Extrinsic stretching, narrowing and anterior indentation of the rectosigmoid junction.
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Barium Sulfate↗
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Results for “DOUGLAS' POUCH”
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Intraperitoneal spread of malignancies and its effect on the bowel.
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Ascitic Fluid↗
Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection.
OBJECTIVE: To evaluate symptom relief following a laparoscopic technique designed for treatment of complete obliteration of the cul-de-sac associated with endometriosis, with fertility preserved. DESIGN: Preoperative and postoperative questionnaire study of a cohort of patients with complete obliteration of the cul-de-sac undergoing a standardized laparoscopic surgical treatment. SETTING: American tertiary referral center for the surgical treatment of endometriosis. PATIENTS: Eighty-four consecutive patients undergoing laparoscopic treatment of endometriosis with complete cul-de-sac obliteration with 67 replying to a postoperative questionnaire. INTERVENTIONS: Laparoscopic excision of all endometriosis including treatment of complete obliteration of the cul-de-sac by en bloc resection and bowel resection as needed. MAIN OUTCOME MEASURES: Symptom relief as measured on a 5-point ranked ordinal scale administered before and after surgery, as well as perioperative complications, postoperative fertility, and prognostic value of preoperative findings on pelvic examination. RESULTS: Symptom reduction was obtained for all symptoms related to cul-de-sac disease, particularly for patients with severe or debilitating symptoms preoperatively. There was no significant complication, and the postoperative fertility rate was 43%. Seventy-three percent of patients with obliteration of the cul-de-sac had histologically proved rectal endometriosis. Nodularity and tenderness on examination were predictive of symptom improvement. CONCLUSIONS: Aggressive laparoscopic excision of endometriosis carried out in a specialist center offers good symptom relief, especially for those with severe or debilitating symptoms. To ensure complete removal of all disease, intestinal surgery is required in most patients with complete obliteration of the cul-de-sac.
Adult↗
Use of intraperitoneal interferon alpha-2b therapy after conservative surgery for endometriosis and postoperative medical treatment with depot gonadotropin-releasing hormone analog: a randomized clinical trial.
OBJECTIVE: To evaluate the possible therapeutic effects of interferon alpha-2b left in the peritoneum after surgery, followed by or not followed by treatment with GnRH analogs. DESIGN: A prospective, randomized clinical trial. SETTING: University hospital. PATIENT(S): Fifty-two infertile patients with moderate or severe endometriosis. INTERVENTION(S): Laparotomic conservative surgery and either interferon alpha-2b or saline alone left in the pouch of Douglas followed by administration of either GnRH analogs depot or oral indomethacin with transvaginal echography and analysis of CA-125, immunoglobulins, and lymphocyte populations. MAIN OUTCOME MEASURE(S): Recurrence of endometriosis was considered clinically, echographically, and laparoscopically. RESULT(S): Recurrence of endometriosis in four cases without interferon (15.4%) versus 11 patients (42.3%) with interferon alpha-2b. Life table analysis showed significant differences between the groups with and without interferon 21 months after conservative surgery. There were no differences in the recurrence between the groups with or without GnRH analogs. Likewise, there were no significant changes in immunoglobulins and lymphocyte populations among patients with and without recurrence of endometriosis. The patients that received GnRH analogs depot showed a decrease in the number of CD16 and an increase of CD11b cells after treatment. CONCLUSION(S): The use of interferon alpha-2b within the peritoneal cavity after conservative surgery may be inappropriate because it increased later recurrence of endometriosis. The postoperative treatment with GnRH analogs did not significantly reduce the recurrence rate. Immunoglobulins and lymphocyte populations did not change in relation to the recurrence of endometriosis.
Adult↗
Exploratory culdotomy in diagnosis of adnexal disease.
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Adnexal Diseases↗
Collection of human oocytes by the use of sonography.
