Laparoscopic salpingostomy utilizing the CO2 laser

Transcription

1 FERTILITY AND STERILITY Copyright e 1984 The American Fertility Society Vol. 41, No.4, Apri11984 Printed in U.SA. Laparoscopic salpingostomy utilizing the CO2 laser James F. Daniell, M.D.* Carl M. Herbert, M.D. Department of Obstetrics and Gynecology, Center for Fertility and Reproductive Research, Vanderbilt University Medical Center, Nashville, Tennessee A new technique for performing a terminal salpingostomy using the CO2 laser via laparoscopy has been developed. This operative procedure is described, and the clinical results of the first 22 patients are reported. A hysterosalpingogramdocumented tubal patency rate of 75% was noted 2 months postoperatively. Within the first 12 months postoperatively, there have been five pregnancies, including one ectopic gestation and one spontaneous abortion. Operative laparoscopy with the CO2 laser for distal salpingostomy may provide an acceptable alternative to laparotomy in selected patients. Fertil Steril 41 :558, 1984 The development of an operative laparoscopic technique that permits safe, accurate, and effective utilization of a CO 2 laser beam intraperitoneally has opened up new possibilities for infertility surgery.1-3 The CO 2 laser, because of its unique tissue effects, is potentially an ideal instrument for opening a hydrosalpinx with minimal blood loss and minimal tissue trauma. An operative technique for surgically opening a hydrosalpinx using the CO2 laser during laparotomy has been reported. 4 That technique has now been successfully utilized during laparoscopic surgery, and the following report reviews the first 12 months' utilization of this new operative procedure at Vanderbilt University Medical Center with a minimum of 6 months' follow-up on all patients. Received September 1, 1983; revised and accepted December 12, *Reprint requests: James F. Daniell, M.D., Women's Health Group, 2222 State Street, Nashville, Tennessee MATERIALS AND METHODS From January 1, 1982, through December 31, 1982, 28 patients underwent laparoscopic evaluation of tubal disease with hydrosalpinges for possible CO 2 laser salpingostomy and/or acceptance into the in vitro fertilization and embryo transfer (IVF-ET) program at Vanderbilt University Medical Center. These patients gave informed consent for an attempt at opening the hydrosalpinx using the CO 2 laser if it appeared technically feasible during the screening laparoscopy. All patients had previously undergone at least one major laparotomy with some form oftuboplasty for infertility. The criteria for attempting CO2 laser salpingostomy included the following: (1) ovaries free of adhesions or with minimal adhesions which could be laparoscopically removed; (2) proximal tubal patency at the cornua confirmed by chromopertubation; (3) a tubal ampullary diameter which was not distensible to > 4 cm with chromopertubation. Twenty-two of the 28 patients who underwent laparoscopy met these criteria in at least one adnexum and underwent the procedure. Procedures were all performed under general endotracheal anesthesia. Mefoxin (Merck Sharp 558 Daniell and Herbert CO 2 laser laparoscopic salpingostomy Fertility and Sterility

2 Figure 1 The three-puncture technique used for CO2 laser salpingos tomy. The middle instrument is the CO 2 laser probe, the upper is the operating laparoscope, and the suprapubic trocar allows use of a 5 mm alligator grasping forceps. & Dohme, West Point, PA), 1 gm, was given intravenously just prior to anesthesia and again subsequently in the recovery room. The patients were placed in the lithotomy position, the bladder was drained, and a cervical cannula was placed for uterine manipulation and intraoperative injection of indigo carmine diluted with normal saline. An operating laparoscope was introduced infraumbilically after standard pneumoperitoneum induction with an insufflation needle and CO 2, After confirming that the laparoscope was in the proper site and preliminary inspection of the anterior pelvis, a 5-mm second-puncture trocar was introduced under direct visualization in the midline 2 to 4 cm above the symphysis pubis, being careful to avoid the bladder or any pelvic adhesions. An atraumatic alligator grasping forceps (Eder Instrument Company, Chicago, IL) was then inserted through this second puncture site for traction and manipulation as needed during the procedure. If the decision was made to attempt CO2 laser salpingostomy, a third puncture was then made in the midline one third of the