Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy.

OBJECTIVE: To determine independent predictors for the development of hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. METHODS: We reviewed 968 laparoscopic cases between January 1, 1997, and December 31, 1998. Patients who had hypercarbia (end-tidal carbon dioxide of 50 mmHg or greater), pneumothorax/pneumomediastinum, and subcutaneous emphysema were compared with controls according to age, operative time, type of surgery, extraperitoneal or intraperitoneal approach, preexisting medical conditions, body mass index, sex, use of Hasson technique, and number of surgical ports. Maximum positive end-tidal CO(2) (PETCO(2)) was added as an independent variable for subcutaneous emphysema, pneumothorax, and pneumomediastinum. Data were analyzed using univariate analysis and then subjected to multivariate analysis using multiple logistic regression analysis. RESULTS: Incidence rates were 5.5% for hypercarbia, 2.3% for subcutaneous emphysema, and 1.9% for pneumothorax/ pneumomediastinum. Independent risk factors for development of hypercarbia were operative time greater than 200 minutes (odds ratio [OR] 2.02), patient age greater than 65 years (OR 2.19), and Nissen fundoplication surgery (OR 3.18). Predictors of the development of subcutaneous emphysema were PETCO(2) greater than 50 mmHg (OR 3.49), operative time greater than 200 minutes (OR 5.27), and the use of six or more surgical ports (OR 3.06). Variables that predicted the development of pneumothorax and/or pneumomediastinum were PETCO(2) greater than 50 mmHg (OR 4. 15) and operative time greater than 200 minutes (OR 20.49). CONCLUSION: Longer operative times, higher maximum measured end-tidal CO(2), greater number of surgical ports, older patient age, and Nissen fundoplication surgery predispose patients to hypercarbia-related complications during laparoscopy.

Evaluating vaginal pH. Accuracy of two commercial pH papers in comparison to a hand-held digital pH meter.

OBJECTIVE: To determine the accuracy, in a clinical setting, of two commercial pH papers compared to a hand-held digital pH meter. STUDY DESIGN: Vaginal specimens from 30 women, ages 17-40, both asymptomatic and symptomatic, pregnant and nonpregnant, were evaluated for vaginal pH using pHydrion paper, ColorpHast paper and a reference hand-held, battery-operated pH meter. Pearson product-moment correlation analysis and concordance correlation analysis were performed comparing each of the pH papers to the pH meter. RESULTS: Pearson product correlation coefficients suggested a strong correlation between the pH papers compared to the commercial pH meter; however, concordance correlation coefficients were fair (< 97%). If a pH cutoff of 4.5 had been used as one of the diagnostic tools for the evaluation of bacterial vaginosis (i.e., pH > 4.5), the ColorpHast paper would have resulted in a theoretical false negative rate of 21%, and the pHydrion paper would have resulted in a false negative rate of 24%. There were no false positives. Using a single pH readout of 5.0 could have resulted in a correct value, ranging from 3.85-6.15 pH units with pHydrion paper and a range of 4.32-5.68 using the ColorpHast pH paper. The accuracy of ColorpHast paper was better than that of pHydrion paper. A 1 SD range for the mean pH difference for pHydrion paper was 1.054-0.854 and for ColorpHast was 0.619-0.501. The correlation coefficient for the pHydrion paper was .87, and the correlation coefficient for ColorpHast paper was .88. CONCLUSION: Two pH papers had questionable accuracy in a clinical setting as compared to the hand-held, battery-powered pH meter. There was a theoretical 24% false negative rate if a pH cutoff of 4.5 had been used for pHydrion paper and a 21% false negative rate for ColorpHast paper. Although correlation coefficients were 88%, concordance correlations were inadequate for both papers.

Laparoscopically assisted extracorporeal neosalpingostomy. A case report.

BACKGROUND: Laparoscopic neosalpingostomies can be time consuming, costly and technically difficult, resulting in suboptimal results in inexperienced hands. Extracorporeal techniques for pelvic and abdominal organs have already been previously reported in the literature, involving such organs as the appendix, ovary and small bowel. CASE: A 33-year-old white woman, gravida 0, diagnosed with a history of primary infertility, underwent diagnostic laparoscopy/hysteroscopy. Stage IV endometriosis was diagnosed and was accompanied with bilateral tubal occlusion with complete obliteration of the fimbriae bilaterally. Extracorporealization of the fallopian tubes was performed followed by microsurgical neosalpingostomies. Operative time for both neosalpingostomies was 20 minutes. CONCLUSION: When controlled for tubal mucosa integrity, previous data from one researcher comparing microsurgical laparotomy and laparoscopic neosalpingostomies shows a higher fertility rate with open surgical techniques. This may be explained, in part, by suboptimal repair of the distal tubes by a laparoscopic technique. This extracorporeal technique may aid in shorter surgery and anesthesia times, higher intrauterine pregnancy rates and higher successful surgical completions. Prospective evaluation of multiple patients will be necessary to assess its efficacy. Even if pregnancy rates do not differ, operative time and cost may be significantly reduced.

Clostridium perfringens septicemia. A case report.

A rare case of cervical pregnancy complicated by Clostridium perfringens septicemia is presented. The relationship of sepsis in association with cervical pregnancy is reviewed.

Fractured femur of the newborn at cesarean section. A case report.

Midshaft femur fractures are not expected in the newborn, particularly with the currently increased cesarean section rate. Such injuries have occurred when the mother had uterine myomas or diabetes or when the fetus had intrauterine growth retardation or osteoporosis secondary to copper deficiency, but they can also occur in newborn infants with normal weights and healthy mothers.