Biomedical subjects
Publications and source records attributed to K Kolmorgen.
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Laparoscopic complications among previously operated patients and patients without prior surgical treatment are compared in a retrospective study during the period 1994-1996. Complications occurred in 2.15% of the 789 (33.2%) previously operated patients and in 1.0% of the 1,588 (66.8%) patients not previously operated. Apart from early conversion to laparotomy if the intraabdominal situation is difficult, approaches recommended to reduce the incidence of severe complications in the case of previously operated patients include, from among the risk-minimized laparoscopic techniques for the Veress needle and optical troicart, the use of open laparoscopy, access from the left mammillary line at the margin of the costal arch and minilaparoscopy. With regard to avoiding severe complications during laparoscopic surgery, attention is drawn to the advantages of conventional surgery (sharp preparation and stitching techniques) as opposed to coagulation techniques, the necessity of exposing the ureter if the situation is unclear and, besides taking all necessary precautions, close visual inspection at the end of laparoscopy.
The high value of laparoscopy for the diagnostic evaluation of appendicitis was established by studying 1001 women with suspected acute adnexitis and a group of 1679 woman patients presenting with chronic pain of unknown origin in the lower abdomen, sterility or the wish for sterilization, among whom a large percentage revealed abnormal appendixes or post-operative adhesion following appendectomy. Both groups underwent laparoscopy. The results allowed for setting up recommendations for the diagnostic evaluation and therapy of both acute and chronic appendicitis from the perspective of gynecological issues such as sterility, chronic or acute pain in the lower abdomen, and endometriosis.
This retrospective study reviews the indications, surgical techniques and complications in 212 laparoscopic myomectomies performed on 150 patients. The indications for laparoscopic myomectomy include myoma with symptoms, irregular menstruation, rapid growth or sterility and pediculate myoma or identified secondary changes without symptoms. Laparoscopy is contraindicated in patients with fibroids larger than 10 cm and extreme localizations such as prevesicular, parametrial and deep intramural myoma in patients desirous of children. Pediculate myomas were resectioned after coagulation or ligation (22.6%), whereas other myomas were enucleated by various other techniques (77.4%). The small intestine of one patient was damaged by alligator forceps. The lesion was noticed the next day as intestinal contents emerged from the Robinson drain. In three other patients, the laparoscopic operation was completed by laparotomy. Laparoscopic myomectomy, the main advantage of which lies in the avoidance of hysterectomy, is recommended, provided the various surgical suturing and morcellation skills are available and the indications and contraindications are observed.
A report is made about 153 women patients who underwent laparoscopic adhesiolysis, and who underwent laparoscopy primarily because of unclear chronic pelvic pain (57.5%), suspected adhesion (13.1%) or sterility (11.7%). For 86.9% of the patients a complete and only for 13.1% an incomplete adhesiolysis was possible. Out of the 123 patients (80.4%) suffering from pain before adhesiolysis 99 (80.5%) patients could be reexamined by questionnaire one to eight years later. 38.0% suffered from no pain any longer, 20.2% stated a clear improvement, 25.5% being temporarily free from pain only, and 16.2% stated unchanged pain. Because of the results laparoscopic adhesiolysis is recommended for women patients with mere adhesions and chronic pelvic pain and for patients without pain with adhesions who are exposed to a danger of ileus.
For estimations of the complaint pattern after comparatable operations per pelviscopiam versus per laparotomiam, in a retrospective study 114 patients after pelviscopic operation and 117 patients after laparotomy were examined. The most important significant differences with an advantage for the pelviscopycally operated patients had been found in asking for postoperative spontaneous miction (84.2% versus 37.2%), spontaneous defecation (68.0% versus 8.1%), the time of completely being free from pain when climbing stair (11.9 compared to 20.8 days), the time when the patient absolutely feel no pain any longer (15.8 compared to 51.7 days), in the average hospitalisation time (3.8 compared to 8.9 days) and the time for unfitness for work (24.5 compared to 48.7 days). Under consideration that also after pelviscopic operations pain occur which are to be treated the present studies confirm the clear improvement of life quality pelviscopic operations.
