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Chemoperitonitis 16 Weeks Gestation
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S91–S113 modified Brief Pain Inventory short form (BPI-sf) and the utilization of analgesics post-operatively. Design: Women who underwent a robotic (rob) or laparoscopic (lsc) gynecologic procedure at our institution from November 2009 to August of 2010 were identified. Pain scores were obtained by the BPI-sf pre-op, up to 24 hours post-op and at 3-4 weeks follow up. Pain was rated from a scale of 0 (no pain) to 10 (pain as bad as you can imagine). Women with a history of chronic pain, procedures converted to laparotomy, incomplete documentation of the BPI-sf at 3 timepoints were excluded. Comparative analysis of pain was performed using Pearson’s chi-square test and logistic regression. Measurements and Main Results: 26 robotic and 26 laparoscopic procedures were identified. There was no difference preoperatively in the percentage of women rating worse pain (rob 92% v. lsc 89%, p = 0.64) and average pain (rob and lsc 96%, p = 0.99) to be % 4. In the immediate 24 hour post-op period, equal percentages described the worse pain as >4 (rob 65% v lsc 68%, p = 0.84), while on average it was %4 (rob 65% v lsc 52%, p = 0.77). Similarly, there was no difference between the two groups in follow up, with worse pain(rob 77% v lsc 85%, p = 0.48) and average pain (rob 92% v lsc 85%, p = 0.39) rated as % 4. Conclusion: Pain perceived by women undergoing robotic and laparoscopic procedures did not differ post-operatively and did not impact overall quality of life. This study represents only a small number of women in the population and we are currently enrolling more women for a larger data set.
358
Open Communications 18dLaparoscopy (9:06 AM d 9:11 AM)
The Use of Straight vs. Curved or Articulating Instruments in Single-Port Surgery for Benign Adnexal Tumor Hisa T, Onoue M, Yoshimi K, Kodama M, Otsuka H, Hashimoto N, Saeki N, Funato T. Obstetrics and Gynecology, Nissay Hospital, Osakashi, Osaka-fu, Japan Study Objective: To evaluate procedures with different instruments used for Single-port surgery for benign adnexal tumor. Design: Retrospective analysis of 54 cases of Single-port surgery with straight (conventional) instruments only and with curved or articulating instruments. Setting: The department of Obstetrics and gynecology, Nissay Hospital, Osaka, Japan Patients: Fifty-four patients (ages 18-54 yrs) with benign adnexal tumor. Intervention: Single-port laparoscopic surgery (ovarian cystectomy, or salpingo-oophorectomy) with straight (conventional) instruments only and with curved or articulating instruments. Measurements and Main Results: The outcome measures included operative time, estimated blood loss, complications, and postoperative pain (NRS). The number of the patients performed ovarian cystectomy were 14/18 in the group 1 and 28/36 in the group 2. The operative time was less in the group 1 (means, 80.7 vs. 91.0 min), but not significant. The estimated blood loss was not significant different between two groups (means, 22.2 vs. 22.5 g). The postoperative pain score was also not significant different between two groups (means, postoperative day0: 2.6 vs. 3.4, day1: 2.3 vs. 2.5). The intraoperative and postoperative complications were not seen in both groups. Conclusion: In our setting, the curved or articulating instruments could not make single-port procedures easier to perform for benign adnexal tumor.
