Cleft lips

This is a cleft case which diagnosed by 3D scan in Kasih Ibu Hospital.

The image was compared with post natal image.

A male baby delivered by C-section in term due to breech presentation.
( dikutif dari hariyasasanjaya.blogspot.com)

Anti-Mullerian Hormon

dr Doster Mahayasa SpOG(K)
ABSTRAK

Latar Belakang : AMH dihasilkan oleh sel granulosa folikel pre antral dan antral, berperan membatasi jumlah folikel primordial berkembang menjadi folikel primer. Kadarnya dapat diukur pada serum, relatif tidak berfluktuasi sepanjang siklus haid dan kadarnya semakin menurun secara gradual seiring bertambahnya usia seorang wanita. Jumlah folikel yang berkembang tergantung dari jumlah folikel yang masih tersisa pada ovarium dan jumlah folilel dominan serta jumlah oosit pada stimulasi ovarium tergantung pada jumlah folikel yang berkembang. Oleh karena itu pemeriksaan kadar serum basal AMH secara tidak langsung dapat menggambarkan cadangan ovarium serta dapat memprediksi respon ovarium terhadap stimulasi ovulasi.
Tujuan : Mempelajari korelasi kadar serum basal AMH dengan respon ovarium terhadap stimulasi ovulasi pada program fertilisasi in vitro.
Bahan dan Cara : Wanita yang telah memenuhi kriteria untuk mengikuti program fertilisasi in vitro di Klinik Fertilitas RS Siloam Surabaya dan Graha Amerta Surabaya mulai Februari 2007 disertakan sebagai sampel penelitian sampai terpenuhi sejumlah 69 sampel. Kadar AMH diperiksa pada hari ketiga haid bersamaan dengan pemeriksaan hormonal basal yang lain. Dilakukan pengumpulan data selama proses stimulasi sampai dengan prosedur petik ovum meliputi : jumlah ampul gonadotropin, kadar E2 serum saat hCG, jumlah folikel pre ovulasi dan jumlah oosit. Dilakukan analisa statistik dengan Pearson’s correlation test untuk menunjukkan hubungan antara variabel.
Hasil : Terdapat hubungan yang bermakna antara kadar serum basal AMH dengan : jumlah folikel pre ovulasi (r=0,529 , p < 0,01) , dengan jumlah oosit (r=0,535 , p<0,01), dengan kadar E2 serum saat pemberian hCG (r=0,456 , p< 0,01) dan jumlah ampul gonadotropin per folikel pre ovulasi (r= - 0,311 , p<0,01).

Kata kunci : kadar serum basal AMH, respon ovarium, stimulasi ovulasi.

Screening asymptomatic bacteriuria dengan leukosituria

dr hariyasa sanjaya spog

Screening asymptomatic bacteriuria pada kehamilan penulis lakukan di tempat praktek sore secara rutin saat usia kehamilan 30 minggu. Dari data yang diperoleh pada 138 pasien ternyata ditemukan leukosituria sebanyak 63 orang (45,65%) dengan rincian leukosituria semikuantitatif sebagai berikut: +1 sebanyak 37 orang(26,81%) ,+2 sebanyak 16 orang (11,59%) dan +3 sebanyak 10 orang (7,24%). Semua pasien dengan leukosituria tersebut diberikan antibiotic Monuril SD (Fosfomycin) sachet. Terdapat 2 kasus dengan ancaman persalinan preterm. Namun kedua kasus tersebut dapat dicegah terjadinya persalinan preterm.
Dari data di atas prevalensi luekosituria pada ibu hamil cukup tinggi yaitu 45,65%. Kemungkinan kontaminasi pada saat pengumpulan specimen urin mungkin saja terjadi. Walaupun dalam setiap pemeriksaan urin, pasien telah diberi penjelasan yang memadai tentang pengambilan urin pada pertengahan curah (midstream).
Data tersebut di atas memberikan pertanyaan apakah perlu skrining asymptomatic bacteruria pada kehamilan dilakukan? Dan untuk menghemat biaya apakah cukup dengan memeriksa leukosituria saja?
Penelitian yang dilakukan oleh Y Uncu, G Uncu, A Esmer, N Bilgel1 mendapatkan kesimpulan bahwa sensitivitas, spesifisitas, positive predictive value dan negative predictive value untuk leucocyturia sebagai test screening untuk asymptomatic bacteriuria adalah 91.3%, 83.6%, 45.6% dan 98.5%, secara berurutan. Dan mereka mendiagnosis preterm labor pada enam dari 23 (26%) dengan asymptomatic bacteriuria dan 16 dari 163 (9.3%) orang dari kelompok wanita dengan kultur urin negatif.

Daftar pustaka
1.http://cat.inist.fr/?aModele=afficheN&cpsidt=14653131

Hubungan seksual pada saat hamil bolehkah?

Kebutuhan akan hubungan seksual pada pasangan yang sudah menikah merupakan kebutuhan batin yang normal. Saat hamil wanita ingin selalu dekat dengan suami, akibat dampak psikologis yang dialami ibu hamil karena pembesaran perut, ibu merasa tidak cantik lagi, takut suami berpaling ke pelukan wanita lain sehingga dekapan, belaian suami, hubungan seksual merupakan obat mujarab untuk mengatasi krisis kepercayaan diri.Pertanyaan kemudian muncul, bolehkah hubungan seksual dilakukan pada saat pasangan sedang hamil?Kehamilan bukan merupakan penghalang bagi suami istri untuk melakukan hubungan seksual selama tidak ada masalah pada kehamilan, dan hubungan seksual pada kehamilan dapat dilakukan seperti biasa, oleh karena pada saat hamil mulut rahim mengandung lendir kental yang mencegah pergerakan kuman dari vagina ke janin, kedua didalam rahim janin terlindung oleh selaput ketuban dan air ketuban. Ketakutan akan melukai janin saat melakukan hubungan seksual merupakan pemikiran yang salah. Namun yang perlu diwaspadai adalah hubungan seksual pada kehamilan dini, oleh karena sperma mengandung prostaglandin yang dapat mempengaruhi kontraksi rahim, dan keguguran merupakan masalah yang paling ditakuti pada saat ini.

BAGAIMANA TETAP MENIKMATI HUBUNGAN SEKSUAL Pada kehamilan lanjut posisi senggama yang normal sulit dilakukan, akibat pembesaran perut,wanita juga merasa kurang nyaman dalam melakukan hubungi seksual sehingga posisi saat senggama perlu disesuaikan sehingga memberi rasa nyaman pada istri.Hubungan seksual pada saat hamil hendaknya dilakukan secara hati-hati dan hanya bersifat rekreatif

BERBAHAYAKAH MELAKUKAN HUBUNGAN SEKSUAL PADA SAAT HAMIL ?Hal diatas berlaku bila selama kehamilan tidak ada masalah, namun bila kehamilan berisiko seperti:Ancaman keguguran atau riwayat keguguran, akan berisiko terjadi keguguran berulangPlasenta letak rendah (ari-ari tertanam di segmen bawah rahim), khawatir terjadi perdarahan hebat saat hubungan seksualRiwayat kelahiran prematur, ini juga mengancam terjadinya persalinan sebelum waktunya.Keluar cairan ketuban, bila ketuban sudah keluar berarti selaput ketuban yang berfungsi sebagai pelindung janin dari kuman yang ada di daerah vagina robek, akibatnya hubungan seksual akan mengantarkan kuman di vagina ke dalam rahim melalui sel-sel sperma, risikonya dapat menyebabkan infeksi pada janinPenyakit hubungan seksual (PHS),seperti: GO, siphilis, HIV/Aids, dll.Suami atau istri yang sedang hamil atau tidak hamil bila menderita penyakit ini sebaiknya tidak melakukan hubungan seksual, sampai benar-benar sembuh berdasakan penilaian dan pemeriksaan dokter yang ahli dalam bidangnya.Bila hubungan seksual tidak dapat di hindari sebaiknya menggunakan kondom. Dampak yang paling ditakuti bukan saja penularan ke janin, namun penularan ke pasangan juga.

BALI PULAU"DEWATA" BANGKITLAH

OLEH :dr Made Darmayasa SpOG(K)

(foto dudukagak di belakang gendong tas)

