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Intraperitoneal pressure and adhesions

From: “AAGL-ENDO-EXCHANGE automatic digest system” < LISTSERV@listserv.brown.edu> Date: Jun 20, 2012 6:01 AM Subject: AAGL-ENDO-EXCHANGE Digest - 18 Jun 2012 to 19 Jun 2012 (#2012-112) To: Date: Tue, 19 Jun 2012 18:33:03 -0400 From: Philippe R Koninckx and Anastasia Ussia Subject: Ideal intraabdominal pressure at laparoscopy to minimize adhesion In animal models the mesothelial hypoxic effect of pure CO2 increases with duration and pressure of pneumoperitoneum as we demonstrated some 10 years ago. In the human however this type of experiment cannot be performed and thus there are no data. Extrapolating from all other the data available today I would summarise as follows. Surgical lesions alone are only slightly adhesiogenic although essential to start the adhesion process. Some 20 times more important is the enhancing effect of the entire peritoneal cavity. The key mechanism is acute inflammation of the cavity of which pressure alone is a minor contributing factor. With full conditioning however preventing as much as possible this acute inflammation we actually in the human can reduce postperative pain while adhesions are virtually absent and this in surgery of long duration as deep endometriosis excision. Philippe R. Koninckx*,** and Anastasia Ussia* Gruppo Italo Belga, Leuven-Rome, Europe EndoSAT NV, Leuven,...

Robotic surgery in gynaecology and endometriosis

The discussion on robotic assisted surgery is continuing . Following our opinion statement on www.endometriosis.org John F Dulemba posted in World Endometriosis Research Foundation 7 January 07:43 PEOPLE. THE ROBOT IS JUST LAPAROSCOPY!!!!!!!!!!!!! PLEASE WATCH THIS MINUTE VIDEO….TO THE VERY END. YOU WILL SEE HOW PRECISE THE INSTRUMENTS CAN BE, AND I DO NOT THINK ANY STANDARD LAPAROSCOPISTS CAN BE AS PRECISE AS THE DOCTOR IN THIS VIDE!!!!!! When I wrote the comment below, the video has been withdrawn Nice video but misleading - obviously for specific movements a robot is superior to the human. Therefore I do expect that a robotic tubal reanastomosis will be superior to standard laparoscopy and come close to classic microsurgery. Unfortunately however , to the best of my knowledge, this superiority has never been demonstrated. No attemps were made even to demonstrate this in animal models. So doubt persists whether there is some uncertainty about outcome of such a trial. Failure indeed would killing a major indication - except tubal reanastomosis I doubt that superiority can be proven for any other gynaecological intervention (since it probably does not exist) - in addition robotic surgery can be potentially dangerous when performed by surgeons without sufficient training in laparoscopic surgery. (see blog http://www.gynsurgery.org/hysterectomy-myomectomy/robotic-surgery-is-not-superior-and-potentially-dangerous/) - finally, in this period of economic crisis, it is unclear who is willing to carry the associated huge cost : the surgeon ? the hospital ? (for marketing reasons) the patient ? (I doubt any patient is willing to pay today if correctly informed) I anyway want to stress my interest in robotic surgery as can be found in de development...

Chronic hydronephrosis surgical management

In response to a question : how to treat silent hydronefrosis (without pain) and a marked reduction in kidney function ? AAGL-ENDO-EXCHANGE Digest - 7 Aug 2011 to 8 Aug 2011 Date:    Mon, 8 Aug 2011 15:50:26 -0400 From:    Philippe Koninckx and Anastasia Ussia <Gary_Frishman@BROWN.EDU> Subject: Chronic hydronephrosis surgical management In all cases seen with hydronephrosis until today (around 100): strategy has been consistently the same * insert a stent if possible * dissect the ureter what will give the diagnosis of the cause of the hydronephrosis ie generally endometriosis, rarely compression only. Anyway this becomes apparent during dissection. * during dissection decide whether excision of surrounding endometriosis is sufficient or whether a resection anastomosis is necessary (a reimplantation almost always is a secondary option after failure as published) Since dissection of the ureter was not done, I would suggest repeat surgery. The prognosis of the kidney function is difficult to predict since the duration that the hydronephrosis existed is unknown. Sincerely Philippe Koninckx and Anastasia Ussia Gruppo Italo Belga, Belgium and...

Diagnostic tests of endometriosis : speculation and misleading information is harmful for patients.

Methylene blue painting of the peritoneum for the diagnosis of endometriosis - Eshre 2011. For insiders the diagnosis of endometriosis seems well established. The public and recently  also contaminating the scientific debate ,however, is  fueled by correct but maliciously misleading “scientific” information. That this harmful to patients, emphasised by several recent emails by patients triggered this blog. This statement about misleading information needs explanation. The gold standard for the diagnosis of endometriosis is and remains laparoscopy. Provided the laparoscopist has the experience. The necessity of experience to recognize endometriosis was clearly shown for minimal lesions. It also was demonstrated that in the absence of experience too often a cystic corpus luteum erroneously is operated for cystic ovarian endometriosis. Also for deep endometriosis as we repeatedly discussed and demonstrated at congresses can be very hard to diagnose and is easily missed, especially the smaller lesions of the sigmoid and lesions remaining after incomplete previous surgery. Lesions remaining after a bowel resection (indeed very often the margins are not endometriosis free) are virtually inpossible to diagnose. Few surgeons will even attempt to do surgery, while neither MRI or ultrasound will provide a reliable diagnosis. Microscopical confirmation is a useful research tool but clinically overvalued. Clinical mistakes indeed are rare for deep endometriosis except after surgery, when fibrosis can erroneously be mistaken as endometriosis (moreover often suggested by ultrasound). Also for cystic ovarian endometriosis or typical lesions microscopical confirmation of endometriosis is rarely useful. Patients need to understand the mechanisms why misleading information so often contaminates the debate. Since repetitive I do not hesitate to call this maliciously misleading, although probably not...

Small bowel herniation in trocar sites and early repeat laparoscopy

Small bowel herniation in trocar sites and early repeat laparoscopy RCTs have not been performed, nor will be performed , in order to document the incidence and the prevention of small bowel herniation in trocar sites. Indeed it is a rare complication and for obvious ethical reasons trials will not be performed. The evidence therefore can only be circumstantial.   We would try to summarise as follows our attitude. 1. The risk of small bowel herniation is believed to depend  on trocar diameter and on the surgical lesion caused by trocar insertion. 2. Unfortunately I am not aware of evidence that the risk of small bowel herniation is decreased by the use of conical trocars instead  of sharp triangular trocars or by the use of  the Termanian trocar. This could be expected given a smaller trauma as demonstrated years ago by Malcom Munro. 3. For the first intra publical trocar the risk seems so low that most of us will not suture the fascia. A plausible explanation could be that the insertion  is generally slightly oblique and that hte insertion thus closes by a flap valve mechanism.  For this reasons,  we only close the fascia of the first trocar insertion when either the patient is extremely thin or afther the incision has been enlarged for specimen retrieval. 4. For the secondary trocars which are inserted perpendicularly (in order to permit eventual backloading of sutures)  we do not close the fascia for 5 mm ports but always close them when 10mm or larger ports were used. 5. The biggest clinical challenge, however, is the diagnosis of a small bowel herniation since symptomatology is insidious.  For this reason, we advocate an early repeat laparoscopy whenever a patient does not improve...

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Shiny trinkets are shiny.