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Uterine arteriovenous malformations (AVM) are rare and can be classified as either congenital or acquired. Acquired AVMs may result from trauma, uterine instrumentation, infection or gestational trophoblastic disease. The majority of acquired AVMs are encountered in women of reproductive age with a history of at least one pregnancy. Traditional therapies of AVMs include medical management of symptomatic bleeding, blood transfusions, uterine artery embolization (UAE) or hysterectomy. In this retrospective case series, we report our experience with AVM and UAE in five symptomatic women of reproductive age who wished to preserve fertility. Patients were 18-32 years old, and had 1-3 previous pregnancies prior to initial presentation. All patients were followed until their deliveries. All five patients delivered live births. Three of the five patients required two embolization procedures and one of these women required a subsequent hysterectomy. Two deliveries were at term and had normal weight babies and normal placenta. One woman had cerclage placed and developed chorioamnionitis at 34 weeks but had a normal placenta. Two pregnancies were induced <37 weeks for pre-eclampsia/b intrauterine growth restriction ± abnormal umbilical artery dopplers. The low birthweight were both <2000 g. Both placentas showed accelerated maturity and infarcts. All estimated blood losses were recorded as <500 cc. In conclusion, UAE may not be as effective at managing AVM as previously thought and should be questioned as an initial therapy in symptomatic women of reproductive age desiring fertility preservation.

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BACKGROUND: To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids. METHOD: We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months. RESULTS: A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal. CONCLUSION: Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.

Contexte : Évaluer l'efficacité et la douleur post-interventionnelle associées à l'embolisation de l'artère utérine (EAU) au seul moyen du produit Gelfoam, par comparaison avec l'utilisation combinée des produits Embosphere et Gelfoam, chez des femmes présentant des fibromes utérins symptomatiques. Méthode : Nous avons mené une étude pilote non randomisée prospective. Une EAU par voie transfémorale guidée par fluoroscopie a été menée seulement au moyen de tampons Gelfoam ou au moyen des produits Embosphere (500-700 mg) et Gelfoam, sous sédation consciente et anesthésie locale, le tout ayant été suivi par la mise en œuvre d'une analgésie contrôlée par la patiente (ACP) pendant la nuit suivant l'intervention (au moyen d'une pompe à morphine). La douleur post-interventionnelle a été évaluée en fonction de la quantité moyenne de morphine auto-administrée au moyen de la pompe d'ACP (ml) entre 0 et 19 heures au sein de chaque groupe. Les volumes moyens de l'utérus et du fibrome dominant ont été calculés par échographie au départ, à trois mois, à six mois et à 12 mois. Résultats : Au total, 17 femmes ont participé à l'étude. Une occlusion bilatérale de l'artère utérine a été menée chez huit femmes en n'utilisant que le produit Gelfoam et la même intervention a été menée au moyen des produits Embosphere et Gelfoam chez neuf autres femmes. Une des femmes du groupe « Embosphere et Gelfoam ¼ en est venue à présenter un hématome au point de ponction ayant nécessité une autre intervention, une semaine plus tard. La quantité moyenne (σ) de morphine auto-administrée au moyen de la pompe d'ACP à 0, à 1 et à 2 heures a été de 3,4 mg (3,1), de 2,9 mg (2,2) et de 2,4 mg (3,3), au sein du groupe « Gelfoam seulement ¼, et de 6,1 mg (3,0), de 9,6 mg (7,1) et de 5,3 mg (4,4), au sein du groupe « Embosphere et Gelfoam ¼, respectivement. Après trois heures, la quantité de morphine utilisée était équivalente au sein des deux groupes. La dose totale moyenne (σ) de morphine utilisée a été de 29,5 mg (18,6) au sein du groupe « Gelfoam seulement ¼ et de 41,1 mg (19,3) au sein du groupe « Embosphere et Gelfoam ¼ (P = 0,228). À 12 mois, la diminution du volume utérin total médian et du volume médian du fibrome dominant était équivalente au sein des deux groupes. Conclusion : La tenue d'une embolisation de l'artère utérine en n'utilisant que le produit Gelfoam ou au moyen des produits Gelfoam et Embosphere a donné lieu à des issues cliniques équivalentes. Bien que la douleur post-interventionnelle immédiate puisse être moins intense lorsque l'on n'a recours qu'au produit Gelfoam, nous n'avons pas été en mesure de le démontrer de façon objective en utilisant la quantité de morphine auto-administrée à titre de mesure de la douleur.