Kota baru, kalimantan selatan
Entah sejak kapan sebutan ini diberikan kepada Bali ? Siapa yang pertama kali memberikan sebutan seagung itu ? Kenapa sebutan itu diberikan kepada Bali. Masih banyak pertanyaan yang dapat diajukan berkaitan dengan sebutan tersebut. Banyak pula orang yang telah memberikan penjelasan. Saya minta maaf, karena saya tidak pernah membaca; Babad, Purana, maupun sastra lain berkaitan dengan nama Bali. Apalagi dengan embel-embel Pulau Dewata. Saya akan berangkat dari suatu istilah yang disebut oleh seorang suci. Beliau mengatakan bahwa dalam shastra India kuno ada istilah “Bhutha-Bali”. Apakah nama Bali berasal dari istilah ini ?Selama ini, Bali memang secara sempit diartikan dengan Banten. Ada lagi yang mengartikan Bali secara umum adalah kurban, yang berarti pemotongan hewan. Ini benar-benar arti yang dibelokkan. Arti sejati dari kata itu adalah pajak yang harus dibayar. Umumnya kita membayar pajak kepada pemerintah untuk air minum, listrik, telepon, pajak bumi, bangunan/rumah dan lain-lainnya, bukan ?. Sama halnya; agar kecemasan, kegelapan, dan kesedihan yang kita alami dihilangkan kemudian kebahagiaan dan kedamaian yang meninggalkan kita diberikan kembali, kita harus membayar pajak tertentu kepada Panchamahabhuta(lima unsur/elemen), yang menopang kehidupan. Pajak yang dimaksudkan itulah yang disebut dengan Bhutabali, dalam bentuk Thyaga(pengorbanan) yang dibayar kepada Panchamahabhuta melalui Yajna. Inilah makna Bali dalam konteks tersebut. Bagaimana hal ini dapat dijelaskan ?Alam semesta, Nay, dan setiap mahkluk hidup mengandung unsur Pancha Maha Bhuta(lima elemen yang terdiri dari unsur tanah, air, api, udara dan ether/akasa). Tanah mempunyai segala kemampuan laten yang dimiliki oleh setiap ciptaan. Bumi mempunyai segenap kemampuan dan bahan yang dibutuhkan untuk kehidupan manusia serta semua mahkluk lain. Ibu bumilah merupakan perwujudan segala kemampuan yang melindungi dan memelihara semua mahkluk. Jika bumi tidak bergerak saja, maka segenap ciptaan akan berakhir. Demikian juga halnya dengan air dan api. Manusia dan ciptaan yang lain juga mengandung unsur air dan api. Tubuh kita segera ambruk kalau tidak ada kedua unsur ini. Di dalam tubuh kita ada Jatharagni(api pencernaan), bahkan didalam lautpun ada Badabagni. Unsur udara tidak terbatas pada suatu tempat tertentu, tetapi memenuhi segala sesuatu. Manusia dapat bertahan hidup kalau tidak ada makanan, tetapi akan segera mati kalau tidak mendapatkan udara. Sedangkan unsur ether(aakasha) adalah asal muasal unsur yang lain. Sehingga disebut dengan Shabda Brahman. Kesimpulannya, kelima unsur/elemen ini memenuhi seluruh semesta serta melindungi dan menopang kehidupan. Sesungguhnya mereka adalah(perwujudan) Tuhan.Keberadaan yang sesungguhnya adalah Brahman. Beliau meresapi dan melingkupi kelima unsur/elemen tersebut. Dengan demikian kelima unsur/elemen ini adalah wujud Tuhan(Five Elements are Form of Divinity). Kemanapun kita melihat, ke planet manapun kita pergi, kita hanya akan mendapatkan bentuk kelima unsur ini yang diselimuti oleh alam semesta yang maha luas. Demikian juga kelima unsur/elemen tersebut adalah penopang alam semesta, tubuh kita, dan setiap ciptaan baik yang bergerak maupun yang tidak bergerak. Kelima elemen inilah yang secara langsung maupun tidak langsung menopang kehidupan manusia. Sudah sewajarnyalah manusia mengucapkan terimakasih dan rasa syukur yang dalam kepadanya. Inilah makna sesungguhnya Bhutabali. Astungkara ! ! Sungguh luar biasa konsep ini.Dengan spirit ini, semoga kita mendapatkan spirit pengorbanan, pemurnian Yajna dan kesadaran, serta membawa kita menuju kebahagiaan Atma. Jadi tidaklah benar kalau Yajna yang kita lakukan dengan motif-motif ekonomi atau motif lain. Seolah-olah kita sedang malakukan barter dengan Tuhan. “Kalau usaha saya sukses, saya sanggup ngaturang Guling,” dll. Dapat dipastikan bahwa kalau pelaksanaan Yajna mengikuti konsep Bhutabali ini, keselamatan dan kesejahteraan duniawi akan menyusul. Bukan sebaliknya, motif ekonomi yang melatarbelakangi pelaksanaan Yajna.Kita patut prihatin dengan berita seorang Profesor yang mempunyai otak dan pikiran yang ruwet sehingga keruwetan itupun dibawanya mati, bahkan menyisakan keruwetan baru bagi generasi penerusnya, seperti yang ditulis oleh bapak Dewa K Suratnaya, pada Media Hindu edisi 51. Seluruh pengetahuan dan keprofesorannya tidak sanggup untuk memahami makna spiritual pelaksanaan Yajna. Atas dasar itu dia ingin meniadakan pelaksanaan Yajna.Kenyataannya benar bahwa saat ini ada upaya-upaya pembusukan yang dilakukan oleh orang-orang untuk menghilangkan Yajna ini, dengan dalih ruwet, rumit, time and money consuming, dll. Hal ini bertambah parah dengan semakin malasnya pengikut Weda/orang Bali untuk melakukan revitalisasi dan reapresiasi terhadap konsep dan plaksanaan Yajna itu sendiri. Orang-orang Hindu khususnya di Bali, terlena dan terseret oleh gaya hidup masa kini, sehingga kehilangan banyak waktu untuk berbenah diri, memajukan ke-Balian/ke-Hinduannya dan menyelami jati dirinya. Kehilangan kesempatan untuk mendalami keluhuran konsep nilai kemanusiaan itu sendiri. Kembangkan budaya baca dan tulis tentang sastra-sastra suci kita, sehingga mempunyai kemampuan melihat aspek lebih tinggi dari setiap Yajna yang dilakukan.Jangan biarkan olok-olok ini berlangsung lebih lama lagi. Energi kosmis telah mengalami penguatan untuk meredam keresahan umat manusia saat ini. Pasanglah bola lampu dan jadikan diri kita sebagai bolamnya. Siapkan, dan siapkanlah dengan baik, sehingga kita menjadi terang, dan mampu menerangi. You are very fortunate that you have a chance to experience the bliss of the vision of the Sarvadaivathwa swaroopam (the form that is all forms of the Love) now, in this life itself. Sungguh luar biasa jaminan diatas. Bagaimana manusia Hindu menyadarinya ?Manusia Hindu, khususnya di Bali bangkitlah dari tidur panjangmu ! Sambut dan tatap cahaya cemerlang kebijaksanaan Weda. Biarlah dunia menyadari-Nya ! !.Brahman adalah sumber dan pelindung yang melingkupi seluruh ciptaan. Dia adalah kekuatan maha tinggi alam semesta dan Dia dapat melakukan apa saja sesuai kehendak Ilahi-Nya. Seluruh ciptaan, kelangsungan dan kehancuran alam semesta seluruhnya adalah kehendak-Nya. Tetapi semua yang dilakukan-Nya adalah untuk kebaikan seluruh alam semesta. Setiap kejadian di dunia ini sekecil apapun adalah atas kehendak-Nya. Kitalah penyebab seluruh penderitaan ini. Pada pengertian ketuhanan tidak ada kehendak untuk menyusahkan atau membuat duka cita. Seluruh yang Brahman lakukan adalah untuk kesejahteraan manusia/kemanusiaan. Manusia khususnya manusia Bali kini pergi kemana-mana, ilmu gaib, dukun sakti, mencari alat-alat mejik dan usaha-usaha bodoh lainnya untuk mengurangi penderitaan dan kesedihannya. Celakanya lagi, mereka bahkan saling menyalahkan dan menimpakan kesalahannya kepada orang lain terhadap kesakitan dan penderitaan dirinya. Mereka jarang mau melakukan pemeriksaan kedalam dirinya, karena sesungguhnya seluruh pengalaman baik buruk dalam hidupnya adalah cerminan dari dirinya sendiri. Apapun yang kita rasakan menyusahkan atau menyenangkan, berpikirlah selalu bahwa semuanya untuk kebaikan kita. Ketidakmampuan untuk merealisasikan kebenaran ini, membuat manusia khususnya Bali mengalami banyak penderitaan dan kesusahan. Setiap orang harus berusaha keras untuk menyadari kebenaran yang mendasari setiap kehendak Tuhan. Akibat pengaruh jaman Kali Yuga, manusia berhasil mengembangkan kecerdasannya pada beberapa cabang pengetahuan dengan semangat yang tinggi, tetapi justru berkurangnya kemampuan untuk memahami kebenaran abadi dibalik seluruh ciptaan. Oleh karena itu, adalah sangat penting bagi kita manusia khususnya manusia Bali untuk menanamkan dengan dalam Nammakam(Faith/Kepercayaan dan keyakinan). Kepercayaan dan keyakinan diibaratkan seperti sepasang mata bagi manusia. Tanpa kepercayaan dan keyakinan, manusia buta.Seseorang yang mempunyai kepercayaan kepada Tuhan akan dapat mengembangkan kepercayaan kepada setiap orang. Jadi setiap orang harus mengembangkan keyakinan yang mantap bahwa Tuhan itu adalah imanen dalam setiap mahkluk hidup, dan seluruh ciptaan. Upanishad mengatakan Isavasyam idam sarvam(seluruh alam semesta diresapi oleh Tuhan) dan Easvara sarva bhutanam(Tuhan melingkupi alam semesta). Tuhan adalah Immanent(tetap ada) didalam setiap ciptaan merupakan sebuah Nammakammu(keyakinan). Oleh sebab itu, seseorang harus mempunyai kepercayaan yang kuat kepada Tuhan, dalam wujud seluruh ciptaan.Seluruh kegiatan Yajna yang dilakukan adalah untuk kemajuan manusia dalam artian spiritualitas, bukan duniawi semata. Lakukan usaha keras untuk memahami prinsip spirtualitas dibalik kegiatan Yajna besar bahkan yang kecil sekalipun. Kalau melakukan Yajna untuk kepentingan duniawi semata itu namanya pengemis.“Menabur benih racun kita berharap memetik buah manis. Tak tahan menelan buah pahit yang didapat kita beralih dan menyalahkan Tuhan”Inilah yang terjadi saat ini. Oleh karena itu miliki dan kembangkan kepercayaan yang kuat didalam diri kita paada Tuhan dan yakini bahwa Beliau ada dimana-mana. Sarvatah panipadam tat sarva thokshi siromukham, sarvatah sruthimalooke sarvamavruthya tisthathi(dengan tangan, kaki, mata, kepala, mulut, dan telinga sebarkan sesuatu yang dikehendaki untuk kesatuan alam semesta).Dalam konteks seperti inilah semestinya Yajna yang harus dilakukan diseluruh Bali, bahkan di seluruh dunia. Kalau kebenaran ini dapat kita realisasikan dalam kehidupan, sebutan “Bali sebagai pulau dewata” adalah hal yang pantas. Jadilah manusia Hindu/Bali yang memahami nilai ketuhanan didalam diri kita, dan seluruh ciptaan.Jangan biarkan Bali dibusukkan dengan pelaksanaan Yajna yang bersifat Tamasik apalagi Rajasik. Terlebih lagi Yajna yang dilaksanakan tanpa manfaat spiritual sama sekali. Jangan pula biarkan Hindu dibusukkan oleh orang-orang yang ingin meniadakan Yajna dalam artian luas. Yajna adalah aktualisasi nilai spiritual Hindu. Terdapat tiga aspek dalam hal ini, yang meliputi; Karma(work=kerja), Upasana(worship=Yajna/persembahan/persembahyangan), danJnana(wisdom=kebijaksanaan). Hanya bila ketiga ini direalisasikan sebagai satu kesatuanlah segala buah manis Yajna akan dapat dihasilkan. Hal ini dapat dibayangkan seperti mempelajari Weda; chantingkan mantramnya, praktekkan nilai-nilai luhurnya, dan dapatkan anugrah-Nya.“Lokah Samasthah Sukhino Bhavantu”Semoga seluruh semesta sejahtera dan bahagiaMade DarmayasaRSUD. Kotabaru. Kalimantan Selatandmsogs@yahoo.co.id

BANTEN,KONOTASI,KEKINIAN

Oleh: AA Ngurah Made ArwataSarad Bali Edisi Mei 2008.

