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Severe Pelvic Abscess Formation after Laparoscopic Myomectomy May Be Complicated by Intraoperative Placement of Oxidized Regenerated Cellulose Barrier – A Case Report
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Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S128–S151
520 Laparoscopic Salpingostomy for Infertile Women with Hydrosalpinx: Rate of Tubal Patency after Operation by Hysterosalpingogram Lee K-H, Yang J-B, Ko Y-B, Lee M-A, Kang B-H. Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon, Korea Study Objective: The purpose of this study was to evaluate the efficacy of laparoscopic salpingostomy in infertile women with hydrosalpinx. Design: Retrospective analysis from January 1999 to December 2005. Setting: University Teaching Hospital. Patients: Eighty one infertile patients with hydrosalpinx. Intervention: Laparoscopic salpingostomy. Measurements and Main Results: The mean age of the patients was 29.84.5 years and mean number of abortion and term delivery were 1.01.6 and 0.20.5, respectively. The average duration of infertility in these patients was 35.328.8 months. The mean operating time was 63.121.9 minutes and the duration of admission was 3.61.3 days. The tubal patency was confirmed in 79 patients (97.5%) during the surgery and in 74 patients (91.4%) by hysterosalpingogram after two menstrual cycles. Following laparoscopic surgical treatment, a total of 19 patients (23.5%) achieved intrauterine pregnancies and most of them (84.2%) were achieved in 18 months after surgery. Conclusion: The pregnancy rate was relatively low compared with tubal patency after laparoscopic salpingostomy. 521 Laparoscopic Management of an Androgen Insensitivity Syndrome: A Case Report Lee WY, Sung SM, Jung HJ, Song ES, Park JW. Obstetrics & Gynecology, INHA University Hospital, Incheon, Korea Study Objective: To present a case of laparoscopic bilateral orchiectomy in androgen insensitivity syndrome. Design: A case report. Setting: University Hospital, Republic of Korea. Patients: A 16-years-old girl whose main complaint was primary amenorrhea was referred to our department for further evaluation. On physical examination, she had no pubic hairs and sparse axillary hairs. Her externl genitalia appeared entirely female and her breast development was Tanner stage 3. Ultrasound and magnetic resonance imaging(MRI) showed absent uterus. Based on these features, male karyotype(46,XY) and high level of serum testosterone (5.49 ng/ml, normal 0.11-0.79) allowed for establishing the diagnosis of complete androgen insensitivity syndrome. Because she attained full development, we decided to remove the gonads laparoscopically. Intervention: Laparoscopic bilateral orchiectomy to prevent from developing gonadal tumors. Measurements and Main Results: Laparoscopy showed bilateral high intraabdominal testes and no uterus. We performed bilateral orchiectomy through the laparoscope and tissue examination result revealed presence of testes, right & left tissue from pelvic cavity. The patient recovered without complications and has kept taking oral pills for hormonal replacement therapy. Conclusion: The diagnosis of Androgen Insensitivity Syndrome can be established by clinical features, imaging techniques, hormonal assays and karyotyping. Laparoscopic procedure may help to confirm the diagnosis and can be used for performing bilateral orchiectomy to prevent from formation of gonadal tumors as well. 522 A Retroperitoneal Lymphocele Post Renal Transplantation Mimicking Ovarian Cyst Treated with Laparoscopic Marsupialization: A Case Report Lin Y-S, Lin MY, Chen S-S. Department of Obstetrics & Gynecology, Chi Mei Medical Center, Yuang Kang City, Tainan, Taiwan Study Objective: We encountered a patient with a pelvic mass 4 years after renal transplantation which under laparoscopic proved to be a lymphocele and treated with marsuplization of lymphocele. Measurements and Main Results: 50 year-old woman, gravida 2 para 2, has had history of polycystic kidney disease and ESRD underwent renal