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Endometriosis can develop in every organ and tissue in the female body except perhaps the spleen. The mechanism of distal metastasis is thought to be hematogenous or lymphatic spread from the uterus. Endometriotic lesions in the central nervous system are rare. Herein, we report the case of a woman with abnormal uterine bleeding who developed catamenial neurologic signs and symptoms. Computed tomography scans and magnetic resonance images demonstrated a circumscribed lesion in the left centrum semiovale of the brain. All neurologic symptoms resolved completely after treatment with gonadotropin-releasing hormone agonist for 3 months and subsequent laparoscopic bilateral oophorectomy. The patient was thought to have cerebral endometriosis, a rare phenomenon, although several cases have been reported in the literature. Temporal association of neurologic signs and symptoms with menstruation that resolves with medical or surgical menopause is highly suggestive of cerebral endometriosis.

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OBJECTIVE: To evaluate the feasibility, safety, and short-term efficacy of bilateral uterine artery occlusion, using a transvaginal Doppler-guided vascular clamp as a minimally invasive therapy for symptomatic uterine leiomyomas. METHODS: We conducted two prospective, non-randomized, phase I pilot studies (Canadian Task Force Classification II-2) at a university-affiliated teaching hospital. Between June 2004 and May 2005, 30 premenopausal women with symptomatic uterine leiomyomas underwent bilateral uterine artery occlusion using a transvaginal Doppler-guided vascular clamp. Bilateral uterine artery occlusion was performed for 5.8 +/- 1.4 hours in the first 17 patients (Group 1) and from 6 to 9 hours (mean 7.05 +/- 1.0 hours) in the latter 13 patients (Group 2). Outcome measures included dominant fibroid volume (cm(3)), uterine volume (cm(3)), and improvement of menorrhagia at one, three, and six months. RESULTS: Bilateral occlusion of the uterine arteries was achieved in all 30 patients. In Group 1, the Ruta Menorrhagia Severity Scores decreased from baseline by 16%, 22% and 39% at one, three, and six months respectively. The dominant fibroid (DF) and uterine volumes decreased by 24% and 16% respectively at six months. In Group 2, the Ruta scores changed from baseline by +3%, -24%, and -42% at one, three, and six months respectively. The DF and uterine volumes decreased by 29% and 16%, respectively at six months. CONCLUSION: Following bilateral uterine artery occlusion using a transvaginal Doppler clamp, the dominant fibroid volume decreased by an average of 24%, uterine volume decreased by 12%, and menorrhagia symptoms were reduced by up to 42%. Uterine artery occlusion may provide the gynaecologist with an alternative to uterine artery embolization (UAE). The system is simple, easy to apply, and short-term efficacy may be equivalent to UAE.

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STUDY OBJECTIVES: To estimate the incidence of incidental miscellaneous uterine malignant neoplasms other than endometrioid adenocarcinoma detected during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and to examine the effect of hysteroscopic surgery on long-term clinical outcome. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: Women with AUB. INTERVENTION: From January 1, 1990, through December 31, 2008, one of the authors (G.A.V.) and several fellows performed primary hysteroscopic surgery at St. Joseph's Health Care in 3892 women with AUB. Of the 7 with malignant disease, one underwent hysteroscopic partial (n = 1) or complete (n = 6) rollerball electrocoagulation or endomyometrial resection. After diagnosis of uterine cancer, the women were counseled about the disease and management in accord with established clinical practice guidelines. Follow-up with office visits and telephone interviews ranged from 2 to 8 years (median, 6 years). MEASUREMENTS AND MAIN RESULTS: Of the 3892 women, 4 had undiagnosed and 3 had suspected miscellaneous uterine malignant neoplasms including 1 endometrial stromal sarcoma, 2 carcinosarcomas, 2 atypical polypoid adenomyomas of the endometrium, 1 minimal deviation adenocarcinoma of the cervix, and 1 smooth-muscle tumor of uncertain malignant potential. At 2 to 8 years of follow-up, 1 patient died accidentally after 1 year, 1 died of carcinomatosis of either coexisting breast cancer or a carcinosarcoma (postmortem examination was declined) after 1 year, and 5 were alive and well. CONCLUSION: Resectoscopic surgery in women with miscellaneous uterine malignant lesions not adversely affect 5-year survival and long-term prognosis.

