The position of diagnostic laparoscopy in current fertility practice

In everyday clinical practice, it is not always clear if and when exactly in the fertility work-up a diagnostic laparoscopy should be offered. The aim of this review is to analyse the available evidence with respect to alternative diagnostic methods for detecting tuboperitoneal infertility and with respect to the position of diagnostic laparoscopy in women with infertility. A literature search of the National Library of Medicine and the National Institutes of Health (PubMed) was performed using the key words 'diagnostic laparoscopy and infertility'. The study methodology was carefully considered in an effort to present conclusions preferably based on randomized controlled trials (RCTs). The routine use of diagnostic laparoscopy for the evaluation of all cases of female infertility is currently under debate. According to data published in retrospective non-controlled studies, diagnostic laparoscopy after several failed cycles of ovulation induction enables the detection of a significant proportion of pelvic pathology amenable to treatment. A Cochrane review has shown that laparoscopic ovarian diathermy in clomiphene-resistant polycystic ovarian syndrome is at least as effective as gonadotrophin treatment, and results in a lower multiple pregnancy rate. The role of laparoscopy before the start of treatment with intrauterine insemination is controversial, according to one RCT. In women with bilateral ultrasonically visible hydrosalpinges, two RCTs have demonstrated increased implantation and pregnancy rates in IVF cycles after salpingectomy. Although RCTs which have studied the benefit of laparoscopic surgery in moderate or severe endometriosis are still lacking, its value has generally been accepted. In conclusion, some specific clinical settings, solid evidence is available to recommend the use of diagnostic laparoscopy in current fertility practice. There is however a need for more RCTs to answer remaining questions regarding its value in the diagnosis and treatment of some patients with infertility

Spider surgical system versus multiport laparoscopic surgery. Performance comparison on a surgical simulator

BACKGROUND: The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS). METHODS: Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system. RESULTS: Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER. Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005). Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007). Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task. CONCLUSIONS: Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience

Cost-effectiveness of diagnostic laparoscopy for assessing resectability in pancreatic and periampullary cancer.

Surgical resection is the only curative treatment for pancreatic and periampullary cancer, but many patients undergo unnecessary laparotomy because tumours can be understaged by computerised tomography (CT). A recent Cochrane review found diagnostic laparoscopy can decrease unnecessary laparotomy. We compared the cost-effectiveness of diagnostic laparoscopy prior to laparotomy versus direct laparotomy in patients with pancreatic and periampullary cancer with resectable disease based on CT scanning

Peritoneal adhesions after laparoscopic gastrointestinal surgery

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO2 pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO2, N2O and O2 seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility

Laparoscopy in liver transplantation: The future has arrived

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic endstage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients

KADAR KORTISOL, TRANSFORMING GROWTH FACTOR β (TGF-β), SERTA DERAJAT ADHESI PASCA LAPAROSKOPI DAN LAPAROTOMI (Penelitian Eksperimental pada Kelinci yang Dilakukan Abrasi Ileum)

ABSTRACT Background: Intraperitoneal adhesions after abdominal surgery occurred in 50-97% cases, and the most cause is laparotomy. This research was done to know the difference between laparoscopy and laparotomy regarding the peritoneal adhesion degree, cortisol and TGF- β level. Material and Method: A randomized control trial post test only design was done on both groups. The 1st group (X1) was performed laparotomy and ileum abrasion, while the 2nd group (X2) was performed laparoscopy, both treatment performed under general anaesthesia. The blood sampel was taken just before and 6 hours after operation to measure the cortisol level. Seven days later, both groups were terminated by making vertebrae cervical dislocation and than performed laparotomy to assess the intraperitoneal adhesion and to collected the peritoneal fluid to measure the TGF-β levels. The differences regarding cortisol and TGF-β level were analyzed by independent t-test, while the intraperitoneal adhesion was analyzed by Mann Whitney. Pearson’s test was performed to analyze the correlation between cortisol and TGF-β level, while the correlation between TGF-β level and the adhesion degree analyzed by Spearman’s test. Result: There were significant difference in the cortisol (mean 20,03 ± 1,550 ng/ml.), TGF-β level (mean 6.772,50 ± 414,77 pg/ml.)and the adhesion degree among both groups (p = 0.021, p < 0.001, p = 0.002 ). There were strong positif correlation between cortisol with TGF-β level (p = 0.030, r = 0.632) and very strong positive correlation between TGF-β level with the adhesion degree (p = 0.001, r = 0.941). Conclusion : Laparoscopic surgery can minimize the increase of the TGF-β and cortisol level, so as to lower the incidence of adhesion. Key words : Degrees of adhesion, cortisol, TGF-β,laparotomy, laparoscopy

