- Email: [email protected]
Laparoscopic management of abdominal ectopic pregnancy using FLOSEAL Hemostatic Matrix
BRIEF COMMUNICATIONS
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References [1] Thapa M, Rawal S, Jha R, Singh M. Ovarian pregnancy: a rare ectopic pregnancy. JNMA J Nepal Med Assoc 2010;49(177):52–5. [2] Choi HJ, Im KS, Jung HJ, Lim KT, Mok JE, Kwon YS. Clinical analysis of ovarian pregnancy: a report of 49 cases. Eur J Obstset Gynecol Reprod Biol 2011;158(1):87–9. [3] Tulandi T. Clinical manifestations, diagnosis, and management of ectopic pregnancy. UpToDate 19.3 September 2011. Available at:http://www.uptodate.com/contents/ clinical-manifestations-diagnosis-and-management-of-ectopic-pregnancy. [4] Backman T, Rauramo I, Huhtala S, Koskenvuo M. Pregnancy during the use of levonorgestrel intrauterine system. Am J Obstet Gynecol 2004;190(1):50–4.
Fig. 1. Transvaginal ultrasound image showing an ectopic pregnancy in the right adnexa.
Conflict of interest The authors have no conflicts of interest to declare.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.006
Laparoscopic management of abdominal ectopic pregnancy using FLOSEAL Hemostatic Matrix Anwen Gorry ⁎, Marie-Laure Morelli, Oladimeji Olowu, Anupama Shahid, Funlayo Odejinmi Whipps Cross University Hospital NHS Trust, Leytonstone, London, UK
a r t i c l e
i n f o
Article history: Received 11 August 2011 Received in revised form 8 November 2011 Accepted 6 December 2011 Keywords: Abdominal ectopic pregnancy FLOSEAL Hemostatic Matrix Laparoscopy Uterosacral ectopic pregnancy
An abdominal pregnancy is a pregnancy that is confined to the peritoneum of the abdominal cavity and which occurs independently of the female reproductive tract. It is very rare and constitutes approximately 1% of all ectopic pregnancies. Mortality rates are 7.7 times higher than tubal ectopic pregnancy [1], and the overall laparoscopy rate for treatment of this type of pregnancy has been reported to be as low as 55% [2]. ⁎ Corresponding author at: Whipps Cross University Hospital NHS Trust, Whipps Cross Road, Leytonstone, London, E11 1NR, UK. Tel.: + 44 7930143251; fax: + 44 2085356841. E-mail address: [email protected] (A. Gorry).
A 32-year-old woman presented with amenorrhea of 8 weeks’ duration together with abdominal pain and bleeding. Transvaginal ultrasound revealed an empty uterus and an inhomogeneous mass in the left adnexa suggestive of ectopic pregnancy. Laparoscopy revealed a primary peritoneal ectopic pregnancy medial to the left uterosacral ligament. This was found to be actively bleeding and attempts at resection with electrocautery worsened the hemorrhage. Laparoscopic sutures did not help. The hemostatic agent, FLOSEAL (FLOSEAL Hemostatic Matrix; Baxter, Deerfield, IL, USA), was applied to the ectopic bed, which stopped the bleeding effectively. The patient made an uneventful recovery and has subsequently become pregnant with a viable intrauterine pregnancy. Resecting abdominal pregnancies can result in torrential hemorrhage [3] and this problem continues to limit laparoscopic management of abdominal pregnancy. When more traditional methods of hemostasis fail, turning to more novel approaches can allow completion of laparoscopic surgery. The FLOSEAL Hemostatic Matrix is a combination of reconstituted human thrombin together with a gelatin, collagen, and cellulose matrix that has been shown to work on actively bleeding tissue. By combining thrombin together with a mechanical matrix, FLOSEAL acts on the coagulation cascade from two angles. Firstly, the cellulose matrix acts on the intrinsic pathway (the contact activation pathway); and secondly, the reconstituted thrombin acts further down the cascade at the common pathway,
84
BRIEF COMMUNICATIONS
leading to the conversion of fibrin from fibrinogen, thereby aiding clot formation. FLOSEAL was first used during laparoscopy for a diaphragmatic hernia repair and has since been used effectively in elective gynecological procedures such as myomectomy, ovarian cystectomy [4], and treatment of endometriosis. It should not be considered as a first-line agent since the majority of hemorrhage can be controlled with meticulous surgical technique. However, if other laparoscopic surgical measures, including suturing, bipolar electrocautery, and the harmonic scalpel have failed, then it is an extremely useful secondary adjunct.
