Capnothorax During Laparoscopy in Trendelenburg Position: A Rare Case Study.

Pneumothorax is an infrequent complication of laparoscopic surgery. Most cases occur during upper abdominal surgery, since a head-down position (Trendelenburg) pushes the liver and peritoneum against the diaphragm, reducing gas release. When it is due to CO2 diffusion across congenital diaphragmatic defects, it usually resolves itself spontaneously after de-insufflation of the pneumoperitoneum. Increasing positive end-expiratory pressure to counteract intra-abdominal pressure is an effective measure when a pulmonary origin is excluded. We report a case of right-sided hypertensive capnothorax due to a diaphragmatic defect, during lower abdominal surgery, which was successfully managed without the need for chest drainage. This case highlights the importance of maintaining active vigilance and a high index of suspicion for pneumothorax during laparoscopic surgery.

O pneumotórax é uma complicação pouco frequente da cirurgia laparoscópica. A maioria dos casos ocorrem em cirurgias da região abdominal superior, uma vez que a posição de Trendelenburg por empurrar o fígado e o peritoneu contra o diafragma, reduz a perda de gás. Quando a causa é a difusão de CO2 através de um defeito diafragmático congénito, habitualmente resolve espontaneamente, após a desinsuflação do pneumoperitoneu. Quando se exclui uma causa parenquimatosa pulmonar o aumento de positive end-expiratory pressure para contrabalançar a pressão intra-abdominal é uma medida eficaz. O caso clínico que apresentamos refere-se a um caso de capnotórax hipertensivo que ocorreu devido à presença de um defeito diafragmático congénito, durante uma cirurgia abdominal inferior e que foi tratado com sucesso sem recorrer ao uso de dreno torácico. Este caso salienta a importância de manter uma vigilância ativa e alto indice de suspeição para o pneumotórax durante a cirurgia laparoscópica.

Successful Treatment of Endometriosis-Related Hemorrhagic Ascites: A Report of Three Cases.

Endometriosis-related ascites is rare and is frequently confused with an ovarian malignancy. Since it affects women in reproductive age, its diagnosis and therapy are even more challenging. These patients usually present with abdominal distension, pelvic pain, and weight loss, but a careful questioning usually reveals the typical endometriosis symptoms-such as dysmenorrhea and dyspareunia. We present three cases of endometriosis-related ascites, one of them with pleural effusion. All cases were associated with extensive disease and required laborious laparoscopic surgery, medical therapy with gonadotropin releasing hormone analogs, and long-term follow-up. One of the patients delivered twins following an in vitro fertilization (IVF) cycle without recurrence of ascites. We aim to raise awareness toward the importance of considering endometriosis in a patient with ascites of unknown origin.

Obturator Internus Muscle Endometriosis with Nerve Involvement: a Rare Clinical Presentation.

STUDY OBJECTIVE: To describe our surgical approach in a rare case of deep infiltrating endometriosis of the obturator internus muscle with obturator nerve involvement. DESIGN: A step-by-step surgical explanation using video and literature review (Canadian Task Force Classification III). SETTING: Endometriosis can be pelvic or rarely extrapelvic and is classically defined as the presence of endometrial glands and stroma outside the uterine cavity [1,2]. Pain along the sensitive area of the obturator nerve, thigh adduction weakness and difficulty in ambulation are extremely rare presenting symptoms [2-4]. PATIENT: We report a case of a 32-year-old patient who presented with cyclic leg pain in the inner right thigh radiating to the knee caused by a cystic endometriotic mass in the obturator internus muscle with nerve retraction. The patient provided informed consent to use the surgical video. Institutional review board approval was obtained. INTERVENTIONS: Pelvic magnetic resonance imaging was performed and confirmed a nodular lesion of about 2.3 cm with high signal on T1WI and T2WI and without fat suppression on T2FS inside the right obturator internus muscle, suggesting an endometriotic lesion (Fig. 1). Surgical removal of the mass was performed using the laparoscopic approach. A normal pelvic cavity was found, and the retroperitoneal space was dissected. A mass located within the right obturator internus muscle, below the right iliac external vein, behind the corona mortis vein, and lateral to the right obturator nerve was identified. The whole region was inflamed, and the nerve was partially involved. Dissection was performed carefully with rupture of the tumor, releasing a chocolatelike fluid (Fig. 2), and the cyst was removed. Pathology examination was consistent with endometriosis. Patient improvement was observed, with pain relief and improved ability for right limb mobilization. No recurrence of endometriosis was found at the follow-up visit 6 months later. MEASUREMENTS AND MAIN RESULTS: The obturator nerve is responsible for motor and sensitive innervation of the joins and internal muscles of thigh and knee as well as the innervation of skin in the internal thigh. Pain along the sensitive area of the obturator nerve at the time of menstruation, thigh adduction weakness, difficulty ambulating, or paresthesia can be presenting symptoms with the involvement of the obturator nerve [5]. Besides paresthesia, our patient presented all the symptoms. The suspected diagnosis of obturator internus muscle endometriosis with retraction of the obturator nerve was confirmed by laparoscopic surgery and pathological examination of the excised tissue. To our knowledge, only 4 cases of endometriosis involving the obturator nerve have been described (according to MEDLINE searched in January 2017) [5-8]. The laparoscopic approach provided an excellent access to the retroperitoneal space, allowing fine dissection of the obturator nerve and the surrounding structures with complete removal of the cystic mass. CONCLUSION: We report a rare case of endometriosis with a single mass located inside the right obturator internus muscle with neuronal involvement of the obturator nerve. The fundamental role of laparoscopy was clearly demonstrated for the diagnosis and treatment of our patient.

