Reproductive surgery is performed with the intention of reconstructing a functional anatomical approximation between the vagina, uterus, fallopian tubes, and ovaries while, at the same time, minimizing postoperative adhesion formation. Pioneers in the field of microsurgery, including Garcia, Mastroianni, Gomel, and Winston, have demonstrated independently that operating under magnification when reconstructing reproductive pathology is superior to conventional techniques in restoring functional anatomy as well as in limiting postoperative adhesion formation. However, microsurgical technique involves more than the use of magnification. Its concept requires gentle handling of tissue by the use of delicate microsurgical instruments, fine needles and suture, constant irrigation, and meticulous haemostasis. Although microsurgery was introduced as a method of improving the success of tubal surgery, the principles of this technique should be applied when operating to preserve any organ of the female reproductive tract.

Gynaecological microsurgery is a highly developed skill that demands a significant degree of neuromuscular hand–eye co-ordination. Skill may be obtained through an apprenticeship with a practising microsurgeon or, preferably, in the laboratories of established microsurgical training workshops. As is expected with a demanding technique, different surgeons will achieve various levels of competence at different rates. For example, it has demonstrated, using the rabbit oviduct as the training model, that more than 100 anastomoses had to be performed in the laboratory to reach an optimal degree of atraumatic, function-restoring surgery.

Operative laparoscopy has enabled the reproductive surgeon to perform many procedures on an outpatient basis (such as salpingostomy, adhesiolysis, and adnexectomy) that had previously only been done through a laparotomy incision. Although the cost advantage of outpatient surgery is appreciable, the use of the laparoscope should not pre-empt the ultimate goal of restoring functional anatomy, which in many cases, is still best accomplished through laparotomy using microsurgical technique. However the laparoscope does provide magnification and, in highly skilled hands, meticulous surgery may be performed with its help. In addition, many surgeons feel that postoperative adhesion formation is reduced when a procedure is performed through the laparoscope, as opposed to a laparotomy; nonetheless, there have been no controlled clinical trials to prove the point.

Magnification may be provided by a mounted operating microscope or by operating loupes worn with a head device by the surgeon. When choosing between the two magnification systems, several optical parameters, including the degree of magnification, focal length, depth of field, stereoscopic vision, field of view, and quality of lens must be considered. The operating microscope offers magnification from ×1 to ×20, while loupes provide magnification from ×2 to ×6. In most circumstances, magnification above ×6 is not necessary because the narrow field of view may decrease manual dexterity.

The basic set of microsurgical instruments includes jeweller's forceps, dissecting rods, iris and spring-handed scissors, microneedle carriers, and a microelectrode and/or bipolar cautery apparatus (Fig. 1) 1481. The microforceps should either have flat or ringed tips to be useful in tying knots and grasping tissue. In addition, toothed forceps are essential for grasping thick adhesions and fallopian-tube segments during a tubal anastomosis. An assortment of glass, plastic, titanium, and Teflon-coated rods is useful in elevating adhesions during their lysis and excision. The surgeon must be aware, however, that the glass, plastic, and Teflon rods may be damaged by a CO&sub2; laser beam. The sharp, pointed iris scissors perform precision cuts needed on the fallopian tube, and dull-pointed scissors (Struely scissors) are used during ovarian cystectomies. Serrated microscissors have the advantage of preventing tissue slippage when the blades are closed. A rounded-handle microneedle carrier is chosen for 8–0 and smaller sutures. A small plastic needle carrier suffices for 4–0 to 7–0 sutures. Use of the microneedle carrier with larger suture may damage the jaws of the instrument.

Both unipolar and bipolar cautery have properties allowing tissue destruction, haemostasis, and cutting. The advantage of the unipolar system is that its effect may be achieved by touching the electrode to the tissue surface. However, in this system the current wanders in an indirect path through the patient to the return plate and could lead to unwanted electrical burning. In contrast, the current in the bipolar system travels from the active electrode to the return electrode on the same bipolar forcep. The only tissue destroyed is that held within the grasp of the forcep, permitting greater precision and less unwanted tissue destruction. When using electrocautery, all surfaces should be irrigated with lactated Ringer's solution to reduce charring, heating of adjacent tissue, and subsequent adhesion formation.

Suture material for microsurgery should have minimal reactivity and good suture ‘memory’. The material may be composed of either absorbable polyglycolic acid, polyglactin, or polydioxanone, or of non-absorbable nylon, as there is no apparent difference in subsequent fertility rates. Seven–0 to 9–0 sutures are suggested for tubal surgery and 4–0 to 6–0 sutures for ovarian reconstruction. A 4-mm tapered needle with a cutting tip easily passes through tissue, with minimal resistance, and is therefore best for most microsurgical procedures.

Lasers have been used in microsurgery since 1974. The four basic lasers in reproductive surgery include CO&sub2;, the most common; argon; neodymium : yttrium aluminium garnet (Nd : YAG); and Nd : YAG passed through a potassium-titanyl-phosphate (KTP) crystal. The characteristics of each laser depends on the wavelength of the specific laser. For example, the CO&sub2; laser is absorbed by water; light from the KTP and argon laser is transmitted through water and is absorbed by haemoglobin. The Nd : YAG laser is absorbed by tissue proteins. The tissue reaction to the laser depends not only upon the power density of the laser and on the duration of exposure, but also on the water content and colour of the tissue.