way between the laparoscopic and the suprapubic trocars. Through this incision a special 8-mm trocar that allowed placement of the special CO 2 laser probe was introduced. Through the operating channel of the laparoscope a 3-mm grasping forceps was then introduced. Thus, for performing the salpingostomy, two grasping forceps and a special CO2 laser probe were all placed intraperitoneally (Fig. 1). Vol. 41, No.4, April 1984 The probe for aiming and firing the CO2 laser under laparoscopic control is shown in Figure 2. This instrument passes through its own 8-mm trocar sheath. The probe is 33 cm long, with a double-ring channel that allows simultaneous suction of the smoke of vaporization and transmission of the laser beam into the pelvis. The channel through which the laser beam passes also provides a passage for insufflation of fresh CO2 Two valves at the hub of the probe allow control of both insufflation and evacuation. Thus, during use the probe allows for introduction of the CO2 laser beam along with fresh CO2 and simultaneous evacuation of the smoke generated by vaporization. This instrument is attached to the articulated arm of a Sharplan 733 CO 2 surgical laser (Advanced Surgical Technologies, Inc., Schaumburg, IL) via a 35-cm zinc arsenide focusing lens with a micromanipulator coupler. This system allows the user to keep the focused laser beam aligned along the shaft of the laser probe to impact on the target tissue without permitting reflection of the beam off the inner walls of the probe. By attaching the CO 2 tubing from the insufflator to the laser channel, fresh CO 2 blows down the probe and keeps the smoke out of the path of the beam and prevents moisture from forming on the focusing lens and mirror in the coupler. This system allows the operator to have two forceps for traction and countertraction plus the smoke evacuator and laser probe all available Figure 2 The second puncture probe that allows intraperitoneal aiming and firing of the CO2 laser is shown with its two entry ports. These provide access to the double ring tubing, which is demo onstrated in the enlarged inset. The housing attached to the end of the probe contains the focusing lens for the beam and a special alignment mirror with a short controlling 'Joy stick" (A) that directs the beam down the shaft of the instrument. Daniell and Herbert CO2 laser laparoscopic salpingostomy 559

3 for intraperitoneal use with a three-puncture technique of operative laparoscopy. To perform the operation, the tube to be opened was first distended with dye by transcervical injection. The end of the tube was held with alligator forceps so that the helium neon aiming laser beam could be aligned at a 90-degree angle to the thin end of the obstructed tube. With the laser set on continuous mode with a power of 35 watts, a linear incision was made with the focused CO 2 laser beam cutting from anterior to posterior along the thinnest scarred area on the distal tube. As soon as the lumen was entered, dye began to spill intraperitoneally, and the tube began to collapse. Fresh dye was injected to keep the distal tube distended as long as possible; but once the incision was enlarged, it became impossible to keep the hydrosalpinx distended. At this point, the two grasping forceps were used to gently grasp the edges of the incised tube. The initial incision was then extended by firing the laser, using the uterus as a backstop for the beam. One or two additional incisions were then made radially in the open end of the tube, following old scar lines present in the wall of the distal tube and avoiding blood vessels. A 3-mm irrigating probe was intermittently passed through the operating channel of the laparoscope and used to irrigate the incised end of the hydrosalpinx with a heparinized lactated Ringer's solution (5000 U/500 mi). Once adequate incisions had been made, the laser power was reduced to 5 watts so that a lower power density could be used to evert the incised edges of the hydrosalpinx. This was accomplished by first withdrawing the laser probe slightly to provide a "defocused" laser beam. This defocused, less powerful beam was then aimed at the serosal surfaces of the incised hydrosalpinx - 1 cm from the cut edge. As the laser was fired, the beam was quickly and continuously moved over the serosal surfaces of the tube to limit the effect of the beam on anyone area. The effect of this low power density beam was to cause absorption of water from, and contraction of, the serosal surface of the tube. This contraction