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Delayed Thermal Injury to the Ureter during Total Laparoscopic Hysterectomy Using Ultrasonic Energy Source: A Case Report
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 Intervention: Standardized questionnaires recording the clinical history of painful deep endometriosis up to diagnosis. Measurements and Main Results: We estimated the length of time from onset of pain to diagnosis, types of pain, disability related to the pain, number of physicians consulted before the diagnosis was made. Women with rectal endometriosis had an earlier onset of dysmenorrhoea (P 5 0.05). The age of dysmenorrhoea and the length of time between the onset of the first pain to the first time that the endometriosis was suspected were significantly increased in women with rectal endometriosis (P 5 0.01). The history of dysmenorrhoea was significantly increased in women with rectal endometriosis.
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(excellent improvement, satisfactory improvement and no improvement). For dysmenorrhea, the mean score according to the VAS was significantly lower postoperatively (6.2 3.1 versus 0.8 1.4) (P!0.001). The dysmenorrhea improvement was considered to be excellent in 33.3% of women (4/12), satisfactory in 66.7% of women (8/12). The dyspareunia improvement was considered to be excellent in 5 women (5/7), satisfactory in 2 women (2/7). The noncyclic chronic pelvic pain improvement was considered to be excellent in all 3 patients. Among 6 infertile patients(42.9%), 3 women achieved pregnancy after the surgery. Follow-up improvement of symptoms was maintained at least for 1 year without recurrence or repeated surgery. Conclusion: Laparoscopic resection of rectovaginal endometriosis with excision of the adjacent tissue of the posterior vaginal fornix results in a statistically significant reduction in painful functional symptoms. Large prospective randomized studies are required to validate this approach.
ENDOSCOPIC COMPLICATIONS 388 Port-Site Implantation of Leiomyoma after Laparoscopic Myomectomy of Uterus: A Case Report Baek SJ, Han AR, Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Obstetrics and Gynecology, Asan Medical Center, Seoul, Republic of Korea
Pain during defecation was more frequent in patients with rectal endometriosis (P 5 0.03). Women consulted an average of 3 physicians before the endometriosis diagnosis was suggested. A non-gynecologist physician made the diagnosis of rectovaginal and rectal endometriosis in respectively 26% and 31% of cases. Conclusion: Rectal endometriosis is associated with an earlier onset and a longer history of painful symptoms until the diagnosis was made when compared to rectovaginal endometriosis locations. These observations support the hypothesis that rectovaginal location may be an intermediate stage of rectal endometriosis.
387 Laparoscopic Treatment of Rectovaginal Endometriosis with Posterior Vaginal Fornix Involvement Yu Z, Jinhua L, Jinghe L, Yi D. Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China Study Objective: To evaluate the efficacy of laparoscopic excision of rectovaginal endometriosis when the vaginal wall was deep-infiltrated. Design: Retrospective analysis. Setting: University-affiliated hospital. Patients: Fourteen patients were included in the study with rectovaginal deeply infiltrating endometriosis with posterior vaginal fornix involvement. Intervention: Laparoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the endometriosis tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure totally by laparoscopic route. Measurements and Main Results: The mean age of the patients was 35.0 5.7 years (range 26e45). 13 patients had painful symptoms. No intra-operative complications were observed; Hysterectomy was done to a patient with uncontrolled vaginal bleeding on the twentith post operative day. Efficiency of surgical excision was assessed according to objective evaluation (visual analog scale, VAS) and subjective evaluation
Study Objective: A case report for port-site implantation of leiomyoma after laparoscopic myomectomy. Design: Retrospective review of the medical recording whose undergone a port-site implantation of leiomyoma after laparoscopic myomectomy. Setting: Asan medical center, Seoul, Korea. Patients: A 46-year-old Korean woman who had a abdominal mass was located in left lower abdominal trocar site. Intervention: The removal of abdominal wall mass through a small abdominal wall incision and laparoscopy. Measurements and Main Results: A 46-year-old Korean woman (Para,20-0-2) presented with palpable left lower abdominal mass with cyclic pain. She had undergone laparoscopic myomectomy at other hospital five years ago. At that operation, myoma was morcellated and extracted through a trocar located in left lower abdomen. On physical examination, about 3 cm sized round, solid and tender mass was located in left lower abdominal trocar site. Computed tomogram of abdomen and pelvis revealed 3 cm sized and 2 cm sized enhancing masses in abdominal wall and pelvic peritoneum, respectively. She underwent removal of abdominal wall mass through a small abdominal wall incision. And, intrapertioneal mass was removed laparoscopically. Histologically, the tumor consists of benign spindle cells. Tumor cells were stained strongly for smooth muscle actin, Ki-67 and progesterone receptoror and not stained for CD34, S-100 protein and CD117. The clinicopathologic diagnosis was consistent with benign metastasizing leiomyomatosis. She refused to undergo hysterectomy with bilateral salpingo-oophorectomy against medical advice. Conclusion: This is the first report of port-site implantaion of leiomyoma. This report indicates that the potential hazard of laparoscopic surgery could be present in benign disease although is a rare event.
