The Role of Laparoscopy in the Management of Gynecologic Malignancy; Camran Nezhat, MD, Farr Nezhat, MD, Ceana H. Nezhat, MD, Matthew O. Burrell, MD, Benedict B. Benigno, MD & Carlos Ramirez, MD; Seminars in Surgical Oncology 10:431-439 (1994)
With the advent of minimally invasive laparoscopic techniques, most gynecologic procedures for benign conditions can be performed in an outpatient setting. However, the role of such techniques in gynecologic oncology is not well defined. By reviewing the literature and presenting some new data, we attempt to elucidate the applications of operative videolaparoscopy in gynecologic oncology. Advanced laparoscopic techniques are utilized for the management of cervical cancer as well as the staging and treatment of endometrial and ovarian cancers. Such techniques are used in performing radical hysterectomy for early stage cervical cancer, pelvic and paraaortic lymphadenectomy, and second look laparoscopy following chemotherapy for ovarian cancer. Even though preliminary data are encouraging, large prospective controlled studies with long-term follow-up are necessary to better define the role and limitations of laparoscopy in the treatment of gynecologic malignancies.
Laparoscopic Management of a Noncommunicating Uterine Horn in a Patient with an Acute Abdomen; D. Paul Amara, MD, Farr Nezhat, MD, Linda Giudice, MD, PhD, & Camran Nezhat, MD; Surgical Laparoscopy & Endoscopy, Vol.7, No.1, pp. 56-59
A 13-year-old girl with a history of cloacal anomalies presented with acute abdominal pain. Abdominal ultrasound was not definitive, and vaginal probe ultrasound was precluded by the patients stenotic vagina. Magnetic resonance imaging delineated a left hematometra and hematosalpinx as well as a more normal appearing right hemiuterus. Operative laparoscopy was used to lyse the extensive pelvic adhesions in a patient with a history of an imperforate anus and to resect a left rudimentary uterine horn with outflow obstruction. A review of cases in the world literature reveals that operative laparoscopy can be used to treat these patients successfully.
Incisional Hernias After Operative Laparoscopy, Ceana Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, and Camran Nezhat, MD; Journal of Laparoendoscopic & Advanced Surgical Techniques Volume 7, Number 2, April 1997
The objective of the study was to determine the possible risk factors of incisional hernias after operative laparoscopy. A retrospective case review was performed in a single referral obstetrics/gynecology clinic and center for special pelvic surgery considering the last 5300 surgeries. Of the approximately 5300 patients who underwent laparoscopy from January 1988 through June 1996, 10 women were evaluated for incisional hernias. A total of 11 hernias occurred, which is an incidence of approximately 0.2%. Omentum herniated in seven cases and bowel herniated in four cases. In one case, the sigmoid epiploica irreducibly herniated through the peritoneum and not the fascia. The hernia occurred through a 5mm trocar incision site in five cases. The median duration of the laparoscopic surgeries was 192 minutes (range, 25-375 minutes). Six women required laparoscopic surgery in order to retract the entrapped omentum or bowel. In one case, laparoscopically assisted bowel resection was necessary. The underlying fascia and peritoneum should be closed not only when using trocars of 10mm and larger as previously suggested but also when extensive manipulation is performed through a 5mm trocar port, causing extension of the incision.
The Incidence of Adhesions after Prior Laparotomy: A Laparoscopic Appraisal; Andrew I. Brill, MD, Farr Nezhat, MD, Ceana H. Nezhat, MD, & Camran Nezhat, MD; Obstet Gynecol 1995;85:269-72
To relate the presence of intra-abdominal adhesions after laparotomy to the site of incision, repeat laparotomy, and the clinical indication for prior surgery. Three hundred sixty women undergoing operative laparoscopy after a previous laparotomy were assessed for adhesions between the abdominal wall and the underlying omentum and bowel. Complications resulting directly from these adhesions were documented. Patients with prior midline incisions had significantly more adhesions (58 of 102) than those with Pfannenstiel incisions (70 of 258). Patients with midline incisions performed for gynecologic indications had significantly more adhesions (109 of 259) than all types of incisions performed for obstetric indications (12 of 55). The presence of adhesions in patients with previous obstetric surgery was not affected by the type of incision. Adhesions to the bowel were significantly more frequent after midline incisions above the umbilicus. Twenty-one women suffered direct injury to adherent omentum and bowel during the laparoscopic procedure. Intra-abdominal adhesions between the abdominal scar and underlying viscera are a common consequence of laparotomy. Patients undergoing laparoscopy after a previous laparotomy should be considered a risk for the presence of adhesions between the old scar and the bowel and omentum.
Dysmenorrhea is Related to the Number of Implants in Endometriosis Patients, Maria Menna Perper, PhD, Ceana H. Nezhat, MD, Farr Nezhat, MD, Camran Nezhat, MD, Harris Goldstein, MD, D.Med.Sc.; Fertility and Sterility, 1995;63:500-3
To determine whether the symptoms of endometriosis were related to the number and/or location of endometrial implants and the number and/or location of adhesions. Prospective, double-blind study. Seventy consecutive female surgical patients undergoing diagnostic and operative laparoscopy for pain, infertility, or both. Patients completed a self-administered questionnaire one day before laparoscopy. The number, type, and location of endometrial implants and the number, type and location of adhesions were evaluated during laparoscopy. These were compared with the type and severity of endometriosis symptoms as reported by patients. The total number of ectopic endometrial implants was associated directly with the intensity of dysmenorhea experienced by patients in the 60 days before operative laparoscopy (n=47). Patients with low pain scores had significantly fewer implants than patients with high pain scores. The intensity of menstrual pain is related to the number of endometrial implants in patients with endometriosis.
Videolaseroscopy for the Treatment Endometriosis Associated with Infertility, Camran Nezhat, MD, Scott Crowgey, MD, Farr Nezhat, MD; Fertility and Sterility, 51:237, 1989
Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results or 243 patients with infertility associated with endometriosis ranging in severity from mild to extensive who were treated by the same surgeon using CO2 laser laparoscopically with videocamera augmentation and control. Of the 243 infertility patients, 168 (69.1%) achieved pregnancy. The pregnancy rates were 71.8% in 39 patients with stage I disease, 69.8% in 86 patients with stage II disease, 67.2% of 67 patients with stage III disease, and 68.6% in 51 patients with stage IV disease. The life table and two-parameter exponential model were used to calculate monthly fecundity, "cure" and "probability of pregnancy" rates. The results indicate that videolaserscopic treatment of endometriosis associated with infertility, in surgically experienced hands, is at least as efficacious as other forms of therapy for mild and moderate cases of disease, but appears to be more successful than laparotomy for the more severe and extensive stages of disease.
Videolaseroscopy: A new Modality for the Treatment of Endometriosis and Other Diseases of Reproductive Organs, Camran Nezhat, MD; Colposcopy & Gynecologic Laser Surgery, Volume 2, Number 4, 1986
In the present study, a total of 311 patients underwent videolaseroscopy for a 12 month period. Of these, 257 patients had endometriosis (stage I to IV/AFS), and 54 patients had other pelvic pathology, such as adhesions or tubal disease. For the procedures discussed herein, the CO2 laser was used almost always through the operating channel of the laparoscope via an especially designed coupler by Cabot Medical (Nezhat coupler) or, occasionally, through a specially adapted second puncture trocar. A micromanipulator coupler was attached to the laparoscope or to the second puncture probe.