Buat orang Bali khususnya yang pemeluk Hindu, babantenan merupakan bagian kehidupan dan penyatuan dirinya dengan kesemestaan alam. Setiap bentuk hubungan peristiwa manusia dan alam diwujudkannya dalam banten dengan susunan sesuai makna dan tujuannya.
Banyaknya kejadian dan semakin kompleknya tuntutan manusia Bali dalam memenuhi kebutuhan hidup dan kehidupannya, menimbulkan masalah yang cukup serius dari berbagai aspeknya. Interaksi sosial, ekonomi, budaya, psikologi semakin rumit. Keterdesakan waktu, ketergesa-gesaan, perasaan tertekan menggeser hidup santai dan kebersahajaan orang Bali. Namun berapapun dahsyatnya faktor pengubah tatanan kehidupan sosial materialistis, ternyata tidak mampu menggemingkan apalagi mematahkan semangat sosial religius yang ditunjukkan dengan babantenan . Hal ini mungkin sulit dipahami oleh banyak orang termasuk intelektual yang berpengetahuan luas, berwawasan spiritual. Tapi tidak bagi orang awam sekalipun yang memiliki kesadaran alam tentang rasa dan mengerti makna kebalian orang Bali. Seruan, imbauan, intruksi yang didasarkan kewenangan maupun kekuasaan, penyadaran-penyadaran yang dilandasi hasil kajian ilmiah, intervensi, intimidasi, provokasi yang bersifat sumbang terhadap babantenan dari berbagai aspeknya, tidak menyurutkan niat orang untuk mabanten (menghaturkan sesaji). Bahkan sebaliknya, terjadi peningkatan niat dan usaha mengembangkan banten dan babantenan dalam frekuensi maupun volumenya.
Jika banten dianggap masalah sehingga perlu dipersoalkan, maka dibutuhkan “kejelasan” letak masalahnya. Apanya yang salah? Tidakkah “anggapan” merupakan faktor sebab perbedaan cara pandang dan sikap kita memberikan penilaian terhadap banten? Pencarian “akar” masalah berdasarkan sikap bijak sangat dibutuhkan. Karena banten dalam implementasinya merupakan hak “privacy” yang menyangkut keyakinan pribadi yang berkaitan dengan lingkungan, semesta, alam yang berkaitan dengan kedamaian hati seseorang. Pengaturan oleh para pihak hanya dapat dilakukan dalam kaitan sosial kemasyarakatan yang dapat diduga dan dibuktikan mengganggu keamanan, kenyamanan, dan kesenangan orang lain. Itu pun mesti sesuai dengan kewenangan dan ketentuan yang sah dan berlaku dengan mempertimbangkan Desa, Kala, Patra. Dari berbagai sumber dapat disimpulkan bahwa banten dan babantenan adalah merupakan cetusan hati manusia/penganut Hindu, sebagai satu pernyataan suksmaning manah (terimakasih) ke hadapan Tuhan Yang Maha Esa (Ida Sang Hyang Widhi Wasa) atas karunia dari kehidupan yang diberikanNya. Dalam melaksanakan kehidupan atas kekurangan, semangat, kemerdekaan untuk mengelola hidup, manusia berintegrasi, berinterelasi, dan berinteraksi dengan berbagai kekuatan energi yang berada disekelilingnya, guna menciptakan tatanan kehidupan yang sejahtera, berkeadilan berdasarkan keselarasan dalam pertentangan membangun kesemestaan yang berkelanjutan.
Dari uraian yang tersurat pun yang tersirat, bahwa banten dan babantenan mengandung makna dualitas pemberian dengan pengorbanan yang dilandasi ketulusan yang bersifat naluriah ( instingtif ), terbebas dari pertentangan rasionalitas materialistis. Dasarnya , jujur terhadap rasa ( seh ), diyakini, dikerjakan dengan sungguh-sungguh dan penuh tanggung jawab. Apapun dampaknya diterima dengan pikiran positif. Logikanya, bahwa karena ungkapan suksmaning manah didasarkan kepada pemberian (karunia dan kehidupan), maka yang disuguhkannya adalah hasil olah pikir, olah laku, olah rasa dari bentuk pemberian ke bentuk baru yang sudah terolah dalam tatanan yang mengandung unsur kesemestaan, keindahan, kemanfaatan, kelestarian bagi keberlanjutan. Artinya , bahan yang digunakan hendaklah yang dihasilkan—apapun itu—dengan bahasa kerennya local product , ditata menggambarkan tatanan kesemestaan dalam satu satuan ataupun total, dan menyempurnakannya dengan unsur-unsur keindahan yang bersumber dari ketrampilan maupun cita rasa.
Raringgitan pada janur, aroma dan warna yang alami pada suguhan, sehingga tampilan banten menjadi resik (bersih, estetis, dan etis). Baik banten yang akan dipersembahkan sebagai ungkapan syukur ( pangajum-ngajum dan pengharum) kepada Tuhan Semesta Alam maupun yang disajikan dalam pengorbanan sebagai bentuk terima kasih kepada energi lain ( babhutan ). Jika pemahaman banten seperti tadi telah diresapi dan diterima, maka banten bukanlah masalah yang perlu diperdebatkan tetapi merupakan sesuatu yang perlu dikawal dalam proses perubahan agar tidak melenceng dari hakekat yang tersirat sebagai media pembelajaran, pemantapan diri melalui olah pikir (melihat ke depan), olah laku (terampil), dan olah rasa (ketajaman naluri). Di samping sebagai upaya menjaga kelestarian dan keselarasan lingkungan (berbagai jenis tanaman, ternak dijaga, dipelihara dan ditata sesuai tatanan ruang karena memiliki nilai sosial dan ekonomi).
Penyadaran diri pada hakekat hubungan keselarasan kelemahan dan keterbatasan (mengurangi keserakahan dan menghayati makna berbagi) mengandung makna distribusi pendapatan dan penciptaan lapangan kerja. Jadi, yang penting dan terpenting berbicara dalam banten dan babantenan , bahwa penekanan tentang pemaknaan banten sebagai ungkapan suksmaning manah harus resik. Banten adalah perwujudan dari berkah, merupakan prasadam (yang harus dinikmati). Surudannya jangan dibuang, karenanya harus dibuat dari bahan-bahan yang bermutu dan layak dikonsumsi—diupayakan hasil lokal.
Sedangkan prinsip yang dipegang dalam penyelenggaraan yajnya dengan babantenan adalah tepet , genep tanding tuna surud , guna mencegah terjadinya pemborosan sekaligus menepis issue bahwa banten mahal, boros dan merupakan aktifitas yang memproduksi sampah. Jangan pernah berhenti mabanten , yang penting rencanakan dengan baik sesuai kemampuan. Kerjakan bersama dalam kebersamaan untuk membangun harmonisasi keluarga melalui pelatihan penalaran minat dan bakat pada pembuatan sarana banten. Kaji ( review ) kelengkapan banten, perhatikan cara kerja ahli banten ( tapini ) untuk menambah pemahaman dan kemampuan berfikir positif terhadap dampak banten. Semoga banten lestari sehingga lingkungan dan budaya Bali tumbuh berkembang dinamis sesuai kultur kebalian orang Bali. Anak Agung Ngurah Made Arwata. Planolog.
Next >

KONSELING KB

Merupakan hal yang amat penting, karena dapat membantu klien keluar dari berbagai pilihan dan alternative masalah kesehatan reproduksi dan keluarga berencana (KB). Konseling yang baik membuat klien puas (satisfied). Juga membantunya dalam menggunakan metoda KB secara konsisten dan sukses.
Lalu, apa yang dibutuhkan dalam konseling yang baik? Terutama untuk klien yang baru pertama kali mengunakan alat KB, ada 6 prinsip yang perlu diperhatikan. Konseling yang baik tidak banyak menyita waktu, yang penting informasi yang diberikan sesuai dengan apa yang dibutuhkan klien.
Kenali klien dengan baikà dengan sikap ramah, respek, tumbuhkan rasa saling percaya. Konselor dapat menunjukkan bahwa klien dapat berbicara terbuka sekalipun hal yang sensitive. Jawablah pertanyaan yang diajukannya secara lengkap dan terbuka. Jaga kerahasiaan dan jangan membicarakannya kepada orang lain.
Interaksià dengarkan, pelajari, dan respon klien. Karena tiap klien itu berbeda, mengerti benar apa yang dibutuhkannya, penuh perhatian, dan mengerti keadaannya. Oleh karena itu, dorong klien untuk bicara dan menjawab tiap pertanyaan yang diajukan secara terbuka.
Sesuaikan informasià pelajari informasi yang dibutuhkan klien, sesuaikan dengan tahap kehidupan yang dilaluinya. Contoh, pasangan muda tentunya ingin mengetahui lebih banyak tentang metoda sementara guna menunda kehamilan; wanita usia tua dengan informasi kontap/sterilisasi (MOW/vasektomi); lain hal dengan anak muda yang belum menikah, mereka butuh pengetahuan tentang bagaimana mengindari IMS termasuk HIV/AIDS. Oleh karenanya, onselor memberikan informasi yang akurat dengan bahasa yang dimengerti klien.
Hindari informasi berlebihà klien tidak dapat menggunakan semua informasi tentang tiap metoda KB. Informasi berlebih membuat klien sulit mengingat informasi pentingnya. Kita sebut ini dengan istilah, “overload information”. Jangan menyita banyak waktu dalam menyampaikan pesan/ informasi.
Metoda konselor, diharapkan klienà membantu klien menentukan pilihan, dan mengahrgai pilihannya. Konseling yang baik di mulai dari apa yang dipikirkan dan diajukan klien. kemudian mengamati apakah klien memahami metoda tersebut. Termasuk untung dan ruginya, bagaimana cara menggunakannya, Bantu klien memikirkan metoda lain juga dan bandingkanlah. Dengan cara ini memberi keyakinan atas metoda pilihannya. Jika tida ada pertimbangan medis, klien dapat menggunakan metodanya. Yang penting ialah klien menggunakan dalam waktu lama (konsisten) dan efektif.
Bantu klien untuk mengingat dan mengertià menunjukkan sampel/contoh alat KB, dorong ia menggunakannya. perlihatkan dan jelaskan dengan plifchart, poster, pamplet bergambar. Tiap saat amati klien, jika ia pulang, ingatkan untuk membagi informasi kepada orang lain.

