The document discusses laparoscopy procedures for various gynecological conditions such as infertility, chronic pelvic pain, ectopic pregnancy, and oncological issues. It notes that laparoscopy can be used for both diagnostic and operative purposes. It then discusses different techniques for laparoscopic access such as direct trocar insertion versus Verres needle insertion. It reviews studies comparing complication rates between different access techniques. The document emphasizes the importance of evidence-based medicine and following guidelines from organizations like NICE when determining appropriate diagnostic tests and treatments for conditions like infertility.

1. La Laparoscopia
Ludovico Muzii
Clinica Ginecologica e Ostetrica,
Università Campus Bio-Medico,
Roma

3. Laparoscopia Diagnostica - Operativa
• Sterilità
• Dolore pelvico cronico, acuto
• Gravidanza ectopica
• Aderenze, endometriosi
• Masse annessiali
• Isterectomia (LAVH, TLH, LSH)
• Miomi uterini
• Patologia del pavimento pelvico
• Oncologia ginecologica

4. Laparoscopia: accesso
• Inserimento ago di Veres
• Inserimento trocar secondo tecnica classica
• Inserimento trocar secondo tecnica diretta
• Open laparoscopy
• Trocar ottico
• Introduzione trocar accessori

5. Complicanze maggiori dovute all’accesso
Garry R. Gynaecol Endosc 8:315-326, 1999
Numero Numero Lesioni x 1000 Lesioni x1000
di studi di procedure intestinali vascolari
Tecnica classica
6 357.257 103 0,4/1000 69 0,2/1000
Tecnica “open”
7 20.410 99 5,0/1000 0 //
6* 12.410 7 0,6/1000 0 //
Tecnica diretta
3 6.833 7 1,1/1000 0 //
*escludendo lo studio AAGL (8000 casi, 92 lesioni, 12/1000)

6. “L’approccio ‘open’ secondo
Hasson dovrebbe essere
quello preferito in ogni caso.”
Thomas WEG: Basic surgical skills: A participants’
hanbook. Royal College of Surgeons 1996

7. Per evitare lesioni vascolari maggiori:
MAI DEVIARE DALLA LINEA
MEDIANA CON UN ANGOLO DI
40-45° VERSO IL BASSO (in pazienti
obese angolo maggiore)

8. Presenza di aderenze in relazione a pregressa
chirurgia
Audebert AJM. Gynaecol Endosc 8:363-7, 1999
Pregressa chirurgia Aderenze n / 1000
Nessuna 4 / 519 ( 8 / 1000)
Laparoscopia 2 / 140 (14/ 1000)
Pfannenstiel 31 / 145 (214/ 1000)
Longitudinale 51 / 96 (531/ 1000)

9. Tecnica classica

10. Tecnica diretta

11. Tecnica open

12. Inserimento trocar accessori

13. Diagnosi di Fattore tubarico di
Sterilita’
Quale metodica?
Quando?

14. Medicina
basata sulla
EVIDENZA
• Two million articles per year in the
biomedical literature
• A physician should read 19 articles per
day, 365 days per year, to keep up with
her/his specialty
Sackett DL, BMJ 1995

15. NICE guidelines
www.nice.org.uk

16. NICE guidelines
Meta-analysis based on three studies with judgement of
laparoscopy without knowledge of HSG results gave pooled
estimates of sensitivity and specificity for HSG as a test for
tubal obstruction of 0.65 and 0.83 respectively. When HSG
suggests the presence of tubal obstruction this will be
confirmed by laparoscopy in only 38% of women.Thus, HSG is
not a reliable indicator of tubal occlusion. However, when HSG
suggests that the tubes are patent, this will be confirmed at
laparoscopy in 94% of women. Thus HSG is a reliable
indicator of tubal patency.

