Repair of a chronic myometrial defect with successful pregnancy outcome.

OBJECTIVE: To surgically demonstrate preconceptional laparoscopic repair of a chronic myometrial defect with mesh reinforcement, resulting in a successful pregnancy outcome. DESIGN: Video case report. The Institutional Ethical Committee was consulted, and the requirement for approval was waived because the video describes a modified surgical technique. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, and others), and other applicable sites. SETTING: A referral advanced gynecological endoscopy center. PATIENT: A 27-year-old woman (P0A1) was diagnosed with myomas during pregnancy, resulting in miscarriage at 22 weeks. Laparotomy and myomectomy were performed 2 months later, and three 8-cm myomas were removed. The endometrial cavity opened posteriorly during surgery, and retained products of conceptions were removed. Periconceptional imaging done after two years showed few intramural myomas and a deficient myometrium in the posterior fundal region. Laparoscopy revealed a defect in the posterior fundal aspect of the uterus with leakage of dye, which was converted to laparotomy and myomectomy with the repair of the myometrial defect. After 1 year, follow-up magnetic resonance imaging showed thinned-out posterior myometrium with a focal area of absent myometrium in the midline and endometrial prolapse. The patient was advised on surrogacy, but she wanted to repair the defect again and try for pregnancy, so she was referred to our center. With the background of a few case reports using mesh to reinforce myometrial repair (1, 2), we counseled the patient about the myometrial repair with the additional use of mesh as an off-label use. INTERVENTION: The risk of uterine rupture after myomectomy is rare (<1%) (3), but it is a severe complication. High-risk cases, like significant myometrial defects or previous ruptures, may require surgical correction. Native repair may not achieve optimal results in all cases. Alternative approaches, like the additional use of mesh or biological materials, have been reported (4). In this case, we demonstrate the use of dual mesh for scar repair. Synthetic mesh over the uterus is used in laparoscopic procedures like sacrohysteropexy and cerclage. We used Parietex (Covidien, New Haven, CT, USA) mesh, a composite macroporous polyester mesh usually used for ventral hernia repair. It has an outer hydrophilic, absorbable collagen barrier that reduces adhesion formation. Laparoscopically, after adhesiolysis, a significant defect was demonstrated on the posterior wall of the uterus (Fig. 1). A complete resection of the fibrotic tissue along the edges of the scar defect was done to expose healthy myometrium. Myometrium was repaired in two layers, excluding the endometrium, with a V-Loc (Covidien, Dublin, Ireland) No. 1-0 suture. Parietex mesh was sutured over the repaired posterior myometrium to reinforce it (Fig. 2). MAIN OUTCOME MEASURES: The postoperative myometrial thickness on imaging and pregnancy outcome. RESULTS: Postoperative ultrasound scan after 6 weeks demonstrated restoration of posterior wall myometrial thickness of 14 mm. The patient was conceived through in vitro fertilization techniques 4 months after surgery. Antenatal follow-up was uneventful except for suspicion of posterior placenta accreta. She underwent an elective cesarean section with uterine artery embolization at 34 weeks and delivered a healthy infant weighing 1,950 g. Placental removal was uneventful. On inspection, the posterior surface of the uterus was intact without dehiscence, meshing in situ with minimal adhesions (Fig. 3). CONCLUSION: Myometrial scar defects can cause potential obstetric complications. Native repair of scar defects may not achieve optimal results, as in our case. Mesh repair of myomectomy scar defects can be used as an alternative approach, as exemplified in this case. However, further studies are required to establish the safety and efficacy of this approach.

Suture-fixation of a levonorgestrel-releasing intrauterine device under hysteroscopic guidance.

