| Home
>> Literature Review |
|
| >> Literature
Review |
| Laparoscopic abdominal cervical encerclage |
 |
| | |
LAPAROSCOPIC TRANSABDOMINAL CERVICAL CERCLAGE
(LTCC)
by Dr Asha Fenn
Case History: 30 year old lady, married for 9 years, with history of two abortions.
Abortion 1: conceived following ICSI.Twin pregnancy for which she had cerclage done vaginally.She spontaneously aborted at 12 weeks gestation.
Abortion 2: also conceived following ICSI.She ruptured membranes at 21 weeks. Had emergency cerclage done vaginally.Expelled fetus at 21 weeks.
On examination: she was found to have a short patulous cervix.
Impression: 30 yr old lady with h/o two failed vaginal cervical cerclages, with a short patulous cervix, for interval abdominal cerclage.
Discussion:Most cerclage operations for cervical insufficiency are performed transvaginally. The transabdominal route, first reported by Benson and Durfee in 1965, is beneficial in treating patients with cervices that are
extremely short
congenitally deformed
deeply lacerated
they may be necessary when the standard transvaginally cerclage failed in a previous pregnancy
The transabdominal route has been regarded as considerably more morbid than a transvaginal cerclage, in part due to the need for two laparotomies. Laparoscopic abdominal cerclage is a less invasive technique that could replace the laparotomy technique. Laparoscopic abdominal cerclage
does not require hospitalization, or the duration of hospital stay is reduced
is associated with less pain
leads to a faster recovery.
this surgical technique makes it possible to put the stitch exactly at the level that is needed.
Laparoscopic abdominal cerclage may be better than abdominal cerclage by laparotomy.
Method: A non-absorbable suture is placed laparoscopically at the level of the internal os as an interval procedure.
The main interest of this technique is to avoid a laparotomy, thus, reducing the abdominal wall aggression and the recovery time. It offers less morbidity and in the proper hands, eliminates or significantly shortens hospital stay. The abdominal cerclages can be left in permanently to benefit future pregnancies. Elective cesareans sections are performed.
SurgicalProcedure: Under general anesthesia, the patient was placed in dorsal lithotomy, in Trendelenberg position. A 12 mm trocar was introduced infraumbilically, and a 0 degree laparoscope introduced intraabdominally.Two 5 mm side ports were made under direct visualization. The vesicouterine fold of peritoneum was dissected transversely. The bladder was dissected off the lower uterine segment. The transverse dissection was generous, to provide an anterior visualization of the uterine arteries.
Vesicouterine fold cut Bladder being seperated
Mersilene tape being passed The knot being tied anterior
A 5 mm Mersilene tape was prepared by straightening the attached curved needles. The tape along with the needles was introduced into the abdominal cavity through the 12 mm port. One of the needle tips was placed against the posterior aspect of the cervical isthmus, 1-2 cms superior to the insertion of the uterosacral ligament. The needle was then driven through the body of the cervical body perpendicularly. The uterus is lowered to see the tip of the needle which is then pulled out anteriorly.The procedure is repeated contralaterally.The needles are cut and removed. The tape is pulled snugly against the cervix and the ligature ends are tied together anteriorly by intracorporeal knot tying.
Laparoscopic cervical cerclage can be considered, during pregnancy, though placement during pregnancy can be more challenging. It can be a safe and an effective treatment for well-selected patients with cervical incompetence, and eliminates the need for open laparotomy.
Preconception transabdominal cervicoisthmic cerclage was associated with a postoperative fetal survival rate of 100% for pregnancies that reached >12 weeks of gestation, compared with a preoperative fetal survival rate of 12%. There were no significant intraoperative, antenatal, intrapartum or neonatal complications.
|
| | | | |
| LEIOMYOMA OF MESOCOLON IN A POST HYSTRECTOMY CASE |
 |
| Ultrasound Scan | | |
 |
| Cross Section View | | |
LEIOMYOMA OF MESOCOLON IN A POST HYSTRECTOMY CASE
AN UNUSUAL PRESENTATION
Dr P Manjula,Consultant, KJK Hospital
Introduction:
A 43yr old lady having had total laparoscopic hysterectomy, ovaries being retained, 3yrs back presented with mass abdomen of 26weeks size.
Case Report:
A 43yr old Para 2, presented to our center complaining of lower abdominal pain, dysuria and constipation of 1week duration. She had total laparoscopic hysterectomy for menorrhagia due to multiple fibroids uterus 3yrs back. Cervical smear report was normal
Findings at TLH:-
1) Uterus enlarged to 14-16week size with multiple fibroids, bladder adherent to cervix, weight of uterus 500gms.
2) Both tubes and ovaries normal, therefore ovaries retained
3) HPR multiple leiomyoma of adenomyotic uterus with chronic cervicits
4) Post operative period was uneventful
She gives no history of medical or surgical illnesses. O/E shes not anaemic, no jaundice, no lymphadenopathy. Systemic examination revealed no abnormality. P/A a firm non tender mass of 26week size palpable.
