Pelvic Pain

Landmark Papers by Adlap Surgeons

Reduction of laparoscopic-induced hypothermia, postoperative pain and recovery room length of stay by pre-conditioning gas with the Insuflow device: a prospective randomized controlled multi-center study.
Ott DE, Reich H, Love B, McCorvey R, Toledo A, Liu CY, Syed R, Kumar K

JSLS 1998 Oct-Dec;2(4):321-9
OBJECTIVE: To assess the efficacy and safety of Insuflow (Georgia BioMedical, Inc.) filter heater hydrator device in reducing the incidence, severity and extent of hypothermia, length of recovery room stay and postoperative pain at the time of laparoscopy. DESIGN: Prospective, randomized, blinded, controlled multi-center study. Patients underwent gynecologic procedures via laparoscopy; surgeons, anesthesiologists and recovery room personnel assessed the results. SETTING: Seven North American institutions. PATIENTS: Seventy-two women for safety evaluation and efficacy studies. INTERVENTIONS: Intraoperative pre-conditioning of laparoscopic gas with the Insuflow device (treatment) or standard raw gas (control) during laparoscopic surgery and postoperatively. MAIN OUTCOME MEASURES: Incidence, severity and extent of hypothermia, postoperative pain perception and length of recovery room stay. RESULTS: The Insuflow group had significantly less intraoperative hypothermia, reduced length of recovery room stay and reduced postoperative pain. Pre-conditioning of laparoscopic gas by filtering heating and hydrating was well tolerated with no adverse effects. The safety profile of the Insuflow pre-conditioned gas showed significant benefits compared to currently used raw gas. CONCLUSIONS: Pre-conditioning laparoscopic gas by filtering heating and hydrating with the Insuflow device was significantly more effective than the currently used standard raw gas and was safe in reducing or eliminating laparoscopic-induced hypothermia, shortening recovery room length of stay and reducing postoperative pain.

Correction of genital prolapse.
Liu CY, Reich H

J Endourol 1996 Jun;10(3):259-
Massive eversion of the vagina is one of the most disturbing disorders confronting a woman. It is a complex disorder that always coexists with other pelvic floor defects. The management is almost always surgical, and all defects must be repaired concomitantly. Current surgical practice relies primarily on the strength of the endopelvic fascia and certain ligaments, which clearly is not ideal for providing the kind of support needed. Current understanding of the neurophysiology, neuroanatomy, and biophysics of the pelvic floor give us hope that management will be more effective in the future. Laparoscopic repair techniques are described.

Laparoscopic retropubic colposuspension (Burch procedure). A review of 58 cases.
Liu CY

J Reprod Med 1993 Jul;38(7):526-Fifty-eight patients underwent laparoscopic retropubic colposuspension (Burch procedure) for the treatment of genuine urinary stress incontinence. Of these 58 patients, 3 developed postoperative detrusor instability, and another 2 had bladder injuries. The overall complication rate was 8.5%, and the success rate was 94.83%. Our limited experience has shown many advantages of laparoscopic retropubic colposuspension over the traditional abdominal retropubic colposuspension; they include easy access to the space of Retzius, better visibility in the operative field, minimal intraoperative blood loss and postoperative need for pain medication, and shortened hospital stay and recovery period. Most patients were discharged from the hospital within 24-36 hours and resumed normal activities within seven days. Previous major pelvic surgery is not a contraindication to this procedure. Based on our initial experience, laparoscopic retropubic colposuspension appears to be a viable alternative to abdominal retropubic colposuspension.

Carcinoid tumors of the appendix detected at laparoscopy for gynecologic indications.
Heller DS, Reich H, Rosenberg J, Blanco J

J Am Assoc Gynecol Laparosc 1999 Aug;6(3):303-STUDY OBJECTIVE: To evaluate the significance of the abnormal-appearing appendix during gynecologic laparoscopy. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: One hundred sixty-six women. INTERVENTIONS: Laparoscopic appendectomy. MEASUREMENTS AND MAIN RESULTS: Five of 166 appendixes removed for abnormal appearance contained a carcinoid tumor. At least one patient was a candidate for additional resection. CONCLUSION: It is important for gynecologists to be aware of the possibility of a carcinoid tumor of the appendix, particularly if an abnormality is seen at the time of surgery. (J Am Assoc Gynecol Laparosc 6(3):303-306, 1999)

A Safer Method of Inserting the Primary Cannula During Laparoscopy.
Garry R, Reich H, Phillips G, Kumar C

