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Study Objective: To assess obstetric performance and fetal outcomes after laparoscopy or laparotomy performed during pregnancy., Design: Nationwide, multicenter, retrospective chart review (Canadian Task Force classification II-2)., Setting: Seventeen hospitals throughout Israel: 12 university or university-affiliated hospitals and 5 general hospitals., Patients: Three hundred eighty-nine pregnant women., Intervention: Laparoscopy or laparotomy for various indications., Measurements and Main Results: Of 192 laparoscopies performed, 141 were during the first, 46 during the second, and 5 during the third trimester; respective figures for 197 laparotomies were 63, 110, and 24. No intraoperative complications were reported for either procedure. Six and 25 women had complications after laparoscopy and laparotomy, respectively. There was no significant difference in abortion rates between groups. Mean gestational age at delivery and mean birthweight were comparable between groups. No significant difference was found in frequency of fetal anomalies between groups or when compared with the Israel register of anomalies., Conclusion: Operative laparoscopy seems to be as safe as laparotomy in pregnancy.

Study Objective: To compare the diagnosis and management of ectopic (EP) and heterotopic pregnancies (HP)., Design: Retrospective comparative study (Canadian Task Force classification II-2)., Setting: University tertiary referral center for endoscopic surgery., Patients: Twelve women with HP and 210 women with laparoscopically confirmed EP., Intervention: Laparoscopic treatment., Measurements and Main Results: Among the 12 women with HP, all but 1 had received ovulation induction, 10 underwent in vitro fertilization-embryo transfer, and 1 conceived with clomiphen citrate. In the EP group 33 patients (15.7%) conceived spontaneously (p <0.05). Six women (50%) with HP had had previous pelvic surgery and three had a history of EP and salpingectomy. Four patients (33.4%) with HP and 29 (13.8%) with EP suffered from hypovolemic shock and required blood transfusion (p <0.05). Three of these four women with HP experienced physician and patient delays before admission. The sonographic diagnosis was correct in all women with HP and in 94.3% of women with EP. The median gestational age at diagnosis was 7.5 and 7.2 weeks for HP and EP, respectively. Six (50%) women with HP had evidence of fetal pulse in the ectopic gestation compared with 17 (8.1%) with EP (p <0.05). In addition, 66.7% and 24.7%, respectively, had ruptured tube (p <0.05). Mean +/- SD hemoperitoneum was 833.4 +/- 777 and 305 +/- 121 ml, respectively (p <0.05). Conversion to laparotomy was required in one (8.3%) and eight (3.8%) women, respectively (p <0.05). No major operative or postoperative maternal complications occurred in either group. Two women with HP had miscarriages, two have a continuing pregnancy, and eight delivered healthy newborns., Conclusion: Women with HP are at significantly greater risk for hypovolemic shock and requiring blood transfusion than those with EP. The diagnosis of EP in cases of HP is difficult due to the presence of an intrauterine gestational sac and hyperstimulated ovaries. A greater level of suspicion may allow early laparoscopic intervention before life-threatening intraabdominal bleeding has occurred.

Study Objective: To compare the frequency of complications of total laparoscopic hysterectomy performed in the first and more recent years of our experience, and based on that, offer ways to prevent them., Design: Retrospective, comparative study (Canadian Task Force classification II-2)., Setting: University tertiary referral center for endoscopic surgery., Patients: During 1989-1995 and 1996-1999, 695 and 952 women, respectively, with benign pathology., Intervention: Total laparoscopic hysterectomy., Measurements and Main Results: No differences in patient characteristics were found between 1989-1995 and 1996-1999. Substantial decreases in major complication rates were noted, 5.6% and 1.3%, respectively. No major vessel injury occurred. Excessive hemorrhage (1.9%) and need for blood transfusion (2.2%) during the first period were statistically higher than in the second period (both 0.1%, p <0.005). Urinary complications (2.2%) including 10 bladder lacerations, 4 ureter injuries, and 1 vesicovaginal fistula occurred more frequently in the first period than in the second period (0.9%), when 6 bladder and 2 ureter lacerations and 1 vesicovaginal fistula occurred (p <0.005). One bowel injury and one bowel obstruction occurred in the first period, but no bowel complications in the second. Between periods, 33 (4.7%) and 8 (1.4%) conversions to laparotomy were necessary. During the first period there were nine reoperations; of six laparotomies, four were due to urinary injuries, one due to heavy vaginal bleeding, and one due to a vesicovaginal fistula; three diagnostic laparoscopies were required due to postoperative abdominal pain. Three reoperations during the second period were two laparoscopies due to heavy vaginal bleeding and one laparotomy due to a vesicovaginal fistula (p <0.005). Statistically significant differences in median (range) uterine weight 179.5 g (22-904 g) and 292.0 g (40-980 g) and operating times 115 minutes (40-270 min) and 90 minutes (40-180 min), respectively, were recorded (p <0.005)., Conclusion: Laparoscopic hysterectomy was safe, effective, and reproducible after training, and with current technique, had a low rate of complications.