Background: Abnormal uterine bleeding (AUB) is a common gynaecological condition. The levonorgestrel-releasing Intrauterine device (LNG-IUD) is an effective medical treatment. option which carries a small risk of device expulsion. For those who experience expulsion, some may benefit from a more robust surgical approach. Objectives: To demonstrate the technique for suture fixation of an LNG-IUD under hysteroscopic guidance. Materials and methods: Stepwise video demonstration of the technique using a 5mm hysteroscope and a 3mm laparoscopic needle holder. The Institutional Ethical Committee was consulted, and the requirement for approval was waived because the video described a modified surgical technique. Informed consent was obtained from the patient. Main outcome measures: A 35yr old parous woman with a nine-month history of AUB and severe dysmenorrhoea had an LNG-IUD sited with effective symptom relief. Unfortunately, the device was expelled six months after insertion, and she responded poorly to other medical treatments. Transvaginal ultrasonography (TVUS) suggested posterior wall adenomyosis. Considering her relief of symptoms with the LNG-IUD and history of expulsion, the patient was counselled regarding suture-fixation of the LNG-IUD. Results: She was followed-up at 6 months post insertion. The LNG-IUD was noted in the uterine cavity without displacement or expulsion. Conclusion: Hysteroscopy-guided suture fixation of an LNG-IUD is a minimally invasive, effective option for patients with a history of expulsion of an IUD. However, further studies are required to establish the safety and efficacy of this approach. Learning Objective: To demonstrate LNG -IUD suture fixation technique using hysteroscopy for patients diagnosed with AUB and a history of device expulsion.

Vaginoscopic Management of OHVIRA (Obstructive Hemivagina and Ipsilateral Renal Agenesis).

OBJECTIVE: To describe the vaginoscopic management of longitudinal vaginal septum in the case of obstructive hemivagina and ipsilateral renal agenesis (OHVIRA) syndrome. DESIGN: Surgical video describing step-by-step management. SETTING: OHVIRA syndrome also known as Herlyn-Werner-Wunderlich syndrome is a triad of obstructed hemivagina, uterus didelphys, and ipsilateral renal anomaly [1] (Supplimentary Video 1). Patients usually present after menarche with progressive dysmenorrhea, lower abdominal pain, a paravaginal mass, foul mucopurulent discharge, and intermenstrual bleeding due to hemi hematocolpos [2]. Magnetic resonance imaging is the choice of investigation [3]. Surgical resection of the septum is the choice of treatment, which can be done vaginoscopically to reduce postoperative pain and promote enhanced recovery [4]. In this video, we will demonstrate a case of a 28-years old, nulliparous woman diagnosed with uterine didelphys having lower abdominal pain and persistent vaginal discharge. INTERVENTIONS: The video demonstrates the technique of vaginoscopic excision of the right hemi-vaginal septum that resulted in complete visualization of both cervices. Diagnostic laparoscopy confirmed uterine didelphys. The left cervix was visualized and the hysteroscope was negotiated into the cervical canal (Supplimentary Video 2). The left cavity was normal with left ostia. Intraoperative transrectal-ultrasound was done to localize the cystic collection in the right hemivagina. Needle aspiration of cystic collection was done over the bulging portion of the right hemivagina and mucoid material was aspirated. Longitudinal obstructive vaginal septum was incised using a collins knife and mucoid secretions were drained (Supplimentary Video 3). Hysteroscope inserted into opened right hemivagina, negotiated through the right cervix and right hemiuterus with right ostia was visualized. The residual septum was resected with a loop electrode and hemostasis was ensured. Cystoscopy done, left ureteric orifice with urine reflux visualized. Vaginal examination showed both cervices with near normal reconstructed vagina. CONCLUSION: The possibility of OHVIRA syndrome should be considered in all cases of uterine didelphys. Vaginoscopic management is a safe and effective method with a minimally invasive approach.

Reproductive Outcomes after Laparoscopic Myomectomy: Conventional versus Barbed Suture.

