Gynecology

Laparoscopic Hysterectomy and Health Care in America -Finding the Balance Between Costs and Outcomes

The mean uterine weight was 146 g (60-569 g). The mean operating time was 94 minutes (60-225 min.). Actual morcellation time was available in 19 cases by reviewing videotape with an average morcellation time of 11.8 minutes (4-23 min.). Average blood loss was 125 cc (20-600 cc) with one case of late postoperative bleeding requiring operative intervention. The average cost for the procedure was $7,998 ($6,989 - $11,581). Thirty-six patients were discharged within 23 hours from the time of admission and all patients were discharged within 48 hours of the time of admission.

In spite of readily available alternatives to hysterectomy such as endometrial ablation, hysterectomy rates have not fallen. Several comparative trials of hysterectomy have shown shorter hospital stay and convalescence after laparoscopic approach compared to an abdominal approach.

The diagnosis of uterine and/or tubal pathology as causes of female infertility represents a fundamental step in the evaluation of the infertile couple. Apart from the invasive diagnostic procedures, several others diagnostic techniques useful to the clinical evaluation of the uterine cavity and tubal anatomy are: transvaginal sonography (TVS), hysterosalpingography (HSG), hysteroscopy and hydrosonography (HDS) and laparoscopy.

Laparoscopic staging of apparent early ovarian cancer may be accomplished in patients where disease appears limited to the adnexa. For example a completely resected complex adnexal mass with intraoperative frozen-section revealing malignancy and no obvious limitation to complete laparoscopic staging.

The role of reproductive surgery has been questioned in the current environment of improving techniques and success rates with in vitro fertilization (IVF). Another emerging obstacle is the declining number of these types of surgeries being performed in response to the increasing numbers of patients opting for IVF.

Since the first laparoscopy was performed in humans by Jacobaeus in 1910, great strides have been made by surgeons in utilizing this valuable tool.1 Unfortunately, the expense of performing even diagnostic laparoscopy has become prohibitive. With the high cost of medical care, measures must be taken to decrease this monumental problem. For years, laparoscopy has been performed under local anesthesia with minimal reported complications.

Reported in the literature are more than 100 different kinds of surgical treatments for stress urinary incontinence in women, including anterior colporrhaphy (Kelly plication), retropubic urethropexy (Marshall-Marchetti-Krantz procedure, Burch procedure, ), paravaginal suspension, various kinds of needle urethropexy, and suburethral sling procedure.

Uterine myomas are the most common tumors of the female genital tract. = Hysterectomy has been a very common therapy in patients who have completed reproduction. In fact, uterine myomas = account for 20% of the 650,000 hysterectomies performed annually in the United States. Interest in uterine = preservation and organ preserving surgery through techniques of minimally invasive surgery has increased since the first = reports of laparoscopic myomectomy in 1980.

Laparoscopic urinary bladder surgery primarily involves retropubic bladder neck suspension procedures. Because variations of the laparoscopic Burch procedure (Tanagho, Hodgkinson) are most frequently performed, this chapter will focus on the complications of the laparoscopic Burch procedure - avoidance, recognition, and treatment.

Over the past decade, a technique has been developed that can reduce or stop your periods without a hysterectomy. This surgery can be done in women who have flooding either with or without fibroid tumors. Dr. Dott was one of the surgeons who introduced this minimally invasive procedure in Atlanta. He has performed this procedure many times and is certified by the Accreditation Council for Gynecological Endoscopy in Advanced Hysteroscopic Surgery. He has taught this procedure in training institutions both in the United States and Russia.

Laparoscopic hysterectomy was first described in 1989 (Reich) and rapidly thereafter in 1991 laparoscopic pelvic lymphadenectomy was also described (Querleu). During the 1990s the role of pelvic and latterly para aortic lymphadenectomy has been extended and is now an integral part of best practice Gynaecological Oncology Departments.

After more than 50 years, pneumoperitoneum with carbon dioxide remains the standard for creating a working space for laparoscopic surgery. Although the physiologic problems resulting from CO2 pneumoperitoneum have been well documented, they are becoming more of a concern as older, more debilitated women are undergoing longer, more extensive laparoscopic procedures

Hysterectomy continues to be a common gynecologic operation. Approximately 600,000 patients undergo surgical removal of the uterus annually at a considerable cost to payers, patients, and society at large. Currently most hysterectomies are via the abdominal or vaginal approach but fortunately for patients laparoscopic assisted procedures are becoming more popular. Many studies have shown the laparoscopic approach as safe, effective, and a less intrusive alternative to open surgery.