Videolaseroscopy for Oophorectomy, Farr Nezhat, MD, Camran Nezhat, MD, & Sheryl L. Silfen, MD; Am J Obstet Gynecol, 1991;165:1323-30
Laparoscopic oophorectomy was performed on 94 ovaries in 76 patients, Indications included recurrent pain associated with endometriosis and adhesions in 47 patients (18 ovaries), ovarian endometriomas in 40 patients (40 ovaries), prophylactic oophorectomy (breast cancer) in one patient (2 ovaries), removal of the ovaries at the time of laparoscopic assisted vaginal hysterectomy in 15 patients (30 ovaries), and other indication in three patients (4 ovaries).
Vaginal Vault Evisceration After Total Laparoscopic Hysterectomy, Ceana H. Nezhat, MD, Farr Nezhat, MD, Daniel S. Seidman, MD, & Camran Nezhat, MD; Obstetrics & Gynecology, 0029-7844/96, SSDI 0029-7844(95)00482-3
Vaginal vault rupture with intestinal herniation, although rare, has been reported after vaginal and abdominal hysterectomies. We report three such cases, two postcoital and one spontaneous, after total laparoscopic hysterectomy.
Use of Laparoscopic Ultrasonography to Detect Ovarian Remnants, Farr Nezhat, MD, Camran Nezhat, MD, Ceana H. Nezhat, MD, Erika Sly, BS, RPMS, Daniel S. Seidman, MD; J Ultrasound Med, 15:487-88/1996
Ovarian remnant syndrome is a complication of oophorectomy. It usually occurs in patients with distorted anatomy from adhesions and endometriosis, which makes surgical dissection difficult. The adhesions frequently result from pelvic inflammatory disease or previous pelvic operations. Although it is often technically difficult, resection is the most effective treatment for ovarian remnant syndrome. We have managed ovarian remnant syndrome successfully during laparoscopy. However, difficulty in diagnosing ovarian remnants during laparoscopy is not uncommon. Laparoscopic ultrasonography has been suggested to overcome the lack of tactile information. This technique has been used successfully to delineate the hepatobiliary anatomy during laparoscopic cholecystectomy, and for identifying hepatic and pancreatic malignancies. We report the use of laparoscopic ultrasonography to locate and monitor resection of bilateral ovarian remnants.
Use of Hysteroscopy in Addition to Laparoscopy for Evaluating Chronic Pelvic Pain, Farr Nezhat, MD, Camran Nezhat, MD, Ceana H. Nezhat, MD, Jeffrey S. Levy, MD, Edit Smith, MD, Leslie Katz, J Reproductive Medicine, 0024-7758/95/4006/-0431
This study assesses whether hysteroscopy can provide information concerning the cause of chronic pelvic pain. We prospectively evaluated the findings in 547 consecutive patients who had laparoscopy to evaluate chronic pelvic pain at a large, referral-based clinic and outpatient suite of a suburban hospital.
Urinary Tract Endometriosis Treated by Laparoscopy, Camran Nezhat, MD, Fariba Nasserbakht, MD, Farr Nezhat, MD, Maurizio Rosati, MD, Ceana H. Nezhat, MD, Daniel S. Seidman, MD; Fertility & Sterility, Vol 66, No 6 - 12/96
The surgical treatment of endometriosis has improved the results because of the introduction of new laparoscopic techniques. Involvement of the urinary tract with endometriosis is relatively uncommon, but it can be clinically significant. Endometriosis can involve the bladder or completely obstruct the ureter, resulting in the loss of kidney function. This report summarizes the laparoscopic management of 28 women who had severe endometriosis of the urinary bladder or ureter.
Traumatic Hypogastric Artery Bleeding Controlled With Bipolar Desiccation During Operative Laparoscopy, Farr Nezhat, MD, Andrew Brill, MD, Ceana Nezhat, MD; Camran Nezhat, M.D., Stanford U Med School, 300 Pasteur Dr., Stanford CA 94305
During multipuncture operative laparoscopy to excise peritoneal endometriosis involving the pelvic sidewall near the origin of the uterine artery, the lower portion of the hypogastric artery was perforated. The acute hemorrhage was controlled by immediately grasping the lacerated blood vessel with a 5-mm atraumatic grasping forceps. A Kleppinger bipolar forceps set at 25 W desiccated and sealed the artery successfully. As no further bleeding was noted, the procedure was terminated. The patient remained overnight for observation, and was discharged from the hospital the next day. She is doing well 18 months after the injury and repair.
Surgical Treatment of Endometriosis Via Laser Laparoscopy, Camran Nezhat, MD, Scott R. Crowgey, MD, Charles P. Garrison, MD; Fertility & Sterility, Vol. 45, No. 6, 6/86
The carbon dioxide laser has been used laparoscopically for the removal of endometriotic implants, excision of endometrioma capsules, and lysis of adnexal adhesion in 102 patients. These patients were followed for a period ranging from 12 to 18 months, during which time there were 62 pregnancies including 9 spontaneous abortions and 1 elective termination. The rates of conception after surgery were as follows: 75% for patients with mild endometriosis, 62% for patients with moderate endometriosis, 42.1% for patients with severe endometriosis, and 50% for patients with extensive endometriosis. Of 102 patients presenting with infertility attributed to endometriosis, 60.7% conceived within 24 months after laser laparoscopy. In this patient group, no immediate or subsequent laparotomy was required before conception was achieved, nor was hormonal therapy enacted during the study period after surgery.
Surgery for Endometriosis, Camran Nezhat, MD, Sheryl Silfen, MD, Farr Nezhat, MD, & Dan Martin, MD; Obstetrics & Gynecology, 1991, 3:385-393
Advanced operative laparoscopy in general, and videolaseroscopy using CO2 laser via operative channel of the laparoscope and video, specifically, has revolutionized the management of endometriosis. Adhesion formation is reduced and subsequent fertility rates exceed those obtained with laparotomy. The most complicated cases of endometriosis, including involvement of the rectovaginal septum, gastrointestine, and urinary tract, can now be treated endoscopically by an experienced operative laparoscopist.
A Simplified Method of Laparoscopic Presacral Neurectomy for the Treatment of Central Pelvic Pain Due to Endometriosis, Camran Nezhat, MD, Farr Nezhat, MD; British Journal of Obstetrics & Gynaecology, 8/92, Vol 99, pp 659-63
To describe optimal procedures and preliminary results for videolaparoscopic presacral neurectomy as part of the surgical treatment of endometriosis associated with intractable dysmenorrhoea. Observational study with follow up for at least one year. Eighty five women (18-45 years) with endometriosis and intractable pain, referred because medical and surgical management had failed. Subjects without a central (midline) component to their discomfort were excluded. Excision and vaporization of endometriotic pathology was followed by presacral neurectomy. During surgery, severity of endometriosis was assessed using revised American Fertility Society scoring. Overall pelvic pain and dysmenorrhoea relief were determined by office visit, telephone interview and questionnaire at a minimum of one year postoperatively. There were no operative complications and all women left hospital within 24 h of surgery. Overall pain relief was reported by 49 (94%) of 52 patients followed. The other three subjects noted no pain abatement. Dysmenorrhoea was reduced in 48 (92%) whereas four (8%) women claimed no relief. Laparoscopic presacral neurectomy is an option for treating dysmenorrhoea and pelvic pain in selected women, but is indicated only if medical management has failed. Videolaparoscopic presacral neurectomy using the CO2 laser is safe in trained hands. Pain relief achieved is within the range reported for laparotomy.
Severe Endometriosis and Operative Laparoscopy, Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD, & Daniel S. Seidman, MD; Current Opinion in Obstetrics in Gynecology, 1995, 7:299-306
Laparoscopic surgery offers the most effective form of treatment for women with sever endometriosis. The development of advanced laparoscopic techniques allows complete removal of deeply infiltrating lesions. Implants can be laparoscopically dissected from all anatomical locations, including severe involvement of the ureter, bladder and colon. When the endometriosis penetrates through the entire depth of the organ wall, complete resection and reanastomosis of the ureter or bowel can be safely performed laparoscopically by the experienced surgeon. However, optimal laparoscopic treatment requires not only surgical skill, but also comprehensive knowledge of pelvic anatomy and a good understanding of endometriosis and its progression.
