Intrauterine device extraction through laparoscopic hysterotomy.

CASE REPORT: A 52-year-old woman with an intrauterine device placed more than 10 years before consulted our department after a failed attempt to its removal in the outpatient area. While performing the colposcopy a completely fibrosed cervical canal permitted no access to the uterine cavity. The IUD was confirmed to still be placed intrauterine by pelvix x-ray and an endovaginal sonography. Due the risk for future infections, a device extraction was recommended, although the patient categorically refused a hysteroscopic approach as an hysterectomy. After discussing all available options the patient agreed on a laparoscopic approach with uterine conservation. It was performed through a vertical hysterotomy with the electrocautery hook and the incision closed using intracorporeal vycril stitches. The patient was dismissed 48 h after surgery. A sonographic control was carried 6 months later revealing no evidence of scar complication. DISCUSSION: Hysteroscopy with or without sonographic intraoperative control to avoid uterine perforation, remains the recommended treatment in case of retained IUD. Difficult cases with a fibrotic cervix can be dilated with a scalpel under general anaesthesia before hysteroscopy to retrieve the coil. Laparoscopic approach is usually being used as a minimally invasive procedure for the extraction of IUD that are misplaced or migrate to the peritoneal cavity. In very seleted cases, laparoscopy can be a useful tool in case other approaches are ineffective or rejected by the patient.

Multiple intestinal perforations due to blister pill pack ingestion.

A 72-year-old woman with morbid obesity and history of psychosis attended the emergency room due to abdominal pain. CT scan revealed a mesenteric infiltration surrounding a thickened wall bowel agglomeration; inside, a dense 2 cm foreign body with no pneumoperitoneum or peritoneal effusion. Surgery revealed four contained bowel perforations due to a blister pill pack inside the ileum; consequently, a 30 cm bowel resection was performed. Ingestion was restarted on day 2, a superficial wound infection was evacuated on day 4 and the patient was discharged 6 days after surgery. Foreign body ingestion is relatively common in paediatric patients. Adult cases are usually related to vision problems, intellectual disability and psychiatric or cognitive disorders. Mostly, no consequences are reported, but some cases (<1%) can lead to complications such as perforations or gastrointestinal (GI) bleeding. Endoscopic extraction may be considered when placed in the upper GI tract, but surgery remains imperative if perforation is established.

Laparoscopic excision of round ligament endometrioma.

A 14-year-old female patient consulted due to 4 months of recurrent right pelvic pain during her menstrual period. Sonography revealed a 35 mm haemorrhagic right ovarian cyst, initially treated with hormone therapy and oral analgesics with no response. Surgery was indicated due to growth on sonography control and no response to medical treatment. Laparoscopy showed a 7 cm leiomyomatous-like mass arising from the right round ligament that was extracted en bloc without rupture with right salpingectomy and ovarian preservation. The histopathological examination confirmed the diagnosis of round ligament endometrioma with no atypia. The patient presented an uncomplicated postoperative course and was discharged home 48 hours after surgery. Hormonal contraceptives were initiated after the histopathological confirmation; the patient remains asymptomatic at 1-year follow-up.

Acute anterograde intussusception as a late complication of distal gastric bypass.

Small bowel intussusception is an uncommon cause of adult intestinal obstruction after gastric bypass for morbid obesity. It usually affects the Roux or the common limb at the jejunojejunostomy site and is mainly retrograde. An altered motility of the Roux limb seems to be the main explanation for its developement. We report the case of a patient with a late acute anterograde intussusception after a previous distal Roux-en-Y gastric bypass. Clinical, radiological and operative findings are presented and surgical solutions described in the literature are reviewed.

Familial history aggregation on acute appendicitis.

Appendectomy is the most commonly performed surgical procedure, affecting 1%-8% of the paediatric population, with a total 7% lifetime risk, most likely in adolescents and young adults.A case of familial aggregation was reported in our hospital in a family composed of nine siblings from which six of them (66.6%) had been treated of acute appendicitis, five of them in our centre.Many factors have been described as predisposing to appendicitis. Several studies have highlighted the influence of genes in the evolution of this disease and its severity, demonstrating a relative risk increase by three when family history is present.Family history of acute appendicitis is an important factor to be taken into consideration during the medical interview. Clinicians attempting to fine-tune their diagnostic accuracy when patients present with acute abdominal pain should inquire about family history of appendicitis.

Secondary aortoduodenal fistula and the unrecognised herald bleed.

A 65-year-old man with history of aortobifemoral surgery 4 years ago was admitted to hospital after sudden abdominal pain. Initially misdiagnosed as renal colic, he was treated with analgesics, and while on observation he started with haematemesis, rapidly responding to volume infusion. Upper gastrointestinal endoscopy showed fresh blood in the stomach with no visible active bleeding. CT scan showed an important contrast extravasation from the aorta to the third duodenal portion, restarting haemodynamic instability and a cardiac arrest. Cardiopulmonary resuscitation (CPR) manoeuvres followed by intense fluid resuscitation and urgent laparotomy with a fast transabdominal supracoeliac aortic clamping was performed. After multiple blood and plasma unit transfusion and intravenous norepinephrine, two more cardiac arrests were recovered. Unfortunately, after aggressive management, the patient rapidly deteriorated and deceased on the table. Aortoduodenal fistula is a rare entity causing life-threatening bleeding. Its diagnosis requires high clinical suspicion and surgery offers the only hope for survival.