Dr. J. B. Dubuisson began the great debated entitled Laparoscopic Myomectomy is a Safe Procedure by outlining the conditions under which laparoscopic myomectomy is a safe procedure.

Transvaginal hydro laparoscopy (THL) is a new approach to pelvic anatomic evaluation in the infertile woman. In this procedure a dilating trocar is inserted through the osterior vaginal wall for endoscopic pelvic examination. Normal saline is used to float the bowel out of the pelvis so that one can evaluate the distal Fallopian tubes, ovarian surfaces, pelvic sidewalls, and the cul-de-sac. The THL procedure makes in-office pelvic endoscopy, hysteroscopy, and dye hydrotubation a reality.

In the last 20 years there has been an increased acceptance of hysteroscopic surgery into the gynecological surgical armamentarium. Endometrial ablation and resection offer viable alternatives to hysterectomy for women with intractable uterine bleeding.

Laparoscopy has revolutionized the practice of modern operative gynecology and has progressed from simple diagnostic work to advanced operative procedures.[

More than ten years have passed by since we first performed a laparoscopic myomectomy in our Department using Semm’s technique. As far as a subserous myoma is concerned, there are no particular problems; difficulties arise when dealing with intramural myomas.

From its beginnings back in 1991, in our Department, the laparoscopic approach to pelvic prolapse has changed considerably over the decade. Initially limited to strict reproduction of the techniques carried out by laparotomy, the introduction of a number of complementary procedures has provided an answer to all the situations encountered in the field of female genital prolapse repair.

Diagnosis and treatment of endometriosis is the most frequent reason for gynecologic operative laparoscopy in the United States (Peterson et al,1990). Therefore, the laparoscopist must be thoroughly familiar with the current standards of diagnosis and management of this complex disease.

The first laparoscopic lymphadenectomy was reported in the late 1980’s and safety of this procedure has been largely proved. Familiarity with instrumentation and management of complication is a prerequisite to perform this procedure.

Introduction: Intestinal endometriosis is a disabling disease present in 6% to 30% of deep endometriosis cases. It can be the cause of abdominal bloating, constipation, intestinal cramping and painful bowel movements, defecation pain and intestinal stenosis up to intestinal occlusion. Colorectal endometriosis requires surgical treatment that can be performed by abdominal route or by laparoscopy. The present study describes the total laparoscopic rectosigmoid resection in case of deep endometriosis with bowel involvement.

After having been almost abandoned, supracervical hysterectomy has been recently re-advocated, especially after the development of laparoscopy, because it is stated to have less morbidity and minor intra-operative complications. However, long term outcomes report high incidences of late complications

Electro-surgery is very important in operative endoscopic surgery and probably represents the cheapest way to carry out a section and a coagulation.

Vaginal hysterectomy can be the standard procedure for removing the uterus, but surgical skills and indications to vaginal surgery are variable. Laparoscopic assistance to vaginal hysterectomy is a way to change the approach to hysterectomy. In this paper we describe our retroperitoneal technique for laparoscopic securing of the uterine pedicles.

The patient was a 30 year old female patient, para 0, who was diagnosed to have a cervical adenocarcinoma on a screening PAP smear. A subsequent endocervical curettage revealed a moderately differentiated adenocarcinoma with focal invasion. She underwent a cone biopsy and a repeated endocervical curettage which revealed an adenocarcinoma in situ with two foci of microinvasion consisting with a Stage IA2 lesion.

To interpret the literature describing the results of surgery for endometriosis, a clear understanding of the evolution and limitations of the various techniques is necessary. Up to the end of the 1970’s, minimal and mild endometriosis was destroyed endoscopically by heat application (endothermia) and by unipolar or bipolar coagulation. Treatment of more severe endometriotic disease was mostly radical by hysterectomy, often leaving some rectovaginal endometriosis which has not been fully recognised before 1989.

Endometriosis can infiltrate the surrounding tissues resulting in an important sclerotic, and inflammatory reaction which can translate clinically in nodularity, bowel stenosis and ureteral obstruction. The most severe forms such as rectovaginal endometriosis and endometriosis invading the rectum or the sigmoid have been known since the beginning of this century. These conditions, however, are relatively rare with an estimated prevalence of less than 1%.

Laparoscopy, looking inside the abdomen through a tube placed through a small incision, is a procedure commonly used by gynecologists to diagnose and treat a number of medical conditions. Since the early 1900's when rudimentary laparoscopes were used to visualize, but not treat, abdominal diseases, advancements in this technique have led to the ability to perform complex surgical procedures through a few small incisions, rather than the larger incisions used in the past.