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Twenty laparoscopic myomectomies were evaluated for the time required to perform procedure. Ten cases were performed with standard morcellation techniques and 10 with the Steiner morcellator. Using the Steiner morcellator, the time required to morcellate the fibroids was reduced by 45 minutes/case on average, large fibroids exceeding 8 cm were easily treated, and no patient injuries occurred. One physician experienced a severe "tennis elbow" that required steroid injections and rest for the epicondylitis from using the manual morcellator. The Steiner morcellator offers significant time and cost savings over manual morcellation techniques. Over a series of 10 cases, 7.5 hours of operating room time were saved, which translates into an approximate saving of $10,000.00. The morcellator capital cost is approximately $16,000.00 and each morcellating sheath costs approximately $100.00. The Steiner morcellator will pay for itself with the performance of 15 procedures through the time it saves.

We compared laparoscopic myomectomies based on location of surgery (outpatient vs hospital), length of stay (outpatient vs hospital), time to return to normal activities, and complications. The length of surgery was evaluated with regard to fibroid size and type of morcellation (manual vs automatic). We also compared the length of time required for surgery for comparable cases using the laparoscopic and the open approaches, and evaluated the length of stay due to complications in these two subsets. Finally, we compared the automatic morcellating device with manual morcellation. The subjects were 50 women with myomas ranging in size from 20 to 500 g. In 40% of patients surgery was performed on an outpatient basis with discharge the same day, and in 60% it was performed in the hospital with a stay of 1 or 2 days. The outcomes were compared, and the laparoscopic procedures were then compared with open procedures performed by other surgeons at the same hospital for length of stay, complications, and return to normal activities. Outpatient therapy proved as safe and effective as hospital-based therapy and provided some time savings in the operating room. Length of stay appeared to be related to where the surgery was performed: patients treated in the outpatient surgical center required a much shorter stay than those treated in the hospital, and hospital laparoscopic surgery required a much shorter stay than hospital exploratory surgery. Women who underwent laparoscopic myomectomy experienced less blood loss and fewer complications than those undergoing the standard exploratory laparotomy approach to myomas. The automatic morcellator reduced operating room time by a minimum of 45 minutes; resection of fibroids larger than 300 g requires patience and time for the operating room staff but results in no increased morbidity, and the patients are discharged home equally as soon as outpatients or within 2 days if the surgery is performed in the hospital. Laparoscopic myomectomies, even for myomas of 500 g, can be performed safely in an outpatient setting. The automatic morcellator provides significant savings in operating room time and is a cost-effective application of new technology.

Ten years of clinical evaluations of women with chronic pelvic pain resulted in concern that diagnostic laparoscopic surgery is performed too frequently in these patients. Of 500 women, the pain was due to urologic, myofascial, musculoskeletal, gastrointestinal, or psychologic causes in 30%, rather than to disorders of the reproductive organs. Laparoscopy would be inappropriate in these patients. By providing women with appropriate therapy of nongynecologic pain, those whose pain is due to gynecologic sources can be treated more appropriately. In approximately 70% of these latter patients, endometriosis is the primary finding. A paradigm for the diagnosis and the cost-effective treatment of women with chronic pelvic pain of gynecologic cause was developed.

Study Objective: To evaluate the effectiveness of laparoscopic surgical treatment for women with chronic pelvic pain., Design: Prospective evaluation of women treated consecutively between January 1, 1989, and December 31, 1992., Setting: A private practice., Patients: One hundred women with chronic pelvic pain., Interventions: Laparoscopic treatment was performed in all patients. Pain level was rated on a scale of 1 to 10 (1 = no pain, 10 = severe, disabling pain). Patients recorded their pain levels before and 1 month, 3 months, and 6 months after surgery, as well as at intervals of 1, 2, and 3 years after surgery., Measurements and Main Results: Preoperatively, the average pain level reported by the patients was 8.2. At 1 month after laparoscopic surgical therapy, it had dropped to 3.6, at 6 months to 1.9, and at 3 years to 2.2. Twenty patients reported pain levels of 5 or greater at the 6-month interval. Six of them proceeded to hysterectomy, and four of these six were found to have adenomyosis. Eleven of the 100 who had pain levels greater than 5 after initial procedure had no further therapy, and 3 underwent repeat laparoscopy., Conclusion: Extensive laparoscopic surgery to restore normal pelvic anatomy and remove all diseased tissue, including treatment of all endometriosis, resection of ovarian cysts, resection of adhesions, removal of the appendix, and treatment of hernias when indicated, together with laparoscopic uterosacral nerve vaporization or presacral neurectomy, results in significant improvement in reported pain levels.

