy (58 patients) or abdominal hysterectomy (58 patients). Inclusion criteria were one or more of the following, where a vaginal hysterectomy would be traditionally contraindicated: uterine size larger than 280 g, previous pelvic surgery, history of pelvic inflammatory disease, moderate or severe endometriosis, concomitant adnexal masses or indication for adnexectomy, and nulliparity with lack of uterine descent and limited vaginal access. An upper limit of uterine size was set at 16 weeks' gestation (ie, 700 g).

RESULTS

There were no differences in terms of patient's age, parity, preoperative hemoglobin levels, mean uterine weight, and total operating time between the 2 groups. Estimated blood losses and postoperative day 1 hemoglobin drop were significantly lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.05). There were 1 major and 2 minor complications in the laparoscopically assisted vaginal hysterectomy group compared with 2 major and 5 minor complications in the abdominal hysterectomy group (P not significant). Postoperative pain was lower for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy on postoperative days 1, 2, and 3 (P<.05). Postoperative hospital stay was significantly shorter for laparoscopically assisted vaginal hysterectomy than for abdominal hysterectomy (P<.001).

CONCLUSIONS

The present study demonstrates that, given adequate training in laparoscopic surgery, laparoscopically assisted vaginal hysterectomy may replace abdominal hysterectomy in most patients who require a hysterectomy and have contraindications to vaginal hysterectomy, with all the benefits associated with the vaginal route.

Endometriosis externa and interna: endoscopic diagnosis

Endometriosis is defined as the presence of the endometrium outside the endometrial cavity. If the ectopic mucosa is located within the endometrium, the disease is defined as endometriosis interna, or adenomyosis, whereas the localization of the endometrium outside the uterus is defined as endometriosis externa, or pelvic endometriosis. The diagnosis of pelvic endometriosis requires invasive techniques, such as laparoscopy or laparotomy, with histologic confirmation on the surgical specimen. The diagnosis of adenomyosis should be based on histology of hysterectomy specimen, since the endoscopic diagnosis is still too inaccurate. Laparoscopy allows the visualization of the different aspects of pelvic endometriosis, i.e. superficial implants, deep lesions, and associated adhesions. Staging is based on a score attributed to each location in order to establish a prognosis in terms of the patient's reproductive performance.

Tubal factor infertility

Various studies demonstrated that there is no close correlation between the intratubal damage and the extent and type of pelvic adhesions. Moreover, the results of prospective studies on the prognostic value of salpingoscopy showed that the tubal mucosal status is the most important prognostic factor in terms of reproductive outcome. Salpingoscopy has modified the management of patients with tubal infertility, since the accurate evaluation of the tubal mucosa permits the selection of patients with a normal mucosa (34-42% of the patients with hydrosalpinx and 76-80% of those with periadnexal adhesions) who can benefit from tubal reconstructive surgery. In these patients the term pregnancy rate is 60% in case of hydrosalpinx and 70% in case of periadnexal adhesions.

Operative laparoscopy

Operative laparoscopy has replaced the conventional approach by laparotomy to the treatment of most benign gynecological diseases (benign adnexal cysts, ectopic pregnancy, tubal infertility, polycystic ovarian disease, endometriosis, myomas), with advantages in terms of shorter hospital stay, less discomfort and complications for the patient, minor social costs due to the early resumption of normal working activities, and comparable results in terms of reproductive outcome.

Postoperative adhesion formation and reproductive outcome using Interceed after ovarian surgery: a randomized trial in the rabbit model

The efficacy of an oxidized regenerated cellulose barrier (Interceed) in reducing postoperative adhesion formation and improving reproductive outcome after ovarian surgery was evaluated in a prospective randomized trial. Twenty-nine New Zealand White female rabbits were submitted to a mid-line laparotomy and a standardized surgical incision was made on both ovaries. At random, one ovary was entirely wrapped in a sheet of Interceed, whereas the contralateral ovary was left uncovered. Four weeks following surgery, the rabbits were mated with a male of proven fertility. Two weeks later, a second-look laparotomy was performed by a blinded observer who evaluated the incidence and score of adhesions, the number of corpora lutea in each ovary, the number of embryos in the ipsilateral uterine horn and also calculated the nidation index for each side. Adhesions were observed in 66% of Interceed-covered and in 97% of control ovaries (P < 0.0001). The adhesion score on the Interceed side was significantly lower than on the control side. The nidation index for the Interceed side was significantly higher than for the control side. The authors conclude that, in the rabbit model, Interceed significantly reduces the incidence and score of postoperative ovarian adhesions and significantly improves reproductive outcome.

Correlation between endometriosis-associated dysmenorrhea and the presence of typical or atypical lesions

OBJECTIVE

To evaluate the correlation between the severity of endometriosis-associated dysmenorrhea and the extent of the disease assessed both with a current classification system and with the number and type of endometriosis lesions.