transplantation on 2003-11-29. After surgery, her renal function was restored, however, a left pelvic tumor was incidentally found in abdominal ultrasound during her regular follow-up. A referral to the gynecological OPD, sonography exam showed this left pelvic cystic mass with separate, measured about 8.8x6.64 cm. The serum level of tumor makers including CA 19-9, CA 1-25 and AFP were within the normal range. Initial impression of the mass favored adnexal origin but with its proximity to the transplant kidney, a lymphocele is also considered. A laparoscopic surgery was arranged and identified the mass as retroperitoneal origin, just below the transplanted kidney. Laparoscopic instrumental incision with creation of a peritoneal window of 5 cm in diameter was performed. Milk-like content within the mass was drained out and tissue for pathology showed cyst is surrounded by hyalinized connective tissue wall and consistent with lymphocele. Conclusion: Occurrence of lymphocele formation following renal transplantation is not uncommon and surgical intraperitoneal marsupialization of lymphocele is considered the treatment of choice. Other means of management such as percutaneous needle aspiration and external drainage are associated with high recurrence and complications. In patients with a clinically significant post-transplantation lymphocele of appropriate size and location as seen in this patient, laparoscopic drainaging and creating a peritoneal window is an effective procedure with minimal recurrence. 523 Severe Pelvic Abscess Formation after Laparoscopic Myomectomy May Be Complicated by Intraoperative Placement of Oxidized Regenerated Cellulose Barrier – A Case Report Lin MY, Lin Y-S, Chen S-H. Obstetrics and Gynecology, Chimei Medical Center, Yung Kang, Tainan County, Taiwan Study Objective: Laparoscopic surgery have a favorable effect on adhesion formation but does not eliminate the risk of adhesions if in event of severe infection with possible foreign-body reactions due to adhesion barrier placement as demonstrated in our case. Design: A case report. Setting: A tertiary teaching hospital in Southern Taiwan. Patients: A 27-year-old single female, Gravida 0, para 0, presented with subserosal myoma and arranged for Laparoscopic myomectomy. Intervention: Laparoscopic myomectomy was done intially. A second laparoscopy was needed to remove pelvic abscess formation and necrotic debris, adhesiolysis after unsuccessful antibiotics treatment. Measurements and Main Results: Laparoscopic myomectomy (multiple subserosal myoma largest 7x7cm) performed with prophylactic antibiotics given as routine. Ten days after discharge, patient visited ER and complaint of abdominal pain and fever plusLeukocytosis (WBC 18600/ul), CRP elevation (116.2mg/L). After ineffective antibiotics treatment, a diagnotic laparoscopy was then arranged (45 days after initial laparoscopic myomectomy) found severe pelvic abscess formation and dense adhesion with pseudocyst of cul-de-sac. Prior uterine wound cover with oxidized regenerated cellulose barrier (interceed) was now dense adhesion and necrotic debris.Adhesiolysis and pelvic irrigation with necrotic debris removal were performed and
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S128–S151
S151
Study Objective: This report describes a case of fallopian tube torsion in a 17 year old virginal female where the affected fallopian tube was able to be salvaged after laparoscopic detorsion. Design: Case Report. Setting: Geisinger Medical Center. Patients: A 17-year-old nulligravid, otherwise healthy Caucassian female presented with acute onset right lower quadrant abdominal pain. She was afebrile and with normal appetite. She reported regular bowel movements and was without leukocytosis. On exam she had tenderness in the right lower quadrant, but was without rebound or guarding. The patient had required a significant amount of narcotics to control her pain, and the pain returned each time the narcotics wore off. Intervention: Operative Laparoscopy, Detorsion of Right Fallopian Tube. Measurements and Main Results: Evaluation with ultrasound revealed a 5 x 4.5 x 4 cm complex ovarian mass. No flow was visualized to the right ovary. The patient was taken to the operating room for diagnostic laparoscopy for presumed right ovarian torsion. On entry to the peritoneal cavity, it was noted that it was the right fallopian tube, not the ovary, which was torsed.