3D Laparoscopy. A potential cutting edge in minimal invasive digestive surgery

Laparoscopic surgery has changed surgical landscape, providing reduced surgical trauma, shorter hospital stays, less postoperative pain and better outcomes than open surgery. Since its first development in the 90’s, 3D technology applied to laparoscopic surgery has had several technical improvements and now it represents, together with high definition technology, the best option in minimal invasive digestive surgery, providing shorter operative times and lower blood loss, making easier to perform surgical tasks both for trainees than for skilled surgeons. It remains a little bit more expensive than standard 2D laparoscopic devices but even cheaper than robotic equipment

Comparison of four serological assays for the diagnosis of Chlamydia trachomatis in subfertile women

Introduction: Chlamydia antibody testing (CAT) in serum has been introduced as a screening method in the infertility workup. We evaluated the test characteristics of two ELISA tests compared to micro-immunofluorescence tests (MIFs). MIFs are considered the gold standard in the C. trachomatis IgG antibodies detection. We also compared the accuracy of all CAT tests in predicting tubal subfertility, using laparoscopy as a reference. Methodology: Four commercial serological methods were used to analyse 101 serum samples for the presence of C. trachomatis IgG antibodies from patients at the Infertility Clinic of Ghent University Hospital. The diagnostic utility for prediction of tubal infertility of serological methods was evaluated based on patients' medical records. Results: A comparison of the serological assays showed little difference in the major performance characteristics: the sensitivities of all MIFs and ELISAs were 100% for all assays (except the ELISA Vircell, with a sensitivity of 90%), and the specificities ranged from 92% for MIF Ani Labsystems to 98% for the MIF Focus and ELISA Vircell. As compared to laparoscopy data, CAT positivity in subfertile women with tubal damage (n=40) did not significantly differ from that of subfertile women without tubal damage (n=61): Positive predictive values (PPV) of CAT ranged from 53% to 60% and negative predictive values (NPV) ranged from 62% to 64%. Conclusion: evaluated ELISAs are comparable to MIFs in the detection of C. trachomatis IgG antibodies and should be preferred for large serological studies, especially in resource poor settings

Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal

BACKGROUND: The prevalence of congenital uterine anomalies in women with reproductive failure remains unclear, largely due to methodological bias. The aim of this review is to assess the diagnostic accuracy of different methodologies and estimate the prevalence of congenital uterine anomalies in women with infertility and recurrent miscarriage (RM). METHODS: Studies from 1950-2007 were identified through a computer MEDLINE search; all relevant references were further reviewed. RESULTS: The most accurate diagnostic procedures are combined hysteroscopy and laparoscopy, sonohysterography (SHG) and possibly three-dimensional ultrasound (3D US). Two-dimensional ultrasound (2D US) and hysterosalpingography (HSG) are less accurate and are thus inadequate for diagnostic purposes. Preliminary studies (n=24) suggest MRI is a relatively sensitive tool. A critical analysis of studies suggests that the prevalence of congenital uterine anomalies is ~6.7% [confidence interval (CI) 95%, 6.0 – 7.4] in the general population, ~7.3% (CI 95%, 6.7 – 7.9) in the infertile population and ~16.7% (CI 95%, 14.8 – 18.6) in the recurrent miscarriage (RM) population. The arcuate uterus is the commonest anomaly in the general and RM population. In contrast, the septate uterus is the commonest anomaly in the infertile population, suggesting a possible association. CONCLUSION: Women with RM have a high prevalence of congenital uterine anomalies and should be thoroughly investigated. HSG and/or 2D US can be used as an initial screening tool. Combined hysteroscopy and laparoscopy, SHG and 3D US can be used for a definitive diagnosis. The accuracy and practicality of magnetic resonance imaging (MRI) remains unclear

Kurt Semm and an automatic insufflator

Work on tubal insufflation marked the beginning of Kurt Semm's (b. 1927) scientific career. In the early 1960s, he directed his attention to the fact that, from a technical standpoint, tubal insufflation was similar to creating pneumoperitoneum. In the mid-1960s, Semm - himself a gynecologist - invested his time and financial resources and risked his university career to develop an automatic abdominal insufflation device. Later he tried it out in the Clinic for Internal Medicine. Since, at that time, the term “laparoscopy” had negative connotations associated with it, Semm formulated a new term “pelviscopy.” In 1967, Semm presented his invention to Melvin Cohen, an American pioneer of gynecological laparoscopy, at the meeting of the American Fertility Society, held in Washington