DESIGN

Prospective, blinded study.

SETTING

Tertiary care, university hospital.

PATIENT(S)

Sixty-five consecutive patients with endometriosis diagnosed at laparoscopy performed for pelvic pain, infertility, or adnexal mass.

INTERVENTION(S)

The patients were submitted preoperatively to a questionnaire including the assessment of the severity of dysmenorrhea by means of a 10-point linear analog scale. Evaluation of all visible signs of endometriosis at laparoscopy was performed by a surgeon not aware of the patients' symptoms.

MAIN OUTCOME MEASURE(S)

The correlation between the severity of dysmenorrhea and the total score for endometriosis and the partial scores for superficial, deep, and adhesion disease as assessed with a current classification system was evaluated. The severity of dysmenorrhea was also correlated with the total number of superficial implants and with the number of typical, pigmented versus atypical, nonpigmented lesions.

RESULT(S)

The linear analog score for dysmenorrhea correlated significantly with the total endometriosis score, the partial score for deep endometriosis, and the partial score for adhesions. There was no correlation between the pain score for dysmenorrhea and the partial score for superficial endometriosis, nor with the total number of endometriosis implants, the number of typical implants, or the number of atypical implants.

CONCLUSION(S)

The current classification system for endometriosis, devised primarily to formulate a prognosis in infertile patients, correlates significantly with endometriosis-associated dysmenorrhea. The present study does not support the suggested association between atypical implants and the severity of dysmenorrhea.

Operative laparoscopy for ovarian cysts. Excision vs. aspiration

OBJECTIVE

To evaluate operative laparoscopy for excision vs. aspiration of ovarian cysts.

STUDY DESIGN

From July 1, 1990, to June 30, 1993, 100 women under 40 years of age were subjected by the senior author to laparoscopic cyst excision, and 31 patients with similar characteristics underwent laparoscopic cyst aspiration by their attending physicians. Four-puncture laparoscopy was performed for laparoscopic cyst excision using the stripping technique, whereas two-puncture laparoscopy was employed for laparoscopic cyst aspiration. All patients underwent postoperative serial clinical examinations and ultrasound scans for the detection of recurrence.

RESULTS

Four recurrences (4%) were observed in the group that underwent laparoscopic cyst excision, whereas 26 (84%) recurrences occurred in the group that underwent laparoscopic cyst aspiration (P < .0001).

CONCLUSION

Provided that patients are carefully selected according to age and sonographic pattern, enucleation of adnexal masses at operative laparoscopy is the treatment of choice.

The prognostic significance of minimal intracystic vegetations during operative laparoscopy for adnexal masses in women of reproductive age

STUDY OBJECTIVE

To evaluate the prognostic significance of minimal intracystic vegetations in ovarian cysts approached by laparoscopy.

DESIGN

Prospective study.

SETTING

A tertiary care university hospital.

PATIENTS

Ten of 208 women with adnexal cysts and minimal intracystic vegetations, under 40 years of age, carefully selected for operative laparoscopy on the basis of a preoperative sonogram suggestive of a unilocular cyst, with no thick septa or solid components in the absence of ascites.

INTERVENTIONS

Adnexal cyst excision at operative laparoscopy.

MEASUREMENTS AND MAIN RESULTS

In all 208 women evaluation of the abdomen, pelvis, and external surface of the cyst was negative. In 10 patients minimal intracystic vegetations, not detected by preoperative sonography, were identified during endocystic evaluation. In all these cases frozen section examination was negative. Definitive histologic diagnosis confirmed the presence of benign cysts.

CONCLUSION

The presence of minimal intracystic vegetations alone when diagnosed in highly selected patients under 40 years of age may not justify immediate midline laparotomy if frozen section is negative.

Laparoscopy versus microsurgery by laparotomy for excision of ovarian cysts in patients with moderate or severe endometriosis

STUDY OBJECTIVE

To compare the efficacy of laparoscopy versus microsurgery by laparotomy in the treatment of ovarian endometriomas.

DESIGN

Retrospective study with historical controls.

SETTING

A tertiary university hospital.

PATIENTS

One hundred thirty-two women under 40 years of age with ovarian endometriotic cysts at least 3 cm in diameter (stage III and IV endometriosis, R-AFS classification). Interventions. A single surgeon (RM) treated 83 patients by laparoscopy for excision of ovarian endometriomas by the stripping technique and 49 by microsurgery at laparotomy.

MEASUREMENTS AND MAIN RESULTS

Data regarding recurrence of ovarian cysts, symptomatic improvement, and reproductive outcome were comparable for the two groups. Postoperative febrile morbidity and length of hospitalization were significantly less for the laparoscopy group than for the laparotomy group (p <0.0005).

CONCLUSIONS

Operative laparoscopy for excision of ovarian endometrial cysts by the stripping technique is as effective as microsurgery by laparotomy. It is associated with less febrile morbidity and a shorter hospitalization.