Salpingectomy Via Laparoscopy: A New Surgical Approach, Farr Nezhat, MD, Wendy Winer, RN, BSN, & Camran Nezhat, MD; Journal of Laparoendoscopic Surgery, Vol. 1, No.2, 1991
This study presents 100 consecutive cases of total salpingectomy performed via laparoscopy for indications of ruptured or recurrent ectopic pregnancy, hydrosalpinges, torsion of the fallopian tube, hematosalpinges or extensive adhesions. A multiple abdominal puncture approach was used, and salpingectomy was accomplished by electrosurgical coagulation and laser transection of the isthmus, mesosalpinx, and tubo-ovarian ligaments using the CO2 laser. The fallopian tubes were removed from the pelvic cavity through one of the suprapubic punctures. The mean duration of the procedure was 22 minutes, and the mean duration of hospitalization after surgery 7.4 hours. No major intraoperative or postoperative complications were encountered. Laparoscopic salpingectomy appears to be a safe and relatively simple procedure associated with the advantages of outpatient surgery.
Safe Laser Endoscopic Excision or Vaporization of Peritoneal Endometriosis, Camran Nezhat, MD, Farr R. Nezhat, MD; Fertility & Sterility, Vol. 52, No. 1, 7/89
Operative laparoscopy is being used with increasing frequency in the treatment of endometriosis. This technique requires skill and practice, and a formidable understanding of the nature of the disease. The risks of injuring sensitive areas such as bowel, ureter, bladder, and major blood vessels are great; therefore, these sites are often excluded from surgical intervention. This is detrimental to the patient, as endometriosis should be treated thoroughly wherever it is encountered if possible. We have used a technique that we believe makes treatment with the carbon dioxide laser in these high risk areas more safe. This technique, which we call hydrodissection, is successful because the CO2 laser beam does not penetrate fluid. Thus, treatment can be confined to the endometrial lesion, leaving adjacent normal tissue unharmed. By creating a bed of water beneath the peritoneum (or serosa of the bowel), the risk of laser beam penetration to underlying tissue is reduced.
Proposed Classification of Hysterectomies Involving Laparoscopy, Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD, Dahlia Admon, MD, & A. Alex Nezhat, MD; J of the American Association of Gynecologic Laparoscopists, 8/95, Vol.2, No. 4
A common terminology for the use of laparoscopy at hysterectomy is necessary so that collected data can be interpreted and conclusions applied. Many procedures are termed laparoscopic hysterectomy regardless of the extent to which laparoscopy is performed. We divided hysterectomy into seven steps and propose a common nomenclature based on the number of steps performed laparoscopically.
Operative Laparoscopy (Minimally Invasive Surgery): State of the Art, Camran Nezhat, MD, Farr Nezhat, MD, & Ceana Nezhat, MD; J Gynecol Surg 8:111 1992
In any body cavity, endoscopic surgery is possible and usually preferable. Advantages include better exposure, magnification, and operating very close to the affected tissue. We demonstrate some of the past, present and future of laparoscopy.
Operative Laparoscopy for the Treatment of Ovarian Remnant Syndrome, Farr Nezhat, MD, Camran Nezhat, MD; Fertility & Sterility, Vol. 57, No. 5, May 1992
To present the technique and assess the efficacy of operative laparoscopy to manage ovarian remnant syndrome. Observational with a follow-up of 6 to 32 months. Thirteen women, 9 with previous bilateral salpingo-oophorectomy and 4 with previous unilateral salpingo-oophorectomy and pain on the ipsilateral side. Multipuncture advanced operative laparoscopy. Patient pain relief was assessed through return examinations, telephone interviews, or contact with referring physicians. Nine patients reported complete pain relief. One reported incomplete but satisfactory pain relief. Two required bowel resection by laparotomy to obtain pain relief, and one, despite subsequent laparotomy, had persistent pain. No intraoperative or postoperative complications were noted. Laparoscopy can be effective in managing ovarian remnant syndrome when performed by an experienced laparoscopist.
Nonvisualized Endometriosis at Laparoscopy, Farr Nezhat, MD, Christopher J. Allan, MD, Camran Nezhat, MD; Intl Fertil, 1991 p.340-43
Apparently conflicting results have been reported regarding the incidence, and even the existence, of endometriosis in visually normal peritoneum. The present study was undertaken in view of the fact that the presence and incidence of nonvisualized deep and/or microscopic endometriosis may be of importance in patient management. One patient in this study demonstrated a 1mm lesion of endometriosis beneath visually normal peritoneum. Two additional patients had cellular surface zones of possible endometrial stroma without a contiguous epithelial component. The results support the existence of unrecognized subperitoneal and microscopic surface endometriosis.
A New Method for Laparoscopic Access to the Space of Retzius During Retropubic Cystourethropexy, Ceana H. Nezhat, Farr Nezhat, Daniel S. Seidman, Fariba Nasserbakht, Camran, Nezhat, & Michael Roemisch; J of Urology, 0022-5457/96/1556-1916
We assessed the feasibility of a new technique for laparoscopic dissection of the space Retzius. In 10 women 40 to 70 years old (median age 45) undergoing laparoscopic retropubic cystourethropexy for stress urinary incontinence hydrodissection was used to create a pneumo-subperitoneal space. A suction irrigator probe was inserted into a mid peritoneal incision created with a 5mm trocar above the symphysis pubis between the 2 umbilical ligaments. The subperitoneal space was developed and insufflated with carbon dioxide without incising the peritoneum. All procedures were completed laparoscopically without intraoperative or postoperative complications. Operative time for cystourethropexy ranged from 30 to 70 minutes (median 40). Estimated blood loss ranged from less than 50 to 300 ml. (median 100). Patients were discharged from the hospital within 24 to 48 hours. All patients reported satisfactory relief of symptoms at 3 to 6 months of follow-up. The new technique is not difficult and may minimize tissue injury. Pneumosubperitoneal pressure provides clear exposure of the space of Retzius with minimal bleeding.
Major Retroperitoneal Vascular Injury During Laparoscopic Surgery, Camran Nezhat, Joel Childers, Farr Nezhat, Ceana H. Nezhat, & Daniel S. Seidman; Human Reproduction, vol.12, no.3, pp 480-83, 1997
We sought to assess the outcome of large retroperitoneal vascular injury that occurred during operative laparoscopy but was not related to trocar or Veress needle injury. We conducted a retrospective review of cases operated and reviewed by our centres. Eight cases were identified. Four women were undergoing lymphadenectomy, where vascular injury is a recognized risk. Distorted anatomy was a compounding factor in three of the remaining four patients who were undergoing intraperitoneal procedures. The injuries involved the inferior vena cava (n=2), the right external iliac artery (n=2), the left external iliac artery (n=1), the hypogastric artery (n=1), and the inferior mesenteric artery (n=1). Injuries were caused by unipolar electrode (n=1), electrosurgical scissors (n=3), sharp scissors (n=2), and CO2 laser (n=2). The vessel injury was repaired at laparotomy in four women. The other four cases were managed laparoscopically. Transfusion attributable to the vascular injury occurred in two cases. The outcome in all cases was good, except for the one in which the patient died. These cases demonstrate that all energy sources used without proper understanding and caution can cause significant vascular injury. The adequacy and safety of laparoscopic control of major vessel bleeding should be investigated further and consultation with a vascular surgeon should be considered in all cases.