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STUDY OBJECTIVE: To compare efficacy of rollerball endometrial ablation with low-voltage (cut) versus high-voltage (coag) waveforms. DESIGN: Pilot comparative clinical study (Canadian Task Force Classification II-1). SETTING: University-affiliated teaching hospital. PATIENTS: Fifty premenopausal women with menorrhagia. INTERVENTION: Women with menorrhagia were allocated randomly to thermal destruction of the endometrium by a 5-mm rollerball with unmodulated cutting current or modulated coagulating current. Complication rate, clinical outcomes, and need for reintervention were evaluated. MEASUREMENTS AND MAIN RESULTS: At 2 years of follow-up, the reintervention rate was 26.3% in the cutting waveform group versus 31.4% in the coagulating waveform group. This difference was not statistically significant. Hysterectomy was performed in 3 (14%) women in the cutting waveform group and 5 (20%) women in the coagulating waveform group. There were no complications in either group. CONCLUSION: Both cutting and coagulating waveforms are equally effective for hysteroscopic endometrial ablation with the rollerball.

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OBJECTIVES: To describe three steps: (1) the initial Veress pressure (VIP-Pressure), (2) transient high-pressure pneumoperitoneum (HIP-Entry) prior to trocar/cannula insertion, and (3) visual entry with a trocarless cannula during closed laparoscopic entry, which may reduce major injuries. DESIGN: Prospective observational cohort study (Canadian Task Force Classification II-2). SETTING: University-affiliated teaching hospital. INTERVENTIONS: VIP-Pressure. During laparoscopic entry, the initial VIP pressure was measured and correlated against the body habitus and parity of 365 consecutive women. HIP-Entry was performed in 2,498 consecutive cases. In 100 women, the CO(2) volume, heart rate, blood pressure, oxygen saturation, and pulmonary compliance were recorded at pressures of 10, 15, 20, 25, and 30 mmHg. Visual entry with a trocarless blunt cannula was performed in 776 women. The cannula, housing a 0 degrees laparoscope, was rotated clockwise applying minimal downward force. MEASUREMENTS AND RESULTS: VIP-Pressure. Pneumoperitoneum was established after one, two or three Veress needle attempts at the umbilicus in 82.4%, 10.9%, and 4.0% of women, respectively. In seven (2.2%), pneumoperitoneum was established at the left upper quadrant (LUQ) during the fourth attempt, and in two (0.6%) entry was abandoned. Median initial Veress pressure was 4 mmHg (range 2-10 mmHg). The VIP pressure correlated positively with women's weight (r = 0.518, p < 0.001) and body mass index (BMI) (r=0.545, p<0.001), and negatively with parity (r= -0.179, p<0.001). HIP-Entry. The abdomen was insufflated to 25-30 mmHg prior to primary trocar/cannula insertion. There were no changes in cardiovascular parameters between 15 and 30 mmHg. A 21% decrease in pulmonary compliance from 15 to 30 mmHg was of no clinical significance. No injury has been experienced with the visual cannula in 776 cases. CONCLUSIONS: (1) A VIP-Pressure (<10 mmHg) indicates intraperitoneal placement of the Veress needle. (2) The use of transient HIP-Entry does not adversely affect cardiopulmonary function in healthy women. (3) Visual cannula offers an additional step towards safer entry.