The CO&sub2; laser, which has an invisible infrared wavelength of 10.6 &mgr;m and is coupled to a visible helium–neon beam for guidance, can ablate tissue or make precise incisions by vaporizing tissues of high water density at 100°C and fat at 200°C. The depth of tissue effect is limited to 0.1 mm, while the normal adjacent tissue beyond 500 &mgr;m is spared any thermal effect. The CO&sub2; beam is directed through the articulating arm of the laser by a series of mirrors and is then focused on the tissue to be vaporized. Waveguides have recently been introduced to deliver the CO&sub2; beam through the laparoscope in order to alleviate focusing difficulties and to allow the surgeon to defocus the CO&sub2; beam rapidly for improved haemostasis. The CO&sub2; laser has been employed successfully for lysis of adhesions, vaporization of endometriosis, excision of ectopic pregnancies, ablation of uterosacral ligament, oophorectomy, and performance of cuff salpingostomy. Some disadvantages of the CO&sub2; laser include production of vaporization plume which may limit the surgeon's visibility, poor coagulative properties for vessels larger than 1.0 mm diameter, and the development of oxidized char tissue, which may impede vaporization of underlying tissues.

The argon laser produces wavelengths in the blue–green portion of the spectrum, which are absorbed by pigmented molecules such as haemoglobin. Because the argon laser beam passes through clear peritoneal tissues, it becomes an excellent tool for vaporizing pigmented endometriotic lesions. Because of its shorter wavelength, the argon laser can be transmitted through a flexible quartz fibre. However, an aiming beam is necessary for accurate direction. Use of the argon laser in reproductive surgery was first reported in 5 women in 1983. In a follow-up study of over 90 women with endometriosis treated with the argon laser, 90 per cent reported significant relief of their pelvic pain and/or dyspareunia. The argon laser is able to ablate ovarian endometriomas, lyse pelvic adhesions, create neosalpingostomies for distal tubal occlusion, and remove ectopic gestations. Advantages of the argon laser include the versatility allowed by transmission through a flexible fibre, paucity of plume with vaporization, and excellent coagulative capabilities. The disadvantage of the argon laser is that it requires a water hook-up for cooling, and tinted filters to protect the eyes of those present in the operating room.

The Nd : YAG is a solid-state laser that uses a crystal seeded with neodymium ions to furnish the lasing medium. The beam, which is in the infrared portion of the light spectrum and requires a helium aiming beam for direction, can also be guided through a quartz flexible fibre. The Nd : YAG laser passes through fluid and is absorbed by all tissues to a depth of 3 to 5 mm, producing little plume. It has good haemostatic capabilities. The use of a sapphire tip not only limits the laser back-scatter but enhances the laser's excellent cutting properties through a touch technique. However, caution should be used when using the sapphire tip because of its high temperatures. CO&sub2; emboli have been reported when this gas is used to cool the tip during hysteroscopic surgery. The Nd : YAG laser has been used to perform vaporization of endometriosis, adhesiolysis, linear salpingostomy, uterosacral ligament transsection, hysteroscopic submucous myoma resection, endometrial ablation, and ovarian wedge resection for polycystic ovarian disease. A disadvantage of the Nd : YAG laser is its depth of penetration (up to 5 mm) and the lack of predictability in healing and necrosis as compared with the CO&sub2; laser.

The KTP crystal laser is generated by passing the Nd : YAG beam through a crystal that doubles the wave frequency and halves the wavelength to 532 nm. This beam, like the Nd : YAG and argon lasers, can be passed through a flexible fibre, and therefore it can be used through the laparoscope and hysteroscope. Unlike the Nd : YAG, however, the KTP laser has a bright green, clearly visible beam. This beam has coagulative properties similar to the Nd : YAG laser but with less back-scatter and more superficial penetration (0.3–1 mm).

The laser has become an integral tool in reproductive surgery. Each type of laser has unique advantages and disadvantages. Corson likened the surgeon and his or her various available lasers to the carpenter with more than one type of hammer in his or her tool box. The choice of laser to be used often depends on the laser available, the job which the laser is to perform, and the surgeon's level of skill with that particular laser. Because the laser has significant potential for damage, the surgeon should be educated in laser use by a hands-on laser course and should practise using his or her own equipment on surgical specimens prior to use in a patient. In addition, the hospital administration must develop criteria for certifying each surgeon who is given the privilege to perform laser surgery.

Postoperative adhesion formation resulting in suboptimal tubo-ovarian function remains a dilemma for the reproductive surgeon. Factors such as tissue ischaemia, tissue abrasion, tissue drying with whole blood contact, infection, and foreign-body exposure create peritoneal injury with a resulting inflammatory response. Subsequently, several lymphokines, monokines, and platelets are released from the inflammatory cells, resulting in the formation of a serosanguineous transudate that could enhance coagulation and create fibrinous attachments between peritoneal surfaces. In addition, the presence of free intraperitoneal blood not only provides a source of fibrin, but also enhances adhesion formation, with the release of thromboplastin and the activation of the clotting cascade.

Fibrinous adhesions are normally lysed within 72 to 96 h after development. This process is begun by tissue plasminogen activator, which cleaves plasminogen into the fibrinolytic enzyme plasmin. Following fibrinolysis, reformation of the mesothelium takes place through cellular metaplasia of the subperitoneal connective tissue cells. If inadequate fibrinolysis occurs, as seen with tissue ischaemia, the adhesions will be permanent. Other factors causing tension, crushing injuries, abrasions, free blood, and foreign bodies, such as reactive sutures, talc, and abdominal packs in contact with normal peritoneum may result in minimal adhesion formation. However, contact with injured peritoneum causes appreciable adhesions.

No ancillary modality can circumvent the importance of surgical technique in the prevention of adhesions. Microinstruments are used to prevent injury by crushing tissue. Peritoneal approximation, when performed, is best accomplished with small (6–0 to 8–0) sutures placed under minimal tension and minimizing ischaemia. Meticulous haemostasis is necessary to prevent contact of free blood with tissue. This objective may be accomplished with unipolar or bipolar cautery or fine sutures. Small blood vessels to be coagulated are seen more easily under magnification provided by the operating microscope or by loupes. Tissue abrasion can be avoided by use of atraumatic instruments and by the surgeon's awareness of serosal injury when placing moist or dry abdominal packs. Continuous intermittent irrigation with fluids such as lactated Ringer's solution supplemented with 5000 units/l heparin, is necessary to avoid tissue drying, to prevent blood accumulation in the peritoneum, and to dilute foreign-body contaminants.