Life-Threatening Hypotension After Vasopressin Injection During Operative Laparoscopy, Followed by Uneventful Repeat Laparoscopy, Farr Nezhat, MD, Dahlia Admon, MD, Ceana H. Nezhat, MD, Joseph E. Dicorpo, MMS, PA, & Camran Nezhat, MD; J of American Association of Gynecologic Laparoscopists, November 1994, Vol2, No. 1
Vasopressin may be associated with systemic hemodynamic changes, including severe myocardial ischemia, even in healthy patients. A 36-year-old woman underwent laparoscopy for the treatment of a uterine leiomyoma. After intravascular injection of vasopressin, she experienced life-threatening hypotension, and the procedure was subsequently aborted. After she recovered, she underwent successful laparoscopy without the use of vasopressin, and no complications occurred. As endogenous vasopressin levels sometimes rise during laparoscopy, patients may become susceptible to the drug’s effects, and appropriate precautions must be taken.
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Laparoscopy During Pregnancy: A Literature Review, Farr R. Nezhat, MD, Salli Tazuke MD, Ceana H. Nezhat, MD, Daniel S. Seidman, MD, Douglas R. Phillips, MD, Camran R. Nezhat, MD; JSLS(1997)1:17-27
To review the literature regarding the role of laparoscopy during pregnancy, particularly adnexal mass and non-obstetric surgery, incorporating the results of a series of 9 cases of laparoscopy during pregnancy at our centers. A Medline search was performed to review the literature, and the reference lists provided by those articles were further explored for citations regarding laparoscopic adnexal surgery, appendectomy, and cholecystectomy. Our series of 9 patients consisted of pregnant patients with adnexal mass or acute abdomen who would otherwise have undergone exploratory laparotomy. Follow-up data for these 9 cases were collected by office visits, inquiry to the primary referring physicians, and telephone calls to the patient. The literature search yielded 42 additional cases of operative pelvic laparoscopy and 51 cases of abdominal operative laparoscopy (cholecystectomy and appendectomy). The publications, particularly regarding cholecystectomy, were supportive of the laparoscopic approach during pregnancy. All of the patients in our series had favorable outcomes. Advanced operative laparoscopy has been successfully performed for certain indications during pregnancy.
Laparoscopically Assisted Myomectomy:A Report of a New Technique in 57 Cases, Camran Nezhat, MD, Farr Nezhat, MD, Oleg Bess, MD, Ceana H. Nezhat, MD, Roy Mashiach, MD; Int J Fertil 39(1):39-44, 1994
This study was undertaken to assess the efficacy of a combined operative laparoscopy and minilaparotomy technique to remove single and multiple large leiomyomas. Laparoscopy was used to treat associated pelvic pathology, to identify the leiomyoma(s) and bring it to a minilaparotomy incision and to remove by irrigation blood clots and debris at the end of the procedure. Through this incision, the leiomyoma(s) is grasped, shelled, morcellated, and the uterine defect is repaired in layers. We retrospectively evaluated the records of 57 women who underwent this procedure. The uteri ranged from 8 to 26 weeks’ gestational size. The weight of the leiomyomas ranged from 28 g to 998 g (mean, 247 g); operative time ranged from 40 to 285 minutes (mean, 127 minutes) and blood loss from 50 mL to 1600 mL) (mean, 267 mL). All procedures were completed without full laparotomy. Complications included on case of Klebsiella pneumonia requiring several days of antibiotics, and an incisional hernia at the minilaparotomy site. Forty-one patients were discharged on or before the first postoperative day, 12 on day 2, and four after 72 hours. Most women resumed normal activity within weeks. We found laparoscopically assisted myomectomy to be a safe alternative to myomectomy by laparotomy. It is technically less difficult than laparoscopic myomectomy, allows better closure of the uterine defect, and may require less time to perform.
Laparoscopically-Assisted Hysterectomy for the Management of a Borderline Ovarian Tumor: A Case Report, Camran Nezhat, MD, Farr Nezhat, MD, Matthew Burrell, MD; J of Laparoendoscopic Surgery, Vol. 2, No. 4, 1992
Borderline ovarian tumors account for 4% of ovarian neoplasms, an incidence which remains constant despite advancing age. Management for younger women can be unilateral oophorectomy, although simple hysterectomy with bilateral salpingo-oophorectomy is more appropriate for women beyond childbearing age. The authors report a laparoscopic approach to a case of borderline ovarian tumor.
Laparoscopically Assisted Anterior Rectal Wall Resection and Reanastomosis for Deeply Infiltrating Endometriosis, Camran Nezhat, MD, Earl Pennington, MD, Farr Nezhat, MD, Sheryl L. Silfen, MD; Surgical Laparoscopy & Endoscopy, vol. 1, No. 2, pp. 106-108
A 28-year-old woman, presented with a history of long-standing, severe pelvic and bowel endometriosis. Pronounced cul-de-sac tenderness and nodularity were noted on pelvic examination. Videolaseroscopy was undertaken, the rectum was mobilized, and the tumor was prolapsed to the level of the anus. Anterior rectal wall resection and reanastomosis were performed; the colon was returned to the pelvis under direct visualization via laparoscope.
Laparoscopic Versus Abdominal Hysterectomy, Farr nezhat, MD, Camran Nezhat, MD, Stephen Gordon, MD, Elizabeth Wilkins, CST; J of Reproductive Medicine Vol. 37, No. 3, 3/1992
The perioperative and postoperative courses of hysterectomy with or without bilateral salpingo-oophorectomy were compared for 10 women who underwent total abdominal hysterectomy and 10 who underwent laparoscopically assisted vaginal hysterectomy. Although laparoscopic hysterectomy took longer (160 versus 102 minutes), the women undergoing it had a shorter duration of hospitalization (2.4 versus 4.4 days), more rapid recuperation (3 vs. 5 wks) and fewer complications. These preliminary results suggest that in the hands of experienced operative laparoscopists, laparoscopically assisted vaginal hysterectomy is preferable to abdominal hysterectomy for selected candidates.
Laparoscopic Vaporization of Diaphragmatic Endometriosis in a Woman with Epigastric Pain: A Case Report, Rakesh Mangal, MD, Omur Taskin, MD, Camran Nezhat, MD, & Robert Franklin, MD; J Reprod Med 1996, 41:64-66
Endometriosis has been observed in 8-15% of reproductive age women and is commonly found in pelvic and nonpelvic organs. Despite its widespread prevalence, the etiology remains obscure. A 22-year-old woman with intractable epigastric and pelvic pain who was treated previously by laser ablation for pelvic and diaphragmatic endometriosis was referred to our clinic. The patient received leuprolide acetate for six months, but the symptoms did not improve. Second-look laparoscopy revealed deep endometriotic spots involving both the diaphragms, exactly in the line of the left ventricle. With visualization, endometriosis was excised in total with the help of hydrodissection an CO2 vaporization. As in pelvic endometriosis, therapy for extrapelvic endometriosis consists of surgical and hormonal manipulation following the diagnosis. The importance of extreme caution, meticulous surgery and cardiothoracic consultation when treating the diaphragmatic surface cannot be overemphasized.
Laparoscopic Ureteroureterostomy, Camran Nezhat, MD, Farr Nezhat, MD, Bruce Green, MD, Gilbert Gonzalez, MD Journal of Endourology, Vol. 6, No. 2, 1992
With the advances in operative laparoscopy, it is now possible to perform ureteroureterostomy laparoscopically. We have developed a technique that has proven successful for treating ureteral obstruction and injury. Other clinical situations, including excision of an isolated ureteral stricture, laparoscopic ureterolithotomy, and excision of a low-grade ureteral tumor may be managed by this technique.