a retention drainage tube placed transabdominally. Post operatively antibiotics continued and the patient recovered well and discharge uneventfully. Conclusion: Application of anti-adhesive material can help to prevent adhesion. An absorbable oxidized regenerated cellulose barrier (Interceed), when applied can form a gelatinous protective coat over the damaged tissue. However, in case of insidious infection and if became fulminant, it not only serves as a niche for bacterial growth but further complicates the effectiveness of postoperative antibiotics treatment. 524 Surgical and Patient Outcomes Using Mechanical Bowel Preparation before Laparoscopic Gynecological Procedures in the Posterior Compartment: A Single Blinded Randomized Controlled Trial Maley P, Verma A, Won HR, Campbell NT, Abbott JA. Endo-Gynecology, Royal Hospital for Women, Randwick, NSW, Australia Study Objective: To investigate patient symptomatology, serological changes, surgical view and bowel handling across three pre-operative preparation groups. It is proposed that mechanical bowel preparation (MBP) improves surgical field view in laparoscopic gynecological surgery, particularly in the posterior pelvic compartment. Studies show that adnexal surgery is not improved by MBP and side effects include patient discomfort and possible electrolyte disturbance. Design: Randomized single blind controlled study. Setting: Department of Endo-Gynaecology, Royal Hospital for Women, Sydney Australia. Patients: Consenting patients undergoing elective laparoscopy for benign pathology of the deep pelvis. Intervention: 270 women to be randomized to one of three pre-operative diets: 1) fasting only, 2) minimal residue diet for one day pre-operatively, and 3) minimal residue and mechanical bowel preparation with an osmotic laxative on the day prior to surgery. Primary outcome measures include patient symptomatology as assessed by headache, thirst, nausea, vomiting, tiredness and weakness, patient electrolyte levels collected before dietary intervention, on the day of surgery and the day after surgery and surgical view and bowel handling assessed in a blinded manner from the operating surgeon through visual analog and verbal descriptor scale assessment. Operative data including type and duration of surgery and complications are available. One week and one month post-operative data assessing bowel function and bowel symptoms is available as assessed by a validated bowel specific questionnaire. Measurements and Main Results: To date, 190 women have been randomized, recruited and have complete data sets available. Data projections show recruitment and data collection will be complete by July 2010. Conclusion: To be presented for the first time at the global meeting. 525 Isolated Fallopian Tube Torsion in a Virginal 17 Year-Old Female: A Case Report Mattison SP, Platte R. Obstetrics and Gynecology, Geisinger Medical Center, Danville, Pennsylvania
The tube was hydropic and cyanotic. Within minutes of detorsion, the tube was noted to be pink and less distended.
Conclusion: Isolated Fallopian tube torsion occurs in 1 of every 1,500,000 women. Although uncommon, it should be considered in the differential diagnosis for acute abdominal pain in the female patient. The lack of pathognomonic signs and symptoms, and the low specificity of imaging studies makes laparoscopy the gold standard in diagnosis and treatment. In our case, the diagnosis of oviduct torsion was established promptly which allowed preservation fallopian tube and future fertility in this patient.
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S128–S151
520 Laparoscopic Salpingostomy for Infertile Women with Hydrosalpinx: Rate of Tubal Patency after Operation by Hysterosalpingogram Lee K-H, Yang J-B, Ko Y-B, Lee M-A, Kang B-H. Obstetrics and Gynecology, Chungnam National University Hospital, Daejeon, Korea Study Objective: The purpose of this study was to evaluate the efficacy of laparoscopic salpingostomy in infertile women with hydrosalpinx. Design: Retrospective analysis from January 1999 to December 2005. Setting: University Teaching Hospital. Patients: Eighty one infertile patients with hydrosalpinx. Intervention: Laparoscopic salpingostomy. Measurements and Main Results: The mean age of the patients was 29.84.5 years and mean number of abortion and term delivery were 1.01.6 and 0.20.5, respectively. The average duration of infertility in these patients was 35.328.8 months. The mean operating time was 63.121.9 minutes and the duration of admission was 3.61.3 days. The tubal patency was confirmed in 79 patients (97.5%) during the surgery and in 74 patients (91.4%) by hysterosalpingogram after two menstrual cycles. Following laparoscopic surgical treatment, a total of 19 patients (23.5%) achieved intrauterine pregnancies and most of them (84.2%) were achieved in 18 months after surgery. Conclusion: The pregnancy rate was relatively low compared with tubal patency after laparoscopic salpingostomy. 521 Laparoscopic Management of an Androgen Insensitivity Syndrome: A Case Report Lee WY, Sung SM, Jung HJ, Song ES, Park JW. Obstetrics & Gynecology, INHA University Hospital, Incheon, Korea Study Objective: To present a case of laparoscopic bilateral orchiectomy in androgen insensitivity syndrome. Design: A case report. Setting: University Hospital, Republic of Korea. Patients: A 16-years-old girl whose main complaint was primary amenorrhea was referred to our department for further evaluation. On physical examination, she had no pubic hairs and sparse axillary hairs. Her externl genitalia appeared entirely female and her breast development was Tanner stage 3. Ultrasound and magnetic resonance imaging(MRI) showed absent uterus. Based on these features, male karyotype(46,XY) and high level of serum testosterone (5.49 ng/ml, normal 0.11-0.79) allowed for establishing the diagnosis of complete androgen insensitivity