Abdominal Wall Endometriosis Excision with Mesh Closure - Report of Two Cases.

Abdominal wall endometriosis (AWE) is a rare condition included in the differential diagnosis of an abdominal wall mass and/or pelvic pain in women of reproductive age. It usually occurs after pelvic surgery, most commonly caesarean section. Given the variable clinical presentation, diagnosis can be challenging if a high index of suspicion for AWE does not exist. Consequently, the correct diagnosis is often missed in the preoperative assessment. The presence of endometriosis in other locations can aid in the diagnosis, but other endometriotic lesions do not always exist. Image studies, particularly ultrasound and magnetic resonance imaging, can also be of help in the differential diagnosis. Even though new management techniques such as ultrasound-guided percutaneous cryoablation seem to be promising, surgical excision is still the mainstay of treatment. When the aponeurosis is involved, lesion excision might need to be followed by wall closure with the use of a mesh to lessen tissue tension. We present two typical cases of AWE after caesarean section, one of them recurrent, in patients with concurrent endometriosis of other locations. Total lesion excision followed by polypropylene mesh closure has been performed, with very good post-operative outcomes. We aim to raise awareness towards this diagnosis and to highlight the importance of complete lesion excision and adequate closure of the abdominal wall.

Laparoscopic Psoas Hitch Double Ureteral Re-implantation in the Duplex Urinary System for Treatment of Ureterovaginal Fistula.

INTRODUCTION: Although laparoscopy is widely established for ablative urologic procedures, pelvic reconstructive procedures are still mostly performed by open-surgery. As urologists continue to introduce advanced laparoscopic skills to reconstructive urologic procedures, we present our experience with a laparoscopic psoas hitch double ureteral re-implantation in a patient with an ureterovaginal fistula and an ipsilateral duplex urinary system. MATERIALS AND METHODS: A 42-year-old patient presented with continuous involuntary urine loss from the vagina after an abdominal hysterectomy. A double modified Lich-Gregoir ureteral re-implantation with a psoas hitch was performed, using a 4-port laparoscopic approach. RESULTS: There were no post-operative complications and the cystography at post-operative day 14 revealed good positioning of the psoas hitch, with no leak or reflux. At three-months follow-up, the patient is completely dry and asymptomatic. CONCLUSION: Laparoscopic ureteroneocystostomy with psoas hitch for the treatment of lesions of the distal ureter is a possible, safe, and effective way to resolve a complex urologic situation with minimally invasive surgery. Laparoscopy is becoming the standard approach to urologic pelvic reconstructive procedures, even in the most complex cases.

Laparoscopic Neurolysis of Deep Endometriosis Infiltrating Left Femoral Nerve: Case Report.

Pelvic endometriosis may infiltrate somatic nerves causing severe neuropathic symptoms with a high impact on quality of life. It is a medical condition poorly known, and few published data about involvement of femoral nerve are available. We report an isolated unilateral endometriosis lesion of the left lumbar region infiltrating the femoral nerve in a 38-year-old woman. She described severe dysmenorrhea, dyspareunia, dischezia, and chronic pelvic pain with irradiation to the anterior part of the left thigh. After investigation, it was identified as a 5-centimeter endometriotic nodule involving the femoral nerve and the psoas muscle. The patient was treated by two laparoscopic surgeries with neurolysis of the involved somatic nerve by a multidisciplinary team, with improvement of the symptoms. Laparoscopic neurolysis is the first approach advocated in these cases, leading to relief of neurological symptoms resulting from nerve infiltration by endometriosis.

