Laparoscopy. Gasless vs. CO2 pneumoperitoneum. Energy sources for laparoscopic colectomy: a prospective randomized comparison of conventional electrosurgery, bipolar computer-controlled electrosurgery and ultrasonic dissection. Operative outcome and costs analysis. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. Laparoscopic surgery in ectopic pregnancy. A randomized trial versus laparotomy. Randomized, prospective, single-blind trial of a new parallel technique of Veress pneumoperitoneum needle insertion versus the conventional closed method. A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: a 2-year follow-up. Randomized trial of low-pressure carbon dioxide-elicited pneumoperitoneum versus abdominal wall lifting for laparoscopic cholecystectomy. A case-control-study comparing laparoscopic versus open surgery for rectosigmoidal and rectal cancer. Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy.
To compare gasless laparoscopy with conventional laparoscopy using CO2 pneumoperitoneum.
                Women undergoing bilateral laparoscopic tubal coagulation (LTC) were randomly assigned to one of two laparoscopy procedures: (1) a gasless laparoscopy system consisting of an intraabdominal fan retractor and electrically powered mechanical arm, and (2) standard CO2 pneumoperitoneum laparoscopy. The two laparoscopic procedures were compared on the basis of intraoperative visualization, operation duration, procedural difficulty, ventilatory parameters, hemodynamic stability, and postoperative pain and nausea.
                Significant disadvantages for the surgeon (increased technical difficulty, poorer visualization, longer operative times) and patient (greater postoperative pain and nausea) were seen with the gasless system. Because of these findings, the study was prematurely terminated after only 18 patients had participated. Intraoperative ventilatory and hemodynamic parameters were more stable in the gasless laparoscopy groups; however, the differences were not clinically significant in this population of healthy patients.
                The markedly increased technical difficulty and absence of clear clinical benefits for the healthy patient led to the conclusion that laparoscopy with CO2 pneumoperitoneum is preferable for routine LTC and most laparoscopic procedures in the pelvis. Gasless laparoscopy may be of benefit for the fragile patient with a compromised cardiovascular system who may suffer complications from hypercarbenemia. The development of operative laparoscopic surgery is linked to advances in ancillary surgical instrumentation. Ultrasonic energy devices avoid the use of electricity and provide effective control of small- to medium-sized vessels. Bipolar computer-controlled electrosurgical technology eliminates the disadvantages of electrical energy, and a mechanical blade adds a cutting action. This instrument can provide effective hemostasis of large vessels up to 7 mm. Such devices significantly increase the cost of laparoscopic procedures, however, and the amount of evidence-based information on this topic is surprisingly scarce. This study compared the effectiveness of three different energy sources on the laparoscopic performance of a left colectomy. The trial included 38 nonselected patients with a disease of the colon requiring an elective segmental left-sided colon resection. Patients were preoperatively randomized into three groups. Group I had electrosurgery; vascular dissection was performed entirely with an electrosurgery generator, and vessels were controlled with clips. Group II underwent computer-controlled bipolar electrosurgery; vascular and mesocolon section was completed by using the 10-mm Ligasure device alone. In group III, 5-mm ultrasonic shears (Harmonic Scalpel) were used for bowel dissection, vascular pedicle dissection, and mesocolon transection. The mesenteric vessel pedicle was controlled with an endostapler. Demographics (age, sex, body mass index, comorbidity, previous surgery and diagnoses requiring surgery) were recorded, as were surgical details (operative time, conversion, blood loss), additional disposable instruments (number of trocars, EndoGIA charges, and clip appliers), and clinical outcome. Intraoperative economic costs were also evaluated. End points of the trial were operative time and intraoperative blood loss, and an intention-to-treat principle was followed. The three groups were well matched for demographic and pathologic features. Surgical time was significantly longer in patients operated on with conventional electrosurgery vs the Harmonic Scalpel or computed-based bipolar energy devices. This finding correlated with a significant reduction in intraoperative blood loss. Conversion to other endoscopic techniques was more frequent in Group I; however, conversion to open surgery was similar in all three groups. No intraoperative accident related to the use of the specific device was observed in any group. Immediate outcome was similar in the three groups, without differences in morbidity, mortality, or hospital stay. Analysis of operative costs showed no significant differences between the three groups. High-energy power sources specifically adapted for endoscopic surgery reduce operative time and blood loss and may be considered cost-effective when left colectomy is used as a model. To compare single dose systemic methotrexate (50 mg/m2) with laparoscopic surgery for the treatment of unruptured tubal pregnancy.
