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OBJECTIVE: To perform a histologic examination of tissue identified as fascia and used during colporrhaphy. METHODS: In patients undergoing primary anterior and posterior colporrhaphy, biopsies were taken from three surgically distinct vaginal tissues types: the wall, the “fascia,” and areolar tissue. The biopsies were placed in formalin, identified numerically, and sent to pathology for staining with hematoxylin-eosin, Masson trichrome for collagen, Movat for elastin, and immunoperoxidase stain for actin in smooth muscle. Simultaneous photographs were taken of the biopsy sites. The histologic diagnosis was compared with the surgical diagnosis. RESULTS: A total of 60 samples were taken from five women. The specimens from two of these patients were disqualified. The pathologist made the following histologic diagnosis for each type of surgical specimen: vaginal wall, mucosa and underlying connective tissue; fascia, moderately dense connective tissue with smooth muscle; areolar tissue, loose connective tissue. The histologic appearance of the “fascia” was indistinguishable from the deeper aspects of the vaginal wall. It was composed of the same proportions of smooth muscle, elastin, and collagen. Using the histologic appearance as the “gold standard,” the accuracy of the surgical diagnosis was: “vaginal wall,” 12 of 12 (100%); “fascia,” seven of 12 (58%); and “areolar tissue,” eight of 12 (67%). CONCLUSIONS: The surgical “fascia” used during colporrhaphy consists of moderately dense connective tissue with smooth muscle similar to the deep aspects of the vaginal wall, is the same in both the anterior and posterior compartments, and is an artifact of the surgical dissection used to separate the vaginal wall from the underlying organs.

The discovery of the immunosuppressant Cyclosporin A (CsA) has improved the survival of transplanted kidneys and has made other solid organ transplants a practical reality. Transplant centres were initially reluctant to use CsA in pediatric patients because of a perceived poor-risk benefit ratio of the drug. However, improved transplant survival, largely because of CsA use in adult transplants, made all centres recognize that withholding this drug from children was not warranted. Hirsutism, coarsening of skin, and nephrotoxicity were the major problems associated with its use. However overall pediatric renal survival rates worldwide were below adult survival figures. 1 The need to improve kidney transplant survival has resulted in the widespread use of CsA along with changes in donor profiles and surgical and postoperative care. The change to CsA in pediatric transplantation has become the backbone of most posttransplant immunosuppressant regimes. The previously used myelotoxic drugs such as Imuran (Burroughs Wellcome Inc, Canada) remain in use for triple therapy regimes or for patients in whom CsA toxicity is particularly prominent. We have had a relatively long experience with CsA, and its use in children has been accepted. The question that was originally asked still looms: Do children have any unique toxicity to this drug, and will the dire predictions of centres that first refused to use it in children be borne out with time?

Objective To provide clinical direction, based on the best evidence available, on laparoscopic entry techniques and technologies and their associated complications. Options The laparoscopic entry techniques and technologies reviewed in formulating this guideline include the classic pneumoperitoneum (Veress/trocar), the open (Hasson), the direct trocar insertion, the use of disposable shielded trocars, radially expanding trocars, and visual entry systems. Outcomes Implementation of this guideline should optimize the decision-making process in choosing a particular technique to enter the abdomen during laparoscopy. Evidence English-language articles from Medline, PubMed, and the Cochrane Database published before the end of September 2005 were searched, using the key words laparoscopic entry, laparoscopy access, pneumoperitoneum, Veress needle, open (Hasson), direct trocar, visual entry, shielded trocars, radially expanded trocars, and laparoscopic complications. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations and Summary Statement 1.Left upper quadrant (LUQ, Palmer's) laparoscopic entry should be considered in patients with suspected or known periumbilical adhesions or history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus (II-2 A). Other sites of insertion, such as transuterine Veress CO 2 insufflation, may be considered if the umbilical and LUQ insertions have failed or have been considered and are not an option (I-A). 2.The various Veress needle safety tests or checks provide very little useful information on the placement of the Veress needle. It is therefore not necessary to perform various safety checks on inserting the Veress needle; however, waggling of the Veress needle from side to side must be avoided, as this can enlarge a 1.6 mm puncture injury to an injury of up to 1 cm in viscera or blood vessels (II-1 A). 3.The Veress intraperitoneal (VIP-pressure ->10 mm Hg) is a reliable indicator of correct intraperitoneal placement of the Veress needle; therefore, it is appropriate to attach the CO 2 source to the Veress needle on entry (II-1 A). 4.Elevation of the anterior abdominal wall at the time of Veress or primary trocar insertion is not routinely recommended, as it does not avoid visceral or vessel injury (II-2 B). 5.The angle of the Veress needle insertion should vary according to the BMI of the patient, from 45° in non-obese women to 90° in obese women (II-2 B). 6.The volume of CO 2 inserted with the Veress needle should depend on the intra-abdominal pressure. Adequate pneumoperitoneum should be determined by a pressure of 20 to 30 mm Hg and not by predetermined CO 2 volume (II-1 A). 7.In the Veress needle method of entry, the abdominal pressure may be increased immediately prior to insertion of the first trocar. The high intraperitoneal (HIP-pressure) laparoscopic entry technique does not adversely affect cardiopulmonary function in healthy women (II-1 A). 8.The open entry technique may be utilized as an alternative to the Veress needle technique, although the majority of gynaecologists prefer the Veress entry. There is no evidence that the open entry technique is superior to or inferior to the other entry techniques currently available (II-2 C). 9.Direct insertion of the trocar without prior pneumoperitoneum may be considered as a safe alternative to Veress needle technique (II-2). 10.Direct insertion of the trocar is associated with less insufflation-related complications such as gas embolism, and it is a faster technique than the Veress needle technique (I). 11.Shielded trocars may be used in an effort to decrease entry injuries. There is no evidence that they result in fewer visceral and vascular injuries during laparoscopic access (II-B). 12.Radially expanding trocars are not recommended as being superior to the traditional trocars. They do have blunt tips that may provide some protection from injuries, but the force required for entry is significantly greater than with disposable trocars (I-A). 13.The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry, but this advantage has not been fully explored. The visual entry cannula trocars have the advantage of minimizing the size of the entry wound and reducing the force necessary for insertion. Visual entry trocars are non-superior to other trocars since they do not avoid visceral and vascular injury (2 B).