17. NICE guidelines

18. NICE guidelines
Altre metodiche?

19. NICE guidelines
In conclusione:
Se non ci sono fattori di rischio
noti, ISTEROSALPINGOGRAFIA
Se ci sono fattori di rischio noti,
LAPAROSCOPIA

20. Fertil Steril 2004; www.asrm.org

21. Diagnosi di Fattore tubarico di Sterilita’
Quale metodica?
A postal survey was conducted among gynecologists
and radiologists to find out the current practice in
the UK regarding the methods employed to assess
tubal patency. In the responses from radiologists, a
HSG was the investigation of choice for both low
risk (61%) and high risk women (50%). In the
responses from gynecologists, in low risk the
majority perfomred a HSG (58%) or HyCoSo
(15ì4%), whereas in high risk most (84%) performed
a laparoscopy
Vvjayanthi S, Hum Fertil (Camb) 2004

22. Quando?

23. Quando?
?
?
The specific definition of infertility is inability of
a couple to conceive after 1 year of sexual
intercourse without contraception. The initial
diagnostic test for infertility should include a
midulteal progesteron assay, a semen analysis
and a test for tubal patency such as HSG.
The ESHRE Capri Workshop Group: “Optimal
use of infertility diagnostic tests and treatments”.
Human Reproduction 15:723, 2000

24. Diagnosi di Fattore tubarico di Sterilita’
E’ necessaria la laparoscopia dopo HSG normale?
When tubal patency has been demonstrated by HSG,
laparoscopy is traditionally suggested as a mandatory
step to preclude the existence of peritubal adhesions and
endometriosis. In women without a hystory suggestive of
tubal disease and a normal HSG, we demonstrate that
the probability of clinicallly relevant disease is very low
and laparosocpy does not seem to be justified or cost-
effective. In these cases surgery has not been proven to
improve fecundity, and we suggest 3-6 cycles of
COH/IUI, and if unsuccesful, IVF
Fatum M, Hum Reprod 2002

25. STERILITA’ DA FATTORE TUBARICO
La sterilità da fattore tubo-peritoneale
(aderenze pelviche, occlusioni tubariche
prossimali e distali, endometriosi)
rappresenta il fattore eziologico nel
40% dei casi di sterilità femminile

26. Fattore Tubo-Peritoneale di Sterilita’
Aderenze
Occlusione tubarica distale –
Idrosalpinge
Occlusione tubarica prossimale
Endometriosi

27. Aderenze

28. ADERENZE POST-CHIRURGICHE
Le aderenze, causate da PID,
pregressi interventi, endometriosi,
possono essere a loro volta causa di
sterilità, dolore pelvico cronico,
occlusione intestinale, gravidanza
extra-uterina, re-interventi

29. COME SI FORMANO LE ADERENZE:
Fenomeni a livello peritoneale (5-7 giorni)
Peritoneum
Trauma
Peritoneal Defect
Increased Vessel Permeab
Inflammatory Exudate
Fibrin Matrix
PA
Plasminogen Fibrinolysis Ischemia
PAI
Normal fibrinolytic activity Suppressed fibrinolytic activity
Persistence of fibrin
Resolution of fibrin Fibroblast Proliferation
Mesothelium
Organisation of fibrin matrix
Repair
Adhesion Formation

30. Classificazione delle Aderenze
• Incidenza
• Estensione
• Severità
• Localizzazione

31. Fertil Steril 1988

32. Incidenza
• Aderenze De Novo
• Riformazione delle Aderenze

33. Incidence of De Novo Adhesions
• 55% - 100% Incidence of Adhesions after Laparotomy
Time from Total Total no.
Inital no. of With % with
Procedures Patients Adhesions Adhesions
Diamomd et al 1 wk -12 wk 106 91 86
DeCherney and Mezer 4 wk - 16wk 20 15 75
1 yr - 3 yr 41 31 76
Surrey and 6 wk – 8 wk 31 22 71
Friedman > 6 mo 6 5 83
Pittaway et al 4 wk – 6 wk 23 23 100
Trimbos-Kemper et al 8 days 188 104 55
Daniell and Pittaway 4 wk – 6 wk 25 24 96
Adapted from Diamond MP, Surgical Aspects in Fertility. In Gynaecology and Obstetrics, 1988

