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Inadvertent gastric injury with veress entry at the umbilicus: a video case report and review of the literature
Abstracts / European Journal of Obstetrics & Gynecology and Reproductive Biology 206 (2016) e1–e127
Minimally invasive surgery
PCOS and hyperandrogenisms
Poster Presentation
No Preference
Inadvertent gastric injury with veress entry at the umbilicus: a video case report and review of the literature
Hyperreactio luteinalis in pregnancy
Samara Sabur ∗ , Supuni Kapurubandara, Yogesh Nikam Department of Obstetrics & Gynaecology, Westmead Hospital, New South Wales, Australia E-mail address: [email protected] (S. Sabur). Laparoscopy is widely used in gynaecological surgery and has numerous benefits including reduced blood loss, lower infection and adhesion formation, shorter recovery and better cosmetic result. The procedure is usually performed under general anaesthesia and face-mask ventilation with positive pressure prior to intubation. The standard point of entry is at the umbilicus where a veress needle is inserted through the abdominal wall and confirmatory tests ensure correct placement before pneumoperitoneum is established via carbon dioxide insufflation. The rate of complications is reported to be low (0.18–0.41%) and a third occur during veress or trocar insertion. Complications include injury to blood vessels, solid organ or hollow viscous. Gastric injury is very rare and few isolated cases have been reported previously. A study reviewing 56 patients with 62 gastrointestinal injuries incurred during gynaecological laparoscopy, revealed one case with gastric injury caused by umbilical veress entry (1.6%). All reported cases describe gastric distension secondary to insufflation via face-mask ventilation, with the exception of one case of ‘aerophagia’ due to patient anxiety. Face-mask ventilation is a necessary step for general anaesthetic induction however carries a risk of up to 26.6% for gastric insufflation. Thus, the possibility of gastric distension and perforation must be considered when entering the abdominal cavity for laparoscopy. We present a case of a 33 year old woman who underwent an elective laparoscopic right ovarian cystectomy for a persistent complex ovarian cyst with an elevated CA 125 level of 58. Her past medical history was significant for bilateral dermoid cysts that were removed laparoscopically at age 23. Following general anaesthesia induction, veress entry and gas flow connection revealed low intra-abdominal pressures of 3–5 mmHg. The pressure rise abnormally fluctuated from low to as high as 19 mmHg by which time an apparent pneumoperitoneum had been created. On optical port insertion, a very distended stomach was seen with a puncture wound to the anterior wall. Further investigation by upper gastrointestinal surgeons revealed a haematoma on the posterior wall, signifying likely complete perforation of the stomach. They proceeded to laparoscopically repair the stomach by oversewing the puncture wounds and placed a drain in the lesser sac. A right ovarian cystectomy was then performed with no further complications. Post-operatively, the patient was fasted with a nasogastric tube and commenced on intravenous pantoprazole until a gastrogafrin swallow confirmed integrity of the stomach wall with no extravasion of contrast or drain output. The nasogastric tube and drain were removed and oral diet gradually introduced. Patient was discharged home on day 3. A video presentation of laparoscopic gastric perforation repair will be demonstrated. A review of the existing literature, preventative measures and management will be discussed. http://dx.doi.org/10.1016/j.ejogrb.2016.07.262
e99
K. Saffar ∗ , A. Ben Amor, K. Dimassi, A. Triki, M.F. Gara Mongi Slim University Hospital, Tunis, Tunisia E-mail address: [email protected] (K. Saffar). Background: Hyperreactio luteinalis (HL) is a rare and typically selflimited benign condition during pregnancy characterized by bilaterally enlarged ovaries with multiple theca lutein cysts causing the ovarian enlargement. HL is usually found incidentally at cesarean section, which can appear anaplastic and lead to unnecessary ovarian resection. Less than 100 cases of HL have been previously reported in the literature. It is necessary to keep in mind that hyperreactio luteinalis is a benign condition and the management is conservative. Aim of the study:We present an unexpected, intraoperatively diagnosed case of bilateral ovarian theca-lutein cysts, found during cesarean section. CASE REPORT A 33 year-old women, with no particular medical history, non-followed up pregnancy, was presented to the hospital at 39 weeks of amenorrhea and has been hospitalized for some pelvic pains and a fundal height of 37 cm. A cesarean section was performed for foetal macrosomia. The course of the cesarean section was normal and one female infant was born. A routine review of the ovaries discovers large bilateral cystic masses measuring 25 cm × 20 cm and 15 cm × 10 cm. An incisional ovarian biopsy was made and the HL was histologically diagnosed. The postoperative course was uneventful, and the cysts regressed in postpartum. Conclusions: There are multiple benign ovarian lesions including hyperreactio luteinalis that can mimic ovarian neoplasms. Accordingly, it is important to exclude these from the differential diagnosis via a wedge biopsy and frozen section to avoid unnecessary surgical excision. The cysts may persist, or appear first, in the puerperium, and the condition almost always regresses. The management should be as conservative as possible. http://dx.doi.org/10.1016/j.ejogrb.2016.07.263 Assisted reproduction Poster Presentation Clomiphene Citrate vs. Letrozole as mild stimulation regimes in women with expected normal ovarian response undergoing IVF Charalampos Siristatidis, George Salamalekis ∗ , Paraskevi Vogiatzi, George Basios, Vasilios Pergialiotis, Tereza Vrantza, Nikolaos Papantoniou Assisted Reproduction Unit, 3rd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12642, Greece E-mail address: [email protected] (G. Salamalekis). Background: Mild ovarian stimulation protocols using low doses of gonadotrophins were implemented in clinical practice as a simpler approach to ovarian hyperstimulation regimes. In this context, clomiphene citrate (CC) and letrozole have been both previously applied in mild ovarian stimulation protocols, although
