Department of Obstetrics and Gynaecology, University of Oulu, FIN-90220 Oulu, Finland
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Abstract |
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Key words: laparoscopic/pneumoperitoneum/sterilization
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Introduction |
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To evaluate the safety of the transfundal technique in relation to the infra-umbilical route, we performed a randomized prospective study in obese subjects scheduled for laparoscopic sterilization. The main goals were to assess the efficacy and safety of the transfundal route when inducing artificial pneumoperitoneum.
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Materials and methods |
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A single experienced surgeon (M.S.) performed all operations, which were carried out under general anaesthesia. The transfundal operation was performed with the subject in a modified lithotomy position. After vaginal cleansing the anterior lip of the cervix was grasped with a tenaculum and the Veress needle was inserted first into the cavity of the strongly anteverted uterus and then pushed through the fundal uterine wall in the midline of the uterus. The snap of the spring-loaded mechanism of the Veress needle and the low pressure of the abdominal cavity (<10 mmHg) immediately indicated that the tip of the needle was in the abdominal cavity. In the infra-umbilical group, the Veress needle was inserted at the lower border of the fossa umbilicus, perpendicularly through the abdominal wall. If a second attempt was unsuccessful in either group, the subject was transferred to the other group.
The laparoscopic sterilization technique was similar in both groups: a 10 mm laparoscope was inserted through a 1.5 cm infra-umbilical incision and the applicator through the lower abdomen on the right side. The subjects left the hospital on the afternoon of the day of surgery. Prophylactic antibiotics were not used.
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Results |
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Laparoscopy revealed moderate or severe adhesions between the posterior cervix and adnexae in two subjects, one in each group.
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Discussion |
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Unexpected perforation of the uterus during gynaecological procedures is an unpleasant complication which increases local bleeding and may increase the risk of infection. Transfundal perforation performed with a Veress needle in the present study was not associated with clinically significant bleeding. All the punctures were aimed at the midline of the uterine fundus, which has a thick myometrium with a good tamponade capacity in comparison, for example, with the cornual region. The diameter of the needle used was 2 mm, which also partly explains the lack of problems from bleeding.
Only one postoperative infection occurred. Endometritis manifested itself 11 days after operation in a Chlamydia-positive woman. Screening for Chlamydia in subjects scheduled for laparoscopic procedures is not included in routine preoperative laboratory tests in our hospital.
No major complications in the pelvic organs occurred in either group. There was no reason to expect a high incidence of complications to occur in the light of previous studies (Chapron et al., 1998), and because the total number of patients was only 100 in the present study. Nevertheless, according to our results it appears that the transfundal route is not associated with an increase in the rate of pelvic organ complications when compared with the infra-umbilical technique. It is essential, however, to perforate the fundus when the uterus is strongly anteverted, in which case the needle is targeted towards the anterior abdominal wall instead of vulnerable pelvic organs.
Contra-indications for the transfundal route were a history of severe pelvic inflammatory disease, and adhesions obliterating the cul-de-sac. In these cases there is an increased risk of bowel perforation. Infertility has also been suggested to be a contraindication as regards this method (Morgan, 1979; Wolfe and Pasic, 1990
). Theoretically, there may also be an increased risk of endometriosis and adenomyosis associated with this method (Trivedi and MacLean, 1994
).
Because the incidence of laparoscopic complications is higher among inexperienced operators (Chapron et al., 1997a,b
, 1998
), the transfundal route in inducing artificial pneumoperitoneum could be the method to consider during the training period of an inexperienced laparoscopist. The results of randomized and larger studies will later show whether the transfundal route could be the method of choice in inducing a safe artificial pneumoperitoneum in women with no known contra-indications for transfundal puncture undergoing gynaecological laparoscopic procedures.
To summarize, the transfundal route of Veress needle insertion is as effective as the conventional infra-umbilical route in inducing artificial pneumoperitoneum, and it is not associated with an increased risk of haemorrhage, infections or pelvic organ injuries.
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Notes |
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References |
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Chapron, C.M., Pierre, F., Lacroix, S. et al. (1997b) Major vascular injuries during gynecologic laparoscopy [see comments]. J. Am. Coll. Surgeons, 185, 461465.[ISI][Medline]
Chapron, C., Querleu, D., Bruhat, M.A. et al. (1998) Surgical complications of diagnostic and operative gynaecological laparoscopy: a series of 2966 cases. Hum. Reprod., 13, 867872.[Abstract]
Morgan, H.R. (1979) Laparoscopy: induction of pneumoperitoneum via transfundal puncture. Obstet. Gynecol., 54, 260261.[Abstract]
Sanders, R.R. and Filshie, G.M. (1974) Transfundal induction of pneumoperitoneum prior to laparoscopy. J. Obstet. Gynaecol. Br. Cmwlth, 81, 829830.
Trivedi, A.N. and MacLean, N.E. (1994) Transuterine insertion of Verres needle for gynaecological laparoscopy at Southland Hospital [see comments]. NZ Med. J., 107, 316317.
Wolfe, W.M. and Pasic, R. (1990) Transuterine insertion of Veress needle in laparoscopy [see comments]. Obstet. Gynecol., 75, 456457.[Abstract]
Submitted on April 6, 1999; accepted on June 17, 1999.