J Am Assoc Gynecol Laparosc 1995 Aug;2(4, Supplement):S68-]
We believe that the volume of gas insufflated into the abdominal cavity is directly related to the safety of laparoscopy. The most dangerous moment is at the insertion of the primary cannula, when the main danger is injury to the major vessels. We believe that the larger the air bubble created between the abdominal wall and the abdominal contents, the less the risk of inadvertent damage. Insufflation until a pressure of 25 mm Hg is obtained producing a tense dome to the abdomen, which is easily and safely penetrated by a sharp cannula. This usually requires between 4 and 10 L of carbon dioxide. Many surgeons are concerned about the effects of this high intraabdominal pressure on the patient's respiratory and cardiac function; however, we believe that this high-pressure technique is both a safe and effective way to minimize serious intraabdominal trauma.

The Clarke Suture Needle Forceps in Operative Laparoscopy.
Clarke HC, Reich H

J Am Assoc Gynecol Laparosc 1995 Aug;2(4, Supplement):S67
The suture needle forceps has a semidisposable needle with an eye at the distal end, on an extendible jaw. The instrument threaded with suture is introduced through a 5-mm cannula with its proximal end maintained extracorporeally. The needle carries suture through tissue and is unthreaded by a tissue forceps. The needle is withdrawn from the tissue, and the distal end of suture is clamped by the jaws of the suture needle forceps and brought extracorporeally for ligation with the Clarke ligator (knot pusher). This suture needle forceps has been useful in retroperitoneal oophorectomy for suture ligation of the infundibulopelvic ligament; in hysterectomy for suture ligation of the utero-ovarian ligaments, uterine vessels, and cardinal and uterosacral ligaments; and in myomectomy to close incisions. The needle can be changed when dull and also exchanged for needles of various types. The time for simple suture ligation was 2 to 3 minutes.

PMID: 9074010

Laparoscopic implant of Gore-Tex surgical membrane.
Crain J, Curole D, Hill G, Hurst B, Metzger D, Murphy A, Perloe M, Reich H, Rowe G, Sanfillipo J, et al

J Am Assoc Gynecol Laparosc 1995 Aug;2(4):417-

Curved needle suturing technique for operative laparoscopy.
McGlynn F, Sekel L, Reich H

Minim Invasive Surg Nurs 1995 Winter;9(4):158-

Instruments and equipment used in operative laparoscopy.
Reich H, Maher PJ

Baillieres Clin Obstet Gynaecol 1994 Dec;8(4):687-
Successful operative laparoscopy is dependent on the proper use and knowledge of a variety of appropriate surgical equipment. This chapter describes cameras, light sources, videos, video positioning, operating tables, anaesthesia, insufflators, laparoscopes, trocars, irrigators, forceps, scissors, electrosurgical instruments, lasers, suturing, staples and uterine manipulators. Knowledge of the best choice and proper use of instruments has a more important role in performing operative laparoscopy than laparotomy.

Argon Assisted CO2 Laser Laparoscopy.
MacGregor T, Bronitsky C, Reich H

J Am Assoc Gynecol Laparosc 1994 Aug;1(4, Part 2
The use of a small amount of Argon gas to purge the operating channel of the CO2 laser laparoscope eliminates the thermal lensing (blooming) that has plagued CO2 laser laparoscopy. By eliminating the blooming, the power density and transmission of laser power is increased. Overall, the efficacy of the CO2 laser/laparoscope system is dramatically improved. This simple procedure allows even older CO2 lasers to equal the efficiency of the newer generation shifted wave length CO2 isotope lasers. This technique is superior to others which require special equipment to achieve extremely high insufflation/evacuation flow rates in order to control thermal blooming.

13CO2 isotopic laser used through the operating channel of laser laparoscopes: a comparative study of power and energy density losses.
Adamson GD, Reich H, Trost D

Obstet Gynecol 1994 May;83(5 Pt 1):717-24
OBJECTIVE: To evaluate the power transmission, spot size, power density, and energy density of a new isotopic carbon dioxide (13CO2) laser compared with a conventional CO2 laser. METHODS: Experiments were performed in a laboratory using a conventional CO2 laser and an isotopic 13CO2 laser. Two laparoscopes with 5-mm and 7.5-mm operating channels were connected to a standard coupler and to each of the lasers. Standardized measurements were made of power transmission and spot size using both nitrogen purge gas and CO2 purge gas at rates of 1-20 L/minute. Power density and energy density were calculated for continuous mode and ultrapulse mode transmission, respectively. RESULTS: The isotopic 13CO2 laser power transmission was higher and proportional to input power, while spot size was smaller compared with the conventional laser and was insensitive to power level or purge rate. Power density and energy density were markedly higher with the isotopic 13CO2 laser, reaching the threshold for complete ablation, and were much more predictable. The 7.5-mm operating channel generally had superior operating results compared with the 5-mm channel because of the smaller spot size and higher power transmission. CONCLUSIONS: The isotopic 13CO2 laser is associated with much higher power density and energy density capabilities than are conventional CO2 lasers. At surgery, we have noted less thermal injury, faster ablation, more precise and predictable tissue effects, and greater control of tissue effect with the isotopic 13CO2 laser than with other CO2 lasers. These results are attributed to the improved beam propagation through CO2 insufflation gas measured in the laboratory. Thermal injury can be varied according to the required surgical situation and can be kept to an absolute minimum at high-pulse energy.
PMID: 8164930, UI: 94218016

