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PubMed1988

Ultrasound versus culdocentesis in the evaluation of early and late ectopic pregnancy.

A retrospective study of patients found to have ectopic pregnancy was undertaken to determine the relative usefulness of culdocentesis and ultrasound in the evaluation of early and late presentations. The patient's history was used as the sole determinant of gestational age, and results of culdocentesis and/or ultrasound were reviewed. In early presentations (less than 42 days gestation), 38% of ultrasound examinations and 89% of culdocenteses performed were positive. In late presentations, 93% of ultrasound examinations and 70% of culdocenteses performed were positive. The difference between the modalities' performance was significant (P less than .05) for both early and late presentations. These data could provide the basis for a prospective study to test the hypothesis that culdocentesis is the diagnostic test of choice in early suspected ectopic pregnancy, whereas ultrasound is more likely to yield clinically useful information in patients presenting after six weeks gestation.

Douglas' Pouch↗
PubMed2000

Benign cystic teratoma of the douglas.

We report a case of a benign cystic teratoma in a 30-year-old woman who underwent laparoscopy for a persisting pelvic mass in the posterior cul-de-sac. Our review of the literature indicates that, this is the second teratoma case of the douglas and the first one removed laparoscopically.

Adult↗
PubMed2001

Peritoneal cytology: impact on disease-free survival in clinical stage I endometrioid adenocarcinoma of the uterus.

The prognostic significance of positive peritoneal cytology in endometrial carcinoma has led to the incorporation of peritoneal cytology into the current FIGO staging system. While cytology was shown to be prognostically relevant in patients with stage II and III disease, conflicting data exists about its significance in patients who would have been stage I but were classified as stage III solely and exclusively on the basis of positive peritoneal cytology (clinical stage I). Analysis was based on the data of 369 consecutive patients with clinical stage I endometrioid adenocarcinoma of the endometrium. Standard treatment consisted of an abdominal total hysterectomy, bilateral salpingo-oophorectomy with or without pelvic lymph node dissection. Peritoneal cytology was obtained at laparotomy by peritoneal washing of the pouch of Douglas and was considered positive if malignant cells could be detected regardless of the number of malignant cells present. Disease-free survival (DFS) was considered the primary statistical endpoint. In 13/369 (3.5%) patients, positive peritoneal cytology was found. The median follow-up was 29 months and 15 recurrences occurred. Peritoneal cytology was independent of the depth of myometrial invasion and the grade of tumour differentiation. Patients with negative washings had a DFS of 96% at 36 months compared with 67% for patients with positive washings (log-rank P<0.001). The presence of positive peritoneal cytology in patients with clinically stage I endometrioid adenocarcinoma of the endometrium is considered an adverse prognostic factor.

Adenocarcinoma↗
PubMed1977

Delayed splenic rupture: diagnosed by culdocentesis.

Culdocentesis is a valuable asset in the diagnosis of hemoperitoneum in women. A case report of delayed splenic rupture diagnosed by this means emphasizes its usefulness. When compared to paracentesis and peritoneal lavage, culdocentesis is more rapid, theoretically more sensitive, and easier to perform. It is a valuable diagnostic tool.

Adult↗
PubMed2005

[Endometriosis with massive hemorrhagic ascites: a case report and review of the literature].

Endometriosis is defined as the presence of endometrial tissue outside the uterine cavity. It generally involves the peritoneum, ovaries and rectovaginal septum. Its characteristic symptoms include dysmenorrhea, pelvic pain, deep dyspareunia and infertility. It may also involve the gastrointestinal tract, urinary tract or extra abdominal sites, giving rise to a wide variety of clinical symptoms such as bloody stools, renal haemorrhage, hemoptysis and pleural effusion during menstruation. Recurrent hemorrhagic ascites secondary to endometriosis is an unusual occurrence, 41 cases have been reported since 1954. Here we report an additional case, in order to draw attention to this condition. A 28 years-old black nulligravida woman was seen for the first time in april 2000 with a chief complaint of infertility. Her past medical history was unremarkable. She had regular menses but associated with severe dysmenorrhea. She also recalled abdominal and pelvic pain for several years. She underwent an ovulation induction with gonadotrophin, which resulted in a progressive increase of pelvic pain. A first laparoscopy was performed, revealing voluminous ascites (10 I). Two years later the ascites recurred spontaneously. Ultrasound examination revealed suspect "para uterine masses". A second exploratory laparoscopy showed a voluminous bloody ascites (71), and extensive adhesions. On histologic examination all specimens (peritoneal biopsies) were compatible with endometriosis and ruled out malignancy. Treatment with Gn RH analog was performed and full remission was obtained after 6 months. One year later the ascites recurred again spontaneously, leading to a third laparoscopy in an other medical institution. Histologic examination showed endometrial stromal tissue and fibrous proliferation. Later she became pregnant after in vitro fertilization. In the first trimester of pregnancy, the pelvic ultrasound showed only a small effusion in the pouch of Douglas. Still, the ascites did not progress during pregnancy. The patient was hospitalized from 27 to 33 weeks of gestational age for threatened labor, but she finally had a normal vaginal delivery at 36 weeks of gestational age. Four months later, she had no complaint, but the pelvic ultrasound showed the recurrence of the ascites. She will have a drainage. The future treatement will consists of GnRH analog for about six months, which will be relayed by a long term progestative therapy. A diagnosis of endometriosis should always be considered in middle-age women who presents with bloody ascites. Long follow-up is advisable for patients who undergo conservative treatment because of thehigh risk of recurrence.