359
S109
Open Communications 18dLaparoscopy (9:12 AM d 9:17 AM)
Single Incision and Multiport Laparoscopy for Benign Adnexal Surgery Marinese D, Bhavsar V, Nimaroff M. Obstetrics and Gynecology, North Shore University Hospital, Manhasset, New York Study Objective: To compare single incision and multiport laparoscopy for benign adnexal surgery. Design: Retrospective analysis of adnexal surgeries by a single practitioner from January 2006 to September 2010. Setting: Urban academic tertiary care center Patients: 106 women undergoing laparoscopic interventions for benign adnexa: multiport procedures occurring from 1/18/06 to 8/7/08 (n = 52); single incision procedures occurring from 9/18/08 to 9/17/10 (n = 54) Intervention: 50% of multiport and 42.6% of single incision cases were prophylactic BSO for BRCA or breast cancer diagnosis. Other procedures included unilateral/ bilateral salpingoopherectomy and ovarian cystectomy. Measurements and Main Results: Patient age, BMI, indications for surgery and surgical procedure were similar in both multiport and single incision groups. The following differences were found between multiport and single incision cases respectively. Average EBL was 28.6 cc and 26.2 cc. Patients with inpatient hospital stay \12 hours were 28 patients (53.8%) and 33 patients (61.1%). Patients with inpatient hospital stays 12-24 h long were 22 (42.3%) and 18 (33.3%). Inpatient hospital stays >24 h were 2 patients (3.8%) and 3 patients (5.6%). Average procedure times were 59.3 minutes and 75.6 minutes. However, when the single incision procedures were subdivided into two groups based on date of procedure, the mean procedure time of the inital 27 cases was 87.92 minutes and 63.81 minutes for the second 27 cases. In both groups, an elevated BMI did not significantly contribute to longer procedure times, while patients with prior surgery had longer procedure times, although not statistically significant. Conclusion: Single incision surgery can be performed with similar outcomes when compared with traditional multiport laparoscopy. Although early procedure times may be longer, with experience single incision procedure times are similar to multiport laparoscopy.
360
Open Communications 18dLaparoscopy (9:18 AM d 9:23 AM)
Chemoperitonitis 16 Weeks Gestation Watson KA. Miami Valley Hospital, Dayton, Ohio Study Objective: MD is a 27 Y.OG3P2 all by c-section and at sixteen weeks presented with an acute of lower abdominal pain with nausea and anorexia. MD was afebrile with normal vital signs and presented to ED. Pelvic ultrasound IUP sixteen weeks, ascites seen in the pelvis and upper abdomen but no appendicitis. MD was treated symptomatically and discharged. During follow-up visit she had generalized deep and rebound tenderness with hypoactive bowel sounds and no passage of flatus. MD was admitted directly to the hospital for hydration and further evaluation. Repeat CBC was performed on admission and general surgical consultation obtained. Design: Setting: CT of abdomen once again showed a viable intrauterine pregnancy, ascites extending around the liver and paracolic gutters and no CT evidence
Serial Blood Counts Ref. Range WBC COUNT RBC COUNT HEMOGLOBIN HEMATOCRIT PLATELET COUNT
Latest Latest Latest Latest Latest
Range: Range: Range: Range: Range:
3.8-10.8 3.90-5.20 12.0-15.6 35.0-46.0 130-400
9/2/2010 16:40
9/3/2010 07:10
9/4/2010 09:30
9/5/2010 11:20
9/6/2010 07:25
8.0 2.64 (L) 7.6 (L) 22.4 (L) 175
7.2 2.70 (L) 7.7 (L) 23.0 (L) 175
6.6 2.64 (L) 7.6 (L) 22.5 (L) 178
7.1 2.97 (L) 8.4 (L) 25.3 (L) 191
11.9(H) 3.33 (L) 9.7 (L) 28.5 (L) 194
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Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S91–S113
of appendicitis. On day four the MD was taken to surgery for laparoscopic exploration of the abdomen was performed by using Palmers Point. Laparoscopy then revealed omental incarceration by an umbilical hernia along with hemoperitoneum of 2 liters of clotted and unclotted blood. Glisson’s Capsule, spleen was intact,the only site of bleeding was found at the incarcerated omentum that was freed by using the Harmonic Scalpel and simultaneous cauterization of the bleeder. MD was transfused with 4 units of packed red blood cells in recovery. On postoperative day one MD’s pain improved dramatically, her appetite returned, she was fully ambulatory, passing flatus, tolerating regular meals, and was discharged on day 2. Patients:
anterior mesh when BaR 1, a posterior Elevate mesh when BpR 1 with associated hysterectomy when CR 1. The main outcome was the objective success rate at pelvic organ prolapse quantification sites. The secondary outcome was the satisfaction appreciates by quality of life validated questionnaires. Measurements and Main Results: Over the 39 patients, 24 underwent pelvic organs repair with anterior mesh, 26 with posterior mesh and 11 with both of them. Nine (23%) patients had a hysterectomy and 14 (35,9%) had a tension-free vaginal tape for stress urinary incontinence. The mean operating time was 59 minutes (30 to 100 min) and the mean hospital stay was 3,8 days. Bladder injuries occurred in 2 cases (5,1%). Finally, 4 patients needed reoperation: 3 for stress urinary incontinence and one for vaginal mesh erosion. Clinical examination comparison before and 6 months after surgery found a significant improvement after surgery at POP-Q sites Ba (p = 0,043), Bp (p = 0,004) and C (p = 0,001). A significant improvement in quality of life evaluated by PFID20 (p = 0,001) and PFIQ7-scores (p = 0,032) was noted. Conclusion: The AMS ELEVATEÒ system seems to be a safe procedure for pelvic organ prolapse surgery. Preliminary anatomic and symptomatic results are very promising.