References [1] Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69(3 Pt 1):333–7. [2] Shaw SW, Hsu JJ, Chueh HY, Han CM, Chen FC, Chang YL, et al. Management of primary abdominal pregnancy: twelve years of experience in a medical centre. Acta Obstet Gynecol Scand 2007;86(9):1058–62. [3] Cristalli B, Guichaoua H, Heid M, Izard V, Levardon M. Abdominal ectopic pregnancy. Limits of laparoscopic treatment [In French]. J Gynecol Obstet Biol Reprod (Paris) 1992;21(7):751–3. [4] Ebert AD, Hollauer A, Fuhr N, Langolf O, Papadopoulos T. Laparoscopic ovarian cystectomy without bipolar coagulation or sutures using a gelatin–thrombin matrix sealant (FloSeal): first support of a promising technique. Arch Gynecol Obstet 2009;280(1):161–5.
Conflict of interest The authors have no conflicts of interest to declare.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.003
Effect of concomitant oophorectomy on the perioperative outcomes of laparoscopic hysterectomy☆ Keisha Jones, Oz Harmanli ⁎, Cara A. Robinson, Sertac Esin, Ayse Citil, Alexander Knee Department of Obstetrics and Gynecology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
a r t i c l e
i n f o
Article history: Received 26 October 2011 Received in revised form 29 November 2011 Accepted 13 December 2011 Keywords: Laparoscopic hysterectomy Oophorectomy Perioperative complications Prophylactic oophorectomy
The dilemma concerning elective oophorectomy continues to resurface as hysterectomy remains the most common major gynecologic surgery performed in the USA [1]. While the pendulum continues to swing, there remains a paucity of information about the surgical outcomes of this practice. The objective of the present study was to assess whether concomitant adnexal removal at the time of laparoscopic hysterectomy has an impact on perioperative outcomes. This is an ancillary analysis from a database created at Baystate Medical Center, USA. The methods have been described previously [2]. This was a retrospective cohort, including all total and supracervical laparoscopic hysterectomies performed for benign conditions between November 1999 and August 2008. Patients with pelvic pain, endometriosis, pelvic mass, or endometrial
☆ Paper presented as an oral poster at the 37th Annual Scientific Meeting of the Society of Gynecologic Surgeons in San Antonio, Texas, USA, held April 11–13, 2011. ⁎ Corresponding author at: Urogynecology and Pelvic Surgery, Baystate Medical Center, Tufts University School of Medicine, 759 Chestnut Street, S1680, Springfield, MA 01199, USA. Tel.: + 1 413 795 5608. E-mail address: [email protected] (O. Harmanli).
hyperplasia were excluded. Patients were categorized based on the presence or absence of elective concomitant adnexal removal. After comparing baseline characteristics, comorbid conditions, and indications for surgery, perioperative outcomes were evaluated including operating time, serious complications, and conversion to laparotomy. Of the 612 eligible cases, 249 (40.7%) included concomitant oophorectomy. As expected, patients who underwent adnexal removal were slightly older (42 ± 5 vs 47 ± 7 years) and more likely to be postmenopausal. This difference did not seem to be clinically significant as a small difference in age would not likely translate into a clinical effect. The hysterectomy only group was more likely to have menorrhagia as the surgical indication and less likely to have pelvic organ prolapse. There were no significant differences in operating time ≥ 200 minutes, change in hemoglobin ≥ 2.5 g/dL, febrile morbidity, urinary tract injury, or serious complications. Conversion to laparotomy was significantly increased in women undergoing concomitant adnexal removal compared with hysterectomy only (11.1% vs 3.3%, Adjusted Relative Risk 3.34; 95% CI, 1.58–7.08; Table 1). The magnitude of these results varied by prior adnexal surgery in the patient and surgeons’ volume of work. Unadjusted estimates suggest that length of hospital stay greater than 24 hours was an increased risk for those with concomitant adnexal removal (RR 1.60; 95% CI, 1.14–2.26; Table 1). Stratified estimates further indicate that, after adjusting, increased risk resides among patients whose surgery was performed by surgeons with a low volume of work. This study did not show an increased risk of complications when elective adnexal removal is performed with laparoscopic hysterectomy. Even after adjustment, there was an increased risk of conversion to laparotomy when hysterectomy was conducted with concomitant adnexal removal compared with hysterectomy alone. The present study provides clinicians with valuable information about the short-term effects of combining
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References [1] Thapa M, Rawal S, Jha R, Singh M. Ovarian pregnancy: a rare ectopic pregnancy. JNMA J Nepal Med Assoc 2010;49(177):52–5. [2] Choi HJ, Im KS, Jung HJ, Lim KT, Mok JE, Kwon YS. Clinical analysis of ovarian pregnancy: a report of 49 cases. Eur J Obstset Gynecol Reprod Biol 2011;158(1):87–9. [3] Tulandi T. Clinical manifestations, diagnosis, and management of ectopic pregnancy. UpToDate 19.3 September 2011. Available at:http://www.uptodate.com/contents/ clinical-manifestations-diagnosis-and-management-of-ectopic-pregnancy. [4] Backman T, Rauramo I, Huhtala S, Koskenvuo M. Pregnancy during the use of levonorgestrel intrauterine system. Am J Obstet Gynecol 2004;190(1):50–4.