Foreign-body exposure may be reduced by rinsing the surgeon's gloves to remove exposed talcum powder prior to surgery. In addition, the use of reactive sutures, such as chromic or silk, should be minimized or avoided. Tissue trauma is further limited by using small, atraumatic needles for suture placement.

Recently, reproductive-system surgeons have advocated a second-look procedure from 1 to 12 weeks postoperatively to lyse postoperative adhesions while they are still forming. Often this adhesiolysis can be performed adequately through the laparoscope, possible avoiding a major procedure at a later date. Long-term follow-up studies on the reformation of the filmy adhesions is currently in progress.

The approach to pharmacological adjuvant therapy in an effort to minimize postoperative adhesion formation has fallen into three categories;

(1)reduction of fibrinous exudate with anti-inflammatory agents;

(2)antihistamines and anticoagulants, removal of the fibrin matrix with fibrinolytic enzymes;

(3)the placement of barriers to prevent peritoneal to peritoneal contact during the reformation of mesothelium.

In addition, prophylactic broad-spectrum antibiotics (such as doxycycline, which covers common reproductive pathogens such as Chlamydia) are widely employed to reduce postoperative infection, which may lead to adhesion formation.

Corticosteroids, which reduce capillary permeability, decrease the release of fibrinous exudates, and stabilize lysosymal membranes, have been used for adhesion prophylaxis since the 1950s. The large doses of corticosteroids necessary to produce adequate tissue levels provoke adverse consequences, including increased risk of infection, prolonged healing time, exacerbation of gastrointestinal disorders, and masking of intra-abdominal complications. Although these reactions occur rarely, psychiatric depression following the completion of the therapeutic course is common. Prophylactic antibiotics are often given concurrently. As with most adhesive-prevention adjuvants, there has been no randomized prospective controlled study demonstrating greater clinical effectiveness of corticosteroids over placebo therapy.

Non-steroidal anti-inflammatory agents reduce inflammation, not only by inhibiting enzymes responsible for the formation of the inflammatory agents such as prostaglandins and leukotrienes but also by reversing vascular occlusion. In animal studies, several agents, such as ibuprofen, oxyphenbutazone, flurbiprofen, and tolmetin, were found to reduce the risk of postsurgical adhesion formation following intramuscular or intraperitoneal administration. Clinical effectiveness, as determined by randomized controlled human trials, remains to be demonstrated.

The antihistamine, promethazine, may decrease the fibrinous exudate normally formed by histamine's action on capillary permeability. It also inhibits fibroblast proliferation. Frequently, 25 mg of promethazine is given in conjunction with 20 mg of dexamethasone intramuscularly 2 to 3 h prior to surgery, intraperitoneally during surgery, and every 4 h after surgery for 48 h. In spite of the wide use of promethazine for adhesion prophylaxis, its effectiveness in limiting the formation of adhesions has not been properly clinically tested.

In principle treatment with exogenous fibrinolysins, either urokinase-related or related to tissue plasminogen activator, might benefit postsurgical adhesion prophylaxis. Studies in dogs demonstrated a reduction in adhesion formation using intravenous and intraperitoneal human fibrinolysin. Similar effective adhesion reduction was noted in animal studies using ancrod (a defibrogenating enzyme from pit-viper venom), urokinase, and recombinant tissue plasminogen activator. Utilizing second-look laparoscopy, reduced adhesion formation was noted in 16 of 20 uncontrolled patients given intraperitoneal aprotinin (a proteinase inhibitor) before closure of the initial incision. In a controlled trial, fewer postoperative small-bowel obstructions were reported in children receiving aprotinin following repair of a ruptured appendix than in controls. Neither of these investigations reported the side-effects, such as haemorrhage or disruption in normal wound healing, that are often a concern with other therapeutic applications of these agents.

The most common currently used agent for prophylaxis of adhesions is 32 per cent dextran–molecular weight 70 000 (Hyskon). The fluid is absorbed slowly in the peritoneal cavity, creating a mechanical separation of fibrin-covered surfaces. In addition, dextran 70 acts both as a local anticoagulant and, more critically, as an osmotic agent that draws body fluids into the peritoneal cavity, creating a floating effect. This effect keeps tissues from sticking together until the fluid is absorbed during the next week. Data from animals have convincingly demonstrated the effectiveness of Hyskon, but clinical studies administering 250 ml intraperitoneally have not been so promising. The Adhesion Study Group demonstrated significant adhesion reduction in Hyskon-treated patients compared with control patients receiving crystalloid alone. However, other groups have been unable to demonstrate effective adhesion prophylaxis using intraperitoneal dextran 70. The use of Hyskon is not without significant risks such as allergic reactions, fever, hypokalaemia, ileus, pulmonary distress, and wound separation, but fortunately these are rare. Anaphylactic reactions may be reduced by the administration of 20 ml dextran 1 (15 per cent) (Promiten® ; Pharmacia) intravenously 2 min before the use of Hyskon.

Sodium carboxymethylcellulose is a highly viscous solution more slowly absorbed, less antigenic, and less likely to support bacterial growth than Hyskon. Animal studies have suggested that carboxymethylcellulose is more effective in adhesion prevention than Hyskon but human data supporting these conclusions are not yet available.

Although barriers prevent the apposition of an injured surface to other tissues, several barriers, such as saline, oils, Gelfoam® , and Surgicel® (TC7) (Johnson and Johnson), a newly developed fabric composed of regenerated oxidized cellulose, is specifically designed to cover surgically traumatized tissue (Fig. 2) 1482. A prospective multicentre study in which 59 infertility patients undergoing bilateral adhesiolysis had Interceed® placed on one randomly assigned side-wall. Second-look laparoscopy performed on each patient 6 months after laparotomy demonstrated a 57 per cent reduction of postsurgical adhesion formation on the treated side-wall compared with the side-wall where only microsurgical techniques were employed. No adverse effect was reported.