Case Report: Laparoscopic Treatment of Symptomatic Diaphragmatic Endometriosis; Farr Nezhat, MD, Camran Nezhat, MD, Jeffrey S. Levy, MD; Fertility & Sterility, Vol. 58, No. 3, Sept 1992
Several theories currently exist regarding the origin of endometriosis, but none of them have proven singly conclusive and the disease continues to be poorly understood. The location of endometrial implants varies widely and has been found to include such uncommon sites as the appendix, ureter, and lungs. To our knowledge, the following is the first case report describing the laparoscopic treatment of diaphragmatic endometriosis in the vicinity of the phrenic nerve. This type of endometriosis can be successfully treated with extreme caution by experienced laparoscopic surgeons, using CO2 laser vaporization and/or excision and hydrodissection.
Laparoscopic Treatment of Obstructed Ureter Due to Endometriosis by Resection and Ureteroureterostomy: A Case Report, Camran Nezhat, Farr Nezhat & Bruce Green; J of Urology, Vol 148, 865-868, September 1992
Partial ureteral resection and ureteroureterostomy were accomplished using operative laparoscopy in a 36-year-old woman with a long-standing history of endometriosis, left ureteral obstruction and nephrostomy.
Laparoscopic Treatment of Infiltrative Rectosigmoid Colon and Rectovaginal Septum Endometriosis by the Technique of Videolaparoscopy and the CO2 Laser, Camran Nezhat, Farr Nezhat, Earl Pennington; British J of Obstetrics and Gynaecology, August/1992, Vol. 99, pp. 665-667
To present the technique and results of videolaparoscopy and the CO2 laser as a treatment for deep, infiltrative endometriosis of the rectovaginal septum, uterosacral ligaments, pouch of Douglas and anterior wall of the rectosigmoid colon. Observational study with 1-5 year follow up. 185 women, ages 25-41 years. All had pelvic endometriosis and were referred because of the failure of previous medical and/or surgical treatment. Vaporization and excision of endometriotic implants and nodules, ureterolysis, ureteric stents, laparoscopic anterior rectal wall resection and reanastomosis, presacral neurectomy, laparoscopic hysterectomy, salpingo-oophorectomy and appendicectomy using the CO2 laser. 174 patients were followed for 1-5 years after surgery by office visit questionnaire or telephone interview. Eleven were lost to follow-up. 175 patients were discharged within 24 h. Nine with bowel perforations and one with a partial bowel resection were discharged 2-4 days postoperatively. Two patients required ureteric stents, which were removed 6 weeks postoperatively without sequelae. 162 women reported moderate to complete pain relief (145 after one procedure, 13 after two and four after three). 12 reported persistent or worse pain following the surgery. Seven eventually underwent total hysterectomy, four had bowel resections and one had a salpingo-oophorectomy. Of 61 with infertility, 25 achieved pregnancy. Postoperative complications included shoulder pain, anterior abdominal wall ecchymosis, urine retention and dyschezia for one to two weeks. Our experience suggests that rectosigmoid colon and infiltrative rectovaginal septum endometriosis can be effectively treated via videolaparoscopy in the hands of experienced endoscopic gynaecologists.
Laparoscopic Treatment of Endometriosis with Laser and Videocamera Augmentation (Videolaseroscopy), Camran Nezhat, Wendy K. Winer, RN, BSN, Farr Nezhat, MD, & Ceana Nezhat, MD; J of Gynecologic Surgery, 5:163, 1989
Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 857 patients with endometriosis who were treated using the CO2 laser laparoscopically with videocamera augmentation (videolaseroscopy). Of 201 infertility patients followed for at least 18 months, 132 (66%) achieved pregnancy. Of 270 patients with pelvic pain, 210 (77%) patients experienced no pain after 1 year. We conclude that when surgical management of endometriosis is indicated, videolaseroscopy offers advantages over standard laser laparoscopy for the surgeon, including reduced back strain and increased magnification control. In addition, comparable, if not improved, results to the patients can be obtained through laser laparoscopy with video augmentation.
Laparoscopic Surgery with a New Tuned High-Energy Pulsed CO2 Laser, Camran Nezhat, MD, Farr Nezhat, MD; J Gynecol Surg, 8:251, 1992
Although CO2 lasers have gained popularity in operative laparoscopy, it has been suggested that they do not deliver sufficiently high power density at the distal end of a laparoscope. Heating of the insufflation gas inside the laparoscope by absorption of some of the laserpower causes the gas density to change and creates distortion and defocusing, resulting in lower power density at the tissue as the laser power is increased. A new laser uses the carbon-13 isotope in the laser gas mix instead of the carbon-12 isotope, which is used in both conventional lasers and CO2 gas. The new laser was found to have no noticeable effect on tissue attributed to distortion or power loss from absorption in the insufflation gas, and it allowed the surgeon to work with minimal thermal side effects, such as the formation of charred tissue. The laser was fitted with separate controls for adjusting pulse energy and average power, allowing the surgeon to control the laser-tissue response at different operating speeds.
Laparoscopic Segmental Bladder Resection for Endometriosis: A Report of Two Cases, Camran R. Nezhat, MD, Farr R. Nezhat, MD; Obstet Gynecol, 1993, 80:882-4
The proper treatment of bladder endometriosis is unknown. Two women with endometriosis involving the full thickness of the bladder wall experienced persistent hematuria during menstruation. They had not responded to previous conservative medical or surgical therapy, so we performed laparoscopic segmental resection, with satisfactory results. Hematuria during menstruation due to endometriosis of the bladder is uncommon. In the two cases presented, good results followed laparoscopic segmental resection.
Laparoscopic Sacral Colpopexy for Vaginal Vault Prolapse, Ceana H. Nezhat, MD, Farr Nezhat, MD, & Camran Nezhat, MD; Obstet Gyneco, 1994;84:885-8
Laparoscopic sacral colpopexy can be used to treat vaginal vault and genital prolapse. After preparation, the vaginal apex is attached to the sacrum over the third and fourth sacral vertebrae using mesh.
Laparoscopic Retropubic Cystourethropexy, Ceana H. Nezhat, MD, Farr Nezhat, MD, Camran R. Nezhat, MD, Howard Rottenberg, MD; J of the American Assoc. of Gynecologic Laparoscopists, August 1994, Vol. 1, No. 4, part 1
To evaluate the efficacy of laparoscopic retropubic urethrovesical suspension. Retrospective review of charts of 62 women over a follow-up period ranging from 8 to 30 months. Sixty-two women, age 34 to 69 years, gravidity 0 to 8, and parity 0 to 7, with gynecologic abnormalities requiring surgical intervention and with pure genuine urinary stress incontinence. Each patient underwent a Burch or Marshall-Marchetti-Krantz procedure, modified to be performed at laparoscopy. Success was measured subjectively and objectively. Subjective success, determined by the lack of need to wear pads, was 100%. Objective success was assessed using several criteria: comparison of preoperative and postoperative symptom diaries; questionnaires; urine characteristics by straight catheter (office dipstick for nitrate, leukocyte extrace, bacteria, and white cell blood count, if suspicious urine culture and sensitivity); postvoid residual volume (< ml was considered complete); urethrovesical junction angle ad determined by catheter or Q-Tip placement (upward, downward, or straight); bladder support; and negative standing stress test. all women reported satisfactory relief of symptoms, with subjective and objective improvement. None have noted urinary leakage during activities similar to those preoperatively associated with this condition. To date, the outcomes have been acceptable, although the limited numbers and relatively short follow-up prohibit any definitive conclusions.
Laparoscopic Repair of Ureter Resected During Operative Laparoscopy, Camran Nezhat, MD, Farr Nezhat, MD; Obstet Gynecol, 1992;80:543-4
Ureteral injury is a recognized complication of gynecologic surgery. During operative laparoscopy performed to treat extensive endometriosis of the pelvic sidewall, a 1.5 cm portion of the right ureter was resected and was repaired successfully. repair of resected ureter may be effectively accomplished endoscopically by experienced operative laparoscopists.
