Biomedical subjects
Publications and source records attributed to S G Kaali.
A retrospective review of 4,532 outpatient laparoscopic procedures was conducted to determine the frequency of dense bowel adhesions at the level of the umbilicus. The umbilicus is the classical site of entry for the laparoscopic trocar. Using direct trocar insertion in all cases we encountered four bowel injuries. Bowel adhesion to the insertion site was noted in one case.
A randomized, prospective trial was designed to compare direct trocar insertion with prior peritoneal insufflation with a Verres needle for laparoscopic tubal sterilization. Direct trocar insertion resulted in fewer instrument insertions (21.8% vs. 7.8%) and use of smaller volumes of CO2 (2.67 vs. 2.32 L). Direct trocar use resulted in a decrease in operating time from 9 minutes, 40 seconds in the needle group to 7 minutes, 30 seconds in the trocar group. Minor omental injuries occurred in a small percentage of each group, while serious complications occurred once in each group.
We performed 2976 first-trimester abortions at our outpatient center in 1986. In 16 cases (0.54%), products of conception could not be confirmed histologically, although history, bimanual pelvic examination, and urine pregnancy test were suggestive of pregnancy. In 1987-1988, we prospectively evaluated 6689 women presenting for first-trimester abortions. Adding sonography and a semiquantitative serum hCG test to our earlier protocol, we were able to date and locate accurately 6510 pregnancies (97.3%) at the first visit. The remaining 179 patients (2.7%) required only one follow-up visit for final evaluation. This protocol reduced the number of visits for accurate evaluation of pregnancy and eliminated the risk of unnecessary curettage and unplanned second-trimester abortions.
Transvaginal sonography represents a new tool for the gynecological diagnosis and decision making. The authors present theoretical and practical aspects of transvaginal sonography with special emphasis on the 6.5 MHz vaginal probe. Based on one thousand one hundred and eight examinations it is obvious that this procedure is valuable in diagnostic algorithm of ectopic pregnancy and to follow follicular growth, as well as ultrasound guided oocyte retrieval.
The frequency and management of uterine perforation during first-trimester abortions remain a matter of continuing debate among gynecologists. The rate of uterine perforations was 1.3/1000 procedures (eight cases) in 6408 women undergoing first-trimester abortions at our clinic. We also performed 706 first-trimester abortions at the time of laparoscopic sterilization. Two perforations (2.8/1000 procedures) were reported before laparoscopy. Twelve (15.6/1000 procedures) unsuspected perforations were discovered during direct laparoscopic visualization. This represents a 19.8/1000 procedure rate of perforation (14 cases). All 22 patients with perforations were managed conservatively, and no immediate or late complications were noted. Our data suggest that the true incidence of uterine perforations is significantly underestimated and serious complications caused by perforations are rare. Conservative therapy is recommended rather than early surgical intervention.
An oocyte donor program was established at the Women's Medical Pavilion, Dobbs Ferry, New York, in 1987 for women lacking normal ovarian function. The oocytes were donated voluntarily in stimulated cycles by women undergoing laparoscopic sterilization. If the donors agreed to use ovulation-induction agents and be monitored, they were compensated for their time and inconvenience. Between Nov 15, 1987, and Feb 15, 1988, 194 laparoscopic sterilizations were performed. Only 41 women (21%) met certain of the eligibility criteria. Of the remaining group, only five (12%) agreed to participate. The preliminary results suggest that tubal ligation patients are reluctant to donate oocytes despite enthusiastic counseling, the relatively small risks involved and offers of financial compensation.
First-trimester suction curettage abortion performed at the time of laparoscopic sterilization does not increase the morbidity or failure rate of either procedure. No studies have been done to determine the safety of laparoscopic sterilization in association with midtrimester pregnancy termination by dilation and evacuation. Between Jan 1, 1987, and Feb 1, 1988, we performed 21 laparoscopic sterilizations at the time of second-trimester terminations of pregnancy. There were no failed procedures or postoperative complications. With proper instrumentation and surgical skill, laparoscopic sterilization can be performed in this group of patients.
Many surgeons believe that women who have undergone laparotomy are not good candidates for laparoscopic sterilization. Many of those women are admitted for minilaparotomy. However, women without previous surgery can also have adhesions. We compared the incidence of significant adhesions in women with and without histories of abdominal surgery. We also examined the outcomes in each group after 955 laparoscopic sterilizations. Two hundred sixty-three women (28%) had had previous surgery. Of them, 61 (23%) displayed significant adhesions. Of the remaining 692 patients, 19 (2.7%) had significant adhesions. There were no major complications in either group. Thus, a history of previous abdominal or pelvic procedures increased the risk of significant adhesion formation nearly tenfold. Since no major complications occurred in those women, we conclude that while such patients are at increased risk, that risk is not inordinate and does not justify the routine use of minilaparotomy.
Direct insertion of the laparoscopic trocar without the aid of a prior pneumoperitoneum has been described previously. Prior laparotomy has been cited as a contraindication to this technique. At our free-standing ambulatory surgical unit, 1,670 consecutive laparoscopies utilizing direct insertion of the trocar were performed during a four-year period. Four hundred sixteen women had had previous abdominal surgery. One bowel injury occurred in this group. A patient without prior surgery sustained an intraabdominal laceration requiring further surgery and hospitalization. Based on this experience, we do not find previous abdominal surgery to be a contraindication to the use of direct insertion of the laparoscopic trocar.
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A retrospective study regarding long-term sequelae among 818 randomly selected patients undergoing elective laparoscopic tubal sterilization is presented. These procedures were carried out at the Women's Medical Pavilion in Dobbs Ferry, NY, a free-standing surgical unit, between January 1, 1980 and June 30, 1985. A questionnaire was sent to each patient's last known address and, at the same time, attempts were made to contact them by telephone; 623 patients were reached and assessed as to satisfaction with tubal ligation, any ensuing menstrual changes requiring a D&C, and/or psychological problems. Also determined was the number of patients in the series who failed to continue routine gynecological care. It was found that the incidence of dissatisfaction with the operation was 2.9%, of undesired menstrual changes, 4.8%, and of psychiatric morbidity, 8.2%. These results were also correlated with the data of our medical records. In our series, 16.9% of the women failed to continue routine gynecological care. The necessity of thorough counseling by strict guidelines and the need for follow-up are discussed.