Laparoscopically assisted vaginal hysterectomy as an alternative to abdominal hysterectomy. A pilot study

Laparoscopically assisted vaginal hysterectomy (LAVH) allows for conversion of some abdominal hysterectomies to a vaginal route. LAVH may be particularly useful when adnexectomy is indicated. In this study the authors evaluate the results obtained in a series of 21 patients prospectively selected for LAVH. The mean operative time was 96 min (range 58-155), with an estimated blood loss of 218 ml (range 50-510). The mean uterine weight was 320 g (range 105-610). Intraoperative complications were limited to one case of bladder injury which occurred during the vaginal phase of the procedure. No patient required heterologous blood transfusion. No postoperative complications were observed. The average length of hospitalisation was 4.4 days (range 2-9). The authors conclude that LAVH allows for conversion of a significant number of abdominal hysterectomies to a vaginal route and that with respect to the former it is definitely less costly since it allows for earlier hospital discharge and resumal of a normal lifestyle.

Use of fibrin sealant for reproductive surgery: a randomized study in the rabbit model

The present study was undertaken to compare adhesion formation and reproductive outcome after reproductive surgery with or without the application of fibrin sealant. At laparotomy, the ovaries and uterine horns of 20 rabbits were longitudinally incised on the antimesenteric side using a monopolar microneedle. At random, one ovary and the ipsilateral uterine horn were covered with fibrin sealant, while those on the contralateral side were left uncovered without application of sutures. The rabbits were then mated, and 2 weeks later a second-look laparotomy was performed by a blinded observer. No statistically significant differences were found in postoperative adhesions, number of corpora lutea in each ovary, number of embryos in the ipsilateral uterine horn, and nidation index for each side. Fibrin sealant for conservative surgery does not appear to significantly affect either postoperative adhesion formation or reproductive outcome.

Correlation between the American Fertility Society classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery

OBJECTIVE

To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery.

DESIGN

Prospective clinical study.

SETTING

Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy.

PATIENTS

Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery.

INTERVENTIONS

Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques.

MAIN OUTCOME MEASURES

Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used.

RESULTS

There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients.

CONCLUSION

Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.

Laparoscopic findings after transvaginal ultrasound-guided aspiration of ovarian endometriomas

From 1 July 1990 to 31 January 1994, 55 patients underwent operative laparoscopy for the excision of monolateral endometriomas. None of the patients had previously undergone surgery by laparotomy or laparoscopy. At the time of laparoscopy, the surgeon staged the disease according to the American Fertility Society classification of endometriosis. A second surgeon, blinded to the preoperative management of the patients, re-staged the disease based on a videotape review. Interobserver disagreement was between 0 and 12%. Total, endometriosis (deep and superficial) and adhesion scores were evaluated separately. These scores in patients who had previously undergone transvaginal ultrasound-guided aspiration of the cyst content (n = 13) were compared with those from patients who had not undergone this procedure (n = 42). The total and endometriosis scores were not significantly different between the two groups, whereas the adhesion score in patients who had undergone a transvaginal aspiration procedure was significantly higher than in patients who had not (mean +/- SD, 12.0 +/- 13.7 versus 5.9 +/- 4.6; P = 0.02). Therefore it is possible that transvaginal ultrasound-guided endometrioma aspiration may determine tissue trauma that enhances adhesion formation.

Reproductive outcome after ovarian surgery: suturing versus nonsuturing of the ovarian cortex

The purpose of this study was to ascertain if microsurgical approximation of the ovarian edges after ovarian surgery alters postoperative results, as determined by both adhesion formation and reproductive outcome. Sixteen female white New Zealand rabbits were anesthetized, and the ovaries were exposed. Each ovary was longitudinally bivalved with a scalpel, but only one ovary was reconstructed microsurgically, whereas the contralateral ovary was left open. Four weeks after surgery, the rabbits were mated, and two weeks later, a laparotomy was performed to evaluate postoperative adhesions, the number of corpora lutea in each ovary, and the number of embryos in each uterine horn. The nidation index was calculated. No significant differences were found between the microsurgically sutured and the nonsutured ovaries for all the parameters evaluated. Our data suggest that not closing the ovarian incision does not alter either postoperative adhesion formation or reproductive outcome.

Absorbable versus non-absorbable sutures in ovarian microsurgery: experimental results in the rabbit model

Microsurgery has been shown to reduce the risk of adhesion formation when compared to conventional surgery in cases of benign ovarian pathology. However, the microsurgeons have contrasting opinions concerning the use of absorbable versus non-absorbable suture materials. In the present study we compared nylon versus vicryl sutures for ovarian surgery using the rabbit as an experimental model. No differences were found in terms not only of post-operative adhesions but also in terms of post-operative reproductive outcome for the sutures analyzed.