1 Department of Obstetrics and Gynecology, São Paulo University School of Medicine, São Paulo, Brazil
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Abstract |
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Key words: diode laser/ectopic pregnancy/endometriosis/microlaparoscopy
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Introduction |
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Others (Risquez et al., 1993) pioneered this technique, reporting 30 cases of microlaparoscopy. A substantial improvement in instruments has also occurred within this short period, permitting increasingly advanced surgery (Risquez et al., 1997
; Wattiez et al., 1999
).
Today, instruments ranging in calibre from 1.23.3 mm are used, with the light provided by a set of lenses or fibreoptic material. The light source preferentially used for these laparoscopes is xenonium.
Another important event in the evolution of laparoscopy is the use of a laser, introduced by Bruhat et al. (1997), which provides more safety and precision. However, there are no reports of the use of a diode laser in microlaparoscopy for the treatment of an intact tubal pregnancy.
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Case report |
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She had a history of moderate dysmenorrhoea during the first 2 days of menstruation and denied dyspareunia. She had been previously submitted to an appendectomy and did not report a history of pelvic inflammatory disease. On 17 May 1999, at 7 weeks and 5 days gestation, she presented with a small amount of vaginal bleeding accompanied by cholic pain of weak intensity in the right iliac fossa. On the same day, ß-HCG concentration was 1300mIU/ml and vaginal ultrasonography revealed the absence of an intrauterine gestational sac and the presence of a complex right adnexal mass measuring 3.5x2.2x2.2 cm. A diagnostic hypothesis of ectopic pregnancy was put forward and, in view of the mild intensity of symptoms, a new examination was performed after 48 h to confirm the diagnosis and to determine the treatment. On 19 May 1999, ß-HCG concentration was 1400 mIU/ml and transvaginal ultrasonography revealed the absence of an intrauterine gestational sac, a complex right adnexal mass of 3.7x2.5x2.5 cm and free fluid in the posterior cul-de-sac. It was then decided to perform microlaparoscopic surgery.
With the patient under general anaesthesia, we performed two punctures of 2 mm (the first infra-umbilical, the second in the left iliac fossa), and one 5 mm puncture in the right iliac fossa. A 2 mm optical instrument (Auto-Suture®; United States Surgical Corporation, Norwalk, CT, USA) was used. Pneumoperitoneum pressure was maintained at 10 mm Hg. An intact ectopic pregnancy was visualized in the right ampullar region, and small numbers of blood clots were collected from the posterior cul-de-sac. A 0.5 cm black superficial lesion suggestive of endometriosis was observed in the vesicaluterine recess.
Right salpingostomy was performed using a diode laser (Diomed Ltd, Cambridge, UK) which was introduced through a trocar measuring 2 mm in diameter (Figure 1). The uterine tube was opened longitudinally, along its antimesenteric surface, with the apparatus set at 10 W power. The embryonic material was removed with the aid of a 2 mm forceps and the tubal lumen was exhaustively washed. The lesion suggestive of endometriosis was biopsied and cauterized with the diode laser. The surgical piece was removed from the abdomen through the 5 mm trocar located in the right iliac fossa. The duration of the procedure was 45 min.
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Pathological analysis revealed necrotic villi in the midst of blood clots, fibrin, neutrophils and red blood cells. The biopsy of the peritoneal lesion revealed endometriosis.
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Discussion |
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Several recent studies have demonstrated that microlaparoscopy is a fully feasible diagnostic and therapeutic method for small surgical interventions (Bauer et al., 1995; Downing and Wood, 1995
; Fuller, 1996
; Haeusler et al., 1996
; Faber and Coddington, 1997
; Kovacs et al., 1998
). However, the images obtained are smaller and of inferior quality, compared with those obtained with 10 mm fibreoptic devices (Haeusler et al., 1996
). Furthermore, it is necessary to develop new expertise in order to visualize the structures in a narrower field of vision and to handle 2 mm instruments.
With the reduction in laparoscope diameter, the risk of herniation due to the surgical incision is also reduced. CO2 insufflation at the wrong site is avoided through visualization of the cavity, provided by the Veress needle itself, which simultaneously functions as a trocar for some fibreoptic devices (Downing and Wood, 1995). Furthermore, the cosmetic result is quite satisfactory, often with no need for skin suture.
Some authors recommend that microlaparoscopy be performed with the patient under conscious sedation, without orotracheal intubation, thus permitting a shorter and more comfortable post-operative recovery (Pellicano et al., 1998). In addition, performing pneumoperitoneum with a lower CO2 pressure prevents pain in the scapular region, a quite common occurrence in conventional laparoscopy.
The result of all of these advances is a briefer hospitalization and prompt return to work, reducing the socio-economic and psychological drawbacks of the procedure.
Other investigators have even recommended the execution of microlaparoscopy in the GP's surgery, creating a debate over the limits of this procedure (Palter, 1999).
In the present report we have described the use of the laser in microlaparoscopy in two conditions that classically benefit from this route, i.e. endometriosis and ectopic pregnancy. In a pioneering approach, we used a diode laser, which is portable and easy to handle. It is a highly precise device which causes heat necrosis up to only 2 mm lateral to the site of application (Lower et al., 1994).
The fact that the ectopic pregnancy in this case was intact and there was not much blood inside the abdominal cavity was decisive in choosing to perform the surgery by microlaparoscopy. When a large haemoperitoneum is present, difficulties can occur during the intervention and become a contra-indication to microlaparoscopy and even to conventional laparoscopy.
The smoke produced by the diode laser did not jeopardize the visualization of structures involved, being similar to the smoke produced by the use of monopolar current.
There was not a significant increase in the duration of the procedure compared to the time required to perform similar interventions by conventional laparoscopy.
In future, the precise determination of the damage caused by laser could be of fundamental importance for this technique, which will frequently be applied to conscious patients, i.e. patients who are likely to make unpredictable movements. In addition, because of the reduced pressure of the pneumoperitoneum, there may be closer proximity of the laser to delicate structures, such as intestinal loops and the ureter, which may therefore be more at risk of damage.
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Notes |
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References |
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Submitted on October 26, 1999; accepted on March 15, 2000.