Mechanical peritoneal retraction as a replacement for carbon dioxide pneumoperitoneum.
Chin AK, Moll FH, McColl MB, Reich H

J Am Assoc Gynecol Laparosc 1993 Nov;1(1):62-
A fan retractor and a mechanical lifting arm were developed to achieve planar displacement of the anterior abdominal wall for gasless laparoscopic procedures. The technique permits the use of conventional open surgical instruments as well as laparoscopic tools through minilaparotomy incisions. It also potentially addresses the technical constraints imposed by pneumoperitoneum, and physiologic concerns regarding carbon dioxide insufflation. Gynecologic, general surgical, and trauma procedures were performed in 104 patients, with successful completion of 86.5%. Continued application is necessary to delineate the full range of benefits of laparoscopy without insufflation.

Brachial plexus neuropathies after advanced laparoscopic surgery.
Romanowski L, Reich H, McGlynn F, Adelson MD, Taylor PJ

Fertil Steril 1993 Oct;60(4):729-
A retrospective review of 3,200 advanced laparoscopic procedures demonstrated five brachial plexus injuries during a 5-month period in 1986 (0.16% incidence rate). Brachial plexus injury can occur during laparoscopic surgery using steep Trendelenburg's position with shoulder braces and the patient's arm extended at 90 degrees. Position modification can reduce the risk for upper extremity neuropathies.

Laparoscopic oophorectomy.
Reich H, Johns DA, Davis G, Diamond MP

J Reprod Med 1993 Jul;38(7):497-
Oophorectomies were performed on 312 women as part of an operative laparoscopic procedure over an eight-year period. The average age of the women was 40.4 +/- 0.6 (SEM) years; 36.5% had previously undergone a hysterectomy. The median operating time was 120 minutes. The length of hospitalization was less than 24 hours in 77.6% of women, between 24 and 48 hours in 15.1% and over 48 hours in 7.4%. Intraoperative and/or postoperative complications occurred in 12 women (3.8%). Estimated blood loss greater than 300 mL occurred in two women. The most frequent diagnoses were endometriosis/endometrioma, functional cysts and normal ovarian tissue (usually from ovaries enmeshed in adhesions); two ovaries demonstrated borderline malignant potential. Laparoscopic oophorectomy is acceptable under appropriate conditions. Further studies are necessary to provide criteria for accurate differentiation of benign from malignant ovarian enlargement.

Incisional hernias after major laparoscopic gynecologic procedures.
Kadar N, Reich H, Liu CY, Manko GF, Gimpelson R

Am J Obstet Gynecol 1993 May;168(5):1493-5
OBJECTIVE: Our purpose was to determine the incidence of incisional hernias after operative laparoscopy. STUDY DESIGN: A retrospective case review was performed. RESULTS: The frequency of incisional hernias at extraumbilical 10 and 12 mm trocar insertion sites was one in 429 (0.23%) cases and five in 161 (3.1%) cases, respectively; the difference is statistically significant (p = 0.007, Fisher's exact test). Incisional hernias were also significantly more common if the fascia was left open (p = 0.021), although three of the five hernias at 12 mm trocar sites occurred after attempted closure of the underlying fascia. CONCLUSION: The underlying fascia should be closed whenever a 10 mm or larger trocar is placed at an extraumbilical site during laparoscopy. The peritoneum may also require closure at 12 mm trocar sites if the trocar is placed through, rather than lateral to, the rectus sheath.

Advances in gynecologic laparoscopic procedures.
Levine RL, Reich H

World J Surg 1993 Jan-Feb;17(1):63-9
Advances in gynecologic procedures using laparoscopic surgical techniques. Gynecologic laparoscopic procedures are described that involve the reproductive system, lymph node sampling, bowel and urinary tract repair, and abscess therapy. Laparoscopic surgery enhances the outcome of most current gynecologic procedures.