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BACKGROUND: Making a histologic diagnosis of leiomyosarcoma in the specimen from a hysterectomy performed for suspected benign fibroids is rare. Currently, there are no reliable diagnostic tools to diagnose uterine sarcomas preoperatively. CASE: A 38-year-old woman presented with menorrhagia and a uterine fibroid measuring 6.0 cm x 8.1 cm x 6.2 cm on ultrasonography. The patient underwent a laparoscopic myolysis with 50% shrinkage of the fibroid volume at follow-up after six months. Six years after myolysis, the patient presented with right lower quadrant pain and a rapidly enlarging uterus. Hysterectomy and bilateral salpingo-oophorectomy was performed and a diagnosis of leiomyosarcoma was histologically confirmed. CT scan was performed biannually after hysterectomy. One year after surgery, the patient presented with radiologic evidence of a right pulmonary nodule. The nodule was excised thoracoscopically and histologic examination demonstrated metastatic leiomyosarcoma. One year later, another pulmonary lesion appeared in the left lung and was excised thoracoscopically. Again, histological assessment showed metastatic leiomyosarcoma. This patient has remained healthy and asymptomatic for two years since the last thoracoscopic excision of the leiomyosarcoma metastasis. CONCLUSION: The current trend in treatment for symptomatic fibroids is therapy sparing the uterus. Such treatment includes both medical therapy and fibroid necrosing therapies such as vascular occlusion, embolization, and thermal coagulation technologies. Women considering uterus-sparing treatment should be advised of the potential risk of uterine malignancy, even though that risk is quite minimal (< 0.5%). A delay in the diagnosis of uterine malignancy may ultimately compromise long-term survival.

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STUDY OBJECTIVE: To determine the effect of hysteroscopic surgery on the long-term clinical outcome of women diagnosed with endometrial cancer. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the principal author (GAV) performed primary hysteroscopic surgery in 3401 women with abnormal uterine bleeding. Among these women, there were 16 occult and 3 known endometrial cancers. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 8) or complete (n = 11) rollerball electrocoagulation and/or endomyometrial resection. After diagnosis of endometrial malignancy, women were counseled regarding their disease and management, in accordance with established clinical practice guidelines. Follow-up ranged from 1 to 14 years and was conducted by office visits and telephone interviews. MEASUREMENTS AND MAIN RESULTS: Among the 3401 women, there were 19 women with endometrial adenocarcinoma, 3 of whom were known to harbor cancer before hysteroscopic surgery. One woman refused hysterectomy and remains alive and well 5 years after total hysteroscopic endomyometrial resection. Two women wished to maintain fertility; 1 consented to hysterectomy after incomplete resection of her lesion. The other was treated with progestins. Her cancer reverted to complex hyperplasia, and she requested hysterectomy 4 years later. No residual cancer was found. After 5 years of follow-up, 1 patient died from carcinoma of the gallbladder (2 years), and 2 died at 4 years; 1 at the age of 87 years of natural causes and the other at the age of 86 years from acute renal failure unrelated to her cancer. Fourteen women remain alive and well at 5 to 14 years of follow-up. Two additional women remain alive and well at 1 and 4 years of follow-up. CONCLUSION: Resectoscopic surgery did not adversely affect the 5-year survival and the long-term prognosis in 14 women with endometrial cancer.

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STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.

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A 53-year-old multiparous woman, with no identifiable risk factor for endometrial cancer, presented with menorrhagia. She had been treated with oral contraceptives for 3 years. Office endometrial biopsy indicated well-differentiated villoglandular adenocarcinoma of the endometrium. The patient refused hysterectomy and would consent only to hysteroscopic resection. She remains alive and well, with no clinical evidence of recurrence 5 years after resection. We propose that skillful resectoscopic surgery, under specific circumstance, may be an appropriate alternative treatment to hysterectomy for some early uterine malignancies.

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Symptomatic uterine fibroids are a relatively common gynecologic condition. In the past, fibroids were exclusively treated by myomectomy and/or hysterectomy. With the advent of uterine artery embolization or uterine artery occlusion, there now exist minimally invasive approaches to fibroid therapy especially for women in whom surgery is contraindicated or for those who wish to retain their uterus and possibly fertility. Fertility and pregnancy outcomes after these minimally invasive therapies are currently being evaluated.