USS findings:-
1) A multi loculated partly solid and partly cystic mass of 15x12cm
2) Solid areas measured 10x10mm, cystic spaces measured 9x4mm
3) Doppler study showed increased peripheral vascularity (RI=0.77, PI=1.96)
4) Both kidneys showed pelvicalyceal dilatation
Clinical Diagnosis:-
Multi loculated ovarian tumor with solid and cystic areas, probably Mucinous Cystadenoma was made and laparotomy was decided.
Investigations:-
Routine investigations in normal limits, CA-125 = 55.3 , CEA = 0.41 (N)
Findings at laparotomy:-
1) Uterus absent, both ovaries and tubes normal
2) A large multi loculated tumor with solid and cystic areas of 15cm, intact but bossy capsule seen arising from mesocolon
3) Tumor ruptured during dissection releasing brown colored and straw colored fluid
4) Liver, under surface of diaphragm, para colic gutters, para aortic lymph nodes and other abdominal organs were normal
5) Peritoneal saline wash sent for cytological examination
6) The tumor resected out completely from mesocolon. Bleeders from tumor bed cauterized and bleeding points secured
7) Mesocolon sutured with 1-0 catgut, BSO done. Peritoneal wash done with saline and abdomen closed in layers
8) Weight of the tumor is 1.75kg
Cytology report:-
1) Cells resembling mesothelial cells arranged in clusters and glandular patterns, mild pleomorphism of nuclei with lymphocytes
2) No definite diagnosis can be made
3) HPR
a. Macroscopic picture partly capsulated, partly fragmented mass with both ovaries, size 17x15x10cm, weight 1.75kg
b. Cut section is grayish white whorled appearance with areas of hemorrhage and cystic degeneration. Both ovaries showed CL
c. Microscopic picture has spindle shaped cells arranged in whorled manner, cells lack features of malignancy, no pleomorphism, no increase in mitotic figures
HPR Diagnosis:-
1) Spindle celled neoplasm, possibly leiomyoma, gastrointestinal stromal tumor (GIST) Features not suggestive of malignancy
In view of large tumor size, 2nd opinion was sought from RCC
1) Spindle celled neoplasm arranged in bundles. Cells with eosinophilic cytoplasm and vesicular nuclei. Mitotic activities sparse.
2) Cystic areas and hyaline necrosis seen
3)Immuno Histochemistry:
a. Strongly positive for SMA and Desmin
b. Negative for C-Kit
Diagnosis:-
Leiomyoma
Discussion:-
Leiomyoma of Mesocolon is a smooth muscle cell tumors of the large bowel are extremely rare and benign lesion. Contrary to expectations from the growth behavior, histological examination revealed well differentiated smooth muscle cells with distinct myofilaments and absence of nuclear abnormalities and mitotic figures. No clinical evidence of malignancy. The tumor is considered as benign multicentric lesion
GIST are mesenchymal tumours of the digestive tract originated in the interstitial cells of Cajal. They express the tyrosine kinase c-kit (CD117) activity receptor. Mutations in this receptor cause neoplastic development. Curative treatment is radical resection of the tumor. It is also resistant to chemotherapy but imatinib, expressed by GIST inhibits C-Kit activity. Imatinib is used to treat not only resectable tumours, but even to allow the possibility to make a subsequent rescue surgery. On the other hand, Imatinib is used in the treatment of the metastatic disease.
Conclusion:-
A post hysterectomy patient with ovaries retained presenting with large abdominal mass is a case of clinical dilemma. Causes other than ovarian tumors should also be thought of in DD and treatment planned accordingly.
|
| | | | |
| Laparoscopy for Mesenteric cyst |
 |
| USG picture mesenteric cyst | | |
 |
| Laparoscopic dissection of mesenteric cyst | | |
LAPAROSCOPIC MANAGEMENT OF MESENTRIC CYST.
by Dr.Anitha.M Consultant KJK Hospital
History:- Mrs.M-47yrs reported with mass abdomen. She had recurrent fever, chills and diarrhea for which She was investigated at local hospital.
USS report showed 13 x 9cm subumbilical thin walled cyst with occasional Septae and debris.
Obstetric History:- 2FTND . LCB-20yrs. Laparoscopic sterilization
done 1 ½ yrs after LCB.
Surgical History:- TAH done in 1997 for fibroid Uterus. Ovaries were retained. Laprotomy in 2000. There was difficulty in opening the peritoneal cavity due to omental adhesions. LSO was done. She is a known diabetic on treatment. Mammogram done in 6/11/05 showed fibroadenoma. Had discharge from both nipples. No malignant cells in HPE.
Gen.Examination: - P/A Vague mass in LIF.