6 TOPIK
Efektifitasà bagaimana kemampuan metoda KB mencegah kehamilan tergantung kepada penggunanya (akseptor). Banyaknya angka kehamilan karena kegagalan KB, tergantung dari konsistensi dan ketepatan penggunaannya. Konselor membantu klien mempertimbangkan apa dan bagaimana mereka menggunakannya, cocok dan tepatnya. Efektifitas merupakan pertimbangan penting dalam memilih metoda KB. Tetapi, banyak klien mempunyai pertimbangan lain.
Untung dan rugià ini penting, mengingat kerugian bagi kebanyakan orang, justru keuntungan bagi yang lainnya. Contoh, seorang wanita cenderung memilih injeksi, sebaliknya yang lain justru menghindarinya dengan alasan takut diinjeksi.
Efek samping dan komplikasià beritahu klien mengenai efek samping dari metoda KB tersebut. Kebanyakan metoda mempunyai efek samping yang hampir sama. Ingat, “efek samping dan komplikasi dapat dikatakan sebagai suatu kerugian”. Jadi bagaimana cara kita meminimalisasinya.
Bagaimana cara penggunaannya guna menghindari kegagalan. Apalagi metode pil yang notabene perlu diingat dengan baik, bagaimana pula membicarakan kondom dengan partner seksualnya.
Mencegah IMS termasuk HIV/AIDS telah merebak di berbagai Negara. Konselor harus membantu klien memahami dan mampu mengukur tingkat resiko untuk terkena IMS. Jelaskan tentang metoda A,B, C, dan D untuk mencegah IMS dan HIV/AIDS.
Kapan kemabalià banyak metoda yang mengharuskan klien kembali ke klinik. Seperti IUD, MOW/MOP yang mengharuskannya secara rutin kembali ke tempat konseling. Konselor selalu memberikan anjuran kepada klien untuk kembali kapanpun dan untuk pertimbangan apapun.

6 LANGKAH KONSELING
Dalam bahasa Inggris kita mengenal istilah GATHER, yakni:
G
reet client sambut klien secara terbuka dan ramah, tanamkan keyakinan penuh, katakana juga bahwa tempat tersebut sangat pribadi. Sehingga hal yang didiskusikan akan menjadi rahasia.
A
sk client about themselves tanyakan klien tentang permasalahannya, pengalamannya dengan alat KB dan kesehatan reproduksinya. Tanyakan pula apakah telah ada metoda yang dipikirkan. Kita menyikapi dan mencoba menempatkan kita pada posisi klien. Dengan begitu akan memudahkan kita memahami apa sebenarnya permasalahan klien. Dengan perkataan lain, klien sebagai subjek sekaligus objek.
T
ell client about choices tanyakan tentang pilihannya, fokuskan perhatian kepada metoda yang dipilih klien. Tetapi ajukan pula metoda lain.
H
elp client make an informed choices Bantu membuat pilihan yang tepat, dorong ia mengemukakan pendapatnya dan ajukan beberapa pertanyaan! Apakah metoda KB tersebut memenuhi criteria medik. Juga apakah partner seksualnya mendukung keputusannya. Jika mungkin bicarakan dengan keduanya. Tanyakan metoda apa yang klien putuskan untuk digunakan.
E
xplain fully how to use the choosen method jelaskan cara menggunakan metoda pilihannya, dorong ia berbicara secara terbuka, jawab pula secara terbuka dan lengkap. Berilah kondom kepada klien yang beresiko IMS. Selain menggunakan kondom, apakah juga menggunakan metoda KB lainnya.
R
eturn visits should be welcomed kunjungan kembali, bicarakan dan sepakati kapan klien kembali untuk follow-up. Dan selalu mempersilakan klien kembali kapan saja.
Siswandi, terjemahan bebas, dari Robert A. Hatcher, M.D, M.P.H, et.al. 1997. The Essentials of Contraceptive Technology, A handbook for Clinical Staff. The John Hopkins School of Public Health.

apakah tiap anak perlu dipeluasang?

dikutip dari:suryadistira

ilustrasi : foto rudi 39 tahun yang lalu
Keyakinan adanya penjelmaan kembali menjadikan umat Hindu khususnya yang berkembang di Bali untuk berusaha ingin tahu, siapa yang sebenarnya yang menjelma atau numadi pada diri seseorang yang baru dilahirkan. Maka muncullah trasisi yang sepertinya menjadi kebiasaan (bukan keharusan) untuk “mepeluasang/meluasang”. Prakteknya, pihak keluarga yang mempunyai kelahiran bayi akan mendatangi seorang balian (dukun) yang kemudian dengan “kemampuannya” bisa “menghubungi” sang pitara sehingga tercipta semacam dialog atau Tanya jawab. Inti dialog itu berkisar pada pertanyaan tentang siapa gerangan yang menjelma (numadi) pada diri si bayi dan apa pula permintaannya. Biasanya akan disebutlah salah seorang leluhurnya yang sudah meninggal. Misalnya, “pernah” kakeknya yang bernama si A atau “pernah” neneknya yang bernama si C yang turun menjelma (numadi) pada diri si bayi.Perlu di pahami bahwa yang dimaksud menjelma disinitidak dalam pengertian secara genital. Artinya karena dikatakan pernah kakeknya yang menjelma maka bayi itu kelamin laki-laki. Tidak selalu begitu. Bisa jadi meski yang dikatakan turun menjelma adalah “pernah” neneknya tetapi kenyataannya yang lahir adalah bayi laki-laki.Dalam pemahaman Sradha Punarbhawa, yang turun menjelma adalah sifat-sifat roh sang numadi yang penjelmaan diharapkan dapat memperbaiki dan atau menyempurnakan karmanya dari asubhakarma menjadi subhakarma. Jadi, dalam proses penjelmaan, bukan jenis kelaminnya yang penting tetapi sifat-sifat sang dumadi itu yang melalui penumadiannya kini akan terus berikhtiar menyempurnakan karmanya. Dengan mengetahui bagaimana sifat-sifat sang Pitara yang yang numadi, maka diharapkan sang bayi yang kelak tumbuh menjadi besar dapat menyadari tentang siapa dan bagaimana sebenarnya jati dirinya. Kesadaran akan jati dirinya itulah yang diharapkan dapat mendorong dirinya untuk menjadi anak yang “saputra”. Karena hakikat “putra” adalah penyelamat leluhur dadi penderitaan.Tentang umur berapa biasanya si bayi dipeluasang, umumnya dilakukan setelah usai memperingati hari yang ke-12 dari kelahirannya. Tetapi ada pula yang langsung meluasang begitu si bayi dilahirkan. Dan dalam proses meluasang itu selain diketahui siapa yang numadi juga didapat keterangan perihal permintaan sang dumadi. Terhadap permintaan ini bisa ditunda pemenuhannya, tetapi karena umumnya permintaan sangat sederhana misalnya minta busana kuning atau agar dipertunjukkan wayang saat ngotonin nanti, maka sungguh tidak baik kalau sampai tidak dipenuhi.

Apa Ciri-ciri Karang Panes

2 oktober 2008

di kutip dari suryadistira

Ajaran agama Hindu dengan konsep kesemestaan alamnya senantiasa menekankan betapa perlu dan pentingnya diciptakan suatu kondisi harmonis antara manusia dengan Tuhan, manusia dengan manusia dan manusia dengan lingkungan. Kondisi yang harmonis itulah yang akan mengantarkan umat Hindu pada tujuan hidupnya – jagadhita dan moksha. Berpijak dadi pandangan demikian maka terhadap penggunaan suatu lingkungan (palemahan/pekarangan) patut juga memperhatikan segi-segi yang diyakini akan turut membuat kondisi harmonis. Karena itu lontar Ling Ira Bhagawan Wiswakarma telah menyuratkan perihal pekarangan atau tanah yang baik dan yang tidak baik dipergunakan untuk mendirikan suatu bangunan, baik perumahan, gedung, kantor, sekolah, tempat suci, dan lain-lain.

Pekarangan yang baik digunakan antara lain disebut: di timur (pascima) menemu labha (penghuninya akan mendapat untung), di utara: paribhoga wredhi (sejahtera dan bahagia), palemahan asah: sedang-sedang saja, palemahan inang: ceria dan asri serta berisi manik, palemahan mambu: sihin (dikasihi sahabat).

Selanjutnya pekarangan yang tidak baik dipergunakan lazim disebut sebagai “karang panes” dengan ciri-ciri berupa risiko yang diterima oleh si penghuni tanah tersebut yaitu: sering jatuh sakit, marah-marah tidak karuan, mengalami kebingungan , mudah bertengkar, dan sejenisnya. Ada pun jenis-jenis tanah yang tergolong karang panes ini di antaranya:

1. Karang Karubuhan
Karang yang berhadap-hadapan atau berpapasan dengan “pempatan” atau “pertigaan” atau persimpangan jalan.

2. Karang Sandanglawe
Karang yang memiliki pitu masuk berpapasan dengan pintu masuk pekarangan orang lain.

3. Karang Kuta Kabanda
Karang yang di apit oleh dua ruas jalan raya.

4. Karang Sula Nyupi
Karang yang berpapasan dengan jalan raya atau numbak marga atau numbak rurung.

5. Karang Gerah
karang yang terletak di hulu Pura/Parahyangan.

6. Karang Tenget
Karang bekas setra (sema), pura, pertapaan, dan lain-lain.

7. Karang Buta Salah Wetu
Karang dimana di tempat tersebut pernah atau sedang terjadi keanehan-keanehan (ketidak lumbrahan) seperti: kelahiran babi berkepala gajah, pohon kelapa bercabang, pisang berbuah melalui batangnya.