389 Delayed Thermal Injury to the Ureter during Total Laparoscopic Hysterectomy Using Ultrasonic Energy Source: A Case Report Brotherton J, Chang F. Department of Obstetrics and Gynecology, Harbor/UCLA Medical Center, Torrance, California Study Objective: The incidence of ureteral injury during hysterectomy is estimated to be 0.2%-6% depending on the type of operation performed. Most ureteral injuries are under reported and only 30% are recognized during the surgery. We report the case of a thermal injury to the ureter presenting 2 weeks after a total laparoscopic hysterectomy performed with the use of an ultrasonic energy source.
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Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
Design: Case Report. Setting: University Based County, Teaching Hospital. Patients: 43-year-old multiparous woman with a history of menometrorrhagia, fibroids, and anemia requiring transfusion, underwent a total laparoscopic hysterectomy performed using ultrasonic energy. She presented post-op day 14 with complaints of copious yellow vaginal discharge for 3 days. Intervention: A vaginal ultrasound revealed a complex collection at the vaginal cuff. A retrograde cystoscopy/urogram revealed a right ureteral injury with vaginal drainage of urine. Urology and Interventional Radiology were consulted. Attempts at placing a ureteral stent and a percutaneous nephrostomy tube were both unsuccessful. A CT/urogram confirmed the distal location of the thermal defect. At the time of submission, the patient was scheduled for a proposed uretero-neocystotomy over a ureteral stent, approximately 8 weeks after her laparoscopic hysterectomy. Measurements and Main Results: Results of the corrective surgery were pending at the time of submission. Conclusion: Thermal injury to the ureter is a known complication of laparoscopic hysterectomy using all energy sources. Although ultrasonic energy works at lower temperatures and has a reported 1e2 mm thermal spread, it is not without risk. One must suspect delayed thermal injury with ultrasonic energy in the appropriate clinical setting in order to identify and correct it.