                An open, pragmatic, prospective randomised trial.
                Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand.
                Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum beta-hCG measurement. Inclusion criteria included a serum beta-hCG concentration < 5,000 IU/L, and a tubal pregnancy of < 3.5 cm diameter.
                Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency.
                Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 - 47%; P < 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and five women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had significantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum beta-hCG concentrations. Ipsilateral tubal patency rates were similar in each group.
                This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum beta-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy. A randomized, prospective clinical trial was conducted to compare the efficacy of laparoscopic treatment with conventional conservative abdominal surgery for tubal pregnancy. Entry criteria were: size of the ectopic gestation less than 4 cm, hemodynamic stability, accessibility for laparoscopic treatment and a trained laparoscopist on duty. There was no difference between the groups regarding gestational duration, size and location of the ectopic gestation, or the mean preoperative hCG values. The groups differed with respect to total operation time (73 min for the laparoscopy group vs. 88 min for the laparotomy group), hospital stay (2.2 vs. 5.4 days) and convalescence period (11 vs. 24 days). The rates of elimination of hCG was similar in the groups, and there were no statistical difference in the rate of second intervention. To evaluate the safety and effectiveness of a new closed parallel technique of Veress needle insertion and to compare this method with the conventional closed approach.
                Sequential, randomized, prospective, single-blind clinical trial.
                University hospital.
                Women undergoing elective diagnostic and/or operative laparoscopy. Subjects (n = 200) were assigned randomly to undergo the conventional closed method (group 1; n = 100) or the new parallel technique (group 2; n = 100) of Veress needle insertion.
                Randomization of the patients was performed in the operating room. The investigator performed both diagnostic and operative laparoscopy in both study groups.
                Safety and effectiveness of the needle insertion technique.
                There were no significant differences in demographics between the groups, or in the time required for Veress needle insertion to establish pneumoperitoneum. There were no nonlethal major or minor intraoperative complications associated with either laparoscopic approach.
                There is no significant disadvantage to the parallel technique of Veress pneumoperitoneum needle insertion compared with the conventional closed approach. This new technique avoids the anatomic location of large vessels during insertion and may serve as a safeguard to decrease the potential for lethal laceration of a major vessel. The overall pregnancy rate after salpingostomy in women with complete bilateral terminal tubal occlusions was 26.9%. No difference was found in the intrauterine pregnancy rate and the surgery-conception interval between salpingostomy with the CO2 laser or the microdiathermy needle at a 2-year follow-up. The advantage of the CO2 laser in other reproductive surgery remains to be seen. Two alternative surgical techniques for elective laparoscopic cholecystectomy (LC), low-pressure insufflation of the peritoneal cavity and abdominal wall lifting (AWL), have been developed over time to minimize the disadvantages associated with CO2-elicited pneumoperitoneum. To the best of our knowledge, the 2 methods have seldom been compared as regards their relative advantages and disadvantages.
                Eighty patients scheduled for elective LC were randomized into either a low-pressure (8 mmHg) CO2 insufflation method (LPLC) group, or a gasless technique using a subcutaneous abdominal wall lifting device (GLC group). The duration of the surgical procedure, the surgical results including level of postoperative pain, and perioperative cardiopulmonary function changes experienced by the members of both groups were compared.