Three short technical hints are given to make gynaecologic laparoscopy safer.
The report deals with first experience and results of 15 patients who had been oophorectomized per laparoscopiam because of advanced breast cancer. The method applied of the "3-sling-technique", for which Roeder-slings and applicators for the slings are self-made, is considered as practicable and safe method for oophorectomy. However, it may be used for other laparoscopic operations, such as adhesiolysis, myomectomy as well as removal of parovarian cyst, too.
488 women have been asked after abdominal or vaginal hysterectomy by way of retrospective questionnaires about preoperative anxieties, postoperative psychosomatic complaints as well as disturbances of their vita sexualis. 48.6% of the patients had anxieties before operation and anaesthesia. After hysterectomy 71.9% of the women reported about hot flushes and other psycho-vegetative complaints. Although hot flushes occurred significantly more frequent in patients with salpingooophorectomy they could be observed also in one third of the women without removal of the ovaries. However libido, cohabitation frequency and orgasm ability were reduced significantly more frequent in the group of women after hysterectomy with salpingooophorectomy. This is caused by the failing blood supply to the ovary via the branches of the uterine artery. The reduce postoperative psychosomatic complaints as well as sexual dysfunctions it is important to give qualited instructions before and after the operation. On no account should a prophylactic exstirpation of the adnexa be carried out before the age of 50 years. A hormonal substitution is recommended to be done in time even for patients whose ovaries have not been removed suffering from psycho-somatio discomforts.
A report is given on 119 patients suffering from abscessforming adnexitis, mainly tubo-ovarian abscesses (40.3%) and pyosactosalpinges (38.7%). These women were operated on within the first 24 hours after admission to the hospital. Before the operation was performed 70.6% of the women had been submitted to laparoscopy. The other ones (28.4%) had unequivocal primary sign of the disease. Laparoscopic diagnosis is recommended because especially in the early phase of abscess formation no clear diagnosis by clinical examination and paraclinical findings is possible. Operation as early as possible in case of formation of a tubo-ovarian abscess is recommended by reason of the good experience and results which become apparent by small intra- and post-operative complication rate of 1.7% respectively, the short hospital stay of 12.8 days and the short time of risamblement of 53 days. The extent of the operation should depend on degree of severity of the illness, reproductive aspects.
59 patients with acute pelvic inflammatory diseases proved and classified by laparoscopy were treated by two kinds of therapies in alternating order. Dispensing with physical measures 27 patients were given ampicilline and metronidazol for 10 days, 32 patients being additionally given prednisolone. The treatment results of both groups during hospital treatment and results during second-look-laparoscopy carried out two months later with chromopertubation have been compared. In the group treated with prednisolone fever was reduced more rapidly and a normalisation of erythrocyte sedimentation rate could be ascertained. However, leukocytosis persisted for a longer time. Also, in connection with the checking of the free passage of the tubes no differences could be detected between the two therapy concepts. 70.6% of the women treated with prednisolone did not have any genital adhesions. Those women who were not treated with it had no such adhesions in 53% of the cases. It is recommended to test the positive adhesion-stopping effect of an additional therapy with prednisolone by bigger, prospective series of examinations.