TVS :- Large anechoic cyst 11 x 8cm on the left side. No increased vascularity. Rt.Ovary seen.
USG of mesenteric cyst
Routine investigations including CA125 and CEA were normal.
CA125-13.3 unit/ml (<35 Normal.)
CEA 1.4 mg-ml(<3.4Normal).
Operative Laproscopy was done . Cyst was extending deep into the side wall on the left side. After releasing the dense omental adhesions cystwall was excised as far as possible. Cyst was thin walled 11 x 9cms on the left side with rectosigmoid medial to it. Rest of the cystwall was marsupialised and base coagulated with bipolar. Rt salpingo oopherectomy done.
Postoperative period was uneventful.
Enucleation of mesenteric cyst
HPR- Haemorrhagic cyst compatible with mesenteric cyst.
Discussion:-
Mesentric cysts are rare, benign intraabdominal lesions without typical clinical findings. They can arise from the mesentry of duodenum to rectum, small bowel being the most common side.
They can be classified as:,
(1) Chlolymphatic.
(2) Enterogenous.
(3) Utrogenital remment.
(4) Dermoid.
Clinical Features:- Common in the second decade of life.
(1) Painless abdominal swelling.
(2) Recurrent attacks of abdominal pain.
(3) Acute abdominal catastrophe as a result of torsion, rupture, haemorrhage in to the cyst or infection.
Differential Diagnosis:-
(1) Ovarian cyst.
(2) Hydronephrosis
(3) Omental cyst.
(4) Cyst of mesocolon.
(5) Tuberculous abscess of mesentry.
(6) Hydatid cyst of the mesentry.
Treatment: A mesenteric cyst can be successfully managed by operative Laparoscopy or Laparotomy.
(a) Total enucleation.
(b) Partial excision, marsupialisation and cauterization.
This is done when enucleation is not possible because of the size of the cyst or its location deep within the root of the mesentry. Cyst lining should always be selerosed to minimize recurrence.
Conclusion:- Mesentric cysts are rare benign intraabdominal lesions.
Treatment is indicated if there are symptoms or possibility of malignancy. Preferred mode of treatment is laparoscopic resection of
surgical expertise is there.
|
| | | | |
| Torsion of the fallopian tube in a pre menarcheal 12year old girl: A rare case report |
 |
| | |
 |
| | |
Torsion of the fallopian tube in a pre menarcheal 12year old girl: A rare case report
Dr P Manjula
Isolated torsion of the fallopian tube in pre menarcheal girls is very rare. However correct diagnosis and treatment are needed in order to optimize salvage of fallopian tube. While torsion of the adnexa is relatively common, isolated torsion of the fallopian tube alone, first described in 1890(Sutton, 1890) remained a rare occurrence with an incidence of 1 in 1.5million women(Hansen, 1970). It most frequently during menstruating years, but also has been reported in pre and pause menopausal women. It has also been reported in infants and pre menarcheal girls. Many etiologies for tubal torsion have been suggested including hydrosalpinx, tubal carcinoma, prior tubal ligation(Krissi et al 1997), ovarian and paraovarian masses, pregnancy, hydatid of Morgagni and peristaltic abnormalities. The condition may also occur in pregnancy, labour and pre menstrual period.
Diagnosis of this condition is often delayed because of the rarity of its occurrence and prolonged investigations to rule out more common causes of acute abdominal pain.
Case Report:
13year old Miss. X, who has not attained menarche, was referred to our centre with history of lower abdominal pain of two days duration and with an ultrasound scan report showing right ovarian cyst of 5x3cm, for diagnostic laparoscopy. She has no significant past medical and surgical illnesses. She has not attained menarche. On examination there was no pallor, vital signs were stable, has normal secondary sexual characters, systemic examination was normal. Abdominal examination revealed no palpable mass or tenderness. Transabdominal scan showed uterus to be 3.5x2.2cm, endometrium 3mm, right adnexal mass of 4.5x4cm seen, which is anechoic with fine basal echoes. Left ovary was not seen. Ultrasonic diagnosis of right ovarian cyst was made and laparoscopy was decided. At laparoscopy the peritoneum, appendix, pouch of Douglas and upper abdomen were normal. Uterus was normal looking, both ovaries normal. Right tube was twisted thrice along with a paratubal cyst of 4cm. The cystic mass appeared bluish. Untwisting of the right tube , right paratubal cystectomy done, edges reformed. Intraoperative and post operative period were uneventful. The patient was discharged was discharged the next day. HPE diagnosis was consistent with paratubal cyst(twisted).
Conclusion:
Isolated fallopian tube torsion is rare entity especially in pre menarcheal age. At first episode of torsion of fallopian tube, tubal preservation must be the rule unless the tube is totally necrotic. A timely diagnosis and surgical intervention may allow preservation of the tube.
|
| | | | |
|
|
|