Study Objective: To document the abnormal findings at hysteroscopy and laparoscopy in patients with chromic pelvic pain., Design: Prospective evaluation at surgery of women treated consecutively between January 1, 1991, and December 30, 1992., Setting: A private practice., Patients: One hundred forty-one women with pelvic pain (average age 35 yrs)., Interventions: Laparoscopy was performed in all patients, and hysteroscopy in all but one, who had had a hysterectomy. Endometrial and endocervical biopsies were performed., Measurements and Main Results: In 42 (30%) of 140 patients with a primary diagnosis of chronic pelvic pain hysteroscopic evaluation with endometrial and endocervical biopsies revealed an abnormality. Findings at hysteroscopy included leiomyomas in 25 patients (18%), intrauterine polyps in 9 (6.4%), and cervical stenosis in 4 (2.9%). Three women (2.1%) had intrauterine scarring and one (0.7%) had a bicornuate uterus. Endometrial biopsies showed adenomatous hyperplasia with atypia, and cystic hyperplasia in one patient each. Endocervical biopsies revealed cervical dysplasia in four women (2. 89%). An abnormal finding was documented on laparoscopic examination in all 141 patients. These included endometriosis in 113 patients (80%), adhesions in 67 (48%), leiomyomas in 59 (42%), and enlarged globular uterus in 34 (24%). In addition, appendiceal abnormalities were present in three women (2.1%) and hernia in two (1.4%)., Conclusions: Hysteroscopic abnormalities were found in 30% and laparoscopic abnormalities in 100% of patients who had a primary diagnosis of chronic pelvic pain.

Ninety-three women in whom conservative surgical therapy for chronic pelvic pain failed required hysterectomy for control of their disabling condition. In 22 of these 93 patients (24%), adenomyosis was the major pathologic finding. In 10 of the 22 (45%) women who had adenomyosis and required hysterectomy for control of their pain, tubal ligation had been previously performed. Only 15% (11/71) of patients without adenomyosis had had a tubal ligation. Over 23% of patients requiring hysterectomy for control of chronic severe pelvic pain had adenomyosis, and almost half of these women had had a tubal ligation performed. The possible relationship of adenomyosis to a previous tubal ligation has been explored.

One hundred patients were treated with laparoscopic techniques for chronic pelvic pain. These procedures included uterosacral nerve vaporization, resection and vaporization of endometriosis, hernia repair, appendectomy, presacral neurectomy, and ovarian surgery. Follow-up over a 3 year period revealed the following results. Women with significant endometriosis had a 75% cure rate with a change in quality of life index from a preoperative level of pain of 8 to a postoperative level of pain of 2. A Score of 1 is no pain and 10 is maximum pain. Patients who did not have endometriosis had an 80% cure rate with a reduction in pain level to an average of 2 from preoperative levels averaging 9. The results and trends from these procedures indicate that approximately 75% of all patients with chronic pelvic pain can be successfully treated by conservative laparoscopic techniques. Adenomyosis has been demonstrated to be the condition resulting in the most failures of treatment.

A case control study of the operative time, blood loss, time for return to work, pain levels, and medications was conducted comparing laparoscopic-assisted vaginal hysterectomies (LAVH) with total abdominal hysterectomy (TAH). The average operating time for LAVH was 151 minutes whereas for TAH it was 99 minutes (P<.01). The average length of stay for the LAVH was 2.5 days and for the abdominal hysterectomy it was 3.5 days (P<.01). During hospitalization the LAVH group required an average of 180 mg of meperidine while the TAH group required 414 mg of meperidine (P<.01). Patients undergoing LAVH reported activity levels of 9.2 on a scale of 1 to 10, with 10 being unlimited activity, by day 14. Abdominal hysterectomy patients' activity was reported as only 6.4 on the same scale (P<.005). The LAVH group, although requiring more operating time, made a more rapid recovery, and less pain medication, and required shorter hospitalization than the TAH group.

We compared laparoscopic-assisted vaginal hysterectomy (LAVH) with total abdominal hysterectomy (TAH) in a case control study that evaluated length of operation, blood loss, length of hospital stay, drug requirements for pain, and postoperative pain and activity levels. Of 81 women who underwent nonradical hysterectomy for a primary diagnosis of pelvic pain between June 1 and December 31, 1992, 19 who underwent each procedure were chosen for inclusion in the study. Patients were matched in a case control manner with age, weight, diagnosis, and uterine weight. All 38 hysterectomies were completed without incident. When indicated, unilateral or bilateral oophorectomies were performed. The average surgery time for LAVH was 144 minutes and for TAH 98 minutes, a significant difference (p <0. 005). There were no significant differences between estimated blood loss and change in hemoglobin from preoperative levels to postoperative day 1 levels between the groups. Women having TAH reported significantly more pain after their release from the hospital. There was no significant difference in pain during hospitalization apparently because patients who had TAH self-medicated to maintain acceptable levels. That group in fact used an average of 436 mg meperidine during their hospital stay, significantly more than the 197 mg used by the LAVH group (p <0.005). The length of stay was 2.125 days for LAVH and 3.542 days for TAH (p <0.001). On a scale of 1 to 10 (10 being complete normal activity) the activity level of women undergoing LAVH was 9.2 by day 14 compared with 6.4 for those having TAH (p <0.005). By the sixth postoperative week the latter group reported an activity level of only 8.5, indicating that the ability to function is much more severely limited after TAH than LAVH.