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.

Videolaparoscopy and Videolaseroscopy: Alternatives to Surgery? Caran Nezhat, MD, Wendy K. Winerer, RN, Farr Nezhat, MD, Ceana Nezhat, MD; The Female Patient, Vol 13, 9/88

According to the authors, it has become possible for the gynecologic surgeon to treat an increasing number of reproductive organ diseases with laser and operative laparoscopy. Now, with the addition of a videocamera and videomonitor to the laser laparoscope, the physician can offer some patients an alternative to laparotomy. The following is a detailed report of one center’s experience with this new technology.

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).

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.

Smoke From Laser Surgery: Is There a Health Hazard?, Camran Nezhat, MD, Wendy K. Winer, BSN, RN, Farr Nezhat, MD, Ceana Nezhat, MD, Deborah Forrest, MS, RN; Lasers in Surgery and Medicine, 7:376-382 (1987)

The composition of plume produced during carbon dioxide laser endoscopic treatment for endometriosis was examined to determine whether it represented a hazard to the surgical staff. A total of 32 plume samples were collected from 17 women undergoing laser laparoscopic treatment for endometriosis and/or adhesions. The smoke was found to consist of particles having a median aerodynamic diameter of 0.31 um with a range of 0.10-0.80 um. The size range has two consequences: 1) using a human red blood cell as a model for all cells, it can be stated with greater than 99.9999% certainty that no cell-size particles, including cancer cells, are present in the plume; 2) particles in this size range are too small to be effectively filtered by currently available surgical mass.

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.

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 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.

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.

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.

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.

A Comparison of the CO₂, Argon, and KTP/532 Lasers in the Videolaseroscopic Treatment of Endometriosis, Camran Nezhat, Wendy K. Winer, and Farr Nezhat; Colposcopy & Gynecologic Laser Surgery, Vol. 4, No. 1; 1988

Several surgical lasers are available currently for laparoscopic use, including the carbon dioxide (CO₂), argon, and potassium-titanyl-phosphate (KTP/532 nm) lasers. These lasers each have different properties that offer advantages and disadvantages in the treatment of endometriosis. In the present study, 120 patients with different stages of endometriosis were divided into three groups of 40 patients. Each group underwent videolaseroscopy using one of the three lasers listed above. All three lasers appear to be safe and effective for the laparoscopic treatment of endometriosis. There were no complications experienced, and satisfactory results were obtained in all three groups. This paper discusses and compares the properties of the CO₂ , argon, and KTP/532 lasers and the results in each of the three groups of patients. Although the number of patients is too small to make a definite conclusion, it appears that the results of argon and KTP/532 lasers are identical. The outcome for pain relief and fertility appears to be better with CO₂ lasers.

Adhesion Reformation After Reproductive Surgery by Videolaseroscopy, Camran Nezhat, MD, Farr R. Nezhat, MD, Deborah A. Metzger, PhD, MD, Anthony A. Luciano, MD; Fertil Steril 53:1008, 1990

After initial videolaseroscopy for the treatment of endometriosis-associated infertility, 157 patients underwent a second-look laparoscopy to evaluate and treat recurrence of disease and/or adhesions. The patients were divided into two groups. Group 1 consisted of 135 patients who underwent second-look laparoscopy for persistent infertility and/or recurrence of pain. Group 2 consisted of 22 patients who achieved a pregnancy after initial surgery and underwent second-look laparoscopy for evaluation of ectopic pregnancy or in association with uterine evacuation for first trimester spontaneous abortion. Both groups of patients demonstrated a significant reduction in adhesion scores involving the ovaries, tubes, posterior cul-de-sac, anterior cul-de-sac, and omentum/bowel. Although the initial mean adhesion scores were similar for both groups, at second-look laparoscopy the mean adhesion scores were significantly lower for group 2, particularly for ovarian and tubal adhesions. None of the patients formed de novo adhesions. From these results we may conclude that videolaseroscopy: (1) is effective in reducing peritoneal adhesions; (2) is associated with a low frequency of postoperative adhesion recurrence; and (3) appears to completely avoid de novo adhesion formation.

Videolaseroscopy and Laser Laparoscopy in Gynaecology, Camran Nezhat/Joyce Hood/Wendy Winer/Farr Nezhat, Fertility and Endocrinologoy Center, Atlanta, Georgia, Scott R. Crowgey, Georgia Institute of Technology, Atlanta, Georgia, Charles P. Garrison, West Paces Ferry Hospital, Atlanta, Georgia; British Journal of Hospital Medicine, 1987.

Laser laparoscopy has greatly expanded the potential applications of laparoscopy in gynaecology. Videolaseroscopy is a new refinement in the technique, which we believe is beneficial, not only to the patient, but also to the treating physician and the operating room staff. The clinical results of the beneficial application of this technique in the treatment of endometriosis and other diseases of the reproductive organs will be presented.

