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The 1991 American Association of Gynecologic Laparoscopists membership survey on operative hysteroscopy had a total of 630 respondents (almost double the 1988 number) who reported performing 17,298 procedures as compared to 7,293 in 1988. Directed biopsy and endometrial ablation were the procedures reported most commonly. Endometrial ablation increased fivefold since 1988, and myomectomy increased fourfold. The majority of operative hysteroscopies were performed for a complaint of abnormal bleeding (73%). The most frequently reported complication was uterine perforation not requiring transfusion (11 per 1,000 procedures). The rate of water intoxication or pulmonary edema dropped from 3.4/1,000 in 1988 to 1.4/1,000 in 1991. However, some serious complications (eight laparotomies for bowel injury, three CO2 embolisms and three deaths) were reported for 1991.

The American Association of Gynecologic Laparoscopists 1991 membership survey on operative laparoscopy had a total of 878 respondents reporting 56,536 procedures, for a 1.5-fold increase over the number of procedures reported in 1988. The most frequent indication was pelvic pain (58% of procedures); next was infertility (42%). Laparoscopic management of ectopic pregnancy increased over twofold, from 1,914 cases in 1988 to 4,620 in 1991. As compared to the 1988 survey data, the rate of unintended laparotomy to manage hemorrhage, bowel or urinary tract injury may have increased, but the death rate remained low, 1.8 per 100,000 procedures.

The 1991 membership survey of the American Association of Gynecologic Laparoscopists indicated more laparoscopic procedures than had been reported in the last survey, in 1988. The respondents reported 30,480 sterilizations, 41,160 diagnostic laparoscopies and 8,015 hysteroscopies. The distribution of sterilization by method of tubal occlusion has remained stable since 1985. Complications from diagnostic laparoscopy remain consistently higher than from sterilization. This year the complication rate for diagnostic procedures was higher than in any other year since 1976 (4.9 per 1,000 cases). One death was reported after sterilization and one after diagnostic laparoscopy.

The American Association of Gynecologic Laparoscopists (AAGL) membership was surveyed on the use of laparoscopy in the management of persistent ovarian masses in 1990. A total of 13,739 laparoscopies were performed for this indication. Ninety-six percent of the respondents performed laparoscopy for this indication on premenopausal women only. Among respondents performing laparoscopy for suspected cancer, there was a 14% conversion rate to laparotomy, compared to 9% among those who performed direct laparotomies when cancer was suspected. An overall incidence of 4 per 1,000 cases of stage I ovarian cancer was found, and about 70% of women with persistent adnexal masses were managed by laparoscopy alone. The risks to women with cancer, as well as the benefits to those without, are discussed.

The 1988 membership survey of the American Association of Gynecologic Laparoscopists (AAGL) indicated that the membership continued to perform fewer sterilizations than previously reported. The respondents reported performing 30,480 sterilizations, 41,160 diagnostic laparoscopies and 13,920 hysteroscopies. The distribution of laparoscopic sterilizations by method of tubal occlusion did not change appreciably since 1985. Complications from diagnostic laparoscopy were consistently higher than those after sterilization; two deaths (4.8 per 100,000 procedures) were identified after diagnostic laparoscopy, and no deaths were reported after sterilization. The relative likelihood of ectopic pregnancy was substantially greater after coagulation procedures than after mechanical ones. The decrease in the membership's performance of laparoscopic sterilization was occurring during a relative increase in the performance of newer diagnostic and therapeutic endoscopic procedures.

The 1988 American Association of Gynecologic Laparoscopists' membership survey on operative hysteroscopy had a 19% response rate. A total of 377 respondents reported performing 7,293 operative hysteroscopies. The number of procedures reported per respondent ranged from 1 to 325; 75% of physicians reported performing 20 or fewer procedures. In 1988 a small number of practitioners performed a large number of procedures. Directed biopsy and polypectomy through the hysteroscope were the procedures reported most commonly. Most operative hysteroscopies were performed for a complaint of either abnormal bleeding (57%) or infertility (27%). The complication reported most frequently was uterine perforation not requiring a transfusion (13 per 1,000 procedures). More serious complications that occurred in at least 1 per 1,000 procedures included water intoxication or pulmonary edema, hospital readmission, hospitalization greater than 72 hours and transfusion for hemorrhage.