34. Adhesion Formation & Laparoscopy
Sites of adhesion formation following laparoscopy
Number of Reformed De Novo
Patients Adhesions Adhesions
Diamond 62 67% tube 23% pelvic
et al, 1991 80% ovary
Canis et al, 42 82% adnexa 21% adnexa
1992
Lundorff et 31 60% tube 17% tube
al, 1991

35. Aderenze post-miomectomia laparoscopica
Autore, anno n.pz 2Look (%) % aderenze
Mais, 1996a 25 100% 40%
Mais, 1996b 25 100% 88%
Bulletti, 1996 16 88% 29%
Dubuisson, 1998 45 100% 36%
Takeuchi, 2002 115 44% 29%
Di Gregorio, 2002 635 19% 2%
Malzoni, 2003 144 12% 33%
Total 1005 289 (29%) 25% (41%)

36. ...THE TWO ENDS OF THE SPECTRUM:
• Do not undertreat, or mismanage, the
unexpected ovarian cancer
• Do not overtreat the functional cyst
• (Do not operate on the incidental myoma)
Muzii and Benedetti Panici, JAAGL 2004

37. FUNCTIONAL CYSTS EXCISED AT
OPERATIVE LAPAROSCOPY
n. of patients Functional cysts %
Nezhat, 1992 1011 358 36
Mecke, 1992 678 207 31
Canis, 1994 757 149 18
Van Her. 1995 121 17 14
Sadik, 1999 220 74 34
Rasmussen, 1999 275 23 8
Mettler, 2001 493 144 29
Benedetti Panici, 282 12 4
2002
Marana, 2004 658 29 4
4495
4495 1013
1013 22.5%
22.5%
Muzii and Benedetti Panici, JAAGL 2004

38. LAPAROSCOPIC EXCISION OF
FUNCTIONAL CYSTS
•COST OF THE PROCEDURE
•ADHESIONS
•HARMFUL OF THE OVARY
•MEDICO-LEGAL IMPLICATIONS

39. From Luciano AA et al, Fertil Steril, 1991
From Luciano AA et al, Fertil Steril, 1991

40. “...to avoid adhesions
you must avoid surgery.”
L Mettler, Ann N Y Acad Sci, 2003

41. ADERENZE POST-CHIRURGICHE
Le aderenze possono essere causa
di dolore pelvico cronico, sterilità,
occlusione intestinale, gravidanza
extra-uterina, re-interventi

42. Pelvic Pain and Adhesions
• 15% - 45% of patients with chronic pelvic pain
(CPP) have pelvic adhesions
• Fix internal genital organs to adjacent structures
• Compress/construct ovaries and fallopian tubes

43. Laparoscopy for Chronic Pelvic Pain
80
70
60
50 Liston et al
40 Lundberg et al
Renaer
30 Kresch et al
20 Rapkin
10
0
no pathology adhesions endometriosis

44. Pain relief after laparoscopic adhesiolysis
No. of Pain Better Pain Not Better
Study Patients (%) (%)
Sutton & Macdonald, 1990 65 53 (82%) 10 (15%)
Goldstein et al., 1980 18 16 (89%) 2 (11%)
Steege & Stout, 1991 30 19 (63%) 11 (37%)
Onders and Mittendorf, 2003 70 50 (71%) 20 (29%)
Totals 183 138 (75%) 43 (23%)

45. Pain & Adhesions Controversy
• Some patients have pelvic pain and no
adhesions
• Some patients have adhesions and no pelvic
pain
• After adhesiolysis, pain but later it could
return or
• No RCTs

46. Adesiolisi?

47. “The best single source of reliable evidence
about the effects of health care”
www.cochrane.org