Fig. 1. Transvaginal ultrasound image showing an ectopic pregnancy in the right adnexa.
Conflict of interest The authors have no conflicts of interest to declare.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.006
Laparoscopic management of abdominal ectopic pregnancy using FLOSEAL Hemostatic Matrix Anwen Gorry ⁎, Marie-Laure Morelli, Oladimeji Olowu, Anupama Shahid, Funlayo Odejinmi Whipps Cross University Hospital NHS Trust, Leytonstone, London, UK
a r t i c l e
i n f o
Article history: Received 11 August 2011 Received in revised form 8 November 2011 Accepted 6 December 2011 Keywords: Abdominal ectopic pregnancy FLOSEAL Hemostatic Matrix Laparoscopy Uterosacral ectopic pregnancy
An abdominal pregnancy is a pregnancy that is confined to the peritoneum of the abdominal cavity and which occurs independently of the female reproductive tract. It is very rare and constitutes approximately 1% of all ectopic pregnancies. Mortality rates are 7.7 times higher than tubal ectopic pregnancy [1], and the overall laparoscopy rate for treatment of this type of pregnancy has been reported to be as low as 55% [2]. ⁎ Corresponding author at: Whipps Cross University Hospital NHS Trust, Whipps Cross Road, Leytonstone, London, E11 1NR, UK. Tel.: + 44 7930143251; fax: + 44 2085356841. E-mail address: [email protected] (A. Gorry).
A 32-year-old woman presented with amenorrhea of 8 weeks’ duration together with abdominal pain and bleeding. Transvaginal ultrasound revealed an empty uterus and an inhomogeneous mass in the left adnexa suggestive of ectopic pregnancy. Laparoscopy revealed a primary peritoneal ectopic pregnancy medial to the left uterosacral ligament. This was found to be actively bleeding and attempts at resection with electrocautery worsened the hemorrhage. Laparoscopic sutures did not help. The hemostatic agent, FLOSEAL (FLOSEAL Hemostatic Matrix; Baxter, Deerfield, IL, USA), was applied to the ectopic bed, which stopped the bleeding effectively. The patient made an uneventful recovery and has subsequently become pregnant with a viable intrauterine pregnancy. Resecting abdominal pregnancies can result in torrential hemorrhage [3] and this problem continues to limit laparoscopic management of abdominal pregnancy. When more traditional methods of hemostasis fail, turning to more novel approaches can allow completion of laparoscopic surgery. The FLOSEAL Hemostatic Matrix is a combination of reconstituted human thrombin together with a gelatin, collagen, and cellulose matrix that has been shown to work on actively bleeding tissue. By combining thrombin together with a mechanical matrix, FLOSEAL acts on the coagulation cascade from two angles. Firstly, the cellulose matrix acts on the intrinsic pathway (the contact activation pathway); and secondly, the reconstituted thrombin acts further down the cascade at the common pathway,
84
BRIEF COMMUNICATIONS
leading to the conversion of fibrin from fibrinogen, thereby aiding clot formation. FLOSEAL was first used during laparoscopy for a diaphragmatic hernia repair and has since been used effectively in elective gynecological procedures such as myomectomy, ovarian cystectomy [4], and treatment of endometriosis. It should not be considered as a first-line agent since the majority of hemorrhage can be controlled with meticulous surgical technique. However, if other laparoscopic surgical measures, including suturing, bipolar electrocautery, and the harmonic scalpel have failed, then it is an extremely useful secondary adjunct.