Laparoscopic Repair of a Vesicovaginal Fistula: A Case Report, Ceana H. Nezhat, MD, Farr Nezhat, MD, Camran Nezhat, MD, & Howard Rottenberg, MD; Obstet Gynecol, 1994;83:899-901
Operative laparoscopy was performed for the management of ovarian remnant syndrome involving the bladder, bowel, vagina, and ureters, and requiring extensive dissection. A vesicovaginal fistula developed postoperatively. Because of the complexity and location of the fistula, a vaginal approach was not appropriate. Using techniques of videolaparoscopy, videocystoscopy, and operative laparoscopy, the fistula was repaired. In experienced hands, endoscopic management of complex vesicovaginal fistulas may be an alternative to the traditional abdominal approach.
Laparoscopic Repair of Small Bowel and Colon A Report of 26 Cases, Camran Nezhat, Farr Nezhat, Wayne Ambroze, & Earl Pennington; Surg Endosc, 1993; 7:88-89
This is a retrospective review of laparoscopic repair for enterotomies created during therapeutic or diagnostic laparoscopy in 26 women. All patients had mechanical and antibiotic bowel preparation preoperatively. The indication for operative laparoscopy was endometriosis (18), sever abdominal adhesive disease (7), adhesions with Crohn’s disease (1). Enterotomies were secondary either to CO2 laser vaporization or excision of endometriosis and/or lysis of adhesions (23) and trocar insertion (3). The injuries included small-bowel enterotomies (9), colotomies (4), and rectotomies (13). No clinical complications related to enterotomy repair were noted. Twenty-three patients were discharged 1 day after surgery; one was discharged on postoperative day 2; and two were discharged on postoperative day 3. We concluded that small and large bowel enterotomies can be repaired safely via the laparoscope with minimum morbidity in patients with prepared bowel.
Laparoscopic Removal of Dermoid Cysts, Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Farr Nezhat, MD; Obstet Gynecol, 73:278, 1989
Nine reproductive-age women underwent removal of unilateral or bilateral dermoid cysts via laparoscopy. Over a follow-up period of 12-42 months, there were no immediate or long-term complications. Four patients have had repeat laparoscopy for evaluation of possible pelvic adhesion formation; one had mild periovarian adhesions and the pelvis appeared normal in the other three.
Laparoscopic Radical Hysterectomy with Paraaortic and Pelvic Node Dissection, Camran R. Nezhat, MD, Matthey O. Burrell, MD, Farr R. Nezhat, MD, Benedict B. Benigno, MD, & Charles E. Welander, MD; Am J Obstet Gynecol, 1992;166:864-5
We report the first case of a laparoscopic radical hysterectomy an paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.
Laparoscopic Radical Hysterectomy and Laparoscopically Assisted Vaginal Radical Hysterectomy with Pelvic and Paraaortic Node Dissection, Camran R. NEzhat, MD, Farr R. Nezhat, MD, Matthew O. Burrell, MD, Carlos E. Ramirez, MD, Charles Welander, MD, Jesus Carrodeguas, MD, & Ceana H. Nezhat, MD; J Gynecol Surg, 9:105, 1993
Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging.
Laparoscopic Proctectomy for Infiltrating Endometriosis of Rectum, Farr Nezhat, MD, Camran Nezhat, MD, Earl Pennington, MD; Fertility & Sterility, Vol. 57, No. 5, 5/92
Five percent of cases of endometriosis involve the colon and 76% of these cases involve the rectum or rectosigmoid area. Deeply infiltrating rectal lesions traditionally required open laparotomy for bowel resection and reanastomosis, increasing morbidity and extending recovery. Recently, laparoscopic assisted bowel resections have been described, and the laparoscope’s use in gastrointestinal surgery is increasing . Techniques for laparoscopic assisted bowel resection have been limited to the anterior wall or areas for resection and anastomosis through a separate, smaller abdominal incision. The latter procedure is not recommended for rectal lesions because the rectum is not long enough to be brought up to the abdominal wall. We have previously reported on the technique of anterior rectal wall resection and reanastomosis. Now we have developed a technique for total rectal wall resection combining advanced operative laparoscopy to mobilize and cut the rectum so that it can be prolapsed through the anal canal, resected, replaced into the pelvis, and reanastomosed.
Laparoscopic Ovarian Surgery, William H. Parker, MD, Farr Nezhat, MD, Michel Canis, MD; J Am Assoc of Gynecologic Laparoscopists, Vol. 1, No. 1, 11/93
The following is a summary of an important panel discussion that took place in Chicago, Illinois, at the 21st annual meeting of the American Association of Gynecologic Laparoscopists (AAGL) on September 25, 1992.
Laparoscopic Ovarian Cystectomy During Pregnancy, Farr Nezhat, MD, Camran Nezhat, MD, Sheryl L. Silfen, MD, & Stephen H. Fehnel, MD; J Laparoendoscopic Surgery, Vol. 1, No. 3, 1991
A pregnant woman with a history of endometriosis and persistent bilateral adnexal masses underwent laparoscopic ovarian cystectomies at 16 weeks of gestation. There were no adverse sequelae, and the patient had an otherwise uneventful pregnancy and delivery. Operative laparoscopy should be considered to replace laparotomy in appropriate cases during pregnancy.
Laparoscopic Myomectomy Today: Why, When and for Whom? Farr Nezhat, Daniel S. Seidman, Camran Nezhat, & Ceana H. Nezhat; Human Reproduction, Vol 11, No. 5, pp.933-37, 1996
No abstract available.
Laparoscopic Myomectomy, Camran Nezhat, MD, Farr Nezhat, MD, Sheryl L. Silfen, MD, Natalie Schaffer, LPN, Debra Evans, LPN; Int J Fertil, 36(5), 1991, p.275-280
Laparoscopic myomectomy was performed on 154 women, with minimal perioperative complications resulting. Small and single leiomyomata were managed more easily than multiple and larger tumors. Although suturing the excisional sites improved healing, it increased the incidence of adhesion formation. We conclude that laparoscopic myomectomy can be a safe and cost-effective alternative to laparotomy when performed by a skilled operative laparoscopist, but only in selected cases.
Laparoscopic Management of Intentional and Unintentional Cystotomy, Ceana H. Nezhat, Daniel S. Seidman, Farr Nezhat, Howard Rottenberg & Camran Nezhat; J Urology, 0022-5347/96/1564-1400
With advanced laparoscopic procedures, such as treatment of extensive pelvic adhesions and severe endometriosis, hysterectomy or retropubic urethropexy, there is a risk of bladder injury. The conventional approach to intraperitoneal bladder injury is celiotomy and repair of the perforation in multiple layers. This complication can be treated successfully at laparoscopy regardless of whether partial cystectomy was done intentionally to treat endometriosis or remove ovarian remnants, or the bladder injury was incidental. We summarize the outcome of 19 cases of bladder injury treated laparoscopically.
Laparoscopic Surgery for Gynecologic Cancer, Camran Nezhat, MD, Daniel S. Seidman, MD, Farr Nezhat, MD, Ceana H. Nezhat, MD; Surgical Technology International IV
No abstract available.
Laparoscopic Hysterectomy and Bilateral Salpingo-oophorectomy Using Multifire GIA Surgical Stapler, Camran Nezhat, MD, Farr Nezhat, MD, & Sheryl L. Silfen, MD; J Gynecol Surg 6:287, 1990
A laparoscopic hysterectomy and bilateral salpingo-oophorectomy was performed on a 42-year-old patient with pelvic pain and long-standing endometriosis. A prototype titanium Multifire GIA Stapler, which was designed for use in operative laparoscopy, was used for the first time on this patient, with excellent results.