Minimally invasive surgery
PCOS and hyperandrogenisms
Poster Presentation
No Preference
Inadvertent gastric injury with veress entry at the umbilicus: a video case report and review of the literature
Hyperreactio luteinalis in pregnancy
Samara Sabur ∗ , Supuni Kapurubandara, Yogesh Nikam Department of Obstetrics & Gynaecology, Westmead Hospital, New South Wales, Australia E-mail address: [email protected] (S. Sabur). Laparoscopy is widely used in gynaecological surgery and has numerous benefits including reduced blood loss, lower infection and adhesion formation, shorter recovery and better cosmetic result. The procedure is usually performed under general anaesthesia and face-mask ventilation with positive pressure prior to intubation. The standard point of entry is at the umbilicus where a veress needle is inserted through the abdominal wall and confirmatory tests ensure correct placement before pneumoperitoneum is established via carbon dioxide insufflation. The rate of complications is reported to be low (0.18–0.41%) and a third occur during veress or trocar insertion. Complications include injury to blood vessels, solid organ or hollow viscous. Gastric injury is very rare and few isolated cases have been reported previously. A study reviewing 56 patients with 62 gastrointestinal injuries incurred during gynaecological laparoscopy, revealed one case with gastric injury caused by umbilical veress entry (1.6%). All reported cases describe gastric distension secondary to insufflation via face-mask ventilation, with the exception of one case of ‘aerophagia’ due to patient anxiety. Face-mask ventilation is a necessary step for general anaesthetic induction however carries a risk of up to 26.6% for gastric insufflation. Thus, the possibility of gastric distension and perforation must be considered when entering the abdominal cavity for laparoscopy. We present a case of a 33 year old woman who underwent an elective laparoscopic right ovarian cystectomy for a persistent complex ovarian cyst with an elevated CA 125 level of 58. Her past medical history was significant for bilateral dermoid cysts that were removed laparoscopically at age 23. Following general anaesthesia induction, veress entry and gas flow connection revealed low intra-abdominal pressures of 3–5 mmHg. The pressure rise abnormally fluctuated from low to as high as 19 mmHg by which time an apparent pneumoperitoneum had been created. On optical port insertion, a very distended stomach was seen with a puncture wound to the anterior wall. Further investigation by upper gastrointestinal surgeons revealed a haematoma on the posterior wall, signifying likely complete perforation of the stomach. They proceeded to laparoscopically repair the stomach by oversewing the puncture wounds and placed a drain in the lesser sac. A right ovarian cystectomy was then performed with no further complications. Post-operatively, the patient was fasted with a nasogastric tube and commenced on intravenous pantoprazole until a gastrogafrin swallow confirmed integrity of the stomach wall with no extravasion of contrast or drain output. The nasogastric tube and drain were removed and oral diet gradually introduced. Patient was discharged home on day 3. A video presentation of laparoscopic gastric perforation repair will be demonstrated. A review of the existing literature, preventative measures and management will be discussed. http://dx.doi.org/10.1016/j.ejogrb.2016.07.262
e99
K. Saffar ∗ , A. Ben Amor, K. Dimassi, A. Triki, M.F. Gara Mongi Slim University Hospital, Tunis, Tunisia E-mail address: [email protected] (K. Saffar). Background: Hyperreactio luteinalis (HL) is a rare and typically selflimited benign condition during pregnancy characterized by bilaterally enlarged ovaries with multiple theca lutein cysts causing the ovarian enlargement. HL is usually found incidentally at cesarean section, which can appear anaplastic and lead to unnecessary ovarian resection. Less than 100 cases of HL have been previously reported in the literature. It is necessary to keep in mind that hyperreactio luteinalis is a benign condition and the management is conservative. Aim of the study:We present an unexpected, intraoperatively diagnosed case of bilateral ovarian theca-lutein cysts, found during cesarean section. CASE REPORT A 33 year-old women, with no particular medical history, non-followed up pregnancy, was presented to the hospital at 39 weeks of amenorrhea and has been hospitalized for some pelvic pains and a fundal height of 37 cm. A cesarean section was performed for foetal macrosomia. The course of the cesarean section was normal and one female infant was born. A routine review of the ovaries discovers large bilateral cystic masses measuring 25 cm × 20 cm and 15 cm × 10 cm. An incisional ovarian biopsy was made and the HL was histologically diagnosed. The postoperative course was uneventful, and the cysts regressed in postpartum. Conclusions: There are multiple benign ovarian lesions including hyperreactio luteinalis that can mimic ovarian neoplasms. Accordingly, it is important to exclude these from the differential diagnosis via a wedge biopsy and frozen section to avoid unnecessary surgical excision. The cysts may persist, or appear first, in the puerperium, and the condition almost always regresses. The management should be as conservative as possible. http://dx.doi.org/10.1016/j.ejogrb.2016.07.263 Assisted reproduction Poster Presentation Clomiphene Citrate vs. Letrozole as mild stimulation regimes in women with expected normal ovarian response undergoing IVF Charalampos Siristatidis, George Salamalekis ∗ , Paraskevi Vogiatzi, George Basios, Vasilios Pergialiotis, Tereza Vrantza, Nikolaos Papantoniou Assisted Reproduction Unit, 3rd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Rimini 1, Chaidari, Athens 12642, Greece E-mail address: [email protected] (G. Salamalekis). Background: Mild ovarian stimulation protocols using low doses of gonadotrophins were implemented in clinical practice as a simpler approach to ovarian hyperstimulation regimes. In this context, clomiphene citrate (CC) and letrozole have been both previously applied in mild ovarian stimulation protocols, although