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STUDY OBJECTIVE: To laparoscopically evaluate the pelvis of patients with chronic pelvic pain after hysterectomy and bilateral salpingo-oophorectomy, to determine any associated factors to the pain. DESIGN: Retrospective cohort of patients with chronic pelvic pain after hysterectomy and bilateral salpingo-oophorectomy (Canadian Task Force Classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through May 2002, 124 women with chronic pelvic pain after hysterectomy and bilateral salpingo-oophorectomy underwent laparoscopic and histopathologic evaluation of the pelvis. INTERVENTION: Diagnostic laparoscopy was performed to inspect the pelvis for any signs of pathology. If any abnormalities were visualized, they were treated with CO2 laser resection and sent for histopathologic evaluation. MAIN OUTCOME MEASURES: Laparoscopic and histopathologic findings of the pelvis, as well as subjective pain improvement after laparoscopy. CONCLUSION: The most common histopathologic findings at laparoscopy in women with chronic pelvic pain after hysterectomy and bilateral salpingo-oophorectomy included adhesions, adnexal remnants, and endometriosis. Laparoscopic treatment of any pelvic pathologic condition improved pain symptoms in these women.

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STUDY OBJECTIVE: To determine height, weight, body mass index (BMI), parity, and age effect on the volume of CO2 pneumoperitoneum during laparoscopic access in women. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-1). SETTING: University-affiliated teaching hospital. PATIENTS: From January through June 2004, 100 healthy women underwent operative laparoscopic surgery consecutively by the senior author (GAV). Indications were: chronic pelvic pain (CPP, n = 66), pelvic mass (n = 7), CPP and pelvic mass (n = 4), infertility (n = 23). Median (range) height, weight, BMI, parity and age were 1.65 m (1.45-1.85 m), 70 kg (43-118 kg), 25.5 kg/m2 (17-39 kg/m2), 1.1 (0-5), and 34 years (19-58 years), respectively. INTERVENTIONS: While in supine position, patients received general endotracheal anesthesia and muscle relaxants. Pneumoperitoneum was established by reusable Veres needle. The insufflated CO2 volume was serially recorded at intraperitoneal insufflation pressures (IPIPs) of 10, 15, 20, 25, and 30 mm Hg. The primary 10-mm trocar was introduced at IPIP of 30 mm Hg. Upon entering the peritoneal cavity, the abdominal contents were visualized with the laparoscope to ensure there was no injury, and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg before switching the patient to the Trendelenburg position. MEASUREMENTS AND MAIN RESULTS: The mean (SD) insufflated CO2 volumes at 10, 15, 20, 25, and 30 mm Hg were 1.7 (0.74) L, 3.1 (0.9) L, 3.96 (1.05) L, 4.42 (1.1) L and 4.72 (1.14) L, respectively. Using multivariate analysis, we demonstrated that at 20 to 30 mm Hg the insufflated CO2 volume correlated positively with the height, weight and BMI of women. Parity correlated positively at all pressures. There was no correlation with age at any pressure. CONCLUSIONS: Higher CO2 volume is required to establish appropriate pneumoperitoneum in tall, overweight, and parous women at 20 to 30 mm Hg. Setting the IPIP at 20 to 30 mm Hg before primary trocar insertion eliminates the need to monitor CO2 insufflated volume regardless of women's age, parity, and body habitus.

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OBJECTIVES: We sought to evaluate retrospectively the efficacy of hysteroscopic metroplasty in a population of women with a history of recurrent pregnancy loss or infertility who were also known to have a uterine septum. METHODS: Hysteroscopic metroplasty was performed on 26 women with a uterine septum and a history of either recurrent pregnancy loss or infertility. The metroplasty was performed using a Versapoint bipolar needle device (in 23% of cases) or a resectoscopic knife electrode with cutting current (in 77% of cases). The main outcome measures were rates of clinical pregnancy and live birth. RESULTS: Nineteen women had a hysteroscopic metroplasty because of recurrent pregnancy loss. Postoperatively, the pregnancy rate was 95%, and the live birth rate was 72%. The seven infertile patients had pregnancy and live birth rates of 43% and 29%, respectively. CONCLUSION: Hysteroscopic metroplasty using either the Versapoint bipolar needle device or a knife electrode is both safe and effective. In women with recurrent pregnancy loss, future fertility is not impaired, and live birth rates are significantly improved.

