“INS AND OUTS OF STRAIGHT-STICK LAPAROSCOPIC MYOMECTOMY”
JAMES ROBINSON, MD, MS, AND GABY MOAWAD, MD (SEPTEMBER 2012)
Is adhesion formation reduced after laparoscopic myomectomy?
I would like to thank Dr. Robinson and Dr. Moawad for their excellent presentation. In one of the videos that accompanied this article, the authors closed the uterus laparoscopically, but the incision was large. I wonder whether they have performed any second-look laparoscopies to determine whether adhesion formation is reduced in these women.
Michael D. Birnbaum, MD
Elkins Park, Pennsylvania
Dr. Robinson responds Sound microsurgical principles are recommended
We advocate making incisions that approximate the diameter of the fibroid to facilitate its removal. We have had the opportunity to perform second-look laparoscopies in some patients who needed another surgery—either because of a complication of the first surgery or for an unrelated issue. In general, we have been pleased by the low level of postoperative adhesion formation.
Many of our myomectomy patients have had prior myomectomies (laparoscopic or abdominal). We counsel such patients that the prior myomectomy puts them at significant risk for complications associated with adhesions; we also advise them that future surgery may be complicated by adhesions that occur as a result of the surgery we are performing. In our experience, laparoscopy appears to cause fewer adhesions but is not entirely protective. We have seen patients who have undergone prior laparoscopic myomectomies who have extensive and dense adhesions at their repeat surgery, and patients who have had extensive prior open myomectomies who do not have significant adhesions at their repeat surgery.
The time-honored microsurgical principles of hemostasis, gentle tissue handling, and tissue approximation without strangulation, along with the use of a good adhesion barrier, are more important than the route of surgery—in my unscientific and biased opinion. When laparoscopy leads to less tissue injury than laparotomy, we can extrapolate that postoperative adhesion formation should also be less. A good review article on the subject from the perspective of the American Society for Reproductive Medicine Practice Committee appears in the supplement to the November 2006 issue of the journal Fertility and Sterility (pages 1–5).
“MALPOSITIONED IUDS: WHEN YOU SHOULD INTERVENE (AND WHEN YOU SHOULD NOT)”
KARI P. BRAATEN, MD, MPH, AND ALISA B. GOLDBERG, MD, MPH (AUGUST 2012)
How to manage a partially expelled IUD
Dr. Braaten and Dr. Goldberg made no mention of the partially expelled intrauterine device (IUD)—unless that is the phenomenon they described as the “downward displaced” IUD.
When I have a patient who has a partially expelled IUD, I remove the device and initiate another form of birth control, such as another IUD, depot medroxyprogesterone acetate, or an oral contraceptive. I never advance a partially expelled IUD back into the uterine cavity.
Jonathan Watt, MD
Article on malpositioned Iuds is greatly appreciated
I really enjoyed the article on malpositioned IUDs, especially the visual elements and their respective explanations. The article provided me with an excellent understanding of the problem and showed me how to manage it in a scientific manner. I’ll share it with my colleagues and keep it on hand as a guide. Thank you!
Mariella Camargo, CNM
Port Chester, New York
“STOP PERFORMING MEDIAN EPISIOTOMY!”
ROBERT L. BARBIERI, MD (EDITORIAL; APRIL 2012)
Delivery of the shoulders often gets overlooked in discussions of episiotomy
I have practiced obstetrics and gynecology since my internship in 1974! In my opinion, much is said about delivering the baby’s head, whereas delivery of the shoulders often gets overlooked in discussions. We must remember that the biacromial diameter is the largest diameter that must be delivered.
After observing—and being involved in—thousands of deliveries, I have concluded that there is gross disregard for the shoulders once the head is delivered. In my deliveries, I protect the perineum—with or without episiotomy—until both shoulders have been delivered. I perform external rotation and delivery of both shoulders with one hand while the other hand holds the perineum together.
None of the articles I have read on episiotomy have mentioned management of the shoulders.
Miguel A. Cintron, MD
Median episiotomy is easier on the patient
I take issue with Dr. Barbieri’s recommendation to stop performing median episiotomy. Although I avoid liberal use of episiotomy, I sometimes perform it in challenging vaginal deliveries. When I do, I opt for a midline episiotomy rather than a mediolateral one.
My observations—”science” notwithstanding—are that patients who undergo mediolateral episiotomy are always significantly more uncomfortable than those who receive a mid-line episiotomy, and they experience discomfort for a significantly longer time. Moreover, the mediolateral approach does not always eliminate extension into the rectum. In 33 years of practice, I have not encountered rectovaginal fistula or anal incontinence among my patients who have a midline episiotomy. Nevertheless, I ask about anal continence at every postpartum visit—and try to ensure that every patient is seen postpartum by calling all women who fail to make an appointment. I also inquire about anal continence at every yearly exam.