Adult↗
PubMed1994

Endoscopy in the management of endometriosis.

Endoscopy has replaced laparotomy in nearly all patients requiring surgical treatment of endometriosis. Controlled trials have shown electrosurgery is more effective than expectant treatment in the resolution of infertility due to peritoneal endometriosis and equally effective as laparotomy. Laparoscopy surgery reduces patient morbidity and costs when compared with laparotomy. No significant difference has been demonstrated between laser or electrosurgery in resolving infertility related to peritoneal endometriosis. Peritoneal endometriosis is difficult to diagnose and its extent is obscured by occult endometriosis in microscopic foci. Biopsy is required to establish the diagnosis as all of the described lesions of endometriosis may also be due to other diseases. Excision of the lesions may be by electrosurgery, laser or scissor diathermy. Scissor diathermy has advantages over laser or electrosurgery. Endometriomas may be removed by one- or two-stage excisional surgery. Follow-up laparoscopy is often indicated because of the association with secondary adhesive formation. Pouch of Douglas endometriosis requires special attention to the identification of the extent of disease and the technique of removal. Rectal involvement may require rectal surgery, most of which can be achieved by laparoscopy. Hysterectomy and oophorectomy may be performed laparoscopically and are indicated for recurrent extensive disease not controlled by medical or conservative surgical procedures, for adenomyosis or for extensive pelvic adhesions.

Endometriosis↗
PubMed2002

Successful laparoscopic treatment of a ruptured primary ovarian pregnancy.

A 26-year-old woman had classic symptoms of primary ovarian pregnancy. Ultrasound examination disclosed a cystic mass surrounded by a complex mass that was compatible with hematoma in the pouch of Douglas, as well as an intrauterine device (IUD) displaced near the isthmic portion of the uterine cavity. Laparoscopy revealed a ruptured gestational sac in the cul-de-sac that was encapsulated by a hematoma originating from the right ovary. All deep-seated products of conception were excised from the ovary, and the IUD was removed. Treatment was successful and avoided more invasive intervention.

Adult↗
PubMed2002

Laparoscopic treatment of primary ovarian pregnancy.

Ovarian pregnancy is an uncommon type of ectopic pregnancy. A 35-year-old, gravida 3, para 3 woman was admitted because of a vaginal bleeding of 17 days' duration after amenorrhea for 10 weeks. She had right lower quadrant pain. Serum beta-human chorionic gonadotropin concentration was 1530 mIU/ml. Transabdominal ultrasonography showed a normal-size uterus, empty uterine cavity, solid cystic mass 43 x 39 mm on the right adnexa, and no free fluid in the pouch of Douglas. Diagnostic operative laparoscopy under general anesthesia was performed for suspected ectopic pregnancy. Right oophorectomy was done because of minimal intact ovary tissue. It was later histopathologically confirmed as primary ovarian pregnancy. The woman experienced no postoperative complications.

Adult↗
PubMed2003

Laparoscopic mobilization of the rectosigmoid and excision of the obliterated cul-de-sac.