362
Open Communications 18dLaparoscopy (9:30 AM d 9:35 AM)
A Comparison of Outcomes in Robotic, Abdominal, and Vaginal Hysterectomies Wagner CA,1 Armbrecht ES,2 Chobanian N.1 1Obstetrics & Gynecology, St John’s Mercy Medical Center, St Louis, Missouri; 2The Center for Outcomes Research, St Louis University School of Medicine, St Louis, Missouri
Conclusion: Causes of chemoperitonitis in pregnancy include ruptured benign cystic teratomas, fibroids, torsion or rupture of benign ovarian cysts, perforated viscus and commonly appendicitis. There have been no reported cases of chemoperitonitis associated with incarcerated omentum published to date. The bleeding was due to omental incarceration. Adding another differential diagnosis.
361
Open Communications 18dLaparoscopy (9:24 AM d 9:29 AM)
Use of the AMS ELEVATEÒ System in Surgery for Pelvic Organ Prolapse: 6-Month Outcomes Lesavre M, Legendre G, Fernandez H. Service de GynecologieObstetrique, H^ opital Bic^etre - Assistance Publique des H^opitaux de Paris, Le Kremlin Bic^etre, Val de Marne, France, Metropolitan Study Objective: To assess the effectiveness of ElevateÒ vaginal mesh in treatment of genital prolapse regarding anatomic and symptomatic results. Design: Prospective study over 6 months follow-up. Setting: Gynaecology department in a teaching hospital. Patients: 39 women with a symptomatic vaginal prolapse (with a POP-Q score R 2) from May 2009 to October 2010 were included. Intervention: Each patient had a clinical examination (POP-Q classification) and urodynamic testing before surgery and 6 months afterwards. The surgery performed consisted in the setting of an Elevate
Study Objective: To compare surgical outcomes of Robotically Assisted Laparoscopic Hysterectomy (RALH) with Total Abdominal Hysterectomy (TAH) and Vaginal Hysterectomy (VH). Design: Retrospective medical records review at least 160 days postoperative. Setting: Residency-affiliated community hospital. Patients: 287 women who underwent total hysterectomy (94 RALH, 97 TAH, and 96 VH) for benign indications during 2008 and 2009. Intervention: RALH, TAH, or VH. Measurements and Main Results: RALH was associated with longer operative times (168 min RALH, 99 min TAH, and 69 min VH, p \0.001) and decreased blood loss (101 mL RALH, 187 mL TAH, and 157 mL VH, p = 0.05). RALH and VH had shorter lengths of hospital stay (1.1 and 1.2 days, respectively) than TAH (2.4 days, p \0.05). Rates of major and minor surgical complications were 9.6% and 6.4% for RALH, 8.2% and 6.2% for TAH, and 3.1% and 3.1% for VH (differences did not reach significance, Table 1). RALH was associated with a higher total rate of complications than VH (16.0% versus 6.3%, p = 0.04). Six vaginal cuff complications (6.4%) occurred in the RALH group compared with zero in the TAH and zero in the VH groups (p = 0.01). Analysis of cuff complications by suture material found that 4 of 28 (14.3%) cases involving barbed suture developed cuff complications versus 2 of 63 (3.2%) traditional suture cases (p = 0.07). Complications unique to RALH included four vaginal cuff infections, two vaginal cuff separations, two corneal abrasions, one infected port site, and one ruptured breast implant. Conclusion: With its similar rate of complications, RALH offers a safe alternative to TAH. However, the unique occurrence of vaginal cuff complications with RALH is concerning. The introduction of barbed suture coincided with an unusually high number of vaginal cuff complications. Further research is indicated to ascertain if barbed suture use contributed to these complications.