syndrome. Because she attained full development, we decided to remove the gonads laparoscopically. Intervention: Laparoscopic bilateral orchiectomy to prevent from developing gonadal tumors. Measurements and Main Results: Laparoscopy showed bilateral high intraabdominal testes and no uterus. We performed bilateral orchiectomy through the laparoscope and tissue examination result revealed presence of testes, right & left tissue from pelvic cavity. The patient recovered without complications and has kept taking oral pills for hormonal replacement therapy. Conclusion: The diagnosis of Androgen Insensitivity Syndrome can be established by clinical features, imaging techniques, hormonal assays and karyotyping. Laparoscopic procedure may help to confirm the diagnosis and can be used for performing bilateral orchiectomy to prevent from formation of gonadal tumors as well. 522 A Retroperitoneal Lymphocele Post Renal Transplantation Mimicking Ovarian Cyst Treated with Laparoscopic Marsupialization: A Case Report Lin Y-S, Lin MY, Chen S-S. Department of Obstetrics & Gynecology, Chi Mei Medical Center, Yuang Kang City, Tainan, Taiwan Study Objective: We encountered a patient with a pelvic mass 4 years after renal transplantation which under laparoscopic proved to be a lymphocele and treated with marsuplization of lymphocele. Measurements and Main Results: 50 year-old woman, gravida 2 para 2, has had history of polycystic kidney disease and ESRD underwent renal
transplantation on 2003-11-29. After surgery, her renal function was restored, however, a left pelvic tumor was incidentally found in abdominal ultrasound during her regular follow-up. A referral to the gynecological OPD, sonography exam showed this left pelvic cystic mass with separate, measured about 8.8x6.64 cm. The serum level of tumor makers including CA 19-9, CA 1-25 and AFP were within the normal range. Initial impression of the mass favored adnexal origin but with its proximity to the transplant kidney, a lymphocele is also considered. A laparoscopic surgery was arranged and identified the mass as retroperitoneal origin, just below the transplanted kidney. Laparoscopic instrumental incision with creation of a peritoneal window of 5 cm in diameter was performed. Milk-like content within the mass was drained out and tissue for pathology showed cyst is surrounded by hyalinized connective tissue wall and consistent with lymphocele. Conclusion: Occurrence of lymphocele formation following renal transplantation is not uncommon and surgical intraperitoneal marsupialization of lymphocele is considered the treatment of choice. Other means of management such as percutaneous needle aspiration and external drainage are associated with high recurrence and complications. In patients with a clinically significant post-transplantation lymphocele of appropriate size and location as seen in this patient, laparoscopic drainaging and creating a peritoneal window is an effective procedure with minimal recurrence. 523 Severe Pelvic Abscess Formation after Laparoscopic Myomectomy May Be Complicated by Intraoperative Placement of Oxidized Regenerated Cellulose Barrier – A Case Report Lin MY, Lin Y-S, Chen S-H. Obstetrics and Gynecology, Chimei Medical Center, Yung Kang, Tainan County, Taiwan Study Objective: Laparoscopic surgery have a favorable effect on adhesion formation but does not eliminate the risk of adhesions if in event of severe infection with possible foreign-body reactions due to adhesion barrier placement as demonstrated in our case. Design: A case report. Setting: A tertiary teaching hospital in Southern Taiwan. Patients: A 27-year-old single female, Gravida 0, para 0, presented with subserosal myoma and arranged for Laparoscopic myomectomy. Intervention: Laparoscopic myomectomy was done intially. A second laparoscopy was needed to remove pelvic abscess formation and necrotic debris, adhesiolysis after unsuccessful antibiotics treatment. Measurements and Main Results: Laparoscopic myomectomy (multiple subserosal myoma largest 7x7cm) performed with prophylactic antibiotics given as routine. Ten days after discharge, patient visited ER and complaint of abdominal pain and fever plusLeukocytosis (WBC 18600/ul), CRP elevation (116.2mg/L). After ineffective antibiotics treatment, a diagnotic laparoscopy was then arranged (45 days after initial laparoscopic myomectomy) found severe pelvic abscess formation and dense adhesion with pseudocyst of cul-de-sac. Prior uterine wound cover with oxidized regenerated cellulose barrier (interceed) was now dense adhesion and necrotic debris.Adhesiolysis and pelvic irrigation with necrotic debris removal were performed and
Abstracts / Journal of Minimally Invasive Gynecology 17 (2010) S128–S151
S151
Study Objective: This report describes a case of fallopian tube torsion in a 17 year old virginal female where the affected fallopian tube was able to be salvaged after laparoscopic detorsion. Design: Case Report. Setting: Geisinger Medical Center. Patients: A 17-year-old nulligravid, otherwise healthy Caucassian female presented with acute onset right lower quadrant abdominal pain. She was afebrile and with normal appetite. She reported regular bowel movements and was without leukocytosis. On exam she had tenderness in the right lower quadrant, but was without rebound or guarding. The patient had required a significant amount of narcotics to control her pain, and the pain returned each time the narcotics wore off. Intervention: Operative Laparoscopy, Detorsion of Right Fallopian Tube. Measurements and Main Results: Evaluation with ultrasound revealed a 5 x 4.5 x 4 cm complex ovarian mass. No flow was visualized to the right ovary. The patient was taken to the operating room for diagnostic laparoscopy for presumed right ovarian torsion. On entry to the peritoneal cavity, it was noted that it was the right fallopian tube, not the ovary, which was torsed.