STUDY OBJECTIVE: To evaluate the feasibility and surgical and clinical outcomes of laparoscopic excision of anterior recto-sigmoid wall endometriosis and en bloc dissection of the obliterated cul-de-sac. DESIGN: Retrospective cohort (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Eighty-one women with infertility and/or chronic pelvic pain. Intervention. Laparoscopic excision of all endometrial implants and uterosacral ligaments, and dissection of the cul-de-sac using a horseshoe-shaped approach to mobilize, but not resect, the rectosigmoid. MEASUREMENTS AND MAIN OUTCOMES: Eleven women (24%) had endometriomas. Cumulative pregnancy rates in 34 women with primary infertility and 12 with secondary infertility were 62% and 42%, respectively. Eighty-eight percent of 61 women with pain reported significant improvement of symptoms. CONCLUSION: Laparoscopic excision of cul-de-sac and rectovaginal endometriosis by this approach is feasible and safe when performed by an experienced surgeon, and results in high rates of cumulative pregnancy and relief of pain. Some patient variables may give higher rates of success for pregnancy than others.

Adolescent↗
PubMed2000

Transvaginal videopelviscopy, a new technique for assessing pelvic cysts.

We evaluated a new technique, transvaginal videopelviscopy, of inspecting the internal architecture of pelvic cysts and verifying the possibility of performing intracystic biopsy through the posterior fornix. The procedure was performed in 33 women with pelvic cysts just before operative videolaparoscopy. A 1.2-mm scope was introduced through the pouch of Douglas under transvaginal ultrasound guidance. The inner surface of adnexal cysts was visualized and attempts were made to secure biopsy tissue. Good images of the inner wall of the lesion were obtained in 26 patients (77.8%). Specimens for histopathology were obtained in 27 women (81. 8%) and were sufficient for classifying the tumor as neoplastic or nonneoplastic. On histopathologic analysis, intracystic biopsy tissue and specimens obtained by laparoscopy were concordant in 25 (92.6%) of 27 patients. No complications occurred. Transvaginal videopelviscopy is an effective procedure for assessing pelvic cysts.

Adolescent↗
PubMed1996

Enterocele as a consequence of laparoscopic resection of deeply infiltrating endometriosis.

Laparoscopic excision of deeply infiltrating endometriosis in the cul-de-sac or the rectovaginal septum by means of electrosurgery or laser is performed frequently. Little is known about the long-term results or complications of this surgery. We suggest that enterocele could be a complication of the procedure. A patient developed a large enterocele 3 years after a laparoscopic excision of a deep endometriotic nodule with resection of the uterosacral ligaments. We question whether routine preventive measures should not be taken after excision of a deep endometriotic nodule from the rectovaginal septum.

Adult↗
PubMed1999

A prospective, randomized comparison of port wound and culdotomy for extracting mature teratomas laparoscopically.

STUDY OBJECTIVE: To compare removing teratomas through a culdotomy opening or through an enlarged port wound. DESIGN: Prospective, randomized trial (Canadian Task Force classification I). SETTING: Veterans Hospital. PATIENTS: Thirty-one women with mature teratomas identified by ultrasound examination and biochemical markers. INTERVENTION: Laparoscopic cystectomy. MEASUREMENTS AND MAIN RESULTS: Patients were randomly assigned to have the cysts removed intact in a cellulose bag through an enlarged port site (15, group A) or through a culdotomy opening (16, group B). Inclusion criteria were history of vaginal delivery, no previous abdominal surgery, no history of pelvic inflammatory disease, no medical illness, and no symptoms. Operating time in group B (90 +/- 18 min) was significantly longer than that in group A (70 +/- 22 min, p = 0. 0113). Blood loss was 79 and 49 ml, respectively (p = 0.0010). There was no significant differences in tumor size, patient age, and postoperative recovery between groups. CONCLUSION: It is possible to remove intact ovarian dermoid cysts and prevent rupture and spillage of cyst contents during laparoscopic surgery by both approaches. We prefer the enlarged port because operating time is shorter and blood loss is less.

