Preoperatively, all patients should be assessed for the presence of cardiac, pulmonary, hepatic, renal, or vascular comorbidity. Presupposing appropriate perioperative measures and surgical technique, there is no reason to contraindicate pneumoperitoneum in patients with peritonitis or intraabdominal malignancy. During laparoscopy, monitoring of end tidal CO2 concentration is mandatory. The available data on closed- (Veress needle) and open-access techniques do not allow us to principally favor the use of either technique. Using 2 to 5-mm instead of 5 to 10-mm trocars improves cosmetic result and postoperative pain marginally. It is recommended to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure. In patients with limited cardiac, pulmonary, or renal function, abdominal wall lifting combined with low-pressure pneumoperitoneum might be an alternative. Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5-7 mmHg) pneumoperitoneum. In patients with cardiopulmonary diseases, intra- and postoperative arterial blood gas monitoring is recommended. The clinical benefits of warmed, humidified insufflation gas are minor and contradictory. Intraoperative sequential intermittent pneumatic compression of the lower extremities is recommended for all prolonged laparoscopic procedures. For the prevention of postoperative pain a wide range of treatment options exists. Although all these options seem to reduce pain, the data currently do not justify a general recommendation.

Objective To determine the incidence and describe the complications of laparoscopic procedures in The Design A nationwide prospective multicentre observational study.Methods Data on complications were registered from 1 January to 3 1 December 1994 by 72 hospitals.Any unexpected or unplanned event requiring intra-operative or post-operative intervention was defined as a complication. Complications were classified in two groups: approach and technique related complications. Complication rates were compared with these already published.Results Of 25,764 laparoscopic procedures, 145 complications occurred (rate 5.7 per 1000 [%o]); two deaths occurred. In 84 women laparotomy was necessary (rate 3*3%0). In 83 cases (57%; 95% CI for approach = 4945%) the complication was caused by the surgical approach; in 62 cases (43%) the technique was at fault. Haemorrhage of the epigastric vein and intestinal injury, often requiring laparotomy (90% of cases) were the most frequently observed complications. The complication rate was 2-7%0 for diagnostic laparoscopic procedures, 4.5960 for sterilisation and 17.9Y60 (x2 = 127; dF = 2; P < 0.001) for operative laparoscopy. The highest incidence was registered for complications occurring during laparoscopic (assisted) hysterectomy. Stepwise logistic regression analysis showed that previous laparotomy and surgical experience were associated with complications requiring laparotom y.Conclusions Most complications occurred during operative laparoscopic procedures (rate 17.9%0).Residents in training are required to learn diagnostic laparoscopy and sterilisation and this training programme results in a fall in the risk of the complications. However, operative laparoscopic procedures are still hazardous, especially laparoscopic hysterectomy. Women with a previous laparotomy are particularly at risk.Netherlands.

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Advances in preoperative diagnostic as well as surgical techniques for the treatment of endometriosis, especially deep endometriosis call for a classification system that includes all aspects of the disease such as peritoneal, ovarian endometriosis and deep endometriosis and secondary adhesions. The widely accepted r-ASRM classification has certain limitations due to its incomplete description of deep endometriosis. In contrast, the Enzian classification, which has been implemented in the last decade, has proved to be the most suitable tool for staging deep endometriosis but does not include peritoneal or ovarian disease as well as adhesions. To overcome these limitations, a comprehensive classification system for complete mapping of endometriosis, including anatomical location, size of the lesions, adhesions and degree of involvement of the adjacent organs that can be used with both, diagnostic and surgical methods, has been created via a consensus process and will be described in detail-the #Enzian classification.