In summary, the key to adhesion prevention remains the use of appropriate surgical techniques. The use of pharmacological adjuvants continues to be popular with reproductive surgeons in spite of controversial and inadequate randomized controlled data on their clinical effectiveness. The current prophylactic regimens will no doubt be modified as new agents and new data become available.

Uterine anomalies occur in 0.1 per to 2 per cent of all women, in 4 per cent of women with infertility, and in 15 per cent of women with recurrent abortion. Almost all of the affected women are of 46, XX karyotype. The müllerian ducts arise from an infolding of the coelomic epithelium of the urogenital ridge during the seventh week of fetal life. The ducts grow caudally and medially and joint the urogenital sinus in the eight week to form the müllerian tubercle. Fusion of the ducts then progresses cephalad and the septum between the ducts resorbs, thereby forming the uterus, fallopian tubes, cervix, and upper third of the vagina. The lower two-thirds of vaginal epithelium is derived from the ectoderm of the urogenital sinus; canalization of the entire vagina is normally completed by the twenty-second week of gestation.

The American Fertility Society classification of müllerian anomalies has recently been updated to include seven classes (Fig. 3) 1483. Malformations categorized as class I result from müllerian duct hypoplasia or agenesis. These patients normally present with amenorrhoea or cryptomenorrhoea, which may be due to vaginal outflow tract obstruction from a transverse vaginal membrane located in the lower third of the vagina or to varying degrees of vaginal agenesis. Vaginal agenesis is usually accompanied by an absent cervix and uterus, but with normal ovarian function. Five to 10 per cent of women with vaginal atresia have a functioning endometrium. These women may present with a pelvic mass due to a haematocolpos or haematometra or with endometriosis due to retrograde menstruation. The rate of concurrent urinary tract anomalies is high with class I müllerian duct malformations.

Vaginal agenesis can either be treated with the McIndoe procedure, in which a split-thickness skin graft over a vaginal mould is sewn in place within the newly dissected vaginal space or by our procedure of choice, in which the Frank or Ingram technique non-surgically dilates the vagina. Pregnancies have been reported by correction of vaginal agenesis in the presence of a functioning uterus and cervix. Congenital absence of the cervix in a patient with a functioning endometrium is rare, but a fistulous communication may be created, allowing for menstrual flow. Following the use of this approach, intrauterine pregnancy was reported in 1976, though it has been difficult to reproduce this result. The rate of repeat obstruction is high; because of this, hysterectomy is an appropriate therapy.

Class II malformations, the unicornuate uteri, are due to developmental arrest of one duct and are associated with many urinary tract anomalies similar to those of class I. Class II malformations result in a reduced uterine volume; they are therefore associated with premature deliveries and fetal malpresentations. In addition, cervical incompetence may be a feature. If a non-communicating rudimentary horn is present, the patient is at risk for menstrual regurgitation and pregnancy, or both, in the rudimentary horn, leading to uterine rupture. In this case, the rudimentary horn should be excised. The fallopian tube from the rudimentary horn may be conserved and reimplanted into the unicornuate uterus.

Class III malformations, the didelphus uteri, occur because of complete lack of müllerian duct fusion and result in two symmetrical uterine horns, two cervices, and often a longitudinal vaginal septum to the upper two-thirds of the vagina. Urinary-tract malformations, fetal malpresentation, and premature labour are features. Because the fetal survival rate is greater than 50 per cent, surgery is not indicated initially. Prior to any surgical correction performed to correct recurrent pregnancy loss, a thorough assessment should be completed which includes the evaluation of the patient's luteal phase, endocrine milieu, karyotype, and immunological status. If this evaluation is negative, the patients selected for surgical correction should anticipate an improvement of between 75 and 80 per cent in conceiving and delivering a living child.

The Stassman metroplasty, which unifies the bicornuate or didelphus uterus, begins with an incision through the uterine serosa from cornu to cornu and extends through the myometrium until both cavities are entered. The myometrium and mucosa are then closed in two to three layers using interrupted 2–0 polyglycolic suture, starting in the lower uterine segment anteriorly and posteriorly and ending at the uterine fundus, i.e. the uterus is opened horizontally and closed vertically. The serosa is then imbricated with a running baseball stitch, using a similar 4–0 or 5–0 suture.

A class IV müllerian anomaly is a bicornuate uterus with the two uterine horns partially fused with a single cervix. The uterus has an abnormal external appearance. These anomalies are associated with a 20 per cent incidence of premature labour and/or fetal malpresentation, as well as an increased rate of second trimester miscarriage. The Stassman metroplasty is the procedure of choice and a caesarean section is recommended for any subsequent deliveries.

Class V anomalies, the septate uterus which, as opposed to the class IV anomalies, consists of a uterus with a normal external configuration but with incomplete cavitary fusion. The septate uterus occurs more often than a didelphus or bicornuate uterus. In a series by Buttram, 46 of 47 metroplasties were performed for a septate uterus in fetal wastage. Surgical techniques for the correction of a septate uterus include the Tompkins metroplasty using a median bivalve incision, a Jones wedge technique or, more recently, septum resection via the hysteroscope. The choice of operation will depend on the type of uterine anomaly and the width of the uterine septum. The advantages of hysteroscopic resection over a laparotomy incision include a shorter stay in hospital, shorter recovery period, and a potential vaginal delivery route; however, it is necessary for a second surgeon simultaneously to visualize the outside of the uterus by a laparoscope to minimize the risk of uterine perforation. When the septum is cut using scissors, laser, or a resectoscope, the tissue within the septum retracts, leaving a normal-appearing cavity. The use of adjuvants such as intrauterine devices, antibiotics, or hormonal therapy to prevent intrauterine scarring following septum resection is often performed, but has not been studied adequately in randomized clinical trials. If a preoperative recurrent abortion evaluation is negative, the patients properly selected for surgical correction should anticipate an improvement of between 75 and 80 per cent in conceiving and delivering a child.