8. Karang Boros Wong
Karang yang memiliki dua pintu masuk yang sama tinggi dan berjajar.

9. Suduk Angga
Karang yang dibatasi oleh pagar hidup dimana akar dan tunasnya masuk ke pekarangan lain.

Terhadap jenis pekarangan/tanah di atas bisa saja digunakan asal sudah melalui upacara upahayu halaning palemahan seperti Caru Karang Panes. Tetapi akan lebih rahayu lagi jika tidak dipergunakan.

laparoscopic surgery

Laparoscopic Surgery for Adhesiolysis Harry Reich, M.D., F.A.C.O.G., FACS Attending Physician, Wyoming Valley Health Care System, Wilkes-Barre, PA

Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction. Over 90% of patients undergoing abdominal operations will develop postsurgical adhesions. This was not considered surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation.1 For the surgeon, laparoscopic lysis of bowel adhesions is fraught with danger to his/her reputation as bad results often are accompanied by poor reimbursement and lawsuits. This surgery is not for every surgeon! But if you take up the challenge, be prepared. Fatal sequelae of intraabdominal adhesions were reported as early as 1872 after removal of an ovarian tumor resulted in intestinal obstruction.2 Adhesions are the most common cause of bowel obstruction and most likely result from gynecologic procedures, trauma, appendectomies and other intestinal operations.3 Adhesions have also been proposed to cause infertility and abdominal and pelvic pain. Although nerve fibers have been confirmed in pelvic adhesions, their presence is not increased in those patients with pelvic pain.4 In addition, there does not appear to be an association between the severity of adhesions and complaint of pain. It is generally accepted that adhesions may impair organ motility resulting in visceral pain transmitted by peritoneal innervation.5 Many patients experience resolution of their symptoms after adhesiolysis.6-9 This may be complicated by placebo effect as demonstrated by one study that showed no difference in pain scores between patients who were randomized to adhesiolysis versus expectant management.10 In 1994, adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and $1.3 billion in health care expenditures. Forty-seven percent of these hospitalizations were for adhesiolysis of the female reproductive system, the primary site for these procedures. In comparison to similar data from 1988, the cost of adhesiolysis hospitalizations is down. One significant influence on this trend is the increased use of minimally invasive surgical techniques resulting in fewer days of inpatient care.11 This chapter reviews the pathophysiology of adhesion formation, equipment and technique for adhesiolysis, and methods for adhesion prevention. Pathophysiology of Adhesion Formation Adhesion formation is initiated by peritoneal trauma. Its morphogenesis was described in detail by diZerega.12 Within hours at the site of injury, polymorphonuclear leukocytes appear in large numbers meshed in fibrin strands. At 24-36 hours, macrophages appear in large numbers and are responsible for regulating fibroblast and mesothelial cell activities. By day 2, the wound surface is covered by macrophages, islands of primitive mesenchymal cells and mesothelial cells. By day four the islands of primitive mesenchymal cells have now come into contact with each other. Fibroblasts and collagen are now present and increasing. By day five, an organized fibrin interconnection is now seen composed of collagen, fibroblasts, mast cells, and vascular channels containing endothelial cells. The adhesion continues to mature as collagen fibrils organize into bands covered by mesothelium and containing blood vessels and connective tissue fiber.12 Equipment A review of standard equipment such as light sources and video systems is beyond the scope of this chapter. Equipment useful for advanced procedures and energy sources is included. However, the main technique for adhesiolysis with the least possibility for reformation can simply be described as “cold scissors dissection with bipolar backup.” Laparoscopes Four different laparoscopes should be available for adhesiolysis: a 10-mm 0° straight viewing laparoscope; a 10-mm operative laparoscope with 5-mm operating channel; a 5-mm straight viewing laparoscope for introduction through 5-mm trocar sleeves; and an oblique-angle laparoscope (30-45°) for upper abdominal and pelvic procedures. Scissors Scissors are the preferred instrument to cut adhesions, especially avascular and/or congenital adhesions. Using the magnification afforded by the laparoscope, most anterior abdominal wall, pelvic, and bowel adhesions can be carefully inspected and divided with minimal bleeding, rarely requiring microbipolar coagulation. Loose fibrous or areolar tissue is separated by inserting a closed scissors and withdrawing it in the open position. Pushing tissue with the partially open blunt scissors tip is used to develop natural planes. Reusable 5 mm blunt-tipped sawtooth scissors and curved scissors cut well without cautery. Blunt or rounded-tip 5mm scissors with one stable blade and one moveable blade are used to divide thin and thick bowel adhesions sharply. Sharp dissection is the primary technique used for adhesiolysis to diminish the potential for adhesion formation; electrification and laser are usually reserved for hemostatic dissection of adhesions where anatomic planes are not evident or vascular adherences are anticipated. Thermal energy sources must be avoided as much as possible to reduce adhesion recurrence. Blunt-tipped, sawtooth scissors, with or without a curve, cut well (Richard Wolf Medical Instruments, Vernon Hills, IL and Karl Storz Endoscopy, Culver City, CA). Many disposable scissors depend greatly on electrification for cutting. Hook-scissors are not very useful for adhesiolysis. I use them only to cut suture. Surgeons should select scissors that feel comfortable. To facilitate direction changes, the scissors should not be too long or encumbered by an electrical cord. This author prefers to make rapid instrument exchanges between scissors and microbipolar forceps through the same portal to control bleeding, instead of applying electrification via scissors. Electrosurgery When discussing electrosurgery, the term “cautery” should be abandoned as it is not electrosurgery. Cautery, thermocoagulation, or endocoagulation refer to the passive transfer of heat from a hot instrument to tissue. The hot instrument is usually heated by electrical current. The temperature rises within the tissue until cell proteins begin to denature and coagulate with resultant cell death. Electrical current does not pass through the patient’s body! Monopolar cutting current can be used safely, as the voltage is too low to arc to organs even 1 mm away. Cutting current is used to both cut and/or coagulate (desiccate) depending on the portion of the electrode in contact with the tissue. The tip cuts, while the wider body tamponades and coagulates. Monopolar coagulation current which uses voltages over 10 times that of cutting current can arc 1 to 2 mm and is used in close proximity to tissue, but not in contact, to fulgurate diffuse venous and arteriolar bleeders. It takes 30% more power to spark or arc in CO2 pneumoperitoneum than in room air; thus, at the same electrosurgical power setting, less arcing occurs at laparoscopy than at laparotomy. Monopolar electrosurgery should be avoided when working on the bowel unless the surgeon is well versed in this modality. The expert laparoscopic surgeon can use monopolar electrosurgery safely to cut or fulgurate tissue, but desiccation (coagulation) on bowel should be performed with bipolar techniques.13,14 Electrosurgical injury to the bowel can occur beyond the surgeon’s field of view during laparoscopic procedures from electrode insulation defects or capacitive coupling. While the surgeon views the tip of the electrode, electrical discharge may occur from its body (insulation failure) or from metal trocar cannulas surrounding the electrode if they are separated from the skin by plastic retention sleeves. These problems are eliminated by active electrode monitoring using the Electroshield EM-1 monitor system (Encision, Boulder, CO). This consists of a sheath surrounding the electrode and a sheath monitor (EM-1) to detect any insulation faults and shield against capacitive coupling. Bipolar desiccation using cutting current between two closely opposed electrodes is safe and efficient for large vessel hemostasis.15,16 Large blood vessels are compressed and bipolar cutting current passed until complete desiccation is achieved, i.e., the current depletes the tissue fluid and electrolytes and fuses the vessel wall. Coagulating current is not used as it may rapidly desiccate the outer layers of the tissue, producing superficial resistance thereby preventing deeper penetration. Small vessel hemostasis necessary for adhesiolysis is best achieved by using microbipolar forceps after precisely identifying the vessel with electrolyte solution irrigation. Microbipolar forceps (Richard Wolf Medical Instruments, Vernon Hills, IL) with an irrigation channel work best for precise tissue desiccation with minimal thermal spread. Harmonic Scalpel The use of Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, Ohio) for laparoscopic adhesiolysis is gaining popularity. Although it has its limitations, the benefit of this multifunctional instrument far outweighs any disadvantage. Many factors can be attributed to its progressive acceptance. The lack of electrical energy used to coagulate vessels and the smaller (2mm) lateral energy spread make it more attractive than conventional electrosurgical instruments by potentially reducing the percentage of delayed post-operative bowel injuries (caused by electrical burns.) This is not to say however, that injury cannot occur. As with standard electrosurgical instruments, the Harmonic Scalpel, specifically the jaws, can become hot and cause tissue injury if not used in a prudent manner. Although Harmonic Scalpel has the ability to grasp, cut, and cauterize simultaneously, making it a useful instrument for a judicious operator (requiring fewer instrument changes in and out of port sites), the inability to cut without applying energy assures the need for a sharp pair of conventional scissors in laparoscopic adhesiolysis. Rectal and Vaginal Probes A sponge on a ring forceps is inserted into the vagina or the posterior vaginal fornix, and an 81-French probe is placed in the rectum to define the rectum and posterior vagina for lysis of pelvic adhesions and/or excision of endometriosis when there is a significant degree of cul-de-sac obliteration. Whenever rectal location is in doubt, it is identified by insertion of the rectal probe. CO2 laser The CO2 laser, with its 0.1 mm depth of penetration and inability to traverse through water, allows the surgeon some security when lysing adhesions especially in the pelvis. The Coherent 5000L laser (Palo Alto, CA), by using a 11.1 um wavelength beam, maintains a 1.5mm spot size at all power settings allowing for more precision than most standard 10.6 um wavelength CO2 lasers. Aquadissection Aquadissection is the use of hydraulic energy from pressurized fluid to aid in the performance of surgical procedures. The force vector is multidirectional within the volume of expansion of the uncompressible fluid; the force applied with a blunt probe is unidirectional. Instillation of fluid under pressure displaces tissue, creating cleavage planes in the least resistant spaces. Aquadissection into closed spaces behind peritoneum or adhesions produces edematous, distended tissue on tension with loss of elasticity, making further division easy and safe using blunt dissection, scissors dissection, laser, or electrosurgery. Suction-irrigators with the ability to dissect using pressurized fluid should have a single channel to maximize suctioning and irrigating capacity. This allows the surgeon to perform atraumatic suction-traction-retraction, irrigate directly, and develop surgical planes (aquadissection). The distal tip should not have side holes as they impede these actions, spray the surgical field without purpose, and cause unnecessary tissue trauma when omentum, epiploic appendices, and adhesions become caught. The shaft should have a dull finish to prevent CO2 laser beam reflection, allowing it to be used as a backstop. The market is crowded with many aquadissection