Adolescent↗
PubMed2000

Isolated tubal torsion at menarche- a case report

Background: Adnexal torsion is a well-recognized cause of acute pelvic pain. Isolated tubal torsion with ovarian sparing has certainly been documented, but is uncommon. Although risk factors for the latter include a menstrual period, menarche in particular is not known to predispose a patient to this event. Severe unilateral pelvic pain with first menses is more likely to herald a congenital mullerian anomaly and cryptomenorrhea, particularly when accompanied by a pelvic mass. We present a case of tubal torsion where a coincidental, yet misleading temporal relation to menarche led to a delay in laparoscopy and ultimate diagnosis.Case: KG, an eleven-year-old female, experienced severe right-sided dysmenorrhea with her first and second menses in August and September 1999 respectively. Between episodes, pain, although still present, was more tolerable and the patient never required hospitalization. Ultrasound revealed a lobulated inhomogeneous mass posterior to the uterus and extending from one normal ovary to the other (Figures). MRI further described the mass as pseudoencapsulated with inhomogeneous areas of high attenuation on T1 and T2 images (Figures). Findings were consistent with an endometrioma, but admittedly could have represented a hemorrhagic cystic mass. No definite mullerian anomaly was seen to explain advanced endometriosis, but two focal areas within the endometrial canal raised the possibility of a uterine septum. Examination of the patient (one week after presentation) was not very helpful although she was pubertal, did have a hymenal septum and was mildly tender on bimanual examination in the Pouch of Douglas. The patient had been started on continuous oral contraceptives while undergoing investigations. Pain only recurred during an episode of break-through bleeding. Ultimately she came to laparoscopy and hysteroscopy where chronic right tubal torsion and necrosis was identified with an inflammatory/hemorrhagic reaction in the pelvis (Photos). There were no identifiable fimbria of the right tube which was densely adherent distally to perirectal fat (Photo). No obvious precipitant was found. Laparoscopic lysis of adhesions and right distal salpingectomy was performed (Photo). Her uterine cavity was in fact normal (Photo)Conclusion: Whether or not this patient's right tube was originally normal will never be known. Congenital abnormalities of fallopian tubes do occur and can predispose to torsion. Nonetheless, adnexal torsion must always be kept in mind whenever a woman presents with unilateral pelvic pain. Early diagnosis is paramount in children and women of reproductive age in order to improve the likelihood of adnexal salvage and future fertility. A "gold-standard" radiological investigative tool continues to elude us. Laparoscopy, albeit more invasive, remains an invaluable procedure in this context with relatively low morbidity as compared to the consequences of delayed diagnosis.

Journal Article↗
PubMed2002

Minimally invasive exploration of the female reproductive tract in infertility.

Classically, invasive and non-invasive tests are performed to evaluate the causes of infertility. Transvaginal hydrolaparoscopy (THL) allows the exploration of the pelvic structures with a mini-endoscope, using a vaginal needle-guided trocar introduction technique and saline as a distension medium. A first study on 349 patients demonstrated the feasibility of the procedure and gave a high patient satisfaction. Access to the pouch of Douglas was achieved in 330 patients (94.5%) under local anaesthesia and in an ambulatory environment. The mean pain score measured on a visual analogue scale of 10 was 2.7, comparable to the score of mini-hysteroscopy only and significantly lower than the scores of hysterosalpingography with either metal cannula or balloon catheter. A total of 96% of the patients agreed to repeat the procedure under the same circumstances if required. The diagnostic accuracy of the technique was demonstrated in a prospective study, in which two independent endoscopists explored 10 patients with both THL and standard laparoscopy. The inter-observer agreement for ovarian adhesions was 75% for standard laparoscopy and 90% for THL. In addition, in patients with mild endometriosis, more peri-ovarian adhesions were detected with THL than with standard laparoscopy. A multinational survey to evaluate the risk and outcome of bowel injury during THL registered 24 (0.65%) cases in 3667 procedures. In all cases, the diagnosis was made immediately and the treatment was conservative without complications.

Endometriosis↗
PubMed2002

Transvaginal hydrolaparoscopy: a new diagnostic tool in infertility investigation.

BACKGROUND: To establish the value of a new technique called transvaginal hydrolaparoscopy for exploration of the tubo-ovarian structures in the management of patients with unexplained infertility. METHODS: A total of 120 women with primary or secondary infertility, and without obvious pelvic pathology, were included in the study. The first 14 patients received general anesthesia and underwent transvaginal laparoscopy immediately before standard laparoscopy. The remaining 106 patients had transvaginal laparoscopy performed under local anesthesia, with standard laparoscopy performed only on those with pathology, which required operative intervention. Information on pathology, complications, and successful access to the pouch of Douglas were recorded. RESULTS: The successful rate of access was 93%. Pathology was found in 29 patients, of whom 15 required operative laparoscopy. Also, out of 19 patients with adhesions, 11 (58%) had normal dye test bilateral, and only two (11%) had bilateral occlusion of the tubes. No complications were observed. CONCLUSION: Transvaginal hydrolaparoscopy is a safe and well-tolerated method for investigating the tubo-ovarian structures in unexplained infertility. It is superior to hysterosalpingography for diagnosis of adhesions.

Adult↗