358
Open Communications 18dLaparoscopy (9:06 AM d 9:11 AM)
The Use of Straight vs. Curved or Articulating Instruments in Single-Port Surgery for Benign Adnexal Tumor Hisa T, Onoue M, Yoshimi K, Kodama M, Otsuka H, Hashimoto N, Saeki N, Funato T. Obstetrics and Gynecology, Nissay Hospital, Osakashi, Osaka-fu, Japan Study Objective: To evaluate procedures with different instruments used for Single-port surgery for benign adnexal tumor. Design: Retrospective analysis of 54 cases of Single-port surgery with straight (conventional) instruments only and with curved or articulating instruments. Setting: The department of Obstetrics and gynecology, Nissay Hospital, Osaka, Japan Patients: Fifty-four patients (ages 18-54 yrs) with benign adnexal tumor. Intervention: Single-port laparoscopic surgery (ovarian cystectomy, or salpingo-oophorectomy) with straight (conventional) instruments only and with curved or articulating instruments. Measurements and Main Results: The outcome measures included operative time, estimated blood loss, complications, and postoperative pain (NRS). The number of the patients performed ovarian cystectomy were 14/18 in the group 1 and 28/36 in the group 2. The operative time was less in the group 1 (means, 80.7 vs. 91.0 min), but not significant. The estimated blood loss was not significant different between two groups (means, 22.2 vs. 22.5 g). The postoperative pain score was also not significant different between two groups (means, postoperative day0: 2.6 vs. 3.4, day1: 2.3 vs. 2.5). The intraoperative and postoperative complications were not seen in both groups. Conclusion: In our setting, the curved or articulating instruments could not make single-port procedures easier to perform for benign adnexal tumor.
359
S109
Open Communications 18dLaparoscopy (9:12 AM d 9:17 AM)
Single Incision and Multiport Laparoscopy for Benign Adnexal Surgery Marinese D, Bhavsar V, Nimaroff M. Obstetrics and Gynecology, North Shore University Hospital, Manhasset, New York Study Objective: To compare single incision and multiport laparoscopy for benign adnexal surgery. Design: Retrospective analysis of adnexal surgeries by a single practitioner from January 2006 to September 2010. Setting: Urban academic tertiary care center Patients: 106 women undergoing laparoscopic interventions for benign adnexa: multiport procedures occurring from 1/18/06 to 8/7/08 (n = 52); single incision procedures occurring from 9/18/08 to 9/17/10 (n = 54) Intervention: 50% of multiport and 42.6% of single incision cases were prophylactic BSO for BRCA or breast cancer diagnosis. Other procedures included unilateral/ bilateral salpingoopherectomy and ovarian cystectomy. Measurements and Main Results: Patient age, BMI, indications for surgery and surgical procedure were similar in both multiport and single incision groups. The following differences were found between multiport and single incision cases respectively. Average EBL was 28.6 cc and 26.2 cc. Patients with inpatient hospital stay \12 hours were 28 patients (53.8%) and 33 patients (61.1%). Patients with inpatient hospital stays 12-24 h long were 22 (42.3%) and 18 (33.3%). Inpatient hospital stays >24 h were 2 patients (3.8%) and 3 patients (5.6%). Average procedure times were 59.3 minutes and 75.6 minutes. However, when the single incision procedures were subdivided into two groups based on date of procedure, the mean procedure time of the inital 27 cases was 87.92 minutes and 63.81 minutes for the second 27 cases. In both groups, an elevated BMI did not significantly contribute to longer procedure times, while patients with prior surgery had longer procedure times, although not statistically significant. Conclusion: Single incision surgery can be performed with similar outcomes when compared with traditional multiport laparoscopy. Although early procedure times may be longer, with experience single incision procedure times are similar to multiport laparoscopy.