A New Approach to Performing Laparoscopic Colposuspension, Ceana H. Nezhat, MD, Michael Roemisch, MD, Daniel S. Seidman, MD, Farr Nezhat, MD & Camran Nezhat, MD; Contemporary Ob/Gyn, September 1996
Treating stress urinary incontinence improves a woman’s quality of life. Laparoscopic correction, which reduces the drawbacks associated with open surgery, may encourage more women to obtain relief.
Is Hormonal Treatment Efficacious in the Management of Ovarian Cysts in Women with Histories of Endometriosis? Ceana H. Nezhat, Farr Nezhat, Soheila Borhan, Daniel S. Seidman, & Camran R. Nezhat; Human Reproduction, Vol. 11, No. 4, p.874-77, 1996
In a controlled, randomized study, we evaluated the effectiveness of various hormonal regimens in treating 70 women (mean age 34.7 + 5.7 years) who had unilateral or bilateral ovarian cysts presumed to be physiological (functional) and a history of endometriosis. The patients were assigned randomly to one of the following groups: group I (control), no treatment; group II, oral contraceptives (35 ug ethinyl oestradiol and 1 mg norethindrone); group III, oral contraceptives (50 ug ethinyl oestradiol and 1 mg norethindrone); group IV, danazol 800 mg/day. Serum CA-125 concentrations were measured in 32 women. All medications were taken continuously for 6 weeks. Subjects were re-evaluated by pelvic examination and transvaginal ultrasound. Those with persistent cysts were offered diagnostic and possible operative laparoscopy. As 11 patients did not complete the study and five did not follow-up, the final study population comprised 54 women. At 6 weeks follow-up, complete resolution of cysts was found in: group I, 12 out of 18 (66.7%); group II, five out of nine (55.6%); group III, eight out of 14 (57l1%); and group IV, seven out of 13 (53.9%), Two of the 22 women with persistent cysts opted for 6 weeks further medical therapy and achieved complete resolution; 19 underwent laparoscopy, and one was lost to follow-up. All laparoscopic findings revealed benign masses. We found no statistically significant effect when hormonal treatment was compared with expectant management. There was no correlation between serum CA-125 concentrations and the persistence or resolution of cysts.
Injuries Associated with the Use of a Linear Stapler During Operative Laparoscopy: Review of Diagnosis, Management, and Prevention, Camran Nezhat, MD, Farr Nezhat, MD, Oleg Bess, MD, Ceana H. Nezhat, MD; J Gynecol Surg 9:145, 1993
We report 7 recent examples of intraoperative and postoperative complications and injuries resulting from the use of an automatic stapling device during operative laparoscopy. The cases were collected throughout the United States and represent a cross-section of common complications. This report should alert surgeons to the possibilities of ureteral, bladder, and bowel injuries, postoperative bleeding, and instrument malfunctions. In addition, precautions and techniques to prevent and resolve complications are discussed.
Incidental Appendectomy During Videolaseroscopy, Camran Nezhat, MD, & Farr Nezhat, MD; Am J Obstet Cynecol 1991; 165:559-64
One hundred incidental appendectomies were performed in patients undergoing operative laparoscopy (videolaseroscopy) for evaluating and treating various major diseases of the reproductive organs. Except for a fever resolving within 24 hours in one case and mild periumbilical ecchymosis, there were no intraoperative or postoperative complications. All patients were discharged within 24 hours of surgery. Average hospital stay was 14 hours. All cases have been followed up for a minimum of 8 months. We believe any risk associated with elective appendectomy as reported here is minimal and outweighed by the benefits of eliminating future emergency appendectomy, simplifying future differential diagnosis of pelvic pain and removing unsuspected abnormality found in the appendix.
Hospital Cost Comparison Between Abdominal, Vaginal, and Laparoscopy-Assisted Vaginal Hysterectomies, Camran Nezhat, MD, Oleg Bess, MD, Dahlia Adon, MD, Ceana H. Nezhat, MD, & Farr Nezhat, MD; Obstet Gynecol 1994;83:713-6
To evaluate and compare the hospital charges for total abdominal hysterectomy (TAH), vaginal hysterectomy, and laparoscopy-assisted vaginal hysterectomy performed with the linear stapler. Thirty cases of each of the three types of hysterectomies, performed at the same hospital by various surgeons, were selected at random. The authors did not participate in any of the cases evaluated. Operating room, postoperative hospitalization, and pharmacy costs were compared. Independent, two-tailed Student t test analysis was performed. The mean cost of performing laparoscopy-assisted vaginal hysterectomy with the linear stapler ($7161.66) was significantly higher (P< .05) than that of both vaginal hysterectomy ($4868.06) and TAH ($4926.80). The cost of vaginal hysterectomy was nonsignificantly lower (P > .05) than that of TAH. The mean operating room supplies and equipment charge for laparoscopy-assisted vaginal hysterectomy with the linear stapler ($2468.43) was, as expected, significantly higher (P< .05) than those for both abdominal ($761.65) and vaginal ($676.16) procedures. The average operating room time charge for laparoscopy assisted vaginal hysterectomy ($1264.56) was also significantly higher (P< .05) than for the other two procedures (TAH $642.76, vaginal hysterectomy $955.66). The mean total pharmacy charges were similar for all groups ($1114.27 for laparoscopy-assisted vaginal hysterectomy, $1163.16 for vaginal hysterectomy, and $1098.71 for TAH). Reflecting the longer operating time for laparoscopy-assisted vaginal hysterectomy, the intraoperative pharmacy costs were significantly higher for this type ($417.00) than for the TAH patients ($290.62) The difference, however, was almost erased when postoperative pharmacy charges were included, reflecting the lower cost of a shorter hospital stay in the laparoscopy-assisted vaginal hysterectomy group. Some savings were realized by laparoscopy-assisted vaginal hysterectomy when postoperative hospitalization charges were considered. The average hospitalization time was 2.3 days for laparoscopy-assisted vaginal hysterectomy, 3.0 days for vaginal hysterectomy, and 3.3 for TAH. The cost savings expected with the advent of laparoscopy-assisted vaginal hysterectomy when performed with the linear stapler have not been realized at present. In most cost categories studied, the use of laparoscopy to perform a hysterectomy was associated with much higher costs. The predicted savings associated with the shorter hospital stay in these patients failed to offset the exorbitant intraoperative costs. However, when bipolar electrocoagulation with the CO2 laser and reusable instrument replace staplers and disposables, respectively, the projected savings are appreciated.
Gynecologic Laparoscopy: Behind the Gloss, Camran Nezhat, MD, Farr Nezhat, MD, Hugh R. K. Barber, MD, John Rock, MD, Carl Levinson, MD; The Female Patient, Vol. 18, 9/93, p14
While gynecologic surgeons continue to develop new applications and refinements for laparoscopy, the technique still occupies a somewhat uneasy position in the therapeutic armamentarium. Even with the revolution well under way, controversy still rages about training, benefits, cost, complications, and quality assurance. this panel of experts takes a candid look at the state of the specialty today.
A Fresh Look at Ovarian Endometriomas, Farr Nezhat, MD, Ceana Nezhat, MD, Camran Nezhat, MD, & Dahlia Admon, MD; Contemporary Ob/Gyn, Vol. 39, No. 11, 11/94
Endometriosis of the ovaries has unique manifestations. A new classification of endometriomas offers practical implications for diagnosis and treatment.