The arcuate uterus is a class VI anomaly and is a mild form of an asymptomatic septate uterus; it requires no therapy. Diagnosis is best made by hysterosalpingography.

Class VII müllerian anomalies due to in utero diethylstiboestrol exposure are the most common anomalies seen today. The changes include a T-shaped cavity with cornual bands and pretubal bulges, cervical dilation, small uterine cavities with irregular borders,and foreshortened convoluted tubes with constricted fimbriae. The obstetrical outcome in these patients includes a 30 per cent of risk of spontaneous abortion or ectopic pregnancy, a tripled prematurity rate, and an increased rate of cervical incompetence, leading to second trimester abortions. In addition, the infertility rate in these women may be greater if constrictive cornual bands or a T-shaped uterus are present. In general, surgical approaches to correct these anomalies have been unsuccessful. It appears that ‘DES daughters’ are more likely to have increased miscarriages, ectopic gestations, and premature labour but, in general, they can usually have a successful intrauterine pregnancy.

Uterine myomata are benign smooth muscle tumours, which are thought to arise from a single cell. Sarcomatous changes occur in 0.1 per cent of enucleated tumours and are most often found in rapidly growing tumours during the adolescent and postmenopausal periods. Because uterine myomata are oestrogen sensitive, they are found most commonly in women of reproductive age. They are more common in Negroid than in Caucasian women and occur least often in Asian women.

One-half of all uterine myomata are asymtomatic; because of their benign nature, they require no surgical therapy. Interventional therapy is indicated because of hypermenorrhoea, dysmenorrhoea, pelvic pain and extrinsic pressure on pelvic viscera, hydronephrosis, constipation, urinary frequency, infertility, recurrent fetal wastage, rapid growth of the myomata, and a uterine distortion preventing an adequate ovarian evaluation by bimanual examination. Any patient presenting with complaints attributable to these tumours should undergo a thorough evaluation to rule out other causes of these symptoms before treatment of the myomata is undertaken.

Heavy uterine bleeding is the most common complaint and is thought to be due to uterine vascular congestion and compression resulting from the presence of the tumour, especially in a submucous site. The heavy bleeding, pelvic pain from pressure, rapid-growth dyspareunia, dysmenorrhoea, and bladder and bowel symptoms may often necessitate myomata removal for satisfactory relief. Women who have recurrent spontaneous abortions and in whom a complete evaluation for this has determined the presence of submucous fibroid will benefit from hysteroscopic submuscous myomata resection if all other factors that may contribute to this condition are ruled out. In contrast, it is not clear what influence uterine myomata have on patients with unexplained infertility and in whom a uterine myoma is the only abnormality. Rosenfeld reported a 65 per cent pregnancy rate in patients who had undergone abdominal myomectomy with otherwise unexplained infertility.

Uterine myomata may be subserosal, intramural, or submucosal. Subserosal and pedunculated myomata may be treated with laparoscopic surgery if adequate haemostasis at the base of the myoma can be accomplished using the CO&sub2;, KTP, or argon laser, or electrosurgery. Often the removal of the myoma through the laparoscope is as time consuming as resecting the myoma via laparotomy. Closure of the uterine serosa is optional and may be performed through the laparoscope using 4–0 or 5–0 polydioxanone or polyglycolic suture. Similarly, submucosal fibroids on thin stalks can be removed through the hysteroscope under laparoscopic guidance. The myomata can be resected using a resectoscope, KTP or Nd : YAG laser, or scissors with electrosurgery. If haemostasis is a problem, a 5 ml intrauterine balloon can be placed intraoperatively and removed 4 to 6 h after the procedure.

Intramural myomata are best treated by transabdominal myomectomy. The most common complication of this procedure is intraoperative haemorrhage and therefore adequate haemostasis is paramount. Each patient undergoing uterine myomectomy should give consent preoperatively for a total hysterectomy in the event of the very rare appearance of uncontrolled uterine bleeding. In addition, preoperative storage of blood for possible autotransfusion is recommended. It has been suggested that, in order to reduce intraoperative blood loss, preoperative treatment should be performed with an agent creating a hypo-oestrogenic environment, causing shrinkage of myomata and reducing uterine vascularization. Friedman et al. have demonstrated this phenomenon using a gonadotropin-releasing hormone agonist preoperatively for 3 months. Preoperative use of these agents, however, may shrink, small myomata so that they become non-palpable during surgery but then regrow with the discontinuation of the hypo-oestrogenic stage. More data are required before this therapy can become routine. Intraoperative haemostasis may be obtained by intramural injection of dilute vasopressin, use of a vascular tourniquet around the ovarian and uterine vessels, or careful dissection with individual vessel ligation or desiccation.

Ideally, all the uterine myomata should be removed through one anterior serosal incision to minimize the risk of postoperative adhesion formation. For posterior wall myomata, a transendometrial cavity approach is preferred. The incision should be made with a cold knife to minimize serosal damage and then carried through to the pseudocapsule of the myoma. The myoma is then grasped and placed on traction using a towel clip, which will allow for improved haemostasis and recognition of the plane of dissection (Fig. 4) 1484. The myoma can be dissected from its surrounding normal myometrium using a periosteal elevator to assist in blunt dissection and Metzenbaum or Struely scissors to lyse adhesive bands. The myometrial defect should be closed using a 3–0 polyglycolic suture in a concentric, spiralling purse-string fashion from the base of the defect continuing toward the serosa. The key to closing the myometrial defect is in obliterating all potential dead space in order to decrease the risk of postoperative bleeding and infection. The serosa should be approximated with a 5–0 non-reactive suture using subserosal imbricating stitch that does not create tissue necrosis.