STUDY OBJECTIVE: To study the reproductive outcomes after laparoscopic myomectomy comparing conventional (nonbarbed) suture with barbed suture used for myometrial defect closure. DESIGN: Monocentric retrospective cohort study with prospective follow-up survey for reproductive outcomes conducted in April and May 2020. SETTING: Tertiary care center (center for advanced gynecologic laparoscopy and infertility). PATIENTS: Women who underwent laparoscopic myomectomy for uterine leiomyomas from January 2004 to December 2017. INTERVENTIONS: Laparoscopic myomectomy with closure of the myometrium using either conventional (nonbarbed suture) or barbed suture and follow-up survey regarding reproductive outcomes. MEASUREMENTS AND MAIN RESULTS: The outcomes measured included the rate of conception, pregnancy complications, mode of delivery, and perioperative complications for both kinds of suture materials used. Of the 399 women who underwent laparoscopic myomectomy, 343 satisfied the inclusion criteria and were followed up; 235 patients responded. A total of 120 patients were included in the nonbarbed group (group A), and 115 patients were included in the barbed group (group B). A total of 182 (group A: 97 vs group B: 85; p = .204) women had actively sought pregnancy postoperatively, of whom 93 (51.09%) in total and 51 (54.8%) in group A vs 42 (45.1%) in group B reported at least 1 pregnancy with no significant difference in the incidence rate ratios between the 2 groups. Of the recorded pregnancies84.9% (group A: 88.2% vs group B: 80.9%) live births, 6.4% (group A: 5.8% vs group B: 7.1%) had first-trimester miscarriages, 2.1% (group A: 1.9% vs group B: 2.3%) had an ectopic pregnancy, and 6 were ongoing pregnancies at the time of the study analysis, which were compared statistically between both study groups. Pregnancy-related complications were noted in 12 of the 93 pregnant women (12.9%), which were comparable in both groups. No case of uterine rupture was reported. CONCLUSION: Our study supports good reproductive outcomes in women after laparoscopic myomectomy with barbed sutures. Furthermore, the inclusion of nonbarbed sutures as a control group in our study reinforces that barbed sutures in myomectomy are as safe as, and an easier alternative to, conventional sutures without affecting pregnancy outcomes.

Wheat yield potential in controlled-environment vertical farms.

Scaling current cereal production to a growing global population will be a challenge. Wheat supplies approximately one-fifth of the calories and protein for human diets. Vertical farming is a possible promising option for increasing future wheat production. Here we show that wheat grown on a single hectare of land in a 10-layer indoor vertical facility could produce from 700 ± 40 t/ha (measured) to a maximum of 1,940 ± 230 t/ha (estimated) of grain annually under optimized temperature, intensive artificial light, high CO2 levels, and a maximum attainable harvest index. Such yields would be 220 to 600 times the current world average annual wheat yield of 3.2 t/ha. Independent of climate, season, and region, indoor wheat farming could be environmentally superior, as less land area is needed along with reuse of most water, minimal use of pesticides and herbicides, and no nutrient losses. Although it is unlikely that indoor wheat farming will be economically competitive with current market prices in the near future, it could play an essential role in hedging against future climate or other unexpected disruptions to the food system. Nevertheless, maximum production potential remains to be confirmed experimentally, and further technological innovations are needed to reduce capital and energy costs in such facilities.

Is the Kok effect a respiratory phenomenon? Metabolic insight using 13 C labeling in Helianthus annuus leaves.

The Kok effect is a well-known phenomenon in which the quantum yield of photosynthesis changes abruptly at low light. This effect has often been interpreted as a shift in leaf respiratory metabolism and thus used widely to measure day respiration. However, there is still no formal evidence that the Kok effect has a respiratory origin. Here, both gas exchange and isotopic labeling were carried out on sunflower leaves, using glucose that was 13 C-enriched at specific C-atom positions. Position-specific decarboxylation measurements and NMR analysis of metabolites were used to trace the fate of C-atoms in metabolism. Decarboxylation rates were significant at low light (including above the Kok break point) and increased with decreasing irradiance below 100 µmol photons m-2  s-1 . The variation in several metabolite pools such as malate, fumarate or citrate, and flux calculations suggest the involvement of several decarboxylating pathways in the Kok effect, including the malic enzyme. Our results show that day respiratory CO2 evolution plays an important role in the Kok effect. However, the increase in the apparent quantum yield of photosynthesis below the Kok break point is also probably related to malate metabolism, which participates in maintaining photosynthetic linear electron flow.

Leaf Carbon Export and Nonstructural Carbohydrates in Relation to Diurnal Water Dynamics in Mature Oak Trees.