caused the cut ends of the tube to become everted outward and rolled back, exposing a greater mucosal area of the newly incised ampulla for potential ovum pickup. The end of the tube was again irrigated, and chromopertubation was carried out to confirm location and patency of the tubal ostium. The opposite tube, if present and repairable, was then treated in a similar fashion. The mean operating time for repair of a single tube was 55 minutes, and for repair of both tubes, 75 minutes. The only technical difficulties encountered were associated with the repair of several tubes with thick walls. These tubes tended to be more vascular, even at the distal end, and occasionally resulted in minor bleeding. Hemostasis was easily obtained in all cases by utilization of bipolar cautery and a 3-mm laparoscopic grasper. The thick-walled tubes also did not evert or roll back as well as the thin tubes when the defocused low power laser beam was used. These tubes were left with more poorly defined ostia following the procedure. At the end of the procedure, the mixture of irrigation fluid, chromopertubation solution, and peritoneal fluid was suctioned from the pelvis, and 200 ml of a 32% dextran 70 (Hyskon, Pharmacia Laboratories, Piscataway, NJ) was instilled prior to termination of the laparoscopy. The three incisions were closed with absorbable subcuticular sutures, and the intravenous fluids were run at a high flow rate (150 to 200 mllhour) until discharge 3 to 6 hours after laparoscopy. Occasionally the patient was hospitalized overnight by request or because of postoperative pain. When discharged, the patient was instructed to return for a postoperative visit after completing her next menses. During that visit hydropertubation with 50 ml of normal saline was attempted for an initial evaluation of tubal patency. Obviously, when both tubes had been repaired, this test could only confirm patency of at least one of the tubes. A hysterosalpingogram (HSG) was then performed following the patients' second menses. If the x-ray study revealed recurrent tubal obstruction, the patient was offered entrance into the IVF-ET program. However, if one or both tubes were patent, the patient was encouraged to attempt conception for 12 to 18 months before considering IVF-ET or further surgery. RESULTS Of the 28 patients who underwent laparoscopy as part of this study, 6 were judged to have laparoscopically unrepairable tubes and thus were offered immediate entrance into the IVF-ET pro- 560 Daniell and Herbert CO 2 laser laparoscopic salpingostomy Fertility and Sterility

4 gram. In the remaining 22 patients at least one tube was considered operable, and CO 2 laser laparoscopic salpingostomy was attempted. Table 1 shows that six of these patients had only one tube available for repair. Of the 16 patients with bilateral hydrosalpinx, there were 5 who had one adnexum that was considered inoperable. Thus, a total of 33 salpingostomies were performed in 22 patients. None of the patients were hospitalized for longer than 24 hours. On retrospective questioning of the patients during their first follow-up office visit, those who had undergone previous laparoscopy could subjectively tell no difference in the amount of postoperative pain or other discomforts when comparing their past recoveries with the recent laparoscopy involving the CO 2 laser. Follow-up hydropertubation done on 21 of the 22 patients after surgery suggested tubal patency in 17 patients. One patient did not return for hydropertubation or HSG and was lost to followup. At HSG 2 months following surgery, patency was confirmed in all of the 17 patients with presumed patency on hydropertubation, indicating good correlation between the two techniques for evaluation of tubal patency. However, the hydropertubation was not diagnostic for unilateral obstruction when both tubes were repaired. A total of 24 tubes out of 32 opened with the CO 2 laser were found to be patent at HSG at 2 months, for a tubal patency rate of 75%. With a follow-up time of 6 to 18 months, five pregnancies have occurred in the 21 patients followed after surgery, for a conception rate of 24%. No patient has yet conceived twice. Table 2 shows that three of these pregnancies have been normal intrauterine gestations with one ectopic and one first-trimester spontaneous abortion. DISCUSSION The results of classical tubal surgery via laparotomy for repair of a hydrosalpinx have been disappointing regardless of adjunctive therapy or particular operative technique. 