Videolaseroscopy: The CO₂ Laser for Advanced Operative Laparoscopy, Camran R. Nezhat, MD, FACOG, Farr R. Nezhat, MD, FACOG, and Sheryl L. Silfen, MD, FACOG Obstetrics and Gynecology Clinics of North America, Vol. 18, No. 3, 9/1991

Advanced operative laparoscopy offers an appealing alternative to laparotomy for benign gynecologic disease. By eliminating a large abdominal incision, a laparoscopic surgical procedure generally requires short-stay hospitalization of less than 24 hours and allows full recovery in less than a week. Patients prefer laparoscopy intuitively because it is less painful and cosmetically acceptable; furthermore, patients perceive surgery done by laparoscopy as less invasive physically and less intrusive in their lives. Surgeons can visualize deep pelvic structures more easily and produce less de novo adhesions than with laparotomy, preserving patients’ future fertility. Health care costs are reduced, and workers return to full productivity rapidly. Thus, in the hands of a skilled, experienced operative laparoscopist, advanced operative laparoscopy is universally preferable to laparotomy for appropriately selected cases.

The Risk of Carbon Monoxide Poisoning After Prolonged Laparoscopic Surgery, Camran Nezhat, MD, Daniel S. Seidman, MD, Hendrik J. Vreman, PhD, David K. Stevenson, MD, Farr Nezhat, MD, and Ceana Nezhat, MD; Obstetrics & Gynecology, Vol. 88, No.5, p. 771-4, November 1996

To evaluate whether thermal energy produced by laser and bipolar electrosurgery during laparoscopic procedures significantly elevates blood carboxyhemoglobin levels.

Initial Report of the Carbon Dioxide Laser Laparoscopy Study Group: Complications, Nezhat et al, J Gynecologic Surgery, 5:269, 1989

Operative laparoscopy using the CO₂ laser is becoming increasingly common in reproductive pelvic surgery. However, to date, characterization of the safety of this technique has been limited. However, to date, characterization of the safety of this technique has been limited. To assess this issue, the reports of the 821 women in the database of the Carbon Dioxide Laser laparoscopy Study Group were reviewed. Procedures performed at laparoscopy included vaporization of endometriosis, adhesiolysis, transection of the uterosacral ligaments, fimbrioplasty, salpingostomy for ectopic pregnancy, ovarian cystectomy, and neosalpingostomy. Ninety (11%) were hospitalized overnight, and 22 (2.6%) were hospitalized two or more nights. Operative complication were limited and consisted of 9 cases of intraabdominal bleeding, 3 women with uterine perforation, 1 with trocar injury to the uterus, and 1 with an omental hemotoma. None of these women required laparotomy. One patient underwent laparotomy to rule out small bowel injury, but none was noted. Postoperative complications reported consisted of 2 women with urinary retention and 1 each with postconization bleeding, periumbilical hematoma, acute infectious colitis, and allergic reaction to i.m. Depo Provera. Thus, operative or postoperative complications attributable to performance of operative CO2 laser laparoscopy per se were rare and without clinically significant morbidity or mortality. It is concluded that in experienced hands, CO2 laser laparoscopy can be safely used in the performance of reproductive pelvic surgery.

Videolaseroscopy Camran Nezhat, MD, Farr Nezhat, MD, and Ceana Nezhat, MD; Clinical Practice of Gynecology:2, 137-145, 1990

Since the introduction of endoscopy in 1910, there has been a dramatic change of pattern and approach to the diagnosis and treatment of various diseases of the reproductive organs. Recent advances in the techniques of operative endoscopy and high-technology instrumentation (such as endoscopes, videocameras, and videomonitors) have made it possible to perform endoscopically almost all of the infertiltiy and noninfertility related procedures that previously required laparotomy.

Videolaseroscopy for Endometriosis, Camran Nezhat, MD, Wendy K Winer, RN, BSN, Farr R. Nezhat, MD Ceana Nezhat, MD; Lasers in Endoscopy, Chapter 9

Operative laparoscopy is a cost effective and clinically efficacious technique in the treatment of endometriosis. The CO2 laser is useful in situations requiring precise application, safety, and minimal tissue damage. The fine beam provides precise control for vaporization or dissection of endometriosis through the laparoscope. The use of the CO2 laser through the laparoscope was first reported by Bruhat, Mage and Manhes in 1979 and later by Tadir. Incorporation of the videocamera and laparoscope in human and animal studies has been described and the advantages have been noted. Previously, due to the weight of the cameras, low resolution of both cameras and monitors and high cost, videocameras had not been widely used in gynecology.