Trees typically experience large diurnal depressions in water potential, which may impede carbon export from leaves during the day because the xylem is the source of water for the phloem. As water potential becomes more negative, higher phloem osmotic concentrations are needed to draw water in from the xylem. Generating this high concentration of sugar in the phloem is particularly an issue for the ∼50% of trees that exhibit passive loading. These ideas motivate the hypothesis that carbon export in woody plants occurs predominantly at night, with sugars that accumulate during the day assisting in mesophyll turgor maintenance or being converted to starch. To test this, diurnal and seasonal patterns of leaf nonstructural carbohydrates, photosynthesis, solute, and water potential were measured, and carbon export was estimated in leaves of five mature (>20 m tall) red oak (Quercus rubra) trees, a species characterized as a passive loader. Export occurred throughout the day at equal or higher rates than at night despite a decrease in water potential to -1.8 MPa at midday. Suc and starch accumulated over the course of the day, with Suc contributing ∼50% of the 0.4 MPa diurnal osmotic adjustment. As a result of this diurnal osmotic adjustment, estimates of midday turgor were always >0.7 MPa. These findings illustrate the robustness of phloem functioning despite diurnal fluctuations in leaf water potential and the role of nonstructural carbohydrates in leaf turgor maintenance.

Laparoscopic Cervical Encerclage in Pregnancy in 6 Steps.

STUDY OBJECTIVE: Cervical insufficiency occurs in 0.1% to 1 % of all pregnancies and is associated with a high risk of second-trimester abortion and/or preterm delivery [1]. Laparoscopic encerclage is highly recommended for a previous failed vaginal encerclage and is superior to the laparotomy approach in terms of low morbidity and faster recovery [2]. Laparoscopic encerclage in pregnancy is more challenging than that in the nonpregnant state. This is because of the enlarged uterine size, engorged uterine vessels, and infeasibility of using a uterine manipulator. The standardization and description of the technique are the main objectives of this video (Video 1). We have described the surgery in 6 steps that could make this procedure easier and safer. DESIGN: A step-by-step video demonstration of the technique. SETTING: Paul's Hospital, Centre for Advanced Endoscopy & Infertility Treatment, Kochi, India. A 29-year-old pregnant woman, gravida 3 abortions 2, at 13 weeks period of gestation, with a history of 2 second-trimester abortions owing to cervical insufficiency. The patient had a failed vaginal cervical encerclage at 18 weeks in the second pregnancy. INTERVENTIONS: This is a step-wise laparoscopic approach for successful cervical encerclage in pregnancy. In this video, we demonstrate our technique for laparoscopic cervical encerclage in a pregnant woman's uterus in 6 steps using a Mersilene tape (Ethicon US, LLC, Somerville, NJ) as follows: (1) Opening the uterovesical fold and dissecting the bladder, (2) opening the left broad ligament and creating a window, (3) opening the right broad ligament and creating a window, (4) placing the Mersilene tape on the left side medial to the uterine vessels at the cervicoisthmic junction, (5) placing the Mersilene tape on the right side medial to the uterine vessels at the cervicoisthmic junction, (6) tying the Mersilene tape anteriorly. CONCLUSION: The standardization of laparoscopic cervical encerclage in pregnancy using the above 6 steps could make this procedure easier and safer to perform. Moreover, the standardization of the surgical technique could shorten the learning curve.

Adverse Cardiac Events and Mortality in Patients with Critical Limb Ischemia.

BACKGROUND: Both surgical and endovascular treatment in elderly patients with critical limb ischemia are associated with high mortality rates. Patients with critical limb ischemia are at increased risk of adverse cardiovascular events and subsequent cardiovascular death. Little is known about the incidence and consequences of these adverse events. The aim of this study was to investigate the effect of adverse cardiac events on mortality in patients with critical limb ischemia undergoing surgical or endovascular treatment. METHODS: A retrospective cohort study including all patients with critical limb ischemia aged ≥65 undergoing surgical or endovascular treatment for critical limb ischemia between January 2013 and June 2018 was conducted. Data on adverse cardiac events were collected from medical records. The effect of an adverse cardiac event on mortality during 6 months follow-up was analyzed with a multivariable cox proportional hazards model to adjust for confounders. Effects are displayed as hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: A total number of 449 patients were included. Median age was 76 years, 52.8% of patients were male. In total, 51 patients (11%) developed an adverse cardiac event, 31 patients (10%) in the surgical group and 20 patients (14%) in the endovascular group. After adjustment for confounders, adverse cardiac events were associated with an increased risk of mortality (HR 3.5 95% CI 2.1-5.9). CONCLUSIONS: This study showed that adverse cardiac events commonly occur in elderly patients with critical limb ischemia. Adverse cardiac events continue to occur even months after treatment and are associated with an increased mortality risk. These findings justify routine cardiac evaluation in both surgical and endovascular treatment. Additionally, frequent postdischarge cardiac follow-up in the outpatient clinic may be helpful in limiting the occurrence of adverse cardiac events.