390 Chylous Ascites after Laparoscopic Retroperitoneal Lymph Node Dissection for Ovarian Cancer: A Case Report and a Review of Literature El-Sahwi K, Soto-Wright V, Tuerk I. Gynecology, Lahey Clinic Medical Center, Burlington, Massachusetts Study Objective: Chylous ascites, a rare entity, is a documented complication of surgical dissection in the retroperitoneal space due to interruption of lymphatics. More cases of postoperative chylous ascites are being reported in the gynecologic literature. We report a case of postoperative chylous ascites and review the literature. Design: A case report on postoperative chylous ascites that developed after laparoscopic staging for Stage 1A Grade 3 epithelial ovarian cancer in a 48year-old patient. A review of the gynecologic literature follows. Setting: Department of gynecologic oncology at a community-based teaching hospital in the suburbs of Boson, MA. Patients: Forty eight year-old nulligravid patient with a BRCA1 mutation and breast cancer was found to have poorly differentiated left ovarian carcinoma after risk-reducing laparoscopic bilateral salpingoopherectomy. Subsequently laparoscopic assisted vaginal hysterectomy and staging were performed. Two weeks later patient presented with chylous ascites, lymphedema, and anterior abdominal wall lymphocele. Intervention: A case report; review of basic anatomy and physiology; presentation of illustrative figures and CT scan photographs; and review of the gynecologic literature. Measurements and Main Results: Treatment with low salt, low fat diet; Medium Chain Triglycerides; Somatostatin; paracentesis; and percutaneous drainage of lymphocele was successful. Patient was disease-free on 2-year follow-up. Conclusion: The incidence of postoperative chylous ascites may be increasing simultaneous with an increase in laparoscopic and aggressive surgeries. Surgical management has been successful in refractory cases. Conservative management is effective in most cases. Meticulous surgical technique may prevent its development. 391 Abstract Withdrawn 392 Effect of Abdominal Pressure to Subcutaneous Emphysema during Laparoscopic Surgery Kim CJ,1 Lee HN,2 Lee YS,2 Park EK,2 Park TC,3 Namkoong SE,4 Park JS.4 1Department of Obstetrics and Gynecology, St. Pauls’s Hospital,
The Cathoilic University of Korea, Seoul, Republic of Korea; 2Department of Obstetrics and Gynecology, Daejeon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Daejeon, Republic of Korea; 3 Department of Obstetrics and Gynecology, Uijongbu St May’s Hospital, Catholic University Medical College of Korea, Uijonbu City, Kyonggi-do, Republic of Korea; 4Department of Obstetrics and Gynecology, Kangnam St Mary’s Hospital, Seoul, Republic of Korea Study Objective: Subcutaneous emphysema during laparoscopy may be precursor of pneumothorax or pneumomediastinum which is so dangerous. This study evaluated relation between subcutaneous emphysema during laparoscopy and intraabdominal pressure and other several factors. Design: From March 2007 to September 2007, we performed prospective randomized study for 50 patients received laparoscopy due to benign gynecologic disease at our four Hospital. Patients: Patients were randomly assigned to either 12 mmHg intraabdominal pressure group (n 5 25) or 10 mmHg intraabdominal pressure group (n 5 25). Intervention: Each patient had Trendelenberg position at adequate table tilting angle after general anesthesia during laparoscopy. We analyzed subcutaneous emphysema at each group. In addition to Intraabdominal pressure, we also analyzed relation between age, body mass index (BMI), table tilting angle, operation time and emphysema. Measurements and Main Results: We used 4 ports at only one patient and used 3 ports at other patients. There was no significant difference in age, BMI and table tilting angle between 12mmHg intraabdominal pressure group and 10mmHg intraabdominal pressure group. There was also no significant difference in operation duration between two groups, therefore decreased intraabdominal pressure didn’t prevent operation. Any subcutaneous emphysema didn’t occur in 10mmHg intraabdominal pressure group but emphysema occurred in four patients of 12mmHg intraabdominal pressure group (P 5 0.504). In spite of insignificant statistically, it seems to be more incidence of emphysema in 12mmHg group than 10mmHg group. There was no pneumothorax or pneumomediastinum in all patients with emphysema. Conclusion: Incidence of subcutaneous emphysema which may be precursor of pneumothorax or pneumomediastinum decreased at low intraabdominal pressure group compared to high intraabdominal pressure group. And it is necessary that intraabdominal pressure is lowly maintained to prevent emphysema during laparoscopy in the range of not interrupting operation.
393 Trocar Site Herniation through a 5mm Trocar Site Following Removal of Drains after Gynecologic Laparoscopy Lee YS, Jeung IC, Lee HN, Kim CJ. Obstetrics and Gynecology, The Catholic University Medical Colledge, Daejeon, Chung Nam, Republic of Korea Study Objective: The importance and the frequency of the laparoscopic surgery has recently been emphasized and the interest about the complications due to laparoscopic procedures is increasing. Trocar site herniation of the small bowel and omentum is one of the important laparoscopic complications and this is related to many factors, including diameter of the trocar. This condition is difficult to differentiate from simple post operative ileus and it could lead to fatal results due to the delayed diagnosis. Design: Most of the trocar site herniations occur in association with the use of a trocar greater than 10 mm and it rarely occurs when a 5 mm trocar is used. Setting: Therefore, fascial suture at the 5 mm trocar site must be selectively carried out. Patients: We experienced 2 cases of small bowel and omental herniation at 5 mm port sites, which probably occurred in connection with withdrawal of the drain at the end of the laparoscopic procedure.