Study Objective: To evaluate short-term outcome of total laparoscopic hysterectomy (TLH) performed in women with very enlarged uteri., Design: Case control study (Canadian Task Force classification II-2)., Setting: Hospital gynecologic service., Patients: Thirty-four consecutive women with very enlarged uteri., Intervention: Total laparoscopic hysterectomy for benign pathology., Measurements and Main Results: Women with uterine enlargement (group 1) were compared with 68 women with uteri weighing 300 g or less (group 2) who underwent TLH during the same period. Matching was based on patient age +/- 2 years, surgeon (experienced senior, fellow), whether or not Burch operation was performed, and whether or not adnexectomy was performed. The groups were compared for complication rates, operating time, hospital stay, change in perioperative hemoglobin concentration, and vaginal and laparoscopic uterine morcellation. They did not differ statistically significantly in terms of indications for surgery, parity, postmenopausal status, and preoperative hemoglobin levels. No difference was seen in complication rates between groups. Operating time was significantly shorter (p <0.001) in women with smaller uteri than in those with very enlarged uteri, 108 +/- 35 and 156 +/- 50 minutes, respectively. The groups did not differ significantly in day 1 hemoglobin level drop, analgesia requirement (oral, intravenous opioid), time to passing gas and stool, or hospital stay. No conversion to laparotomy was required in either group., Conclusion: A very enlarged uterus should not be considered a contraindication for TLH. However, it may be necessary to undertake certain surgical steps to ensure optimal exposure of the operative field and more effective and safer excision of the uterine vascular pedicle.

We created a neovagina by sigmoid colpoplasty using a combined laparoscopic-perineal approach in a 19-year-old woman with Rokitansky syndrome. Operating time was 4 hours and 45 minutes. No perioperative or postoperative complications occurred. Hemoglobin level fell by 1 g/dl. Total doses of morphine, nonsteroidal antiinflammatory drugs (NSAIDs), and paracetamol were 20 mg, 350 mg, and 28 g, respectively. Hospital stay was 7 days. The length of the neovagina was 12 cm. By comparison, in the three reported cases of laparotomic-perineal sigmoid vaginoplasty, mean operating time was 5 hours and 40 minutes; 24-hour fall in hemoglobin was 3.2 g/dl (range 2.1-4.3 g/dl); mean doses of morphine, NSAIDs, and paracetamol were 42.6 mg, 300 mg, and 40 g, respectively; mean hospital stay was 11.3 days; and length of neovaginas was 10, 12, and 12 cm. Although sigmoid colpoplasty is a reliable and reproducible technique, it requires experience in laparoscopic colonic surgery. The combined laparoscopic-perineal approach is associated with less analgesic requirement, shorter hospital stay, and similar anatomic results compared with the laparotomic-perineal approach.

Study Objective: To determine the safety of operative laparoscopy in the management of ectopic pregnancy in women with hypovolemic shock., Design: Retrospective chart review., Setting: University-affiliated hospital., Patients: Two hundred eleven women with tubal pregnancy, of whom 33 were suffering from hypovolemic shock, based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill., Intervention: Laparoscopic surgery., Measurements and Main Results: Mean +/- SEM intraabdominal blood loss was significantly (p <0.01) higher in women with hypovolemic shock, 1369 +/- 149 versus 114 +/- 14 ml. Blood transfusions were given to 88% and 0.5%, respectively (p <0. 01). Laparoscopic salpingectomy was performed in all hemodynamically compromised women compared with 87% of stable women. Conversion to laparotomy was required in three patients in the hypovolemic shock group and five in the stable group. All patients had an uncomplicated postoperative course and made a full recovery., Conclusion: The availability of optimal anesthesia and advanced cardiovascular monitoring, and the ability to convert rapidly to laparotomy if required, allow safe performance of operative laparoscopic surgery in most women in hypovolemic shock. In fact, the superior exposure of laparoscopy, providing rapid diagnosis and control of the source of bleeding, makes it a highly suitable approach.

We evaluated the safety of operative laparoscopy for the management of ectopic pregnancy in 119 women with hypovolemic shock. In 19 (16.0%) of these women hypovolemic shock was based on a combination of signs and symptoms including hypotension, tachycardia, anxiety, thirst, tachypnea, and slow capillary refill. The table below presents the results (mean &plusmn; SEM; ap <0.01). One case in each group was converted to laparotomy, and all patients made full recovery. Laparoscopy allows rapid diagnosis and control of the source of bleeding, making it highly suitable for the surgical management of a ruptured ectopic pregnancy. The availability of appropriate anesthesia and advanced cardiovascular monitoring, and ability to convert rapidly to a laparotomy if necessary, allow safe performance of operative laparoscopic surgery in women with hypovolemic shock.