Laparoscopic Disk Excision and Primary Repair of the Anterior Rectal Wall for the Treatment of Full-thickness Bowel Endometriosis, C. Nezhat, F. Nezhat, E. Pennington, C. H. Nezhat, W. Ambroze; Surg Endosc, 1994, 8: 682-85
We used a new laparoscopic technique to treat infiltrative symptomatic intestinal endometriosis. Eight women, ages 29-38, with extensive symptomatic pelvic endometriosis were included in this series. All were diagnosed as having severe pelvic endometriosis and had not responded to previous conservative surgical and hormonal therapy. In a 5-18 month postoperative follow-up, six women have reported complete relief of the symptoms. Two have right lower quadrant pain and menstrual cramping. Second-look laparoscopy was offered to all patients and so far, two have accepted. these procedures were performed 6 weeks postoperatively. At that surgery, we found that the anastomotic site had healed completely with filmy adhesions between the posterior aspect of the uterus and the rectosigmoid colon in one patient. The second woman had undergone extensive adhesiolysis at the first surgery, and these adhesions recurred; however, the anastomotic site had healed completely. One of the two infertility patients has achieved pregnancy. The only complication was one patient with echymosis of the anterior abdominal wall. Sigmoidoscopy was performed 6 weeks postoperatively, and has been or will be performed at 6 months postoperatively. To date, all anastomotic sites have healed well wit no sign of stricture. Our results with this technique in a small series were positive, and it appears that, in the hands of experienced laparoscopists, it may prove useful in treating symptomatic infiltrative endometriosis.
Laparoscopic Amputation of a Noncommunicating Rudimentary Horn After a Hysteroscopic Diagnosis: A Case Study, Farr Nezhat, MD, Camran Nezhat, MD, Oleg Bess, MD, & Ceana H. Nezhat, MD; Surgical Laparoscopy & Endoscopy, Vol. 4, No. 2, p. 155-56
This report describes the diagnosis and management of a non-communicating rudimentary horn complicated by severe pelvic pain and associated endometriosis. this condition was diagnosed by simultaneous laparoscopic and hysteroscopic examinations. The hysteroscopic evaluation was significant in the diagnosis, as the noncommunicating horn was not recognized during a previous laparoscopy. the laparoscopic removal of the horn afforded complete long-term resolution of pain coupled with speedy postoperative recovery.
Four Ovarian Cancers Diagnosed During Laparoscopic Management of 1011 Women with Adnexal Masses, Farr Nezhat, MD, Camran Nezhat, MD, Charles E. Welander, MD, & Benedict Benigno, MD; Am J Obstet Gynecol, 1992;167:790-6
The study was conducted to assess the value of laparoscopic management of adnexa masses. Two concerns we wish to address are the failure to diagnose early ovarian cancer at laparoscopy and worsening the prognosis of stage I cancer by spilling fluid during surgery. All operations were performed in the outpatient surgical suite of a large suburban hospital. After extensive patient screenings, which included history and physical examination, preoperative serum CA-125 levels (since 1988), and pelvic ultrasonography, 1209 adnexal masses were managed laparoscopically. Of 1011 patients with surgical management, ovarian cancer was discovered intraoperatively in four. Our findings indicate that with consistent use of frozen sections of all cyst walls and suspicious tissue, laparoscopic management did not alter the prognosis. Neither CA-125 level, pelvic ultrasonography, nor peritoneal cytologic testing had sufficient diagnostic specificity to predict malignancy. Experienced surgeons using intraoperative histologic sampling may safely evaluate adnexal mass laparoscopically.
Fimbrioscopy and Salpingoscopy in Patients With Minimal to Moderate Pelvic Endometriosis, Farr Nezhat, MD, Wendy K. Winer, RN, BSN, & Camran Nezhat, MD; Obstet Gynecol 75:15, 1990
Fimbrioscopy and salpingoscopy were performed with a rigid salpingoscope during operative laparoscopy in 100 patients with minimal to moderate endometriosis and in 20 normal controls. Five women with endometriosis had perifimbrial adhesions, compared with none of the controls. No subject in either group had adhesion formation of the endosalpinx. These observations indicate that there is no association between endometriosis and intratubal disease.
Is Endoscopic Treatment of Endometriosis and Endometrioma Associated With Better Results Than Laparotomy, Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Farr Nezhat, MD; Am J Gynecologic Health Vol. II, No. 3
Endoscopic treatment of endometriosis and endometrioma employing two different techniques was achieved on 20 infertility patients using the laser laparoscope with video augmentation or videolaseroscopy. Results of each technique are discussed.
Endoscopic Infertility Surgery, Camran Nezhat, MD, Wendy K. Winer, RN, BSN, Jeffrey D. Cooper, MD, Farr Nezhat, MD, Ceana Nezhat, MD; J Reproductive Medicine, 0024-7758/89/3402-127
Since the introduction of endoscopy by Jacobaeus in 1910, there has been a dramatic change in the pattern of and approach to the diagnosis and treatment of various diseases of the female reproductive organs. The advances in techniques of operative endoscopy, in high technology and in instrumentation (such as endoscopes, video cameras and videomonitors) have made it possible to perform laparoscopically many of the infertility-related procedures previously requiring laparotomy. The advantages of such surgery are the rapid recovery time, decreased time lost from work, smaller scars, reduced cost, avoidance of risks and complications of laparotomy, and perhaps, better results.
Endometriosis of the Intestine and Genitourinary Tract, Camran Nezhat, MD, Farr Nezhat, MD, Ceana Nezhat, MD; Surgical Technology International 1994, Vol. 3, p. 343-974.
As with other organs, the etiology of bowel endometriosis is unknown. Its occurrence was reported as early as 1922 by Sampson. Following his investigation of nineteen cases, he proposed that "implantation adenoma of endometrial type of some portion of the intestinal tract may be present in at least one half of the cases of perforated ovarian hematoma of endometrial type with peritoneal implantations."
Complications and Results of 361 Hysterectomies Performed at Laparoscopy, Farr Nezhat, MD, Ceana H. Nezhat, MD, Dahlia Admon, MD, Stephen Gordon, MD, & Camran Nezhat, MD; J. Am. Coll. Surg., 1995, 180:307-16
Before the appropriate use of laparoscopy in hysterectomy can be determined, it is necessary to evaluate the results, including complications. There must also be an accepted classification system to facilitate accurate comparison to total abdominal hysterectomy. We retrospectively evaluated the charts of 361 women who underwent hysterectomy for various benign pathologic condition. Intraoperative and postoperative complication rates for hysterectomy performed at operative laparoscopy were examined. The hysterectomies were classified as one of four types according to the number of steps performed laparoscopically. All women were candidates for total abdominal hysterectomy, but not vaginal hysterectomy. The overall complication rate for hysterectomy performed at operative laparoscopy was 11.1%. Most complications were minor, including cystitis (1.66 %), transient high fever (1.39%), abdominal wall ecchymosis (1.12 %), and pneumonia and bronchitis (1.12 %). There was no correlation between the type of laparoscopic hysterectomy performed and the complication rate. Our rate of intraoperative and postoperative complications associated with laparoscopic hysterectomy compares favorably with published complication rates for vaginal and abdominal hysterectomy.
Comparison of Direct Insertion of Disposables and Standard Reusable Laparoscopic Trocars and Previous Pneumoperitoneum With Veress Needle, Farr R. Nezhat, MD, Sheryl L. Silfen, MD, Debra Evans, LPN, & Camran Nezhat, MD; Obstet Gynecol 78:148, 1991
A randomized prospective study was conducted to evaluate the ease of use and safety of direct insertion of laparoscopic trocars. comparison of previous pneumoperitoneum by Veress needle insertion with direct insertion of the reusable conventional laparoscopic trocar and direct insertion of the disposable shielded trocar revealed minor complication rates of 22, 6 and 0%, respectively. No major complications occurred in this series of 200 patients.