48. DJ Swank, Lancet 2003

49. DJ Swank, Lancet 2003

50. “This finding suggest that the value of laparoscopic adhesiolysis
does not lie in the adhesiolysis itself.
Adhesions do not cause pain unless they are causing an
obstruction.
Diagnostic laparoscopy could be of benefit to patients by
revealing other causes of their pain.
We recommend that clinicians consider abandoning laparoscopic
adhesiolysis as a treatment”
DJ Swank, Lancet 2003

51. L Demco, JAAGL 2004

52. “Filmy adhesions between a
moveable structure, such as an
ovary, and the peritoneum had
the highest pain scores. Fixed or
dense adhesions, no matter
where they were located, had
the lowest pain scores.” L Demco, JAAGL 2004

53. Do not lyse the dense,
fixed, difficult adhesions.
If in doubt, lyse only the
easy adhesions

54. ADERENZE POST-CHIRURGICHE
Le aderenze possono essere causa
di dolore pelvico cronico, sterilità,
occlusione intestinale, gravidanza
extra-uterina, re-interventi

55. Role of Adhesions in Infertility
• Interference with ovum escape
• Impairment of tubal function
• Tubal occlusion
Buttram VC Jr., Reiter RC. Surgical Treatment of the Infertile Female. Baltimore, MD:
Williams & Wilkins; 70, 1985
Gordji M. Pelvic Adhesions and Sterility. Acta Eur Fertil 6:279, 1975

56. Adhesions & Infertility
• Impair fertility severely
• Surgical correction only partly effective…
- Due to mucosal damage
- Due to adhesion reformation

57. Infertility
Cumulative Pregnancy Rates of Untreated
Tubal/Pelvic Damage vs Surgery
100
Percent Couples
90 Normal
80
70 Grade I - Surgery
60
50 Grade II - Surgery
40
30
Grade I - Untreated
20
10 Grade II - Untreated
0
12 24 36
Months

58. Seppure in assenza di studi controllati
randomizzati, l’adesiolisi in caso di
sterilita’ e’ sicuramente indicata

59. Occlusione tubarica
distale (DTO)

60. OCCLUSIONE TUBARICA DISTALE

61. Fertil Steril 1988

63. Salpingoneostomia: creazione della neostomia con elettrodo
monopolare o con laser a CO2 ad elevata densità di potenza (spot
piccolo, potenza alta)

66. Eversione delle fimbrie; tale manovra viene eseguita in
laparoscopia con il laser defocalizzato o con il bipolare a
bassa potenza

67. Stabilizzazione della neostomia con punti. In laparoscopia
tale procedura non è necessaria

68. SALPINGONEOSTOMIA:
CONFRONTO TRA LAPAROTOMIA
E LAPAROSCOPIA
n. pazienti % grav. EP
totali
Laparotomia 1011 34% 2-38%
Laparoscopia 370 30% 0-18%

69. …We recommend intraoperative salpingoscopy to
visualize the whole length of the ampullary lumen.
Whereas the status of the ampullary endosalpinx is also
an important prognostic parameter, we elected not to
include it in the scoring system at this time, since
salpingoscopy is not being practiced universally…
The American Fertility Society, 1988

72. SALPINGOSCOPY
-classification of lesions-
Grade 1: normal fold pattern
Grade 2: separation and flattening of
folds
Grade3: focal lesion, e. g. small
adhesions
Grade 4: extensive adhesions and/or
disseminated flat areas
Grade 5: complete loss of folds
Brosens, 1987

73. GRADE 1-2

74. GRADE 3

75. GRADE 4

76. GRADE 5

77. CUMULATIVE TABLE OF PREGNANCIES
-According to the salpingoscopic grade
of the better tube-
Salpingoscopic grade
I II III IV V
SALPINGO-OVARIOLYSIS
Number of patients 16 1 3 3 1
Intrauterine 11 1 0 0 0
Extrauterine 0 0 1 0 0
SALPINGONEOSTOMY
Number of patients 10 1 2 11 3
Intrauterine 6 1 0 0 0
Extrauterine 0 0 0 2 0
Marana 1999