devices. Plume Eliminator Smoke evacuation during electrosurgery or CO2 laser laparoscopy is expedited using a Clear View EBS ICM 350 smoke evacuator (I.C. Medical, Phoenix, AZ). Gasless laparoscopy (abdominal wall retractors) Abdominal wall subcutaneous emphysema occurs frequently during anterior abdominal wall adhesiolysis as peritoneal defects result in free communication with the rectus sheath. This compromises peritoneal cavity operating space. A useful technique is to insert an anterior abdominal wall retractor (AbdaLift, Storz, CA) once the umbilicus has been cleared of adhesions. Laparoscopic Peritoneal Cavity Adhesiolysis Adhesiolysis by laparoscopy and laparotomy can be very time-consuming and technically difficult and is best performed by an expert surgeon. However, despite lengthy laparoscopic procedures (two to four hours), most patients are discharged on the day of the procedure, avoid large abdominal incisions, experience minimal complications, and return to full activity within one week of surgery. In this section, general adhesiolysis, pelvic adhesiolysis, ovariolysis, salpingo-ovariolysis, and salpingostomy are described. The laparoscopic treatment of acute adhesions has not been included. However, the best treatment for sexually transmitted disease adhesive sequelae may be prevention through early laparoscopic diagnosis and treatment of acute pelvic infection, including abscesses. Acute adhesiolysis will often prevent chronic adhesion formation.17-19 Classification Extensive peritoneal cavity adhesion procedures need a classification system that relates to their degree of severity and the surgical expertise necessary for adhesiolysis. The single best indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies. The frequency of small bowel obstruction symptoms indicates the need for surgery. Peritoneal adhesiolysis is classified into enterolysis including omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis). Bowel adhesions are divided into upper abdominal, lower abdominal, pelvic, and combinations. Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division. The extent, thickness, and vascularity of adhesions vary widely. Intricate adhesive patterns exist with fusion to parietal peritoneum or various meshes. Extensive small bowel adhesions are not a frequent finding at laparoscopy for pelvic pain or infertility. In these cases, the fallopian tube is adhered to the ovary, the ovary is adhered to the pelvic sidewall, and the rectosigmoid may cover both. Rarely, the omentum and small bowel are involved. Adhesions may be the result of an episode of pelvic inflammatory disease or endometriosis, but most commonly are caused by previous surgery. Adhesions cause pain by entrapment of the organs they surround. The surgical management of extensive pelvic adhesions is one of the most difficult problems facing surgeons today. Surgical plan for extensive enterolysis A well-defined strategy is important for small bowel enterolysis. For simplification, this is divided into three parts: 1. Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel). 2. Division of all small bowel and omental adhesions in the pelvis. Rectosigmoid, cecum, and appendix often require some separation during this part of the procedure. 3. Running of the bowel Using atraumatic grasping forceps and usually a suction-irrigator for suction traction, the bowel is run. Starting at the cecum and terminal ileum, loops and significant kinks are freed into the high upper abdomen to the ligament of Treitz. 4.(Optional) Finally tubo-ovarian pathology is treated if indicated. Time frequently dictates that all adhesions cannot be lysed. From the history, the surgeon should conceptualize the adhesions most likely to be causing the pain, i.e., upper or lower abdomen, left or right, and clear these areas of adhesions. Preoperative preparation Patients are informed preoperatively of the high risk for bowel injury during laparoscopic procedures when extensive cul-de-sac involvement with endometriosis or adhesions is suspected. They are encouraged to hydrate and eat lightly for 24 hours before admission. A mechanical bowel preparation (GoLYTELY or Colyte) is administered orally the afternoon before surgery to induce brisk, self-limiting diarrhea to cleanse the bowel without disrupting the electrolyte balance.20 The patient is usually admitted on the day of surgery. Lower abdominal, pubic, and perineal hair is not shaved. Patients are encouraged to void on call to the OR, and a Foley catheter is inserted only if the bladder is distended or a long operation anticipated. A catheter is inserted during near the end of the operation and removed in the recovery room when the patient is aware of its presence, to prevent bladder distension. Antibiotics (usually cefoxitin) are administered in all cases lasting over two hours, at the two-hour mark. Patient Positioning All laparoscopic surgical procedures are done under general anesthesia with endotracheal intubation. An orogastric tube is placed routinely to diminish the possibility of a trocar injury to the stomach and to reduce small bowel distention. The patient’s arms should be tucked on both sides so that the surgeon’s position is comfortable and not limited. The patient’s position is flat (0°) during umbilical trocar sleeve insertion and anterior abdominal wall adhesiolysis but a steep Trendelenburg position (30 degrees), reverse Trendelenburg position, and side-to-side rotation are used when necessary. Lithotomy position, with the hip extended (thigh parallel to abdomen) is obtained with Allen stirrups (Edgewater Medical Systems, Mayfield Heights, OH) or knee braces, which are adjusted individually to each patient before she is anesthetized. Anesthesia examination is performed prior to prepping the patient. Incisions In the absence of suspected periumbilical adhesions, an intraumbilical vertical incision is made through the skin of the inferior umbilical fossa extending to and just beyond its lowest point. A Verres needle is placed through this low point while pulling the umbilicus towards the pubic symphysis and insufflation with CO2 is continued until an intraabdominal pressure of 25-30mm Hg is obtained. The palmed short trocar is positioned at a 90o angle inside the deep funnel shaped portion of the umbilical fossa where fascia and peritoneum meet and inserted through this into the peritoneal cavity at a 45o angle in one continuous thrusting motion, with wrist rotation. This is performed without lifting the anterior abdominal wall as the high intraabdominal pressure provides counterpressure against the parietal peritoneum to lift it above the large vessels below. The result is a parietal peritoneal puncture directly beneath the umbilicus. Once the trocar is in place within the abdominal cavity, the intra-abdominal pressure is lowered to 12-15 mm Hg to diminish the development of vena caval compression and subcutaneous emphysema. Special alternate entry sites and techniques are used when there is a high suspicion for periumbilical adhesions in patients who have undergone multiple laparotomies, have lower abdominal incisions traversing the umbilicus, or who have extensive adhesions either clinically or from a previous operative record. Open laparoscopy at the umbilicus carries the same risk for bowel laceration if the bowel is fused to the umbilical undersurface. One alternate site is in the left ninth intercostal space, anterior axillary line. Adhesions are rare in this area, and the peritoneum is tethered to the undersurface of the ribs, making peritoneal tenting away from the needle unusual. A 5-mm skin incision is made over the lowest intercostal space (the 9th) in the anterior axillary line. The Veress needle is grasped near its tip, like a dart, between thumb and forefinger, while the other index finger spreads this intercostal space. The needle tip is inserted at a right angle to the skin (a 45o angle to the horizontal) between the ninth and tenth ribs. A single pop is felt on penetration of the peritoneum. Pneumoperitoneum to a pressure of 30 mmHg is obtained. A 5 mm trocar is then inserted through this same incision that has migrated downward below the left costal margin because of the pneumoperitoneum. Another alternate entry site is Palmer’s point21 located 3 cm inferior to the subcostal arch in the left medioclavicular line.22 Also, if the uterus is present and thought to be free of adhesions, the surgeon may consider inserting a long Veress needle transvaginally through the uterus.23 When unexpected extensive adhesions are encountered initially surrounding the umbilical puncture, the surgeon should immediately seek a higher site. Thereafter, the adhesions can be freed down to and just beneath the umbilicus, and the surrounding bowel inspected for perforations. The umbilical portal can then be reestablished safely for further work. Other laparoscopic puncture sites are placed as needed, usually lateral to the rectus abdominis muscles and always under direct laparoscopic vision. When the anterior abdominal wall parietal peritoneum is thickened from previous surgery or obesity, the position of these muscles is judged by palpating and depressing the anterior abdominal wall with the back of the scalpel; the wall will appear thicker where rectus muscle is enclosed, and the incision site is made lateral to this area near the anterior superior iliac spine. If an umbilical insertion is possible and extensive adhesions are present close to but below the umbilicus, the operating laparoscope with scissors in the operating channel is the first instrument used. If a left upper quadrant 5 mm incision is necessary, there is usually room for another puncture site to do initial adhesiolysis with scissors. Abdominal Adhesiolysis Anterior abdominal wall adhesions involve the parietal peritoneum stuck to the omentum, transverse colon, and small bowel with varying degrees of fibrosis and vascularity. Adhesions may be filmy and avascular, filmy and vascular, or dense, fibrous and vascular. All of these adhesions to the anterior abdominal wall are released. If adhesions extend from above the level of the laparoscope in the umbilicus, another trocar is inserted above the level of the highest adhesion and the laparoscope is inserted there. Adhesions are easier to divide when working above them, instead of within them, as gravity helps to delineate the plane for separation after which the CO2 pneumoperitoneum can disperse into the dissection plane. Adhesiolysis is done using scissors alone if possible. Rarely, electrosurgery, CO2 laser, and the Harmonic Scalpel can be are used. In most cases, the initial adhesiolysis is performed with scissors. CO2 laser through the laparoscope on adhesions close to the trocar insertion often results in reflection with loss of precision. Electrosurgery (cutting current) is used only when there is little chance that small bowel is involved in the adhesion. Initially, blunt-tipped scissors in the operating channel of an operating laparoscope are inserted into the interface between the anterior abdominal wall parietal peritoneum and the omentum. Rotating the laparoscope so that the scissors exit at 12 o’clock instead of 3 o’clock facilitates early adhesiolysis. Blunt dissection is performed by inserting the scissors at the interface, opening, and withdrawing them. This maneuver is repeated many times to delineate the thin avascular adhesions from thicker vascular fibrotic attachments that are individually coagulated and divided. Frequently, adhesions can be bluntly divided by grasping the adhesion in the partially closed scissors and gently pushing the tissue. If the plane of adhesions cannot be reached with the tip of the scissors, the abdominal wall can be pressed from above with the finger to make it accessible to the scissors. After initial adhesiolysis, visualization is improved allowing better access and exposure for further adhesiolysis. Secondary trocar sites can now be placed safely. After their insertion, the remainder of the adhesions can now be lysed using scissors with microbipolar backup for rare arteriolar bleeders. Small venule bleeders are left alone. On occasion, in operations in which symptomatic bowel adhesions are not the main problem, an electrosurgical spoon or knife is used to divide the remaining omental adhesions if bowel is not involved. If bowel is involved, dissection proceeds with scissors, without electrosurgery, through the