Abstract
We have reported the experience of two referral laparoscopic gynecologic centers in Italy considering the results of almost 1000 laparoscopic myomectomies, including complication rate and fertility outcome. From January 1991 to December 2003, a total of 982 single or multiple laparoscopic myomectomies (LM) were performed. Indications were infertility, recent and significant uterine enlargement, and other symptoms such as pelvic pain, menometrorrhagia, and abnormal bleeding. All surgical procedures were performed by three surgeons in two different endoscopic centers. Surgery outcome and information about subsequent fertility and obstetric outcome were reported. Myomectomies were performed using a standard technique with three ancillary suprapubic ports. In cases of deep intramural myomas, we injected the myomas with vasoconstrictive agents. A vertical incision of the serosa was made and mechanical enucleation of the myomas was performed whenever possible. A suture in one or two layers with large, curved needles (CT 1, 30 mm) swaged to polyglactin 1 or 0 sutures was performed. Extraction of the removed myomas took place with electric morcellation. Most patients (47%) had more than one myoma, with a maximum of eight per patient (average myomas removed for patients: 2.23). Myoma size ranged from 1 cm to 20 cm (average 67.20 mm ± 27.1 mm ). Most of the myomas (75%) were intramural. The average drop in hemoglobin concentration was 1.06 g ± 0.86 g/100 ml. The duration of the entire procedure ranged from 30 min to 360 min with a mean of 104.5 min. The conversion rate to laparotomy was 1.29% and no major intraoperative complications occurred. The mean postoperative hospital stay was 2.02 days ± 0.61 days and we had three serious postoperative complications. The overall rate of intrauterine pregnancy following LM was 62.53% and the abortion rate was 15.9%. Data suggest that laparoscopic myomectomy is a safe and reliable procedure, even in the presence of multiple or very enlarged myomas, with a low complication rate and satisfying long-term results.

Abstract
We investigated the feasibility and outcome of adhesiolysis in patients with severe and reccurent adhesions using lift (gasless) laparoscopy and a SprayGel™ adhesion barrier at the Institute for Endoscopic Gynecology (EndoGyn®). The design included a prospective evaluation of lift (gasless) laparoscopic adhesiolysis in combination with a SprayGel™ adhesion barrier. A new score for bowel adhesions was developed and applied. All 35 patients with severe and reccurent adhesions underwent a lift-laparoscopic adhesiolysis with the Abdo-Lift™ and SprayGel™ adhesion barrier, a second-look laparoscopy at Day 7 and, in case of continuation of pain, a third-look laparoscopy within 6 months after the initial surgery. All patients were operated upon without conversion to laparotomy. The reduction in the adhesion score of adhesions at the second-look laparoscopy was overall (sum) 89.8% (90.1% reduction in extent, 89.3% reduction in severity, and 89.9% reduction in grade). Five patients (14.3%) had a third-look laparoscopy within 6 months after the initial surgery, in which four cases of adhesion reformation were confirmed. However, the scores were reduced compared to the initial surgery, especially in grade (94.2%) and severity (93.2%). In these analyses, SprayGel™ was uniquely effective in improving the success rates of adhesiolysis when combined with lift (gasless) laparoscopy and good hemostasis techniques. Adhesiolysis with Abdo-Lift™ and SprayGel™ had unparalleled efficacy in the adhesiolysis procedure even in those patients in whom other solutions have not worked. An overall reduction of adhesions by 89.9% at second-look laparoscopy was found. Even if five patients (14.3%) required a third-look laparoscopy where four cases of adhesion reformation were confirmed, the scores were reduced when compared to the initial surgery, especially in grade and severity.

Abstract
Laparoscopic myomectomy (LM) is an increasingly accepted method of treatment for symptomatic uterine leiomyomas. It affords patients a minimally invasive surgery compared to the more traditional abdominal approach. Studies have shown the benefits of decreased blood loss, shorter hospital stay and recovery period, as well as decreased postoperative pain and fever in comparison to abdominal myomectomy (AM). Even myomas larger than 5 cm can be laparoscopically resected safely in the hands of an experienced surgeon. To date, studies indicate a decreased adhesion rate with the laparoscopic approach compared to the abdominal procedure. The use of adhesion barriers may decrease this rate further. In infertile women with myomas, pregnancy and live-birth rates improve following LM, and appear to be comparable with those rates achieved following AM. The data regarding the risk of uterine rupture in pregnancy following LM is limited. However, small studies show safe outcomes when patients are managed with the same degree of caution one might employ with post-abdominal myomectomy patients. In performing LM, a precise and diligent technique should be exercised to ensure a secure, multilayer closure.