Validation of the Portuguese Version of EHP-30 (The Endometriosis Health Profile-30).

INTRODUCTION: Endometriosis Health Profile Questionnaire-30 is currently the most used questionnaire for quality of life measurement in women with endometriosis. The aim of this study is to evaluate the psychometric properties and to validate the Portuguese Endometriosis Health Profile Questionnaire-30 version. MATERIAL AND METHODS: A sequential sample of 152 patients with endometriosis, followed in a Portugal reference center, were asked to complete a questionnaire on social and demographic features, the Portuguese version of the Endometriosis Health Profile Questionnaire-30 and of the Short Form Health Survey 36 Item â version 2. Appropriate statistical analysis was performed using descriptive statistics, factor analysis, internal consistency, item-total correlation and convergent validity. RESULTS: Factorial analysis confirmed the validity of the five-dimension structure of the Endometriosis Health Profile Questionnaire-30 core questionnaire, which explained 83.2% of the total variance. All item-total correlations presented acceptable results and high internal consistency, with Cronbach's alpha ranging between 0.876 and 0.981 for the core questionnaire and between 0.863 and 0.951 for the modular questionnaire. Significant negative associations between similar scales of Endometriosis Health Profile Questionnaire-30 and Short Form Health Survey 36 Item â version 2 were demonstrated. Data completeness achieved was high for all dimensions. The emotional well-being scale in the core questionnaire and the infertility scale in the modular section had the highest median scores, and therefore the most negative impact on the quality of life of participating women. DISCUSSION: The test-retest reliability and responsiveness of the questionnaire should be evaluated in future studies. CONCLUSION: The present study demonstrates that the Portuguese version of the Endometriosis Health Profile Questionnaire-30 is a valid, reliable and acceptable tool for evaluating the health-related quality of life of Portuguese women with endometriosis.

Introdução: O Endometriosis Health Profile Questionnaire-30 é atualmente o questionário mais utilizado para avaliação da qualidade de vida em mulheres com endometriose. O objetivo do presente estudo é avaliar as propriedades psicométricas e validar a versão portuguesa do Endometriosis Health Profile Questionnaire-30.Material e Métodos: Amostra sequencial de conveniência, constituída por 152 doentes com endometriose, de um centro de referência no país, que autopreencheram um questionário sociodemográfico, a versão portuguesa do Endometriosis Health Profile Questionnaire-30 e do Short Form Health Survey 36 Itemâversão 2. Procedeu-se a análise estatística apropriada, com estatística descritiva, análise fatorial, avaliação da consistência interna, correlação item-total e validade convergente (usando o Short Form Health Survey 36 Itemâversão 2).Resultados: A análise fatorial confirmou a validade da estrutura em cinco dimensões do questionário central, explicando uma variância total de 83,2%. A correlação item-total apresentou resultados aceitáveis em todos os itens e a consistência interna foi elevada, com α Cronbach variando de 0,876 a 0,981 nas dimensões do questionário central, e de 0,863 a 0,951 no modular. Demonstrou-se associação negativa significativa entre as dimensões similares do Endometriosis Health Profile Questionnaire-30 e do Short Form Health Survey36 Itemâversão 2. A taxa de preenchimento do questionário foi elevada para todas as dimensões. A perda do bem-estar emocional (no questionário central) e a infertilidade (no modular) apresentaram as pontuações médias mais elevadas e, consequentemente, impacto mais negativo sobre a qualidade de vida.Discussão: São necessários estudos para avaliar a fiabilidade teste-reteste e a sensibilidade à mudança desta versão portuguesa do Endometriosis Health Profile Questionnaire-30.Conclusão: Este estudo demonstra que a versão portuguesa do Endometriosis Health Profile Questionnaire-30 é um instrumento adaptado, validado e bem aceite para a avaliação da qualidade de vida das mulheres portuguesas com endometriose.

[Total laparoscopic hysterectomy: retrospective analysis of 262 cases]. / Histerectomia totalmente laparoscópica: análise retrospetiva de 262 casos.