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(excellent improvement, satisfactory improvement and no improvement). For dysmenorrhea, the mean score according to the VAS was significantly lower postoperatively (6.2 3.1 versus 0.8 1.4) (P!0.001). The dysmenorrhea improvement was considered to be excellent in 33.3% of women (4/12), satisfactory in 66.7% of women (8/12). The dyspareunia improvement was considered to be excellent in 5 women (5/7), satisfactory in 2 women (2/7). The noncyclic chronic pelvic pain improvement was considered to be excellent in all 3 patients. Among 6 infertile patients(42.9%), 3 women achieved pregnancy after the surgery. Follow-up improvement of symptoms was maintained at least for 1 year without recurrence or repeated surgery. Conclusion: Laparoscopic resection of rectovaginal endometriosis with excision of the adjacent tissue of the posterior vaginal fornix results in a statistically significant reduction in painful functional symptoms. Large prospective randomized studies are required to validate this approach.
ENDOSCOPIC COMPLICATIONS 388 Port-Site Implantation of Leiomyoma after Laparoscopic Myomectomy of Uterus: A Case Report Baek SJ, Han AR, Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. Obstetrics and Gynecology, Asan Medical Center, Seoul, Republic of Korea
Pain during defecation was more frequent in patients with rectal endometriosis (P 5 0.03). Women consulted an average of 3 physicians before the endometriosis diagnosis was suggested. A non-gynecologist physician made the diagnosis of rectovaginal and rectal endometriosis in respectively 26% and 31% of cases. Conclusion: Rectal endometriosis is associated with an earlier onset and a longer history of painful symptoms until the diagnosis was made when compared to rectovaginal endometriosis locations. These observations support the hypothesis that rectovaginal location may be an intermediate stage of rectal endometriosis.
387 Laparoscopic Treatment of Rectovaginal Endometriosis with Posterior Vaginal Fornix Involvement Yu Z, Jinhua L, Jinghe L, Yi D. Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China Study Objective: To evaluate the efficacy of laparoscopic excision of rectovaginal endometriosis when the vaginal wall was deep-infiltrated. Design: Retrospective analysis. Setting: University-affiliated hospital. Patients: Fourteen patients were included in the study with rectovaginal deeply infiltrating endometriosis with posterior vaginal fornix involvement. Intervention: Laparoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the endometriosis tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure totally by laparoscopic route. Measurements and Main Results: The mean age of the patients was 35.0 5.7 years (range 26e45). 13 patients had painful symptoms. No intra-operative complications were observed; Hysterectomy was done to a patient with uncontrolled vaginal bleeding on the twentith post operative day. Efficiency of surgical excision was assessed according to objective evaluation (visual analog scale, VAS) and subjective evaluation
Study Objective: A case report for port-site implantation of leiomyoma after laparoscopic myomectomy. Design: Retrospective review of the medical recording whose undergone a port-site implantation of leiomyoma after laparoscopic myomectomy. Setting: Asan medical center, Seoul, Korea. Patients: A 46-year-old Korean woman who had a abdominal mass was located in left lower abdominal trocar site. Intervention: The removal of abdominal wall mass through a small abdominal wall incision and laparoscopy. Measurements and Main Results: A 46-year-old Korean woman (Para,20-0-2) presented with palpable left lower abdominal mass with cyclic pain. She had undergone laparoscopic myomectomy at other hospital five years ago. At that operation, myoma was morcellated and extracted through a trocar located in left lower abdomen. On physical examination, about 3 cm sized round, solid and tender mass was located in left lower abdominal trocar site. Computed tomogram of abdomen and pelvis revealed 3 cm sized and 2 cm sized enhancing masses in abdominal wall and pelvic peritoneum, respectively. She underwent removal of abdominal wall mass through a small abdominal wall incision. And, intrapertioneal mass was removed laparoscopically. Histologically, the tumor consists of benign spindle cells. Tumor cells were stained strongly for smooth muscle actin, Ki-67 and progesterone receptoror and not stained for CD34, S-100 protein and CD117. The clinicopathologic diagnosis was consistent with benign metastasizing leiomyomatosis. She refused to undergo hysterectomy with bilateral salpingo-oophorectomy against medical advice. Conclusion: This is the first report of port-site implantaion of leiomyoma. This report indicates that the potential hazard of laparoscopic surgery could be present in benign disease although is a rare event.
