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An unusual complication of culdoscopy
AN (From
the
UNUSUAL
Divisiow
of
COMPLICATION
OF CULDOWOPY
EMILY
J. GEAR, M.D., OTTAWA,
Women,
Hahnemann
is often CULDOSCOPY doubtedly increasing.
Medical
College
ONTARIO and
Hospital,
Philadelphia,
Pa.1
a very valuable diagnostic aid and its use is un-There are complications reported both during and
after culdoscopy, however. Those occurring after culdoscopy have mainly
arisen from two sources :
1. Air escaping from around the culdoscope into the extraperitoneal space and thence to the mesentery of the sigmoid,5 to the retroperitoneal spaces and upward to mediastinal and cervical regions7 or even to the subcutaneous tissue of the upper part of the trunk.l* g 2. Bleeding from the edge of the wound with formation of a mass in the posterior fornix containing blood.2, s The following
is the report
of an additional
complication:
M. K., a 27syear-old white woman, was admitted on April 2, 1954. She was gravidt iv, para i, with a history of one abortion and one tubal pregnancy. She stated that her last normal period had been Feb. 20, 1954. About March 20 she had scanty vaginal bleeding for two days. On March 26 she began to experience right lower quadrant pain which steadil? increased in severity. She noted some urinary frequency but no dysuria. She further recounted that she had had an appendectomy in 1950, a left salpingectomy for a tubal pregnancy in 1952, and a left oophorectomy in 1953. Physical examination showed some eolostrum present in the breasts and bilateral lower quadrant tenderness with rebound tenderness on the right side. Pelvic examination showed the uterus to be anteflexed, anteverted, and tender to palpation; there was tenderness of the adnexa on the left and on the right a 4 to 5 cm. cystic mass which was fixed and very tender. A provisional diagnosis of right tubal pregnancy was made and culdoseopy was performed. The right ovary was visualized and found to be enlarged and cystic. The right tube could not be seen but, since no blood was present in the peritoneal cavity or close to the right ovary, it was felt that ectopio pregnancy had been ruled out. The following day, when old records were available, it was discovered that she hati previously been subjected to culdoscopy in 1952 for a possible ectopic pregnancy but that salpingitis was found. Subsequently that year she had a Falk procedure* and then in 1953 at another hospital she had had a left salpingo-oophorectomy. The patient continued to complain of lower abdominal pain and on April 5 a pelvi(* examination disclosed a mass prolapsed through the small culdoscopy site. In the operating room the culdoscopy site was enlarged by means of a colpotomy incision exposing the lower part of the pelvis for examination. The sigmoid colon was visualized and the prolapsed mass proved to be two appendices epiploicae of the sigmoid colon. These werP The eolpotomy incision was closed ligated at the bases, excised, and the bowel replaced. with interrupted sutures. The postoperative course was uneventful. *By “#Falk procedure” is meant bilateral cornual resection of the Fallopian tubes without salpingectomy. This procedure has been advocated in certain cases of chronic recurrent gonorrhea1 salpingitis as an alternative to the more radical procedures such as bilateral salpingectomy or bilateral salpingectomy with supracervical or total hysterectomy.
667
668
Culdoscopy has been done several hundred times in the department8 and this was the first instance of prolapse of any intraperitoneal tissue. Several patients have had culdoscopy more than once and Decker4 feels tha.t previous culdoscopy is not in itself a contraindication to the procedure. This might have been a factor in delayed approximation of the edges of the foramen, however. At the end of the procedure as outlined by Eichner,6 pressure is applied firmly on the upper abdomen as the patient slowly slips into the prone position and is maintained for thirty to sixty seconds before the sleeve is removed. Again it was suggested that this increase in intraperitoneal pressure might have initiated the prolapse. Commonly some distention, upper abdominal discomfort, and shoulder pain for twenty-four to thirty-six hours are seen, but the persistence of pain should certainly suggest the possibility of a complication. summary A case has been presented of prolapse of two appendices patient following her second culdoscopic examination. Grateful Women, and use this case
acknowledgment is made to Dr. Newlin F. Paxson, to Dr. Bruce V. MacFadyen, Professor of Gynecology, and their encouragement in reporting it.
Chief for
epiploicae of the Division their permission
in a of to
References 1. 2. 3. 4. 5. 6. 7. 8. 9.
Angell, Buxton, Decker, Decker,
J. H., and Te Linde, R. W.: Ann. Surg. 135: 690, 1952. C. L., and Herrmann, W.: AM. J. OBST. & GYNEC. 68: 786, 1954. A., and Cherry, T. H.: Am. J. Surg. 64: 40, 1944. A.: Culdoscopy-A New Technique in Gynecologic and Obstetric Diagnosis, Philadelphia, 1952, W. B. Saunders Company, p. 46. Decker, A.: AM. J. OBST. & GYNEC. 63: 654, 1952. Eichner, E.: Ohio M. J. 49: 410, 1953. Fortier, Q. E.: Fertil. & Steril. 5: 173, 1954. MacFadyen, B. V., Reishtein, W. A., and Kannapel, A. R.: AM. J. OBST. & GYNEC. 64: 319, 1952. Te Linde, R. W., and Rutledge, F.: AM. J. OBST. & GYNEC. 55: 102, 1948.
the
UNUSUAL
Divisiow
of
COMPLICATION
OF CULDOWOPY
EMILY
J. GEAR, M.D., OTTAWA,
Women,
Hahnemann
is often CULDOSCOPY doubtedly increasing.