78. PERCENTAGE OF PATIENTS WITH
NORMAL TUBAL MUCOSA:
ADNEXAL ADHESIONS
Marana (1995) 76%
Brosens (1996) 80%
Expected intrauterine pregnancy rate: 70%

79. PERCENTAGE OF PATIENTS WITH
NORMAL TUBAL MUCOSA:
HYDROSALPINGES
Marana (1995) 42%
Brosens (1996) 34%
Expected intrauterine pregnancy rate: 60%

80. Occlusione tubarica
prossimale (PTO)

82. Anastomosi tubo-tubarica (in caso di “reversal”): apposizione
di un punto sul mesosalpinge e del primo punto a ore 6

83. Completamento del primo strato con punti a ore 3, 9 e 12

85. Louise Brown, born July 25, 1978
JP Toner, Fertil Steril 2002

86. Al di la’ di ogni discussione di tipo
etico, medico, economico, va
salvaguardata la discussione sulle
INDICAZIONI !

87. DIAGNOSI ISTEROSALPINGOGRAFICA
PREOPERATORIA DI OCCLUSIONE
TUBARICA: QUANTI FALSI POSITIVI
RIVELATI POI ALLA CHIRURGIA?
Occlusione prossimale 41-61%
Occlusione distale 12%

88. CONCLUSIONI
• Appropriata selezione delle
pazienti e rispetto delle indicazioni
• Conoscere i vantaggi ed i limiti della
chirurgia della sterilità
• Corretta informazione alla paziente

89. video

90. Come prevenire le aderenze in
corso di chirurgia annessiale?

91. In letteratura è disponibile un’ampia
serie di dati, sia sperimentali che clinici,
ma a tutt’oggi non esiste un metodo
universalmente accettato per la
prevenzione delle aderenze

92. For laparoscopy, the perceived
postoperative de novo adhesion
formation rate was 0%-25%,
whereas the adhesion reformation
rate was 26%-75%; for
laparotomy, the rates were 26%-
75% and >75%, respectively.
Sixty-five percent of the respondents were using at least one
method for postoperative adhesion prevention during
laparoscopy, and 68% during laparotomy.The most frequently
used method during laparoscopy was Ringer's lactate (77% of
the respondents), followed by ferric hyaluronate gel (46% of
the respondents), and 4% icodextrin (39% of respondents).
During laparotomy, the most frequently used methods were
Ringer's lactate (28%), normal saline (20%), and 4%
icodextrin (20%). Antibiotic prophylaxis was used by 87.5% of
respondents.
Muzii, JAAGL 2004

93. Crystalloid Solutions
• Continuous irrigation is positive because:
– prevents fibrin deposition and wash away fibrinous exudates
– it can keep the tissues moist
• Intraperitoneal solutions at the end of surgery:
– active on all peritoneal surfaces, possibly preventing de novo
– easy to use, reduced costs
• However, doubts on the efficacy:
– rate of absorption is 35 ml/hour
– 300 ml are absorbed in 8.5 hours
– the process of peritoneal healing and adhesion formation takes
place during the first 5-7 days

94. INTRAPERITONEAL RESIDENCE OF RINGER’S
LACTATE: LONGER THAN EXPECTED
Results from a randomized, double-blind, clinical trial
Kurt Semm Award, AAGL 2003
PRELIMINARY STUDY
ESTIMATED IP VOLUME (mL) =
-4x10-8 V 4 + 4x10-5 V 3 – 1.32x10-2 V2 + 2,45V + 3,4217
V = D1 x D2 x D3

95. RESULTS
96
24
0
48
TIME (hrs) RINGER mL CONTROL mL P
0 289 (+ 38) 18 (+12) p<0.05
24 185 (+72) 3 (+2) p<0.05
48 55 (+28) 7 (+3) p<0.05
96 18 (+6) 6 (+4) N.S.