A technique for ultrasonically guided percutaneous oocyte aspiration was developed utilizing standard real-time, linear-array ultrasound equipment. Forty-four patients attending our in vitro fertilization and embryo transfer (IVF-ET) program were included in this study. In 38 patients, follicular puncture was performed under general anesthesia and in 6 cases performed under local anesthesia. Fifty-two follicles with a mean diameter greater than or equal to 18 mm were punctured, and 40 mature oocytes were recovered corresponding to a success rate of 77% per follicle. Six of the punctured follicles were considered cystic when the aspirated granulosa cells were examined microscopically and, if these were excluded, the corrected recovery rate was 87% per follicle. In two patients, ovulation had occurred at the time for oocyte collection. In one of these patients, a mature oocyte was, however, recovered from the pouch of Douglas by the use of sonography. On the basis of these results, ultrasonically guided puncture of follicles for collection of human oocytes in our IVF-ET program seems suitable for use in all cases where laparoscopy is presently used and, moreover, in cases with severe adhesions, where laparoscopy may fail.
Embryo Transfer↗
Peritoneal endometriosis: scanning electron microscopy and histology of minimal pelvic endometriotic lesions.
In 36 patients with laparoscopically diagnosed endometriosis, biopsies were taken from different areas of the pelvic peritoneum bearing foci of endometriosis. The biopsies were studied by scanning electron microscopy and by light microscopy. Combined use of these techniques resulted in the differentiation of three topographically and morphologically different types of endometriotic lesions: intraperitoneal endometriotic polyps with no glandular openings but associated with deeper endometriotic glands and stroma; intraperitoneal endometriotic foci with surface epithelium, glands, and stroma; and retroperitoneal small lesions with few glands and scant stroma. The morphologic features of endometriotic foci indicate that they do not follow the typical cyclic changes described for the uterine endometrium. Our microanatomic characterization of endometriosis is discussed in relation to the conflicting data concerning peritoneal fluid constituents and infertility in patients with minimal endometriotic lesions.
Biopsy↗
Deeply infiltrating pelvic endometriosis: histology and clinical significance.
In 179 consecutive laparoscopies for infertility (n = 105), pain (n = 60), or both problems (n = 14), endometriosis was diagnosed in 77%, 82%, and 86%, respectively. Eighty implants with positive histology and with careful assessment of depth were sampled by CO2 laser excision from 53 patients. Deep (greater than or equal to 5 mm), intermediate (2 to 4 mm), and superficial (less than 1 mm) infiltration was found in 48%, 35%, and 17% of implants, respectively. Deep infiltration was observed in the pouch of Douglas (55%) and at the uterosacrals (34%), but was absent from the ovarian fossas. Deep implants were found to be active in 68%. At an intermediate depth, however, only 25% of implants were active, whereas 58% of superficial foci showed activity. Deep implants were in phase with the endometrium in 74%. At an intermediate depth, however, only 38% showed regular cyclicity, whereas 57% of superficial implants were in phase with the cycle. Deep infiltration occurred through loose connective tissue septa into the fibromuscular tissue and was always stopped at the underlying fat tissue. Very deep implants (greater than 10 mm) were found exclusively in patients with pain; superficial implants, on the contrary, were found most frequently in patients with infertility (83%).
Age Factors↗
Fallopian tubes and ultrasonography: the Sion experience.
OBJECTIVE: To compare the accuracy of three new ultrasonographic methods of detecting tubal patency and pathology with established methods like hysterosalpingography (HSG) and laparoscopy. DESIGN: Sixty-seven cases were evaluated by performing the Sion test using endosonography to check for tubal patency. The Sion procedure includes filling up the pouch of Douglas with approximately 300 mL of sterile normal saline to elucidate not only the patency but visualize the motility, the fimbriae, and peritubal adhesions, if present. We have compared the accuracy of this procedure with HSG and laparoscopy in 24 infertile women. Color-coded duplex Doppler sonography was used in 38 patients to check for tubal patency. RESULTS: Our experience at the Sion Hospital using the three new ultrasonographic techniques for evaluating the status of the fallopian tubes is very encouraging. The accuracy with the three modes shows agreement in > 90% of cases with established investigative modalities such as HSG and laparoscopy. CONCLUSION: These three new investigative modalities are offered not as substitutes for HSG, laparoscopy, hysteroscopy, or salpingoscopy but as office-screening procedures that would be complementary to the armamentarium of infertility investigations already available.