                Laparoscopic surgery was completed for all but 1 patient from each group due to an inadequate surgical-site exposure. There was no mortality for study participants, and no major complications were noted for members of either group. The LPLC group evidenced a shorter surgical duration as compared to the GLC group (77 +/- 28 minutes vs. 98 +/- 27 minutes, respectively; p < 0.01) and a lower incidence of postoperative shoulder pain (2/38 vs. 8/39, respectively; p < 0.05), although significant differences in intraoperative pulmonary function were noted (an increased PaCO2, Pet CO2 and peak-airway pressure and decreased arterial blood pH; p < 0.01) for the LPLC group compared to the GLC group.
                Both alternative methods for this type of surgery appeared feasible and safe for LC. Low-pressure CO2 pneumoperitoneum had a shorter surgical duration and less postoperative shoulder pain compared to the GLC technique, but did not feature any other advantage over the AWL technique with regard to impact on cardiopulmonary function. This study compared laparoscopic with open surgery for the cure of cancer of the rectosigmoid and rectum. Results of surgery, postoperative recovery, and oncological follow-up were compared between 32 laparoscopic curative procedures (19 laparoscopic-assisted anterior resections for cancer of the rectosigmoid or upper rectum and 13 laparoscopic abdominoperineal resections for low rectal cancer) and 32 controls matched for age, UICC stage, tumor site, and type of resection who underwent open surgery during the same observation period. Morbidity was identical after laparoscopic and open resection (31.3%). Surgery was equally radical in the two groups regarding yield of lymph nodes and lateral and distal margins. Survival, recurrence, and cancer-related mortality showed no statistical differences. There was no port-site recurrence. The benefits of laparoscopic surgery were shown with a reduction in perioperative blood transfusion and earlier return of bowel function. However, the operative time was significantly increased in the laparoscopic group. This study shows that laparoscopic surgery for the cure of colorectal cancer is technically feasible, and that oncological short-term outcome does not differ from the results achieved by open techniques. However, prospective randomized trials are mandatory to evaluate the definite role of laparoscopic surgery for malignancy. To evaluate the safety and efficacy of prophylactic mesosalpingeal vasopressin injection for hemostasis during laparoscopic salpingotomy for ectopic pregnancy.
                Prospective, randomized clinical study.
                Reproductive endocrinology and endoscopic surgery clinic of a tertiary care hospital.
                Forty women with ectopic pregnancy.
                Laparoscopic linear salpingotomy was attempted, with prophylactic mesosalpingeal dilute vasopressin injection in 20 patients (study group), and without vasopressin in 20 patients (control group). The two groups were similar with regard to age, size of ectopic pregnancy, gestational age, and initial beta-hCG values. A multipuncture operative laparoscopy technique was used in all cases and bipolar electrocoagulation was used for hemostasis.
                The operating time was significantly shorter and the need for electrocoagulation was significantly less in the study than in the control group (p <0.05). Laparoscopic salpingotomy was performed successfully in 85% of study group patients compared with 70% of controls (p >0.05). Postoperative hysterogram revealed patency of the affected tube in 76.5% of women in the study group compared with 57.1% of controls (p >0.05). Possible complications of vasopressin, such as hypertension, bradycardia, and delayed bleeding, did not occur in any patient.
                Vasopressin use reduces both operating time and the need for electrocoagulation for hemostasis, which can have undesirable effects on the tube. Vasopressin was not associated with side effects in this relatively small sample.
From these limited data there is no evidence of benefit or disadvantage of tubal surgery versus no treatment or alternative treatments. Likewise there is no evidence of advantage or disadvantage of using microsurgery over standard techniques; laparoscopic approach over laparotomy; the use of CO2 laser; or electrocoagulation over thermocoagulation. Randomised controlled trials should be undertaken to determine the role of tubal surgery versus no treatment or alternative treatments. Randomised controlled trials should be undertaken to determine the role at tubal surgery of magnification, laparoscopic approach, the use of lasers or electrocoagulation.