A report is given on the findings of second-look-laparoscopy in 229 patients with condition after laparoscopically ascertained and classified inflammations of the adnexes which were treated on the basis of uniform criteria. We also want to report about the pregnancy rate dependent upon the degree of severity of the inflammation in 121 patients. It could be proved with absolute certainty that there was a dependence of the frequency of pathologic changes of the tubes with negative chromopertubation on the degree of severity of the preceding illness and also on the kind of the causative organisms. The most frequent pathologic findings came up after advanced fibrinous-suppurative inflammations as well as after gonorrhoic inflammations of the adnexes, the latter not depending on the degree of severity. The pregnancy rate, 1-5 years after treated salpingitis, for patients having the wish to deliver a child, came to 72.5% after serous salpingitis, 72.2% after operation of the adnex on one side and 59.1% after fibrinous-suppurative salpingitis. In connection with the demand for general laparoscopic diagnostics of the inflammable illnesses of the adnexes it is important to point to the necessity of early registration and treatment as well as to the cultural diagnostics of gonorrhoea. In the case of abscesses of the adnexes on one side and wish to deliver a child immediate operation is recommended.(ABSTRACT TRUNCATED AT 250 WORDS)
Statistic from 81 women hospitals in which a total of 35,013 laparoscopies had been made figures were collected by means of questionnaires (inquiry forms). The largest increase of laparoscopies (56.2%) could be found since 1980. Results showed that in 48 hospitals (59.3%) less than 50 laparoscopies were made per year. In all hospitals laparoscopy was performed under clinical conditions by the gynaecologist, mainly using endotracheal anesthesia (96.3%). 20 hospitals (24.7%) are able to perform laparoscopies in the day-time only. More than 90% of the questioned ones regarded thoracic roentgenogram, electrocardiogram as well as urine examination and hemoglobin determination as sufficient pre-examinations. 70.4% of the questioned hospitals demand a written confirmation that before the operation was carried out appropriate instructions had been given. The technical performance of laparoscopy corresponds to today's usual practice. For the pneumoperitoneum, for which 51.8% of the hospitals use an automatic system, CO2 (6.7%) is preferred. Patients are dismissed from hospital on 1st (19.8%), 2nd (50.6%) or 3rd day after the operation and later in 29.5% of the cases. Women are unable to work for an average of eight days following laparoscopy.
In 81 women's hospital, in which 35,013 gynaecological laparoscopies were made, 42.9% of the specialists are able to perform laparoscopies by themselves. 51.9% of the questioned hospital directors recommend learning how to perform laparoscopies during specialization, and 48.1% plead for laparoscopy training only for gynaecologic specialists. 64.2% of the questioned ones were in favour of laparoscopy courses. Performance of diagnostic laparoscopies was recommended for all gynaecological institutions by 82.7%. In the opinion of the majority (74.8%) operative laparoscopies should be done only in larger central hospitals. It was generally agreed that chronic diseases of the lower abdomen, sterility and suspected ectopic pregnancy are indications for laparoscopy. Other acute complaints have been diagnosed less frequently by means of laparoscopy. Second-look-laparoscopies were made by 59.3% and 55.6% of the questioned doctors, mainly for checking the situation operations because of ovarian cancer and sterility. In 61.1% of all hospitals other diagnostic and therapeutic operations per laparoscopiam are done. The rate of severe complications was 0.21%, and the mortality rate amounted to 0.057%.
First experiences and results in 14 tubal pregnancies are reported operated on by laparoscopy. In 11 cases the tubes were removed. In 3 patients there was a conservative operation with preservation of the tubes. A laparotomy had to be done in one patient for a hemorrhage from the mesosalpinx. Duration of stay in the hospital lasts from 4 to 5 days. Second-look-laparoscopies of 9 patients whose fallopian tubes had been removed resulted in 7 normal findings. In two cases there were adhesions between omentum majus and uterus on that side operated on. Following expressions of the gestational sac in two patients there was one normal tube and in the other one slight peritubal adhesions. Two patients who were operated on conservatively had been delivered afterwards.
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Cultures of abdominal bioptic material from 102 cases of acute pelvic inflammatory disease diagnosed laparoscopically revealed that anaerobes were involved in 42.2% of the cases; 18.6% of the cultures were sterile. There were no signs that anaerobes predominate in cases, in which an abscess has already formed. The proportion of predominantly polymicrobial multiple infections was 54.2%, the remaining 45.8% of the cases involving mono-microbial infection. Scrutiny of the abdominal and cervical distribution of the germs in 42 of our female patients confirmed that cervical smears are inadequate for detecting the causal germ involved in a case of acute pelvic laparoscopy it seems advisable to use abdominal cultures of tissue taken from the locality of the inflammation in order to identify exactly the causal germ and to test these cultures also for anaerobes and gonococci.
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