96. Mechanical Separation of Raw Surfaces
• Liquid Instillates
– Cystalloid solutions (i.e. Lactated Ringer’s)
– Hyskon (32% dextran 70)
– Intergel
– Adept
– Spraygel
– Hyalobarrier
– Sepracoat
• Mechanical Separation via barriers
– Interceed
– Preclude (Gore-tex)
– Seprafilm

97. www.cochrane.org

98. Cochrane menstrual disorders
and subfertility group
Reviews:
• Barrier agents for preventing
adhesions after surgery for subfertility
• Liquid and fluid agents for
preventing adhesions after surgery for
subfertility

99. AGENTI DI BARRIERA
• 15 RCTs
• LPTM = 9, LPS = 6
• Aderenze pelviche 6, Miomectomia 5, Chirurgia
ovarica 4, Endometriosi 2, Indicazioni varie 1
• 13 studi: Interceed vs. controllo, 2 studi: Interceed vs.
Gore-Tex, 1 studio: Gore-Tex vs. controllo, 1 studio:
Seprafilm vs. controllo
• In nessuno studio sono state valutate Gravidanze e
Riduzione del dolore

100. AGENTI DI BARRIERA
• L’uso dell’Interceed e’ associato ad una minore incidenza
di formazione di aderenze (sia ri-formazione che
formazione de novo) dopo chirugia laparoscopica e
laparotomica
• Il Gore-Tex e’ piu’ efficace di nessun trattamento o di
Interceed
• Evidenze limitate sull’efficacia del Seprafilm per la
prevenzione di aderenze dopo miomectomia
• Interceed efficace nel ridurre le aderenze, ma dati
insufficienti per raccomandarne l’uso per migliorare le
percentuali di gravidanza

101. AGENTI LIQUIDI / FLUIDI
• Nessuno degli agenti liquidi o fluidi studiati ha
determinato un aumento delle percentuali di gravidanza.
• Alcune evidenze sull’efficacia degli steroidi nel ridurre
l’incidenza e la severita’ della formazione di aderenze.
Destrano inefficace.
• L’uso di routine di questi agenti non puo’ essere
raccomandato sulla base delle evidenze disponibili.
• L’evidenza sugli steroidi e’ ben lontana dall’essere
perfetta, ma suggerisce l’efficacia. Dovrebbero essere
condotti studi addizionali.

102. Intergel
Adept

103. DB Johns, Fertil Steril 2001

104. “You should
immediately
discontinue use
of the device”
March 2003

105. Hum Reprod. 2002 Apr;17(4):1031-8.
A randomized, controlled pilot study of the safety and efficacy of
4% icodextrin solution in the reduction of adhesions following
laparoscopic gynaecological surgery.
diZerega GS, Verco SJ, Young P, Kettel M, Kobak W, Martin D, Sanfilippo J, Peers EM,
Scrimgeour A, Brown CB.
University of Southern California Keck School of Medicine, Los Angeles, CA, IGO Medical
Group, San Diego Fertility Center, Private Practice, Memphis TN, and ML Laboratories PLC,
Leicester, UK.
DiZerega, 2002
P = n.s.

106. CONCLUSIONI - Aderenze
Nonostante l’enorme mole di dati presenti in
letteratura, non esiste oggi un approccio
universalmente accettato. L’Interceed è il
metodo sul quale oggi esistono più studi. Nuovi
metodi di barriera in studio. L’approccio
laparoscopico, probabilmente, determina una
riduzione delle aderenze “de novo”. La
riformazione delle aderenze dopo adesiolisi
sembra invece essere la norma più che
l’eccezione, anche in laparoscopia.

107. CONCLUSIONI
La corretta indicazione all’intervento chirurgico
è probabilmente il mezzo più efficace per
prevenire le aderenze postoperatorie.
L’accurata selezione delle pazienti e il rispetto
delle indicazioni sono i punti-chiave per ottenere
i migliori risultati in chirurgia laparoscopica del
fattore tubo-peritoneale di sterilità
L’utilizzo di tecniche chirurgiche nel rispetto dei
tessuti è l’altro punto fondamentale.

108. Grazie per l’attenzione!