360
Open Communications 18dLaparoscopy (9:18 AM d 9:23 AM)
Chemoperitonitis 16 Weeks Gestation Watson KA. Miami Valley Hospital, Dayton, Ohio Study Objective: MD is a 27 Y.OG3P2 all by c-section and at sixteen weeks presented with an acute of lower abdominal pain with nausea and anorexia. MD was afebrile with normal vital signs and presented to ED. Pelvic ultrasound IUP sixteen weeks, ascites seen in the pelvis and upper abdomen but no appendicitis. MD was treated symptomatically and discharged. During follow-up visit she had generalized deep and rebound tenderness with hypoactive bowel sounds and no passage of flatus. MD was admitted directly to the hospital for hydration and further evaluation. Repeat CBC was performed on admission and general surgical consultation obtained. Design: Setting: CT of abdomen once again showed a viable intrauterine pregnancy, ascites extending around the liver and paracolic gutters and no CT evidence
Serial Blood Counts Ref. Range WBC COUNT RBC COUNT HEMOGLOBIN HEMATOCRIT PLATELET COUNT
Latest Latest Latest Latest Latest
Range: Range: Range: Range: Range:
3.8-10.8 3.90-5.20 12.0-15.6 35.0-46.0 130-400
9/2/2010 16:40
9/3/2010 07:10
9/4/2010 09:30
9/5/2010 11:20
9/6/2010 07:25
8.0 2.64 (L) 7.6 (L) 22.4 (L) 175
7.2 2.70 (L) 7.7 (L) 23.0 (L) 175
6.6 2.64 (L) 7.6 (L) 22.5 (L) 178
7.1 2.97 (L) 8.4 (L) 25.3 (L) 191
11.9(H) 3.33 (L) 9.7 (L) 28.5 (L) 194
S110
Abstracts / Journal of Minimally Invasive Gynecology 18 (2011) S91–S113
of appendicitis. On day four the MD was taken to surgery for laparoscopic exploration of the abdomen was performed by using Palmers Point. Laparoscopy then revealed omental incarceration by an umbilical hernia along with hemoperitoneum of 2 liters of clotted and unclotted blood. Glisson’s Capsule, spleen was intact,the only site of bleeding was found at the incarcerated omentum that was freed by using the Harmonic Scalpel and simultaneous cauterization of the bleeder. MD was transfused with 4 units of packed red blood cells in recovery. On postoperative day one MD’s pain improved dramatically, her appetite returned, she was fully ambulatory, passing flatus, tolerating regular meals, and was discharged on day 2. Patients:
anterior mesh when BaR 1, a posterior Elevate mesh when BpR 1 with associated hysterectomy when CR 1. The main outcome was the objective success rate at pelvic organ prolapse quantification sites. The secondary outcome was the satisfaction appreciates by quality of life validated questionnaires. Measurements and Main Results: Over the 39 patients, 24 underwent pelvic organs repair with anterior mesh, 26 with posterior mesh and 11 with both of them. Nine (23%) patients had a hysterectomy and 14 (35,9%) had a tension-free vaginal tape for stress urinary incontinence. The mean operating time was 59 minutes (30 to 100 min) and the mean hospital stay was 3,8 days. Bladder injuries occurred in 2 cases (5,1%). Finally, 4 patients needed reoperation: 3 for stress urinary incontinence and one for vaginal mesh erosion. Clinical examination comparison before and 6 months after surgery found a significant improvement after surgery at POP-Q sites Ba (p = 0,043), Bp (p = 0,004) and C (p = 0,001). A significant improvement in quality of life evaluated by PFID20 (p = 0,001) and PFIQ7-scores (p = 0,032) was noted. Conclusion: The AMS ELEVATEÒ system seems to be a safe procedure for pelvic organ prolapse surgery. Preliminary anatomic and symptomatic results are very promising.