Approximately 60 per cent of women who have received a myomectomy for infertility are able to conceive. Most women suffering with hypermenorrhoea and dysmenorrhoea achieve significant improvement. Women in whom the uterine cavity is entered at the time of transabdominal myomectomy should undergo a caesarean section for their subsequent deliveries to lessen the chance of uterine rupture during labour. Although uterine myomata can be excised successfully, the ability to prevent the formation of new myomata does not exist. There is a 20 per cent recurrence rate of symptomatic myoma within 5 years after myomectomy. Inasmuch as hysterectomy eliminates the risk of recurrence, it is therefore a reasonable alternative for women with symptomatic myomata who have completed childbearing.

Today, infertile women with a tubal disorder have the option of undergoing major surgery or in-vitro fertilization–embryo transfer which currently has a 15 to 20 per cent success rate per cycle. Patients with suspected tubal disease should therefore undergo a thorough evaluation, including a diagnostic laparoscopy, so that realistic estimates on the prognosis of surgical repair can be conveyed and can be compared with current success rates of in-vitro fertilization–embryo transfer. Procedures commonly performed on the fallopian tube to enhance fertility include adhesiolysis, repair of distal and proximal occlusion, and tubal reanastomosis.

Often adhesions around the tube can be lysed through the laparoscope using a three-puncture technique. A wand is placed through the second suprapubic puncture site to place the adhesions on tension while they are then cut in their most avascular plane with either the laser, cautery, or microscissors introduced through the third site. At the conclusion of the procedure the pelvis should be lavaged extensively with a dilute heparinized solution to remove blood clots and debris. Adhesiolysis through a laparotomy incision with microsurgical technique may be required for patients with severe adhesive disease or in whom prior laparoscopic attempts were unsuccessful.

The prognosis for achieving an intrauterine pregnancy after correcting fimbrial occlusion is directly related to the amount of remaining healthy tissue. Tubes that are completely obstructed and that display distal tubal dilation offer the poorest prognosis, as opposed to fimbria, which display protruding tufts that can be uncovered with surgical dissection. When repairing distal occlusion, often a dimple can be found at the distal fimbria, serving as a landmark for the tubal ostium. The tube can be entered at this point with a small curved clamp, which is then spread; tissue planes are bluntly dissected as the clamp is gently withdrawn. To evert the endosalpinx, a small skin hook is placed approximately 1 cm into the lumen, and the tubal wall is pulled upward. The fimbria are secured with several interrupted 6–0 or 7–0 polyglycolic sutures placed through the tubal serosa, the everted ends of the tube near the edge, and back through the tubal serosa, thereby burying the knot between serosal surfaces. Success is related to the state of the fimbria as well as to whether the ovaries are free of adhesions. If pregnancy does not ensue 6 months to 1 year following this surgery, a diagnostic laparoscopy should be performed to evaluate the anatomical status and patency of the tubes. Adhesions may be lysed at this time, but if occlusion and dilation were to recur, in-vitro fertilization–embryo transfer would be the next appropriate step.

Proximal tubal occlusion is present in 10 to 40 per cent of women with infertility secondary to tubal disease. This diagnosis is made only after multiple attempts to demonstrate patency by hysterosalpingography or chromopertubation during laparoscopy. Either test alone is associated with a 40 per cent false-positive occlusion rate, probably secondary to tubal spasm. Traditionally, proximal tubal occlusion has been treated by microsurgically excising the occluded proximal segment and either reimplanting the distal tube in the posterior uterine wall using a borer technique, or by a Winston reanastomosis, in which the healthy intramural portion of the fallopian tube is identified and is reanastomosed to healthy-appearing endosalpinx. Proximal tubal occlusion can be recanalized with hysteroscopic or fluoroscopic guidance, using either a balloon catheter or a Teflon-coated guidewire. The success rates for achieving tubal patency using these less invasive techniques (approximately 80–90 per cent) have compared favourably with laparotomy, with the obvious advantage of significantly reducing the morbidity.

Tubal reanastomosis following a sterilization procedure is not uncommonly desired. Because of the availability of in-vitro fertilization–embryo transfer prior evaluation with laparoscopy is recommended. The prognosis of a tubal reanastomosis depends on:

(1)the type of sterilization that was done (e.g. unipolar electrocautery is worst; a clip is best);

(2)the combined tubal length following the procedure;

(3)the segment of tube that is to be reapproximated.

Reapproximation of tubal segments of the same diameter offers a better outcome than that of segments requiring surgical modification in order to achieve proper approximation. Success rates of at least 70 per cent are expected with an isthmic to isthmic reanastomosis in which the combined length is greater than 6 cm, with few pregnancies achieved when the combined length is less than 3 cm. Technically, the reanastomosis procedure is straightforward; it should always be carried out under magnification. The scarred segments of the tube are resected and the muscularis is reapproximated with 7–0 or 8–0 polyglycolic interrupted sutures at 12 o'clock, 6 o'clock, 9 o'clock, and 3 o'clock. It is advisable to bring the portions of the tube together over a nylon stent (Fig. 5) 1485. The serosa should then be reapproximated with a 6–0 polyglycolic suture in either an interrupted or running fashion. Patency of the tube can be evaluated by placing a Buxton or Seegler–Helman clamp around the cervix and injecting indigo carmine dye into the uterine fundus. The site of reanastomosis need not be watertight to permit subsequent intrauterine pregnancies.

Young women undergoing adnexal surgery for benign disease are at increased risk of impaired fertility. In a comparison of macrosurgical and microsurgical technique in performing ovarian wedge resections in the monkey, there was a significant reduction in postoperative adhesion formation when microsurgery was used. In the rabbit model, through-and-through haemostatic mattress sutures were associated with vascular compression and increased tissue ischaemia. Therefore, microsurgical technique should be used for ovarian surgery due to benign disease, to minimize formation of adhesion and to preserve ovarian function.