second puncture site, aided by traction on the bowel from an opposite placed puncture site. Rarely, the CO2 laser may be used through the operating channel of the operating laparoscope. When using the CO2 laser for adhesiolysis, aquadissection is performed to distend the adhesive surface with fluid before vaporizing the individual adhesive layers. The suction-irrigator can also be used for suction traction, instead of a laparoscopic Babcock, and as a backstop to prevent thermal damage to other structures. The suction irrigator is also used to clean the laparoscopic optic which is then wiped on the bowel serosa before continuing. Denuded areas of bowel muscularis are repaired transversely using a 3-0 or 4-0 Vicryl seromuscular stitch. Denuded peritoneum is left alone. Minimal oozing should be observed and not desiccated unless this bleeding hinders the next adhesiolysis step or persists towards the end of the operation. With perseverance, all anterior abdominal wall parietal peritoneum adhesions can be released. The Harmonic Scalpel is also useful for adhesiolysis. It bears repeating, the Harmonic Scalpel is not a scissor. This instrument works by coagulating tissue in between the blades and allowing it to be “pressed apart” after full coagulation of the tissue between the active blade and the compressing surface. Tissue is first grasped between the blades of the Harmonic Scalpel, steadily compressed, and the blade is activated allowing the tissue to separate once it is fully coagulated. Any tissue between the blades of the Harmonic Scalpel will be heated and then be allowed to fall apart. This includes all blood vessels up to 3mm in diameter incorporated in the tissue between the blades. As stated before, the Harmonic Scalpel can be used to grasp tissue in a general manner when the blades are not active. However, prior to grasping any tissue, the operator must allow the active blade to cool sufficiently so it will not burn any tissue it may come in contact with. The operator must remember that a Harmonic Scalpel does not replace the scissor, especially when dealing with bowel in the same proximity to an adhesion plane. Harmonic Scalpel comes in 5- and 10-mm size instrumentation with active jaws as well as adaptable adjuncts to the instrument such as a spatula type dissector, “ball” type dissector and hook dissector. All of these type instruments can be used in the same location as you would normally use a monopolar electrode; bear in mind once again that the lateral energy spread is only just 2mm with the Harmonic Scalpel. Pelvic Adhesiolysis The next step is to free all bowel loops in the pelvis. Small bowel attached to the vesicouterine peritoneal fold, uterus or vaginal cuff, and the rectum is liberated. There are three key points when performing bowel adhesiolysis within the pelvis: scissors dissection without electrosurgery, countertraction and blunt dissection. The bowel is gently held with an atraumatic grasper and lifted away from the structure to which it is adhered, exposing the plane of dissection. When adhesive interfaces are obvious, scissors are used. The blunt-tipped scissors are used to sharply dissect the adhesions in small, successive cuts taking care not to damage the bowel serosa. Countertraction will further expose the plane of dissection and ultimately free the attachment. Electrosurgery and laser are generally not used for adhesiolysis involving the bowel due to the risk of recurrent adhesions from thermal damage. However, when adhesive aggregates blend into each other, initial incision is made very superficially with laser, and aquadissection distends the layers of the adhesions, facilitating identification of the involved structures. Division of adhesions continues with laser at 10-20 W in pulsed mode. The aquadissector and injected fluid from it are used as a backstop behind adhesive bands that are divided with the CO2 laser. The rectosigmoid can be adhered to the left pelvic sidewall obscuring visualization of the left adnexa. Dissection starts well out of the pelvis in the left iliac fossa. Scissors are used to develop the space between the sigmoid colon and the psoas muscle to the iliac vessels, and the rectosigmoid reflected toward the midline. Thereafter, with the rectosigmoid placed on traction, rectosigmoid and rectal adhesions to the left pelvic sidewall are divided starting cephalad and continuing caudad. Cul-de-sac adhesions can cause partial or complete cul-de-sac obliteration from fibrosis between the anterior rectum, posterior vagina, cervix, and the uterosacral ligaments. The technique of freeing the anterior rectum to the loose areolar tissue of the rectovaginal septum before excising and/or vaporizing visible and palpable deep fibrotic endometriosis is used.24 Attention is first directed to complete dissection of the anterior rectum throughout its area of involvement until the loose areolar tissue of the rectovaginal space is reached. Using the rectal probe as a guide, the rectal serosa is opened at its junction with the cul-de-sac lesion. Careful dissection ensues using aquadissection, suction-traction, laser, and scissors until the rectum is completely freed and identifiable below the lesion. Excision of the fibrotic endometriosis is done only after rectal dissection is completed. Deep fibrotic, often nodular, endometriotic lesions are excised from the uterosacral ligaments, the upper posterior vagina, (the location of which is confirmed by the Valtchev retractor or a sponge in the posterior fornix), and the posterior cervix. The dissection on the outside of the vaginal wall proceeds using laser or scissors until soft pliable upper posterior vaginal wall is uncovered. It is frequently difficult to distinguish fibrotic endometriosis from cervix at the cervicovaginal junction and above. Frequent palpation using rectovaginal examinations helps identify occult lesions. When the lesion infiltrates through the vaginal wall, an “en bloc” laparoscopic resection from cul-de-sac to posterior vaginal wall is done, and the vagina is repaired laparoscopically with the pneumoperitoneum maintained with a 30-cc foley balloon in the vagina. Or, more recently, the vaginal lesion is mobilized vaginally, the vagina closed over the mobilized portion, and the en bloc lesion excision completed laparoscopically. Sometimes the fibrotic cul-de-sac lesion encompassing both uterosacral ligament insertions and the intervening posterior cervix-vagina and anterior rectal lesion can be excised as one en bloc specimen. Endometriotic nodules infiltrating the anterior rectal muscularis are excised usually with the surgeon’s or his assistant’s finger in the rectum just beneath the lesion. In some cases, the anterior rectum is reperitonealized by plicating the uterosacral ligaments and lateral rectal peritoneum across the midline. Deep rectal muscularis defects are always closed with suture. Full thickness rectal lesion excisions are suture or staple repaired laparoscopically. When a ureter is close to the lesion, its course in the deep pelvis is traced by opening its overlying peritoneum with scissors or laser. On the left, this often requires scissors reflection of the rectosigmoid, as previously described, starting at the pelvic brim. Bipolar forceps are used to control arterial and venous bleeding. Adnexal Adhesiolysis25 SalpingoOvariolysis26 Ovarian adhesions to the pelvic sidewall can be filmy or fused. Initially, adhesions between the ovary and fallopian tubes and other peritoneal surfaces are identified. It is imperative that the surgeon knows the surrounding anatomy prior to cutting any tissue to avoid damage to vital structures. The plane of dissection is identified and followed to avoid damage to other structures. The uteroovarian ligament may be held with an atraumatic grasper to facilitate countertraction and expose the line of cleavage. During ovariolysis, it is important to preserve as much peritoneum as possible while freeing the ovary. Dissection starts either high in the pelvis just beneath the infundibulopelvic ligament or deep on the pelvic sidewall beneath the ureter in the pararectal space. In each case, scissors are used both bluntly and sharply to mobilize the ovary from the sidewall. Alternatively, aquadissection may be used to facilitate identification of adhesion layers and to provide a safe backstop for the CO2 laser. Once an adhesion layer is identified, the aquadissector can also be placed behind this ridge and used as a backstop during CO2 laser adhesiolysis. Adhesiolysis is performed sharply and bluntly in a methodical manner working caudad until the cul-de-sac is reached. If fimbrioplasty is to be performed, then hydrodistention is achieved by transcervical injection of dilute indigo carmine through a uterine manipulator. This distends the distal portion of the tube which is stabilized, and the adhesive bands are freed using scissors, laser or micropoint electrosurgery. If necessary, the fimbriated end can be progressively dilated using 3 mm alligator-type forceps. The closed forceps are placed through the aperture, opened, and removed. This is repeated one or more times. If the opening does not remain everted on its own, the intussusception salpingostomy method of McComb27 is used to avoid thermal damage to the ciliated tubal epithelium from CO2 laser or electrosurgery. The tip of the aquadissector is inserted approximately 2 cm into the newly opened tube, suction applied, and the tube fimbrial edges pulled around the instrument to turn the tube end inside-out. The borders of the incision act as a restrictive collar to maintain the mucosa in this newly everted configuration. In some cases, the ostial margin is sutured to the ampullary serosa with 6-0 Underwater surgery at the end of each procedure28 At the close of each operation, an underwater examination is used to document complete intraperitoneal hemostasis in stages; this detects bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The integrity of the rectum and rectosigmoid is often checked at this time by instillation of dilute indigo carmine solution or air transanally through a 30 cc Foley catheter. The CO2 pneumoperitoneum is displaced with 2 to 5 L of Ringer’s lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned until the effluent is clear of blood products, usually after 10-20 L. Underwater inspection of the pelvis is performed to detect any further bleeding which is controlled using microbipolar irrigating forceps to coagulate through the electrolyte solution. First hemostasis is established with the patient in Trendelenburg position, then per underwater examination with the patient supine and in reverse Trendelenburg, and finally, with all instruments removed, including the uterine manipulator. To visualize the pelvis with the patient supine, the 10-mm straight laparoscope and the actively irrigating aquadissector tip are manipulated together into the deep cul-de-sac beneath floating bowel and omentum. During this copious irrigation procedure, clear fluid is deposited into the pelvis and circulates into the upper abdomen, displacing upper abdominal bloody fluid which is suctioned after flowing back into the pelvis. An “underwater” examination is then performed to observe the completely separated tubes and ovaries and to confirm complete hemostasis. A final copious lavage with Ringer’s lactate solution is undertaken and all clots directly aspirated; at least 2 L of lactated Ringer’s solution are left in the peritoneal cavity to displace CO2 and to prevent fibrin adherences from forming by separating raw operated-upon surfaces during the initial stages of reperitonealization. Displacement of the CO2 with Ringer’s lactate diminishes the frequency and severity of shoulder pain from CO2 insufflation. No other anti-adhesive agents are employed. No drains, antibiotic solutions, or heparin are used. Handoscopy Hand assisted laparoscopy or “handoscopy” has become popular over the last 5 years, mainly in the field of solid organ surgery and bowel surgery. The main advantage of handoscopy is that it allows the surgeon to regain the tactile feel of surrounding tissues previously lost to “laser” laparoscopists and permits a more purposeful manipulation of larger organs. Often, it is the use of handoscopy for tissue palpation, that enables a successful laparoscopic adhesiolysis. At times, during laparoscopic procedures, visualization can be poor due to dense adhesions and the inability to