1. Diagnostic Laparoscopy for Pelvic Disorders Venice June 2005 George S. Ferzli MD, FACS George E. Khoury, MD

7. Gynecologic: PID Clinical diagnosis of PID is often difficult especially when symptoms are mild, as frequently when the primary organism is C. trachomatis. Laparoscopy is the gold standard for the diagnosis of PID – should be used when diagnosis is uncertain, especially in young women for whom the preservation of fertility is important. Sellors et al. reported that only by resorting to diagnostic laparoscopy were they able to demonstrate that PID was the cause of acute pelvic pain in 46% of a group of 95 women. Laparoscopy should be considered for patients who have not responded to antibiotic therapy within 48 to 72 hours. The role of laparoscopy in the management of pelvic pain in women of reproductive age. Maria Grazia Porpora, M.D. FERTILITY AND STERILITY Vol. 6M, No. 5, November 1997.

8. Gynecologic: Tubo-ovarian Abscess Most commonly isolated pathogens from a tubo-ovarian abscess are C. trachomatis and peptostreptococci. At laparoscopy the peritoneal cavity (pelvis and abdomen) is inspected carefully. The surgical steps include adhesiolysis, aspiration of the abscess cavity, dissection and excision of necrotic tissue, tubal lavage, and irrigation of the peritoneal cavity before completion of the procedure. Laparoscopic surgery combined with adequate broad-spectrum antibiotic therapy has proven successful in the treatment of more than 95% of patients.

10. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000. Brownish lesion on the ovary White fibrotic lesion on the uterosacral ligament Peritoneal pocket of endometriosis Red stellate lesions in the cul-de-sac Endometriosis presents with a variety of appearances that may make visual diagnosis difficult and inaccurate .

13. Gynecologic: Adhesions Pre-operative history of PID, endometriosis, perforated appendix, prior surgery or inflammatory bowel disease. Presently the only definitive way to diagnose adhesions is by surgical visualization usually via laparoscopy instead of laparotomy. Laparoscopic studies reveal adhesions on average in 24% of CPP patients and 17% of non-CPP patients. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000.

17. Gynecologic: Ovarian Cysts The nature of the fluid is characteristically diagnostic : chocolate (usually endometrioma or haemorrhagic corpus luteum) sebaceous (teratoma), or mucinous (mucinous cystoma). Mucinous cyst Teratoma Dermoid cyst

18. Gynecologic: Adnexal Torsion A rare gynecologic emergency that nearly always occurs unilaterally. Common causes are benign ovarian tumors and cysts; malignant processes are rare. Relapse or bilateral adnexal torsion can cause sterility interfering with fertility. In 30% of the patients, there is torsion of a normal adnexa, while the majority of the cases are associated with ovarian pathology. Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje) F. Admiraala,* European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.

19. Gynecologic: Adnexal Torsion Conservative management by laparoscopy is the best approach when tissues are viable and should be carried out promptly to preserve the adnexa (basic principles of conservative management are to untwist the structure and treat the underlying cause ‘ie - ovarian cyst’). Once untwisted, the organ must be observed to ensure color change to normal, confirming viability and blood supply. Adnexal torsion in very young girls: diagnostic pitfalls. Marieke Emontsa, Heleen Doornewaardb, J.(Co’tje) F. Admiraala,* European Journal of Obstetrics & Gynecology and Reproductive Biology 116 (2004) 207-210.

20. Gynecologic: Endosalpingiosis Endosalpingiosis is the presence of fallopian tubal glandular epithelium in an ectopic location. Visually it appears as white to yellow, opaque or translucent, punctate, cystic lesions. Endosalpingiosis is generally not recognized by gynaecologists at the time of laparoscopic evaluation or is misdiagnosed as endometriosis. The role of laparoscopy as a diagnostic tool in chronic pelvic pain. Fred M Howard MS, MD BaillieÁ re's Clinical Obstetrics and Gynaecology Vol. 14, No. 3, pp. 467-494, 2000

21. Gynecologic: Leiomyomata (fibroids)

24. Infertility

26. Gastrointestinal: IBS Approximately one third of women with chronic pelvic pain have irritable bowel syndrome (IBS) IBS is characterized by abdominal pain and bowel symptoms such as bloating, urgency, diarrhea and constipation IBS is associated with gynecologic problems such as endometriosis, dyspareunia, and dysmenorrhea IBS is most prevalent during menstruating years – exacerbated during menstruation Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain. Rachel E. Williams, PhD, Katherine E. Hartmann, MD, PhD American Journal of Obstetrics and Gynecology (2005) 192, 761-7.

27. Gastrointestinal: Acute Appendicitis Diagnostic accuracy in young men is ±95% – in fertile women it varies from 55%-65% Older age (>70 years) lowers diagnostic accuracy to ± 66% for men and women Traditionally, a normal-appearing appendix is removed after a laparotomy in the right fossa. Diagnostic laparoscopy offers the possibility of sparing a normal-appearing appendix. Introducing diagnostic laparoscopy for patients with suspected acute appendicitis. AC Moberg, A Montgomery Surg Endosc (2000) 14: 942–947.

32. Pediatric Hernias The incidence of recurrent inguinal hernias in children is low (0% to 0.8%) Laparoscopy accurately identifies the nature of the defect in children with recurrent groin hernias, detecting unsuspected contralateral indirect, direct, or femoral hernias in 44% of those undergoing laparoscopy. The Role of Laparoscopy in the Management of Suspected Recurrent Pediatric Hernias. Jon Perlstein and Jeffrey J Du Bois Sacramento, California J Pediatr Surg 35:1205-1208

35. Undescended Testes NPT is a preliminary clinical diagnosis. Diagnostic laparoscopy (DL) is the technique of choice for exploration of nonpalpable testes (NPT) . The testes may either be: present and located at different intraabdominal sites, “vanished” with the result of a small remnant, nubbin or completely absent. Laparoscopy is a valuable tool in diagnosing and treating more than 50% of cases of NPT. Laparoscopic evaluation of abdominal testes can provide indications for the most suitable surgical technique; in 23% of patients, it makes abdominal exploration unnecessary. Laparoscopic management of nonpalpable testes: A multicenter study of the Italian Society of Video Surgery in Infancy. Alfonso Papparellaa,*, Pio Parmeggiani Journal of Pediatric Surgery (2005) 40, 696-700. Groin Exploration for Nonpalpable Testes: Laparoscopic Approach. J Schleef, S von Bismarck, K Burmucic, A Gutmann, and J Mayr Journal of Pediatric Surgery, Vol 37, No 11 (November), 2002: A high testicle, located well above the internal inguinal ring. A low intra-abdominal testicle identified at the level of the internal ring

36. RPLND RPLND is an accurate staging tool providing important information to determine the need for chemotherapy. When performed properly, RPLND eliminates the retroperitoneum as a site for relapse, which in turn provides emotional and psychological relief to the patient, and simplifies the follow-up protocol Laparoscopic RPLND for the treatment of clinical Stage I NSGCT has evolved into an excellent alternative to traditional modes of therapy. The procedure can replicate the advantages of open RPLND without the morbidity of a large incision. Laparoscopic RPLND for clinical stage I nonseminomatous germ cell testicular cancer: current status Sam B. Bhayani, M.D., Mohamad E. Allaf, M.D., Louis R. Kavoussi, M.D.* Urologic Oncology: Seminars and Original Investigations 22 (2004) 145–148

37. Conclusion: Laparoscopy provides a vital tool for diagnosing pelvic pain – it provides first hand visual comprehension of the problem as well as an immediate opportunity to continue with therapeutic surgical correction.