a retention drainage tube placed transabdominally. Post operatively antibiotics continued and the patient recovered well and discharge uneventfully. Conclusion: Application of anti-adhesive material can help to prevent adhesion. An absorbable oxidized regenerated cellulose barrier (Interceed), when applied can form a gelatinous protective coat over the damaged tissue. However, in case of insidious infection and if became fulminant, it not only serves as a niche for bacterial growth but further complicates the effectiveness of postoperative antibiotics treatment. 524 Surgical and Patient Outcomes Using Mechanical Bowel Preparation before Laparoscopic Gynecological Procedures in the Posterior Compartment: A Single Blinded Randomized Controlled Trial Maley P, Verma A, Won HR, Campbell NT, Abbott JA. Endo-Gynecology, Royal Hospital for Women, Randwick, NSW, Australia Study Objective: To investigate patient symptomatology, serological changes, surgical view and bowel handling across three pre-operative preparation groups. It is proposed that mechanical bowel preparation (MBP) improves surgical field view in laparoscopic gynecological surgery, particularly in the posterior pelvic compartment. Studies show that adnexal surgery is not improved by MBP and side effects include patient discomfort and possible electrolyte disturbance. Design: Randomized single blind controlled study. Setting: Department of Endo-Gynaecology, Royal Hospital for Women, Sydney Australia. Patients: Consenting patients undergoing elective laparoscopy for benign pathology of the deep pelvis. Intervention: 270 women to be randomized to one of three pre-operative diets: 1) fasting only, 2) minimal residue diet for one day pre-operatively, and 3) minimal residue and mechanical bowel preparation with an osmotic laxative on the day prior to surgery. Primary outcome measures include patient symptomatology as assessed by headache, thirst, nausea, vomiting, tiredness and weakness, patient electrolyte levels collected before dietary intervention, on the day of surgery and the day after surgery and surgical view and bowel handling assessed in a blinded manner from the operating surgeon through visual analog and verbal descriptor scale assessment. Operative data including type and duration of surgery and complications are available. One week and one month post-operative data assessing bowel function and bowel symptoms is available as assessed by a validated bowel specific questionnaire. Measurements and Main Results: To date, 190 women have been randomized, recruited and have complete data sets available. Data projections show recruitment and data collection will be complete by July 2010. Conclusion: To be presented for the first time at the global meeting. 525 Isolated Fallopian Tube Torsion in a Virginal 17 Year-Old Female: A Case Report Mattison SP, Platte R. Obstetrics and Gynecology, Geisinger Medical Center, Danville, Pennsylvania
The tube was hydropic and cyanotic. Within minutes of detorsion, the tube was noted to be pink and less distended.
Conclusion: Isolated Fallopian tube torsion occurs in 1 of every 1,500,000 women. Although uncommon, it should be considered in the differential diagnosis for acute abdominal pain in the female patient. The lack of pathognomonic signs and symptoms, and the low specificity of imaging studies makes laparoscopy the gold standard in diagnosis and treatment. In our case, the diagnosis of oviduct torsion was established promptly which allowed preservation fallopian tube and future fertility in this patient.