5 - B Gomel,6 using criteria for careful case selection and employing preliminary diagnostic laparoscopy, has reported only a 27% pregnancy rate when performing an initial open operative procedure without laser utilization for distally obstructed tubes. In addition, all of his reported intrauterine pregnancies have occurred after the first year of follow-up. Similarly, Rock et a1. 7 reported a pregnancy rate Table 1. Pelvic Findings in Patients Undergoing Laparoscopic Salpingostomy With the CO 2 Laser Type of pelvic anatomy remaining Both tubes One tube Both ovaand ova- and ovary ries and ries one tube Total No. of patients " Tubes avail able for repair Tubes repaired "All tubes were obstructed distally at initial chromopertubation. of 26% in 99 patients treated for distal tubal obstruction, including a 6% ectopic gestation rate. Jansen B reported follow-up on 91 patients treated with bilateral salpingostomy and determined a follow-up pregnancy rate of only 18.7%. More recent reports on attempts to open distal tubal obstruction laparoscopically with electrocautery have met with varied success in several small series Fayez lo recently reported 19 cases of laparoscopic salpingostomy with only a 31 % patency rate at follow-up HSG. There were two conceptions in his series of patients, for a conception rate of 10%. Both of those pregnancies occurred after 1 year's follow-up, and both proved to be ectopic gestations. Mettler et a1. 11 reported a mixed group of patients with endometriosis, pelvic adhesions, and tubal disease. Using laparoscopic techniques, they achieved a tubal patency rate of 79% overall and a pregnancy rate of 26% in 38 patients who underwent laparoscopic salpingostomy. Gomel 9 reported nine patients treated laparoscopically with either unilateral or bilateral salpingostomy. There was a 90% patency rate for at least one tube postoperatively, and four patients (44%) achieved an intrauterine pregnancy without ectopic gestation. The CO2 laser has been used for performing salpingostomy at open surgery by the Reproductive Surgery Division of the Obstetrics and Gyne- Table 2. CO 2 Laser Laparoscopic Salpingostomy Patients at 6 to 18 Months' Follow-Up Total patients followed 21" Patency of at least one tube Pregnancy results at HSG 2 months ---::- --:-:----.,,:----;:;--:--~ after surgery Intra- Abortion Ectopic uterine 17(81%) 3 (14%)b 1 (5%) 1 (5%) "One of 22 lost to follow-up. ~o live births at date of submission. Vol. 41, No.4, April 1984 Daniell and Herbert CO 2 laser laparoscopic salpingostomy 561

5 cology Department at Vanderbilt University Medical Center since the fall of This technique, as suggested by Bruhat and Mage,4 is atraumatic, rapid, and effective for reopening an obstructed distal tube. Because of the "minimal touch" technique used with CO2 laser surgery to open a hydrosalpinx, it seemed reasonable to attempt the operation under laparoscopic control. Once the laparoscopic instruments had been developed that allowed safe and effective use of a CO2 laser intraperitoneally, a group of patients was identified for treatment. Through a fortuitous coincidence, an IVF-ET clinical program was simultaneously being organized at Vanderbilt University Medical Center. Many of the initial applicants for the IVF-ET program had undergone previous tubal surgery and had recurrent hydrosalpinx. Because of the documented poor results from a second tuboplasty procedure,12 it seemed appropriate for these patients to investigate IVF as an alternative to further major surgery. In addition, it was thought at that time that these patients needed a preliminary screening laparoscopy prior to acceptance into the IVF -ET program.13 The combination of the availability of a laser laparoscope, the published results of successful operative laparoscopic salpingostomy, and the availability of patients with a recurrent hydrosalpinx desiring to conceive who were thought to need a laparoscopy to be admitted into our IVF-ET program led us to begin attempts at CO2 laser laparoscopic salpingostomy. The fact that the very first patient conceived within 3 months also encouraged us to continue the evaluation of this operative procedure. Since completing the initial investigative phase of this new technique, we have modified our protocol. Because hydropertubation 1 month postoperatively is not therapeutic, is less accurate than HSG for documenting tubal patency, and may predispose the patient to injection, we have subsequently dropped this practice from our management plan. The tubal patency rate of 