362
Open Communications 18dLaparoscopy (9:30 AM d 9:35 AM)
A Comparison of Outcomes in Robotic, Abdominal, and Vaginal Hysterectomies Wagner CA,1 Armbrecht ES,2 Chobanian N.1 1Obstetrics & Gynecology, St John’s Mercy Medical Center, St Louis, Missouri; 2The Center for Outcomes Research, St Louis University School of Medicine, St Louis, Missouri
Conclusion: Causes of chemoperitonitis in pregnancy include ruptured benign cystic teratomas, fibroids, torsion or rupture of benign ovarian cysts, perforated viscus and commonly appendicitis. There have been no reported cases of chemoperitonitis associated with incarcerated omentum published to date. The bleeding was due to omental incarceration. Adding another differential diagnosis.
361
Open Communications 18dLaparoscopy (9:24 AM d 9:29 AM)
Use of the AMS ELEVATEÒ System in Surgery for Pelvic Organ Prolapse: 6-Month Outcomes Lesavre M, Legendre G, Fernandez H. Service de GynecologieObstetrique, H^ opital Bic^etre - Assistance Publique des H^opitaux de Paris, Le Kremlin Bic^etre, Val de Marne, France, Metropolitan Study Objective: To assess the effectiveness of ElevateÒ vaginal mesh in treatment of genital prolapse regarding anatomic and symptomatic results. Design: Prospective study over 6 months follow-up. Setting: Gynaecology department in a teaching hospital. Patients: 39 women with a symptomatic vaginal prolapse (with a POP-Q score R 2) from May 2009 to October 2010 were included. Intervention: Each patient had a clinical examination (POP-Q classification) and urodynamic testing before surgery and 6 months afterwards. The surgery performed consisted in the setting of an Elevate
Study Objective: To compare surgical outcomes of Robotically Assisted Laparoscopic Hysterectomy (RALH) with Total Abdominal Hysterectomy (TAH) and Vaginal Hysterectomy (VH). Design: Retrospective medical records review at least 160 days postoperative. Setting: Residency-affiliated community hospital. Patients: 287 women who underwent total hysterectomy (94 RALH, 97 TAH, and 96 VH) for benign indications during 2008 and 2009. Intervention: RALH, TAH, or VH. Measurements and Main Results: RALH was associated with longer operative times (168 min RALH, 99 min TAH, and 69 min VH, p \0.001) and decreased blood loss (101 mL RALH, 187 mL TAH, and 157 mL VH, p = 0.05). RALH and VH had shorter lengths of hospital stay (1.1 and 1.2 days, respectively) than TAH (2.4 days, p \0.05). Rates of major and minor surgical complications were 9.6% and 6.4% for RALH, 8.2% and 6.2% for TAH, and 3.1% and 3.1% for VH (differences did not reach significance, Table 1). RALH was associated with a higher total rate of complications than VH (16.0% versus 6.3%, p = 0.04). Six vaginal cuff complications (6.4%) occurred in the RALH group compared with zero in the TAH and zero in the VH groups (p = 0.01). Analysis of cuff complications by suture material found that 4 of 28 (14.3%) cases involving barbed suture developed cuff complications versus 2 of 63 (3.2%) traditional suture cases (p = 0.07). Complications unique to RALH included four vaginal cuff infections, two vaginal cuff separations, two corneal abrasions, one infected port site, and one ruptured breast implant. Conclusion: With its similar rate of complications, RALH offers a safe alternative to TAH. However, the unique occurrence of vaginal cuff complications with RALH is concerning. The introduction of barbed suture coincided with an unusually high number of vaginal cuff complications. Further research is indicated to ascertain if barbed suture use contributed to these complications.