Medical
College
ONTARIO and
Hospital,
Philadelphia,
Pa.1
a very valuable diagnostic aid and its use is un-There are complications reported both during and
after culdoscopy, however. Those occurring after culdoscopy have mainly
arisen from two sources :
1. Air escaping from around the culdoscope into the extraperitoneal space and thence to the mesentery of the sigmoid,5 to the retroperitoneal spaces and upward to mediastinal and cervical regions7 or even to the subcutaneous tissue of the upper part of the trunk.l* g 2. Bleeding from the edge of the wound with formation of a mass in the posterior fornix containing blood.2, s The following
is the report
of an additional
complication:
M. K., a 27syear-old white woman, was admitted on April 2, 1954. She was gravidt iv, para i, with a history of one abortion and one tubal pregnancy. She stated that her last normal period had been Feb. 20, 1954. About March 20 she had scanty vaginal bleeding for two days. On March 26 she began to experience right lower quadrant pain which steadil? increased in severity. She noted some urinary frequency but no dysuria. She further recounted that she had had an appendectomy in 1950, a left salpingectomy for a tubal pregnancy in 1952, and a left oophorectomy in 1953. Physical examination showed some eolostrum present in the breasts and bilateral lower quadrant tenderness with rebound tenderness on the right side. Pelvic examination showed the uterus to be anteflexed, anteverted, and tender to palpation; there was tenderness of the adnexa on the left and on the right a 4 to 5 cm. cystic mass which was fixed and very tender. A provisional diagnosis of right tubal pregnancy was made and culdoseopy was performed. The right ovary was visualized and found to be enlarged and cystic. The right tube could not be seen but, since no blood was present in the peritoneal cavity or close to the right ovary, it was felt that ectopio pregnancy had been ruled out. The following day, when old records were available, it was discovered that she hati previously been subjected to culdoscopy in 1952 for a possible ectopic pregnancy but that salpingitis was found. Subsequently that year she had a Falk procedure* and then in 1953 at another hospital she had had a left salpingo-oophorectomy. The patient continued to complain of lower abdominal pain and on April 5 a pelvi(* examination disclosed a mass prolapsed through the small culdoscopy site. In the operating room the culdoscopy site was enlarged by means of a colpotomy incision exposing the lower part of the pelvis for examination. The sigmoid colon was visualized and the prolapsed mass proved to be two appendices epiploicae of the sigmoid colon. These werP The eolpotomy incision was closed ligated at the bases, excised, and the bowel replaced. with interrupted sutures. The postoperative course was uneventful. *By “#Falk procedure” is meant bilateral cornual resection of the Fallopian tubes without salpingectomy. This procedure has been advocated in certain cases of chronic recurrent gonorrhea1 salpingitis as an alternative to the more radical procedures such as bilateral salpingectomy or bilateral salpingectomy with supracervical or total hysterectomy.
667
668
Culdoscopy has been done several hundred times in the department8 and this was the first instance of prolapse of any intraperitoneal tissue. Several patients have had culdoscopy more than once and Decker4 feels tha.t previous culdoscopy is not in itself a contraindication to the procedure. This might have been a factor in delayed approximation of the edges of the foramen, however. At the end of the procedure as outlined by Eichner,6 pressure is applied firmly on the upper abdomen as the patient slowly slips into the prone position and is maintained for thirty to sixty seconds before the sleeve is removed. Again it was suggested that this increase in intraperitoneal pressure might have initiated the prolapse. Commonly some distention, upper abdominal discomfort, and shoulder pain for twenty-four to thirty-six hours are seen, but the persistence of pain should certainly suggest the possibility of a complication. summary A case has been presented of prolapse of two appendices patient following her second culdoscopic examination. Grateful Women, and use this case
acknowledgment is made to Dr. Newlin F. Paxson, to Dr. Bruce V. MacFadyen, Professor of Gynecology, and their encouragement in reporting it.
Chief for
epiploicae of the Division their permission
in a of to
References 1. 2. 3. 4. 5. 6. 7. 8. 9.
Angell, Buxton, Decker, Decker,
J. H., and Te Linde, R. W.: Ann. Surg. 135: 690, 1952. C. L., and Herrmann, W.: AM. J. OBST. & GYNEC. 68: 786, 1954. A., and Cherry, T. H.: Am. J. Surg. 64: 40, 1944. A.: Culdoscopy-A New Technique in Gynecologic and Obstetric Diagnosis, Philadelphia, 1952, W. B. Saunders Company, p. 46. Decker, A.: AM. J. OBST. & GYNEC. 63: 654, 1952. Eichner, E.: Ohio M. J. 49: 410, 1953. Fortier, Q. E.: Fertil. & Steril. 5: 173, 1954. MacFadyen, B. V., Reishtein, W. A., and Kannapel, A. R.: AM. J. OBST. & GYNEC. 64: 319, 1952. Te Linde, R. W., and Rutledge, F.: AM. J. OBST. & GYNEC. 55: 102, 1948.