75% is certainly equivalent to, or better than, the previous reports noted above. This figure is especially noteworthy because all our patients had undergone at least one previous tuboplasty procedure. Similarly, a pregnancy rate of almost 25% in our small series approximates the rates reported by other authors. The risk of ectopic gestation in any patient who has tubal disease and/or who has undergone tubal surgery was confirmed by our single ectopic pregnancy in five conceptions, representing a 20% incidence. Obviously, a larger cohort of patients will need to be evaluated before accurate statistical evaluations can be made. As mentioned previously, the degree of success in everting the tubal mucosa after neosalpingostomy is related to distal tubal thickness. The thinner-walled tubes usually can be everted easily, while thicker-walled tubes may only be partially everted and can have more bleeding associated with the procedure. However, an inability to estimate the degree of tubal thickness and to accurately predict which tubes would not be everted well has prevented the establishment of absolute contraindications to this procedure based on tubal thickness. Also, eversion of the distal tube mayor may not relate to the tube's ability to capture and transport an oocyte for eventual fertilization and pregnancy. Whether the CO2 laser laparoscope might be as effective as careful open surgery as a primary method of repairing a hydrosalpinx remains to be seen. Certainly, the savings in hospital expenses, time off from job or home activities, and reduced patient discomfort with this type of operative laparoscopy are significant factors to be considered. We are now beginning to offer this new operative procedure to patients as an alternative to primary major surgery. We caution the patients that the true efficacy of the procedure is unknown when compared with classic microsurgical open techniques with or without laser. As more infertility surgeons who are accomplished laparoscopists become familiar with the intraabdominal use of the CO2 laser, more information will be forthcoming concerning the true efficacy of this operative procedure. Laparoscopic CO2 laser salpingostomy, although technically a somewhat cumbersome procedure, can be safely and efficiently performed on thin-walled, mobile hydrosalpinges. Although further clinical evaluation and longer follow-up is needed before any firm conclusions concerning this operation can be drawn, it appears that this laparoscopic technique of salpingostomy is safe, technically feasible, and of benefit in selected patients... REFERENCES 1. Tadir Y, Ovadia J, Zuckennan Z, Kaplan I: The 4th Congress of International Society for Laser Surgery, Edited by K Atsumi, N Nimsakul. Tokyo, Jerusalem Academic Press, 1981, p Daniell and Herbert CO 2 laser laparoscopic salpingostomy Fertility and Sterility

6 2. Daniell JF, Brown DH: Carbon dioxide laser laparoscopy: initial experience in experimental animals and humans. Obstet Gynecol 59:761, Daniell JF, Pittaway DE: Use of the CO 2 laser in laparoscopic surgery: initial experience with the second puncture technique. Infertility 5:15, Bruhat M, Mage G: Use of the CO 2 laser in neosalpingostomy. In Proceedings of the 3rd International Congress for Laser Surgery, Edited by I Kaplan. Tel Aviv, Jerusalem Academic Press, 1979, p Harris WJ, Daniell JF: Use of corticosteroids as an adjuvant to terminal salpingostomy. Fertil Steril 40:785, Gomel V: Salpingostomy by microsurgery. Fertil Steril 29:380, Rock JA, Katayama KP, Martin EJ, Woodruff JD, Jones HW Jr: Factors influencing the success of salpingostomy techniques for distal fimbrial obstruction. Obstet Gynecol 52:591, Jansen RPS: Surgery-pregnancy time intervals after salpingolysis, unilateral salpingostomy, and bilateral salpingostomy. Fertil SteriI34:222, Gomel V: Salpingostomy by laparoscopy. J Reprod Med 18:265, Fayez JA: An assessment of the role of operative laparoscopy in tuboplasty. Fertil SteriI39:476, Mettler L, Giesel H, Semm K: Treatment offemale infertility due to tubal obstruction by operative laparoscopy. Fertil Steril 32:384, Lauritsen JG, Pagel JD, Vangsted P, Starup J: Results of repeated tuboplasties. Fertil Steril 37:68, Wentz AC, Torbit CA, Daniell JF, Fleischer AC, Garner CH, Pittaway DE, Christianson CD, Repp JE, Maxson WS: Combined screening laparoscopy and timed follicle aspiration for human in vitro fertilization. Fertil Steril 39:270, 1983 Vol. 41, No.4, April 1984 Daniell and Herbert CO 2 laser laparoscopic salpingostomy 563