389 Delayed Thermal Injury to the Ureter during Total Laparoscopic Hysterectomy Using Ultrasonic Energy Source: A Case Report Brotherton J, Chang F. Department of Obstetrics and Gynecology, Harbor/UCLA Medical Center, Torrance, California Study Objective: The incidence of ureteral injury during hysterectomy is estimated to be 0.2%-6% depending on the type of operation performed. Most ureteral injuries are under reported and only 30% are recognized during the surgery. We report the case of a thermal injury to the ureter presenting 2 weeks after a total laparoscopic hysterectomy performed with the use of an ultrasonic energy source.
S104
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
Design: Case Report. Setting: University Based County, Teaching Hospital. Patients: 43-year-old multiparous woman with a history of menometrorrhagia, fibroids, and anemia requiring transfusion, underwent a total laparoscopic hysterectomy performed using ultrasonic energy. She presented post-op day 14 with complaints of copious yellow vaginal discharge for 3 days. Intervention: A vaginal ultrasound revealed a complex collection at the vaginal cuff. A retrograde cystoscopy/urogram revealed a right ureteral injury with vaginal drainage of urine. Urology and Interventional Radiology were consulted. Attempts at placing a ureteral stent and a percutaneous nephrostomy tube were both unsuccessful. A CT/urogram confirmed the distal location of the thermal defect. At the time of submission, the patient was scheduled for a proposed uretero-neocystotomy over a ureteral stent, approximately 8 weeks after her laparoscopic hysterectomy. Measurements and Main Results: Results of the corrective surgery were pending at the time of submission. Conclusion: Thermal injury to the ureter is a known complication of laparoscopic hysterectomy using all energy sources. Although ultrasonic energy works at lower temperatures and has a reported 1e2 mm thermal spread, it is not without risk. One must suspect delayed thermal injury with ultrasonic energy in the appropriate clinical setting in order to identify and correct it.
390 Chylous Ascites after Laparoscopic Retroperitoneal Lymph Node Dissection for Ovarian Cancer: A Case Report and a Review of Literature El-Sahwi K, Soto-Wright V, Tuerk I. Gynecology, Lahey Clinic Medical Center, Burlington, Massachusetts Study Objective: Chylous ascites, a rare entity, is a documented complication of surgical dissection in the retroperitoneal space due to interruption of lymphatics. More cases of postoperative chylous ascites are being reported in the gynecologic literature. We report a case of postoperative chylous ascites and review the literature. Design: A case report on postoperative chylous ascites that developed after laparoscopic staging for Stage 1A Grade 3 epithelial ovarian cancer in a 48year-old patient. A review of the gynecologic literature follows. Setting: Department of gynecologic oncology at a community-based teaching hospital in the suburbs of Boson, MA. Patients: Forty eight year-old nulligravid patient with a BRCA1 mutation and breast cancer was found to have poorly differentiated left ovarian carcinoma after risk-reducing laparoscopic bilateral salpingoopherectomy. Subsequently laparoscopic assisted vaginal hysterectomy and staging were performed. Two weeks later patient presented with chylous ascites, lymphedema, and anterior abdominal wall lymphocele. Intervention: A case report; review of basic anatomy and physiology; presentation of illustrative figures and CT scan photographs; and review of the gynecologic literature. Measurements and Main Results: Treatment with low salt, low fat diet; Medium Chain Triglycerides; Somatostatin; paracentesis; and percutaneous drainage of lymphocele was successful. Patient was disease-free on 2-year follow-up. Conclusion: The incidence of postoperative chylous ascites may be increasing simultaneous with an increase in laparoscopic and aggressive surgeries. Surgical management has been successful in refractory cases. Conservative management is effective in most cases. Meticulous surgical technique may prevent its development. 391 Abstract Withdrawn 392 Effect of Abdominal Pressure to Subcutaneous Emphysema during Laparoscopic Surgery Kim CJ,1 Lee HN,2 Lee YS,2 Park EK,2 Park TC,3 Namkoong SE,4 Park JS.4 1Department of Obstetrics and Gynecology, St. Pauls’s Hospital,