The American Association of Gynecologic Laparoscopists' (AAGL) 1988 membership survey on operative laparoscopy had a response rate of 24%. A total of 880 respondents reported performing 36,928 operative laparoscopy procedures. A total of 75% of the respondents reported performing 47 or fewer procedures. The most frequently reported conditions managed with operative laparoscopy were endometrial implants, extensive adhesions and ovarian cysts. Most operative laparoscopies were performed because of infertility (40%) or pelvic pain (41%). The overall serious complication rate was 15.4 per 1,000 procedures. Complications that occurred in greater than 1 per 1,000 procedures included hospitalization greater than 72 hours, persistent human chorionic gonadotropin titer elevation after ectopic pregnancy, hospital readmission and unintended laparotomy to manage bowel injury, urinary tract injury or hemorrhage. Two deaths (5.4 per 100,000 procedures) were reported.

The 1985 membership survey of the American Association of Gynecologic Laparoscopists (AAGL) revealed that the membership performed dramatically fewer laparoscopic sterilizations in 1985 than were reported in any previous AAGL survey. The distribution of laparoscopic sterilizations by method of tubal occlusion has changed, with the percentage of mechanical methods of occlusion showing a relative increase and the percentage of electrocoagulation procedures showing a relative decrease. Whereas bipolar coagulation without division continues to be the most popular technique, only 6% of respondents reported using unipolar coagulation. The data suggest that the relative likelihood of ectopic pregnancy after laparoscopic sterilization may be greater after coagulation methods than after mechanical ones. Members often used conservative surgical approaches to ectopic gestation, with 39% managed with salpingotomy and 7% managed with laparoscopy alone. The likelihood that sterilization reversal would be performed varied by method of occlusion, with reversal most likely to be performed (71%) after spring clip application.

Safe and adequate pneumoperitoneum is dependent upon intraperitoneal pressure and not upon the number of liters of gas insufflated. Volume of gas delivered depends upon the size of the patient and whether there is any possible leakage. The Carboflator is a useful instrument for establishing controlled insufflation of gas and fail-safe intraperitoneal pressure.

A survey of 1,024 U.S. members of the American Association of Gynecologic Laparoscopists (AAGL) concerning 1982 practice revealed that 125,560 laparoscopic sterilizations had been performed. The bipolar method was the most frequent one, used by 65%. The band was used by 21%, the clip by 4% and the unipolar method by 11%. Local anesthesia was used in 4% of cases and open laparoscopy in 4%. No correlation was possible between technique used and the incidence of hemorrhage (0.45 per 1,000), bowel injury (0.42 per 1,000), postoperative pelvic infection (0.42 per 1,000) or anesthetic complications (0.16 per 1,000).

In 1981 the American Association of Gynecologic Laparoscopists and the Division of Reproductive Health, Centers for Disease Control, jointly conducted a study of tubal sterilizations performed in 141 freestanding, ambulatory-care surgical facilities in 1980 in the United States. Information was collected through mailed questionnaires and telephone interviews. Of 330 potential responding facilities, 141 we identified as freestanding, ambulatory-care surgical facilities. About 16,500 tubal sterilizations were performed in these facilities in 1980. The mean number of tubal sterilizations per freestanding, ambulatory-care surgical facility was 212. Sixty-seven percent of tubal sterilizations were performed in the south and west. General anesthesia was the anesthetic method used in 97% of the procedures. Nearly 91% of tubal sterilizations were done via laparoscopy, with bipolar electrocoagulation the tubal-occlusion method used most frequently. After tubal sterilization the patients were observed for an average of 2.4 hours before discharge. The average cost of laparoscopic tubal sterilization was $801; for nonlaparoscopic tubal sterilization it was $850.

The average AAGL physician does general obstetrics and gynecology, with 135 deliveries, 41 hysterectomies and 38 IUD insertions a year in addition to about 50 laparoscopies for sterilization and 43 for diagnosis. About 1 in 10 will experience a major complication, and 1 in 25 will undergo medicolegal actions, although their complication rates as a group are no higher than those of the total membership.