determine tissue planes. With the placement of the operator’s hand inside the peritoneal cavity the surgeon is usually able to palpate surrounding organs and allow for a better tissue dissection plane that otherwise may not have been possible through direct visualization only. Not only can the use of a hand port facilitate an otherwise tedious procedure, it effects a safer operation for the patient with less chance of bowel injury. If bowel resection should become necessary, the use of the hand port allows for exteriorization of the segment that requires resection once again making the procedure easier and less time consuming. A handoscopy incision is usually only 7-8 cm and is either placed in the left or right lower portion of the abdomen with insertion of the operator’s non-dominant hand. The muscle splitting technique is used in a similar method as in performing an open appendectomy. The entire peritoneal cavity can be examined through either one of these incisions with the operator’s hand and it can be used for organ extraction as well. Several different types of handoscopy ports are available and all provide equal access to the peritoneal cavity. When placing a handoscopy port for adhesiolysis, the operator must first choose a location on the abdominal wall that will allow optimal access to the point where adhesions are greatest. After the hand port location is chosen, a marking pen should be used to outline the area of the abdominal wall where the hand port is to be placed. The area for the incision should be anesthetized with bupivicaine for post operative pain control and an incision should then be made into the skin. The size of the incision should be the same size as the operator’s glove size. After this is completed, a muscle splitting technique should be used to enter the peritoneal cavity just as the operator would in performing an open appendectomy. Once the peritoneal cavity is entered, the hand port can then be placed. All of the hand port apparatus require that any adhesions on the peritoneal side of the incision be lysed prior to inserting the handoscopy device. Additionally, these devices should not be placed over any bony prominences, i.e., iliac crest, or encompassing any bowel in the peritoneal ring surface as to injure any bowel in the abdomen. If the handoscopy port is placed in the upper abdomen, the falciform ligament may require division prior to inserting the ring. Once the handoscopy device is in place the lysis of adhesions can precede in an orderly fashion by identifying the tissue planes by feel with the operator’s fingers and additionally being able to provide appropriate traction and countertraction to allow for a safe adhesiolysis. Incidental enterotomies can be sutured with conventional suture and then tied using one hand knot tying technique with the intra abdominal hand. Should any bowel resections be required the hand port can be used as a mini laparotomy site for extraction of any specimens and for exteriorizing any bowel that may require resection and/or repair. Additionally all handoscopy devices that are placed through the abdominal wall act as a wound protector and may minimize post operative wound infections as well as protect from any potential tumor seeding if the operation is for malignancy. The opening of the Ethicon Lap-DiscTM device is like a camera shutter that can be circumferentially reduced to seal the pneumoperitoneum around any size 5 mm trocar. Once the procedure is completed the hand port device is removed, anterior and posterior rectus sheath muscle fascia are closed with either 0 or 2-0 absorbable suture and the skin is then closed in a subcuticular manner. Additionally, a variety of “pain buster” catheters are now available for insertion into the supra fascia layer of the wound which allows for excellent postoperative analgesia. These help to minimize postoperative narcotic requirements thereby facilitating an earlier return of bowel function and more expedient discharge from the hospital. It has been the author’s personal experience that patients undergoing a handoscopy type of operation parallel their recovery in the same manner as a conventional laparoscopic case with a delay of only one day in recovery. If a bowel resection should be required the patient usually only requires to be NPO overnight and clear liquids may be started on the first postoperative day. The patient is maintained on clear liquids until passing flatus and moving bowels. Most patients are discharged home on the second postoperative day if a bowel resection has been required. In the event that a bowel resection is required, stapling instruments are used routinely for division of the bowel and anastomosis. The mesentery of the bowel can be divided with the use of surgical ties, Harmonic Scalpel, or vascular cartridge stapling devices. Bowel resection is preceded by first identifying the lines of resection, transection of the bowel, the use of stapling devices to transect the bowel proximally and distally, division of the mesentery, followed by re-anastomosis once again using stapling devices and closing the enterotomy required by the tines of the stapling device with an additional stapling device. Any mesentery defect caused by a small bowel resection are closed with a running 0 or 2-0 absorbable suture. Mesenteric defects need not be closed after large bowel resections. Open Adhesiolysis In certain situations an open adhesiolysis is best for the patients. It is usually performed after an attempted laparoscopic approach has been abandoned. If only a pelvic adhesiolysis is needed, a Pfannenstiel incision usually is adequate. However if the entire peritoneal cavity is encased in dense fibrotic adhesions a midline incision is usually required. Open adhesiolysis should be reserved for the worst possible cases where laparoscopic adhesiolysis has failed, where there has been several incidental enterotomies made, or adhesiolysis cannot be performed secondary to encasement of the bowel. Open adhesiolysis should also be considered in a patient unable to tolerate CO2 insufflation. An open adhesiolysis is performed in the exact same way as a laparoscopic adhesiolysis. First, all adhesions are taken down from the abdominal wall usually with the Metzenbaum scissors. Second, all loops of bowel are extracted out of the pelvis. Finally, all interloop adhesions are lysed from the ligament of Treitz to the ileo-cecal valve. Any incidental enterotomies should be repaired at the time of discovery to avoid intra peritoneal contamination and development of an infection. Hemostasis must be meticulous during the entire dissection as in a laparoscopic procedure. An abundant use of warm irrigation fluid is used as well. It is extremely important to keep the tissues moist to prevent desiccation from atmospheric air as this can stimulate adhesion reformation. It has been a personal experience that the use of adhesion barriers has been ineffective in open procedures on the bowel and is not indicated. Adhesion Prevention Intraoperatively, the surgeon can minimize adhesion formation through careful tissue handling, complete hemostasis, abundant irrigation, limited thermal injury, infection prophylaxis, and minimizing foreign body reaction.29,30 A recent Cochrane Database Systematic Review investigated whether pharmacological and liquid agents used as adjuvants during pelvic surgery in infertility patients lead to a reduction in the incidence or severity of postoperative adhesion (re-)formation, and/or an improvement in subsequent pregnancy rates. The results of this review are as follows: there is some evidence that intraperitoneal steroid administration decreases the incidence and severity of postoperative adhesion formation; intraperitoneal administration of dextran did not decrease postoperative adhesion formation at second look laparoscopy; there is no evidence that intra-abdominal crystalloid instillation, calcium channel blocking agents, non-steroidal anti inflammatory drugs and proteolytics decrease postoperative adhesion formation.31 Barrier agents for prevention of adhesion formation are commercially available. The Cochrane Menstrual Disorders and Subfertility Group investigated the effects these agents have on postoperative adhesion formation. The 15 randomized controlled trials comprised laparoscopic and laparotomic surgical techniques. Results of the investigation were as follows: oxidized regenerated cellulose (Interceed: Johnson & Johnson Medical, Somerville, NJ) reduces the incidence of adhesion formation and re-formation at laparoscopy and laparotomy in the pelvis; polytetrafluoroethylene (GoreTex: W.L. Gore & Associates, Flagstaff, AZ) appears to be superior to Interceed in preventing adhesion formation in the pelvis but is limited by the need for suturing and later removal; Seprafilm (Genzyme, Cambridge, MA) does not appear to be effective in preventing adhesion formation.32 If Interceed is to be used for prevention of adhesion formation, the intrapelvic fluid should be completely aspirated. A piece of Interceed large enough to cover the at-risk area is placed and moistened with a small volume of irrigant. Complete hemostasis must be achieved prior to placing the material. If hemostasis has not been achieved, the Interceed will turn brown or black and must be replaced as this may actually increase adhesion formation.33 Animal studies and clinical trials of a gel form of modified hyaluronic acid, a naturally occurring glycosaminoglycan, show evidence for reducing de novo adhesion formation.34 Intergel (Gynecare, Johnson & Johnson Inc., Somerville, NJ) is commercially available for open surgery use. The ideal barrier material should be easy to apply, both in open and laparoscopic surgeries. Additionally, it should be nonreactive, persist during the critical wound reepithelization period, stay in place on the target tissue for several days, and eventually be resorbed following peritoneal healing A new product, currently undergoing clinical trials, SprayGel (Confluent Surgical, Waltham, MA), meets these criteria. SprayGel is composed of two liquids which are polyethylene glycol (PEG)-based. PEG is widely used in a variety of medical products. When these two liquids are applied while mixing them in situ, they polymerize within seconds to form a visible, adherent, and conforming hydrogel barrier on the target tissues. The gel remains intact for the next 5 to 7 days before breaking down by hydrolysis, and eventual clearance through the kidneys. Preclinical safety studies of SprayGel adhesion barrier demonstrate that it is a remarkably inert, biocompatible material, resulting in no signs of toxicity at multiple time points, even when tested at 25 times the anticipated normal dose. Clinical studies in Europe and the US further support the safety profile of this material as an implant. Preliminary prospective randomized clinical trials have evaluated SprayGel adhesion barrier in open and laparoscopic myomectomy surgery, as well as in laparoscopic ovarian surgery. In the European myomectomy study, a significant improvement was demonstrated in the tenacity of adhesions between the treated and control populations, when comparing the initial procedures and second-look laparoscopies, as evaluated by the surgeon. The product is currently under review in a multicenter pivotal clinical trial in the US. Conclusion Adhesion formation after gynecologic surgery is common. When compared to laparotomy, laparoscopy has been shown to result in less de novo adhesion formation, but adhesion reformation continues to be a problem.35 Sequelae of intra-abdominal adhesion formation can be fatal, result in infertility, and be a source of chronic pelvic pain. Minimally invasive surgical management of adhesion formation affords the patient all of the known benefits of laparoscopic surgery including less postoperative analgesics, shorter hospital stays, and more rapid convalescence and return to normal activities. Unfortunately, recurrence rates after adhesiolysis for intestinal obstruction are reported to range from 8%36 to 32%37. Thus, for some patients, adhesiolysis may become a repeat surgical procedure. No longer can the surgeon ignore the benefits of minimally invasive surgery for adhesiolysis. While these techniques and procedures are not without risk, patients should not be denied their inherent advantages. Astute clinicians must work together to discern the most appropriate uses for this therapy