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STUDY OBJECTIVES: Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-1). SETTING: University affiliated teaching hospital. PATIENTS: We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively. INTERVENTION: Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity. MEASUREMENTS AND MAIN RESULTS: The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively. CONCLUSION: A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

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STUDY OBJECTIVE: To determine hemodynamic and pulmonary compliance changes during laparoscopic entry using transient hyperinsufflated pneumoperitoneum. DESIGN: Prospective observational cohort study (Canadian Task Force classification II-1). SETTING: University-affiliated teaching hospital. SUBJECTS: From January through June 2004 one hundred healthy women underwent operative laparoscopy consecutively. Indications included chronic pelvic pain (CPP, N=66), pelvic mass (N=7), CPP and pelvic mass (N=4), primary or secondary infertility (N=23). The mean age was 34 years (range, 19-58) and the mean BMI 25.5 kg/m2 (range, 17.1-39.4). INTERVENTIONS: With the patients under general anesthesia, muscle relaxants, and in supine position, pneumoperitoneum was established using a Veres needle. The following information was prospectively collected at different intraperitoneal insufflation pressures (IPIP): CO2 volume, heart rate, blood pressure, and pulmonary compliance. At IPIP of 30 mm Hg the primary trocar was inserted and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg. MEASUREMENTS AND MAIN RESULTS: The mean initial IPIP was 4.7 mm Hg (range, 2-9 mm Hg). The mean volume of CO2 at IPIP of 10, 15, 20, 25, and 30 mm Hg was 1.7, 3.1, 4, 4.4, and 4.7 L, respectively. There was no statistically significant change in the heart rate or pulse pressure between IPIP of 15 and 30 mm Hg. The difference in CO2 volume (1.6 L) required to achieve IPIP of 15 and 30 mm Hg was statistically significant (p<0.0001). A statistically significant increase of 7 mm Hg in the mean arterial pressure (MAP) was found between IPIP of 15 & 30 mm Hg (p<0.0001). The additional 21% drop in pulmonary compliance from IPIP 15 to 30 mm Hg was statistically significant (p<0.0001). This decrease in pulmonary compliance was well tolerated by the patients, and the oxygen saturation remained above 92% in all cases. The elevated MAP was not clinically significant. CONCLUSION: The use of transient hyperinsufflated pneumoperitoneum caused minor hemodynamic alterations which were not clinically significant. The alterations in pulmonary compliance were statistically significant; however, they had no clinical significance and were tolerated well by healthy women.

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STUDY OBJECTIVE: To evaluate the feasibility and surgical and clinical outcomes of laparoscopic excision of anterior recto-sigmoid wall endometriosis and en bloc dissection of the obliterated cul-de-sac. DESIGN: Retrospective cohort (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Eighty-one women with infertility and/or chronic pelvic pain. Intervention. Laparoscopic excision of all endometrial implants and uterosacral ligaments, and dissection of the cul-de-sac using a horseshoe-shaped approach to mobilize, but not resect, the rectosigmoid. MEASUREMENTS AND MAIN OUTCOMES: Eleven women (24%) had endometriomas. Cumulative pregnancy rates in 34 women with primary infertility and 12 with secondary infertility were 62% and 42%, respectively. Eighty-eight percent of 61 women with pain reported significant improvement of symptoms. CONCLUSION: Laparoscopic excision of cul-de-sac and rectovaginal endometriosis by this approach is feasible and safe when performed by an experienced surgeon, and results in high rates of cumulative pregnancy and relief of pain. Some patient variables may give higher rates of success for pregnancy than others.

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