When performing ovarian reconstruction the reproductive surgeon should attempt to preserve two important structures. The first is the specialized peritoneal layer of epithelium covering the condensed stroma of the ovarian cortex (measuring approximately 35 &mgr;m), which contains the primordial follicles. Removal of as little of the ovarian cortex as is possible is paramount, especially in view of the availability of oocyte retrieval and in-vitro fertilization–embryo transfer. Secondly the fimbriaovarica (which extends from the tubal fimbria to the ovary) should not be disrupted because it contains skeletal muscle that aids the fimbria in the capture of oocytes.

The three common procedures involving the ovaries are ovarian cystectomy, ovariolysis, and ovarian biopsies. When simple cysts, endometriomata, or benign cystic teratomas are to be removed, the visceral peritoneum is incised to the level of the cystic capsule. The cyst is dissected free from the ovarian stroma using both sharp and blunt dissection. Where the cyst is densely adherent to the ovarian cortex, as is often the case with ovarian endometriomata, the involved cortex can be removed with the intact cyst wall. Compression of the ovarian hilus between the index and middle finger permits stabilization of the ovary and haemostasis while removing the ovarian cyst. Once the cyst is removed, the bleeding is controlled by 3–0 polyglactin sutures placed at the base of the ovarian defect. The defect is closed with a 3–0 polyglactin suture in a circumferential purse-string suture similar to the one used for closure of uterine myomata described above, allowing restoration of the normal contour of the ovary. The surface of the ovary is closed by a 4–0 polyglactin baseball stitch in which the sutures are placed close together with minimal tension so as not to create tissue ischaemia, or left open for healing by secondary intention.

Lyses of adhesions from the ovarian surface may be accomplished by sharp scissors, laser energy, or the cutting current of electrosurgery. Electrosurgery will vaporize the adhesive tissue and at the same time maintain haemostasis. If the ovarian cortex is not severely denuded, reperitonealization is not recommended.

Ovarian biopsies are commonly performed to diagnose the aetiology of premature ovarian failure or to obtain tissue from a grossly suspicious lesion for histological diagnosis. Often this can be performed through the laparoscope and, if adequate haemostasis is accomplished, the defect does not have to be closed. If a large section needs to be removed, as is necessary for an ovarian wedge resection, the ovary should be closed in two layers. The stroma should be reapproximated with 3–0 polyglactin and the cortex closed with a baseball 4–0 polyglactin suture, using the same technique described for repair following ovarian cystectomy.

Endometriosis (the presence of endometrial glands, stroma, and haemorrhage outside the uterine cavity) is present in 5 to 15 per cent of premenopausal women and in up to 50 per cent of women with infertility. The aetiology of endometriosis is unknown. The two most accepted proposals are Sampson's theory of retrograde menstruation and consequent coelomic metaplasia resulting from repeated inflammation. There are no pathognomonic symptoms of endometriosis, and the severity of the symptoms does not correlate with the extent of disease. Severe dysmenorrhoea, deep dyspareunia, and perimenstrual backache occur in 12 to 65 per cent of women with endometriosis, and most patients have at least one of these symptoms. The inheritance of endometriosis is probably polygenic-multifactorial. First-degree relatives not only have a sevenfold increased risk of developing the disease, but have a higher rate of recurrence and are twice as likely to have severe disease. The pathophysiology of endometriosis causing symptoms in infertility, is likely to be due to the numerous proteins secreted by the endometriotic tissue. For example, endometriotic glandular epithelium produces and secretes complement component 3 (C3), a chemotactic factor and cell activator for most of the inflammatory cells found elevated in the peritoneal fluid of patients with endometriosis. In addition, C3 can induce the production of prostaglandins, which are secreted by endometriotic tissue and may play a direct role in the pain associated with the disease.

Although many symptoms may be suggestive of the disease, endometriosis can be diagnosed only through direct visualization, for example laparoscopy. The most common sites of endometriosis are the ovaries and the cul de sac, followed by the serosa of the uterus, rectosigmoid, and the bladder. Typically, the lesions appear as black ‘powderburn’ spots, but atypical biopsy-proven endometriotic implants have been described which appear as clear, red, light-brown, or white lesions. When diagnosed, the extent of endometriosis should be documented using the American Fertility Society's classification so that comparisons of therapies can be made from institution to institution.

Minimal, mild, and moderate endometriosis may be properly treated medically or surgically, or by using a combination of both therapies. The goal of medical therapy is to create a hypooestrogenic, non-cyclic environment to promote the atrophy of endometriotic tissue. This goal has been accomplished with continuous, oral contraceptives, progestins, testosterone, danazol, and most recently, gonadotropin-releasing hormone agonist. The aim of surgical therapy for endometriosis is the removal of disease and restoration of normal anatomy. Often with minimal to mild disease the removal of endometriotic tissue can be accomplished through the laparoscope via electrocoagulation, laser vaporization, or excision. Ovarian endometrioma smaller than 2 cm in diameter may be vaporized, but larger endometrioma should be excised because of their high rate of recurrence.

Conservative surgery by laparotomy is indicated in the presence of adnexal masses, severe endometriosis associated with infertility, symptoms refractory to no therapy or medical therapy, and concomitant conditions such as leiomyomas or müllerian fusion defects. The endometriotic lesions should be fulgurated or excised; excision is preferable in areas near the ureter, bladder, or bowel. When unilateral ovarian involvement is extensive and the opposite ovary is grossly normal, removal of the affected ovary gives a better subsequent pregnancy rate than reconstruction of the affected ovary.