Fallopian Tube Patency Tests↗
Cul-de-sac fluid in women with endometriosis: fluid volume, protein and prostanoid concentration during the periovulatory period--days 13 to 18.
Cul-de-sac fluid from women with histologically confirmed endometriosis (n = 45) or from infertile women without evidence of endometriosis (n = 28) was collected at the time of laparoscopy during the periovulatory period (days 13 to 18). This fluid was analyzed for prostaglandin E2 (PGE2), prostaglandin F2a (PGF2a), 13,14-dihydro-15 keto-PGF2a (PGFM), and thromboxane B2 (TXB2) by radioimmunoassay (RIA). Protein content of the fluid also was determined. No difference (P greater than 0.05) in cul-de-sac fluid volume was found between women with and without endometriosis, nor were differences detected in the level of any of the prostanoids measured in fluid from infertile control patients compared with those with endometriosis. This was true regardless of whether the prostanoids were expressed as a concentration, total amount in fluid, or as a ratio of prostanoid to protein content. The present study does not support the theory that cul-de-sac fluid prostanoids provide a useful diagnostic index of endometriosis.
Body Fluids↗
The fertilization and cleavage rates of eggs recovered from the cul-de-sac.
Five hundred ninety-one oocytes were laparoscopically recovered in 93 consecutive stimulated cycles. Fifty-three of the 591 oocytes were collected from the cul-de-sac in 39 cycles. The cul-de-sac-originated oocytes had fertilization and cleavage rates of 72 and 79%, respectively; these rates were similar to those achieved in oocytes originating from follicles. A significant decrease in the fertilization rate of cul-de-sac-originated oocytes was noticed in oocytes collected from the cul-de-sac 60 minutes or more after the beginning of the procedure. Oocytes collected from the cul-de-sac yielded 21% of the embryos transferred in cycles where some of the oocytes were recovered from the cul-de-sac. These findings indicate that repeated aspirations of the cul-de-sac may increase the number of embryos transferred.
Body Fluids↗
Can noninvasive diagnostic tools predict tubal rupture or active bleeding in patients with tubal pregnancy?
OBJECTIVE: To evaluate the ability of noninvasive diagnostic tools to predict tubal rupture and active bleeding in patients with tubal pregnancy. DESIGN: Prospective cohort study. SETTING: Two large teaching hospitals in Amsterdam, The Netherlands. PATIENT(S): Consecutively seen patients with suspected tubal pregnancy who were scheduled to undergo confirmative laparoscopy. MAIN OUTCOME MEASURE(S): Tubal rupture and/or active bleeding confirmed at laparoscopy. RESULT(S): Sixty-five (23%) of 288 patients had tubal rupture and/or active bleeding at laparoscopy. Abdominal pain, rebound tenderness on abdominal examination, fluid in the pouch of Douglas at transvaginal ultrasound examination, and a low serum hemoglobin level were independent predictors of tubal rupture and/or active bleeding. Pregnancy achieved with the use of IVF-ET and the presence of an ectopic gestational sac or an ectopic mass at ultrasound examination reduced the risk of tubal rupture. Abdominal pain was the most sensitive predictor, with a sensitivity of 95%. CONCLUSION(S): Because the nonsurgical management of tubal pregnancy should be used only when the risk of tubal rupture and/or active bleeding is low, it can be safely applied in only a limited number of patients.
Adult↗
Transvaginal repair of enterocele.