References [1] Atrash HK, Friede A, Hogue CJ. Abdominal pregnancy in the United States: frequency and maternal mortality. Obstet Gynecol 1987;69(3 Pt 1):333–7. [2] Shaw SW, Hsu JJ, Chueh HY, Han CM, Chen FC, Chang YL, et al. Management of primary abdominal pregnancy: twelve years of experience in a medical centre. Acta Obstet Gynecol Scand 2007;86(9):1058–62. [3] Cristalli B, Guichaoua H, Heid M, Izard V, Levardon M. Abdominal ectopic pregnancy. Limits of laparoscopic treatment [In French]. J Gynecol Obstet Biol Reprod (Paris) 1992;21(7):751–3. [4] Ebert AD, Hollauer A, Fuhr N, Langolf O, Papadopoulos T. Laparoscopic ovarian cystectomy without bipolar coagulation or sutures using a gelatin–thrombin matrix sealant (FloSeal): first support of a promising technique. Arch Gynecol Obstet 2009;280(1):161–5.
Conflict of interest The authors have no conflicts of interest to declare.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.11.003
Effect of concomitant oophorectomy on the perioperative outcomes of laparoscopic hysterectomy☆ Keisha Jones, Oz Harmanli ⁎, Cara A. Robinson, Sertac Esin, Ayse Citil, Alexander Knee Department of Obstetrics and Gynecology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA, USA
a r t i c l e
i n f o
Article history: Received 26 October 2011 Received in revised form 29 November 2011 Accepted 13 December 2011 Keywords: Laparoscopic hysterectomy Oophorectomy Perioperative complications Prophylactic oophorectomy
The dilemma concerning elective oophorectomy continues to resurface as hysterectomy remains the most common major gynecologic surgery performed in the USA [1]. While the pendulum continues to swing, there remains a paucity of information about the surgical outcomes of this practice. The objective of the present study was to assess whether concomitant adnexal removal at the time of laparoscopic hysterectomy has an impact on perioperative outcomes. This is an ancillary analysis from a database created at Baystate Medical Center, USA. The methods have been described previously [2]. This was a retrospective cohort, including all total and supracervical laparoscopic hysterectomies performed for benign conditions between November 1999 and August 2008. Patients with pelvic pain, endometriosis, pelvic mass, or endometrial
☆ Paper presented as an oral poster at the 37th Annual Scientific Meeting of the Society of Gynecologic Surgeons in San Antonio, Texas, USA, held April 11–13, 2011. ⁎ Corresponding author at: Urogynecology and Pelvic Surgery, Baystate Medical Center, Tufts University School of Medicine, 759 Chestnut Street, S1680, Springfield, MA 01199, USA. Tel.: + 1 413 795 5608. E-mail address: [email protected] (O. Harmanli).
hyperplasia were excluded. Patients were categorized based on the presence or absence of elective concomitant adnexal removal. After comparing baseline characteristics, comorbid conditions, and indications for surgery, perioperative outcomes were evaluated including operating time, serious complications, and conversion to laparotomy. Of the 612 eligible cases, 249 (40.7%) included concomitant oophorectomy. As expected, patients who underwent adnexal removal were slightly older (42 ± 5 vs 47 ± 7 years) and more likely to be postmenopausal. This difference did not seem to be clinically significant as a small difference in age would not likely translate into a clinical effect. The hysterectomy only group was more likely to have menorrhagia as the surgical indication and less likely to have pelvic organ prolapse. There were no significant differences in operating time ≥ 200 minutes, change in hemoglobin ≥ 2.5 g/dL, febrile morbidity, urinary tract injury, or serious complications. Conversion to laparotomy was significantly increased in women undergoing concomitant adnexal removal compared with hysterectomy only (11.1% vs 3.3%, Adjusted Relative Risk 3.34; 95% CI, 1.58–7.08; Table 1). The magnitude of these results varied by prior adnexal surgery in the patient and surgeons’ volume of work. Unadjusted estimates suggest that length of hospital stay greater than 24 hours was an increased risk for those with concomitant adnexal removal (RR 1.60; 95% CI, 1.14–2.26; Table 1). Stratified estimates further indicate that, after adjusting, increased risk resides among patients whose surgery was performed by surgeons with a low volume of work. This study did not show an increased risk of complications when elective adnexal removal is performed with laparoscopic hysterectomy. Even after adjustment, there was an increased risk of conversion to laparotomy when hysterectomy was conducted with concomitant adnexal removal compared with hysterectomy alone. The present study provides clinicians with valuable information about the short-term effects of combining