INTRODUCTION: Hysterectomy is one of the most common gynecological procedures and may be performed either by vaginal approach, laparotomy or laparoscopy. Although total laparoscopic hysterectomy has multiple advantages, conflicting major complication rates have been previously reported. OBJECTIVES: To describe our experience performing TLH and to evaluate complication rates. MATERIAL AND METHODS: A retrospective observational study of all total laparoscopic hysterectomy performed in our department, by the same surgical team, between April 2009 and March 2013 (n = 262), was conducted. Medical records were reviewed for patient characteristics, operating time, uterine weight, post-operative hemoglobin variation, length of hospital stay, and intra and postoperative complications. RESULTS: Patient average age was 48.9 ± 9.0 years and 49.2% had previous abdominopelvic surgery. The average body mass index was 26.5 ± 4.5 kg/m(2) and 42% of women were either overweight or obese. The mean operating time during the total study period was 77.7 ± 27.5 minutes, but it decreased significantly as the surgical team's training increased. Average uterine weight was 241.0 ± 168.4 g and average hospital stay was 1.49 ± 0.9 days. The mean postoperative hemoglobin variation was -1.5 ± 0.8 g/dL. The major and minor complication rates were 1.5% (n = 4) and 11.5% (n = 30), respectively. One procedure was converted to laparotomy and two women had a vaginal vault dehiscence. No important urinary tract or bowel injuries occurred. CONCLUSIONS: This study demonstrates that, in experienced hands, total laparoscopic hysterectomy is safe and with low complications rates.

Introdução: A histerectomia é a cirurgia ginecológica major mais frequentemente realizada nos países desenvolvidos, considerando-se três principais vias de abordagem: vaginal, abdominal e laparoscópica. Apesar de múltiplas vantagens, a histerectomia totalmente laparoscópica tem-se associado a controvérsia relativamente à taxa de complicações.Objectivos: Análise da nossa casuística de histerectomia totalmente laparoscópica e avaliação da taxa de complicações.Material e Métodos: Análise retrospetiva dos processos clínicos das doentes submetidas a histerectomia totalmente laparoscópica no nosso departamento, pela mesma equipa cirúrgica, entre abril de 2009 e março de 2013 (n = 262).Resultados: As doentes tinham em média 48,9 ± 9 anos e 49,2% tinha antecedentes de cirurgia abdomino-pélvica. O índice de massa corporal médio era 26,5 ± 4,5 kg/m2, sendo que 42% eram obesas ou tinham excesso de peso. O tempo operatório médio para realização da histerectomia totalmente laparoscópica foi 77,7 ± 27,5 minutos, diminuindo significativamente com o aumento da experiência da equipa cirúrgica. O peso médio da peça operatória foi 241 ± 168,4g e a duração média do internamento após a cirurgia foi 1,49 ±0,9 dias. A diferença entre a hemoglobina pré e pós-operatória foi 1,5 ± 0,8g/dL. A morbilidade major foi 1,5% (n = 4) e a minor 11,5% (n = 30). Salienta-se um caso de conversão para laparotomia e dois casos de deiscência da cúpula vaginal. Não ocorreu nenhuma lesão urinária ou gastrointestinal grave.Conclusões: Esta série demonstra que, se realizada por uma equipa cirúrgica adequadamente treinada, a histerectomia totalmente laparoscópica é segura e associada a baixa taxa de complicações.

Laparoscopic re-anastomosis of a uterine avulsion following cold-knife conization.

This report presents an exceptional case of uterine avulsion following a cold-knife conization, an unprecedented surgical complication of a common gynecological procedure. Furthermore, it describes the outcomes of the conservative laparoscopic reconstruction that was performed. A 30-year-old nulliparous was referred to our department with secondary amenorrhea and cyclic pelvic pain following a cold-knife conization performed 9 months previous in another institution. The patient underwent a diagnostic laparoscopy, which confirmed that the cervix had been completely resected and that the uterine and vaginal cavities were no longer in contact. We performed an end-to-end utero-vaginal anastomosis followed by a prophylactic cerclage. No intraoperative or postoperative complications were observed. One month after surgery the patient was asymptomatic with normal withdrawal bleeding and remained asymptomatic during her 12-month follow-up consult. To our knowledge, this is the first time that this serious complication with a potential for irreversible damage to reproductive function is reported as a complication of cervical conization. Although our conservative surgical correction repaired the anatomy and reestablished menstruation outflow, further follow-up is necessary to confirm the extent to which reproductive function was restored.

Maternal and neonatal immediate effects of sequential delivery.