The urologist actively involved in the treatment of female genitourinary disease must to be able to recognize and treat various forms of pelvic prolapse. Enterocele is commonly seen in conjunction with stress urinary incontinence and cystocele or it may result from surgery to correct these problems. Many techniques to correct enterocele have been developed, including transvaginal repairs as well as intra-abdominal procedures such as the Moschcowitz technique or colpofixation to the sacrum for enterocele with vault prolapse. Surgical management of enterocele must take into account several factors, including the presence of stress urinary incontinence, rectocele, vaginal vault prolapse, prior hysterectomy and the desire to maintain sexual activity. Based on these considerations we discuss our approach to the transvaginal repair of enterocele. In patients without vault prolapse a simple enterocele repair is performed. If vault prolapse is present, then the condition of the anterior vaginal wall is considered. In patients with a cystocele a vault suspension procedure is performed, which involves simultaneous suspension of the uterosacral-cardinal ligament complex and vaginal vault along with the bladder neck and bladder. There are 2 modifications of this technique depending on the degree of cystocele: the 4-corner vault suspension for grades 2 and 3 cystocele, and the vault suspension with grade 4 cystocele repair. Patients with vault prolapse and no cystocele undergo sacrospinous ligament fixation. In elderly patients who are not sexually active, especially if they are in poor medical condition, partial colpocleisis is considered. In these patients partial colpocleisis was not performed as a primary procedure but it was done later in 3 who failed an initial attempt at repair. All coexisting vaginal pathology is fixed at the time of enterocele repair. A total of 83 patients underwent enterocele repair according to this protocol and 81 were available for followup. Mean followup was 15 months (range 3 to 70). Overall a successful result (no recurrence) was achieved in 70 patients (86%). Success for individual procedures was 40 of 49 (82%) for simple repair, 24 of 25 (96%) for vault suspension and 6 of 7 (86%) for sacrospinous fixation. In all cases vault suspension or sacrospinous fixation was able to restore vaginal depth and axis with minimal or no vaginal shortening.
Aged↗
Laparoscopic suture hysteropexy for uterine prolapse.
OBJECTIVE: Vaginal hysterectomy remains the accepted surgical treatment for women with uterine prolapse. The Manchester repair is favored in women wishing uterine preservation. Vaginal hysterectomy alone fails to address the pathologic cause of the uterine prolapse. The Manchester repair has a high failure rate and may cause difficulty sampling the cervix and uterus in the future. The laparoscopic suture hysteropexy offers physiologic repair of uterine prolapse. METHOD: At the laparoscopic suture hysteropexy, the pouch of Douglas is closed and the uterosacral ligaments are plicated and reattached to the cervix. RESULTS: Forty-three women with symptomatic uterine prolapse were prospectively evaluated and underwent laparoscopic suture hysteropexy with a mean follow-up of 12 +/- 7 months (range 6-32). The mean operating time for the laparoscopic suture hysteropexy alone was 42 +/- 15 minutes (range 22-121), and the mean blood loss was less than 50 mL. On review, 35 women (81%) had no symptoms of prolapse and 34 (79%) had no objective evidence of uterine prolapse. Two women subsequently completed term pregnancies and were without prolapse. Both underwent elective cesarean delivery. CONCLUSION: The laparoscopic suture hysteropexy is effective and safe in the management of symptomatic uterine prolapse. The result is physiologically correct, without disfiguring the cervix. This may be an appropriate procedure for women with uterine prolapse wishing uterine preservation.
Adult↗
Commentary on: "Posterior culdeplasty: surgical correction of enterocele during vaginal hysterectomy: A preliminary report". 1957.
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Douglas' Pouch↗
Gallstones presenting as a cul-de-sac mass.
BACKGROUND: Pelvic masses requiring surgical evaluation have many different causes. CASE: In an unusual case, a pelvic mass was found to comprise approximately 40 gallstones. Laparoscopy was performed, and the gallstones were removed easily. CONCLUSION: Nongynecologic causes should be considered in the differential diagnosis of pelvic masses.
Adult↗
Intestinal cul-de-sac phenomena in man.
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Digestive System Surgical Procedures↗
Accuracy of grey-scale ultrasound diagnosis of abdominal and pelvic abscesses in 220 patients.
The accuracy of grey-scale ultrasound in the detection and localisation of abdominal and pelvic abscesses was assessed retrospectively in 220 patients in whom an abscess had been suspected at presentation. Thirty-six out of forty abdominal abscesses were correctly diagnosed (90%), while an abscess was correctly excluded in 112 out of 113 patients (99%). Thirty-two out of thirty-three pelvic abscesses were diagnosed (97%), and a pelvic abscess was correctly excluded in 33 out of 34 patients (97%). Thus the overall accuracy of the method was 96.8%, with a sensitivity of 93% and a specificity of 98.6%.
Abdomen↗