A presacral neurectomy may alleviate associated dyspareunia in up to 80 per cent of patients with endometriosis, but this is still controversial. If there is large-bowel obstruction or involvement of the mucosa, primary resection may be indicated after proper bowel preparation. In addition, the appendix should be inspected and removed if evidence of endometriosis is present. Conservative surgery is associated with a 40 to 75 per cent conception rate, depending on the severity of the disease. The majority of patients who conceive will do so within the first 18 months postoperatively, but conception can occur as late as 5 years later. This timetable is different from that of pelvic inflammatory disease, in which pregnancy 2 years after surgery is unlikely. Endometriosis rarely effects the tubal mucosa. The rate of recurrence following conservative surgical therapy is 14 per cent at 3 years and 40 per cent at 5 years.

Abdominal hysterectomy is the treatment of choice for women with severe disease in whom future childbearing is not desired. The ovaries may be conserved if they are free of disease; nonetheless, as many as 20 per cent of these women eventually require surgical removal of the ovaries. If the ovaries are removed, the patients may be started immediately on oestrogen replacement therapy, provided that significant residual disease is not left behind. Progestins should be added to the therapy to prevent the development of endometrioid carcinoma within residual tissue due to the administration of unopposed oestrogen. When significant disease remains, withholding oestrogen replacement therapy for 6 months may induce atrophy of the endometriotic lesions, and continuous oral contraceptives or progestogens maybe given to alleviate vasomotor flushes. When oestrogen replacement therapy is given, the recurrence rate of 1 to 3 per cent is the same as when oestrogen is withheld.

Ectopic gestation occurs in 1 in 80 pregnancies. Despite the early diagnosis due to the introduction of sensitive assays for serum &bgr;-human chorionic gonadotropin (&bgr;-hCG) detection, and vaginal probe ultrasound, ectopic pregnancy remains the primary cause of maternal mortality in the United States. Many of these deaths result from the lack of clinical suspicion or adequate follow-up of patients of reproductive age with a chief complaint of abnormal bleeding or pain, or both. A methodical evaluation, consisting of serial &bgr;-hCGs and vaginal probe, of all recently diagnosed pregnant patients should distinguish one with a normal intrauterine pregnancy from a patient with an ectopic gestation, even prior to the development of symptoms. Furthermore, early diagnosis allows for management in a controlled setting, which provides a greater opportunity for fertility preservation.

When a pregnant patient with an acute abdomen and haemodynamic instability presents to an emergency room, she should be fluid resuscitated, cross-matched for blood, and transported to the operating room for an exploratory laparotomy. If, however, a pregnant patient is seen who is either asymptomatic or complains of slight vaginal bleeding, expectant management may be considered (Fig. 6) 1486. With the use of vaginal probe ultrasound, an intrauterine sac should be visualized when the level of serum &bgr;-hCG reaches 1500 to 2000 mIU/ml (first international reference preparation). This finding usually occurs within 1 week of a missed menstrual period. In addition, serial quantitative serum &bgr;-hCGs should be obtained in all patients at risk for an ectopic pregnancy, for it is well documented that this level should rise in a normal pregnancy by 66 to 100 per cent every 48 h during the first 8 weeks of gestation. If a vaginal probe ultrasound is performed but no intrauterine pregnancy is seen and the serum &bgr;-hCG is above 1500–2000 mIU/ml, appropriate operative management should be performed. If, on the other hand, no intrauterine pregnancy is seen and the serum &bgr;-hCG is less than 1500 mIU/ml, the &bgr;-hCG should be followed every 48 h until it reaches this discriminatory level—as long as it is rising appropriately. If the &bgr;-hCG titres level or rise inappropriately, operative management is warranted. If the levels fall, an impending miscarriage may be occurring, but the event still does not rule out the possibility of an ectopic pregnancy.

Several reports have been published on the medical use of methotrexate, but surgical management remains the current standard of practice. If a ruptured ectopic pregnancy is present, a unilateral salpingectomy should be performed. Salpingectomy may be accomplished through the laparoscope. If, however, active bleeding is present, laparotomy is necessary. If the tube is not ruptured and the ectopic gestation is located in the ampulla, a linear salpingostomy with removal of the products of gestation is indicated. In this situation, the tube may be left open to heal by secondary intention once adequate haemostasis is accomplished. Ectopic pregnancies located in the isthmic portion of the tube are best treated with segmental resection and tubal reanastomosis only if the patient is haemodynamically stable. If the patient is at risk, reanastomosis is done at a later date. Whether these procedures are performed via laparoscopy or laparotomy, microsurgical technique should be utilized.

When conservation therapy is used, as many as 15 per cent of patients have persistent trophoblastic tissue requiring further therapy. Appropriate follow-up examinations should therefore include serial quantitative &bgr;-hCGs once or twice a week until the titre is 5 mIU/ml or less. If the follow-up values level off or rise, medical treatment with methotrexate should be considered, or salpingectomy may be indicated.

With the advent of new assisted reproductive technologies such as in in-vitro fertilization–embryo transfer, gamete intrafallopian tube transfer, zygote intrafallopian tube transfer etc., patients and reproductive surgeons are constantly faced with the decision as to whether to attempt anatomical restoration by surgical means or whether to bypass the diseased organs in order to achieve an intrauterine pregnancy. Restoration of normal anatomy offers the monthly possibility that a pregnancy would be established and therefore often is the procedure chosen when the prognosis for establishing a pregnancy is significantly greater than the 18 per cent fecundity rate currently associated with in-vitro fertilization–embryo transfer. In addition, many reproductive surgical procedures that have traditionally been performed through a laparotomy can now be successfully done through the laparoscope. However, the surgeon must judge what he or she attempts to correct through the laparoscope based on his or her skill and expertise, as well as the prognosis for the desired pregnancy.

In conclusion, proper surgical management of defects within the reproductive tract is of great importance in patients with infertility, pregnancy wastage, or somatic complaints due to anatomical abnormalities. The improvements in surgical techniques and equipment now permit the repair of most congenital or acquired defects of the female reproductive tract. Because of recent advances in assisted reproductive technologies, the surgeon should carefully select patients who meet specific criteria to undergo infertility surgery.

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