The Cathoilic University of Korea, Seoul, Republic of Korea; 2Department of Obstetrics and Gynecology, Daejeon St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Daejeon, Republic of Korea; 3 Department of Obstetrics and Gynecology, Uijongbu St May’s Hospital, Catholic University Medical College of Korea, Uijonbu City, Kyonggi-do, Republic of Korea; 4Department of Obstetrics and Gynecology, Kangnam St Mary’s Hospital, Seoul, Republic of Korea Study Objective: Subcutaneous emphysema during laparoscopy may be precursor of pneumothorax or pneumomediastinum which is so dangerous. This study evaluated relation between subcutaneous emphysema during laparoscopy and intraabdominal pressure and other several factors. Design: From March 2007 to September 2007, we performed prospective randomized study for 50 patients received laparoscopy due to benign gynecologic disease at our four Hospital. Patients: Patients were randomly assigned to either 12 mmHg intraabdominal pressure group (n 5 25) or 10 mmHg intraabdominal pressure group (n 5 25). Intervention: Each patient had Trendelenberg position at adequate table tilting angle after general anesthesia during laparoscopy. We analyzed subcutaneous emphysema at each group. In addition to Intraabdominal pressure, we also analyzed relation between age, body mass index (BMI), table tilting angle, operation time and emphysema. Measurements and Main Results: We used 4 ports at only one patient and used 3 ports at other patients. There was no significant difference in age, BMI and table tilting angle between 12mmHg intraabdominal pressure group and 10mmHg intraabdominal pressure group. There was also no significant difference in operation duration between two groups, therefore decreased intraabdominal pressure didn’t prevent operation. Any subcutaneous emphysema didn’t occur in 10mmHg intraabdominal pressure group but emphysema occurred in four patients of 12mmHg intraabdominal pressure group (P 5 0.504). In spite of insignificant statistically, it seems to be more incidence of emphysema in 12mmHg group than 10mmHg group. There was no pneumothorax or pneumomediastinum in all patients with emphysema. Conclusion: Incidence of subcutaneous emphysema which may be precursor of pneumothorax or pneumomediastinum decreased at low intraabdominal pressure group compared to high intraabdominal pressure group. And it is necessary that intraabdominal pressure is lowly maintained to prevent emphysema during laparoscopy in the range of not interrupting operation.
393 Trocar Site Herniation through a 5mm Trocar Site Following Removal of Drains after Gynecologic Laparoscopy Lee YS, Jeung IC, Lee HN, Kim CJ. Obstetrics and Gynecology, The Catholic University Medical Colledge, Daejeon, Chung Nam, Republic of Korea Study Objective: The importance and the frequency of the laparoscopic surgery has recently been emphasized and the interest about the complications due to laparoscopic procedures is increasing. Trocar site herniation of the small bowel and omentum is one of the important laparoscopic complications and this is related to many factors, including diameter of the trocar. This condition is difficult to differentiate from simple post operative ileus and it could lead to fatal results due to the delayed diagnosis. Design: Most of the trocar site herniations occur in association with the use of a trocar greater than 10 mm and it rarely occurs when a 5 mm trocar is used. Setting: Therefore, fascial suture at the 5 mm trocar site must be selectively carried out. Patients: We experienced 2 cases of small bowel and omental herniation at 5 mm port sites, which probably occurred in connection with withdrawal of the drain at the end of the laparoscopic procedure.