OBJECTIVE: To evaluate the immediate maternal and neonatal outcomes associated with sequential instrumental delivery (vacuum plus forceps) compared with the use of one instrument only (forceps or vacuum). STUDY DESIGN: A longitudinal observational study was carried out, including all instrumental deliveries performed in term singleton pregnancies, in vertex presentation, at station level 0 or +1. According to the type of the instruments, the deliveries were divided in three groups: the vacuum group, the forceps group and the sequential group. Immediate maternal and neonatal outcomes were evaluated. RESULTS: A total of 275 instrumental deliveries were performed: 126 (45.5%) vacuum assisted deliveries, 62 (22.6%) forceps assisted deliveries and 87 (31.6%) sequential deliveries. Regarding maternal morbidity, there was a significant difference between the three groups (p < 0.001), with a higher rate of complications in the sequential group. The type of instrument was the only factor associated with significant maternal morbidity. The rate of immediate neonatal morbidity was 4.4% and there was no significant association with the instrument type or with other identifiable factors. CONCLUSION: Sequential delivery is associated with a higher maternal morbidity and it seems not to increase neonatal morbidity.

Prevalence and outcome of urinary retention after laparoscopic surgery for severe endometriosis--does histology provide answers?

INTRODUCTION AND HYPOTHESIS: Urinary retention after radical laparoscopic surgery for severe endometriosis is a clinically relevant complication. We hypothesized a relationship between the amount of resected nerves and the occurrence of urinary retention. METHODS: We evaluated, retrospectively, a cohort of 221 patients. The expression of nerves in the resected specimens was investigated in patients with urinary retention and matched controls using standardized immunohistochemistry techniques. RESULTS: The prevalence of urinary retention was 4.6% (n = 10). Importantly, there was no difference between cases and controls regarding the quantity of nerves in the resected specimens. The cumulative probability of 50% to overcome urinary retention was reached after 5.6 months. Age was the main risk factor for persistent retention (40.3 years with vs. 31.6 years without, p = 0.01). CONCLUSIONS: In older endometriosis patients, surgical radicality should be balanced against preservation of organ function. There is a fairly good chance to recover, even after 6 months, which is important for patient counseling.

Prevalence and management of urinary tract endometriosis: a clinical case series.

OBJECTIVE: To report on the prevalence, surgical management, and outcome of urinary tract endometriosis (UTE) in a cohort of 221 patients undergoing laparoscopic surgery for severe endometriosis. UTE can cause significant morbidity, such as silent kidney or progressive renal function loss. Its frequency is underestimated and data on laparoscopic management are scarce. METHODS: Between 2007 and 2010, 43 patients were eligible for this single-center, retrospective study. The inclusion criterion was the presence of UTE (ie, bladder and/or ureteral endometriosis). All patients were operated laparoscopically. RESULTS: The prevalence of UTE was 19.5% (43/221). There was no correlation between bladder and ureteral endometriosis (P >.05). Ureteral endometriosis was associated with patient's age (P <.01). Patients with bladder, but not ureteral, involvement complained more frequently about dysuria, hematuria, and urinary tract infections. Intraoperative and magnetic resonance imaging (MRI) findings revealed a moderate to good correlation. UTE was not associated with rectovaginal or bowel endometriosis, but rather with involvement of the uterosacral ligaments (P <.01). Twenty-two patients with bladder endometriosis were treated by mucosal skinning and 11 patients underwent partial cystectomy. Superficial ureteral excision was performed in 4 patients, whereas resection with ureteroureterostomy was done in 9 patients. There was no difference regarding the intra- and postoperative complications in patients with or without UTE. CONCLUSION: In severe pelvic endometriosis, involvement of the urinary tract is quite common. Laparoscopic management is feasible and safe. Because of the lack of specific symptoms, the preoperative diagnosis of ureteral endometriosis still remains a challenge. Pelvic MRI represents a useful preoperative diagnostic tool.

Twenty years of laparoscopic sacrocolpopexy: where are we now?

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacrocolpopexy (LSC) was first described almost 20 years ago. This technique aims to provide the outcomes of the gold standard abdominal approach while offering the benefits of minimally invasive surgery. However, the widespread diffusion of LSC in the management of pelvic organ prolapse (POP) is hampered by its presumed length and technical difficulties due to the inherent need for laparoscopic suturing skills. METHODS: In this article, we highlight the current status of LSC based on a historical overview and in the paradigm of an interrelationship between the three different approaches to POP correction. RESULTS: The enormous changes over the past 15 years have contributed to a better understanding of the pathologies and their treatment, which has enabled us to refine LSC, to simplify it, and to make it much more reproducible. CONCLUSIONS: In the future, we will need more prospective studies to compare LSC with vaginal reconstructive surgery.