Parasitic Myomas: An Unusual Risk after Morcellation.

A 24-year-old unmarried woman had undergone laparoscopic myomectomy for single degenerated myoma of size 15 cm. Uncontained morcellation of the myoma was done with an electromechanical morcellator. Two years later, she presented with abdominal pain, and laparoscopy revealed enlarged uterus (20 weeks) with multiple degenerated myomas. There were multiple parasitic myomas measuring 1-3 cm in the pelvis and anterior abdominal wall which were removed laparoscopically. Histopathology of all the myomas including parasitic myomas confirmed the diagnosis of leiomyoma. The formation of parasitic myomas was assumed to be due to the myomatous fragments which were left behind during morcellation at the time of initial myomectomy. Methods to prevent this complication are colpotomy, mini-laparotomy, or in-bag morcellation.

Thirteen Years of Experience with Opportunistic Bilateral Salpingectomy During TLH in Low-Risk Premenopausal Women.

BACKGROUND: Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS. PURPOSE OF THE STUDY: To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH. METHODS: A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul's Hospital. RESULTS: The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m2, and median parity was 2 (range 0-7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up. CONCLUSIONS: OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

Dew-induced transpiration suppression impacts the water and isotope balances of Colocasia leaves.

Foliar uptake of water from the surface of leaves is common when rainfall is scarce and non-meteoric water such as dew or fog is more abundant. However, many species in more mesic environments have hydrophobic leaves that do not allow the plant to uptake water. Unlike foliar uptake, all species can benefit from dew- or fog-induced transpiration suppression, but despite its ubiquity, transpiration suppression has so far never been quantified. Here, we investigate the effect of dew-induced transpiration suppression on the water balance and the isotope composition of leaves via a series of experiments. Characteristically, hydrophobic leaves of a tropical plant, Colocasia esculenta, are misted with isotopically enriched water to reproduce dew deposition. This species does not uptake water from the surface of its leaves. We measure leaf water isotopes and water potential and find that misted leaves exhibit a higher water potential and a more depleted water isotope composition than dry leaves, suggesting a ∼ 30% decrease in transpiration rate compared to control leaves. We propose three possible mechanisms governing the interaction of water droplets with leaf energy balance: increase in albedo from the presence of dew droplets, decrease in leaf temperature from the evaporation of dew, and local decrease in vapor pressure deficit. Comparing previous studies on foliar uptake to our results, we conclude that transpiration suppression has an effect of similar amplitude, yet opposite sign to foliar uptake on leaf water isotopes.

Extrauterine adenomyoma: a review of the literature.

Adenomyosis is the presence of endometrial glands and stroma within the myometrium. The focal and localized form of adenomyosis is known as adenomyoma. It is rarely located outside the uterus which is termed as extrauterine adenomyoma. We describe three cases of extrauterine adenomyomas which were located in pararectal space, round ligament and ovary. These cases were treated by laparoscopic excision and diagnosis was confirmed by histopathological examination. A review of the literature identified 34 cases of extrauterine adenomyomas. The most common locations were pararectal space, ovary and broad ligament. Other pelvic locations included the round ligament, paraovarian, parametrial and pelvic wall. Extrapelvic adenomyomas were located in the liver, upper abdomen, inguinal scar, appendix and small bowel mesentery. The abdominopelvic pain was the most common clinical presentation of extrauterine adenomyoma. Various imaging modalities were used to identify extrauterine masses, but a definitive diagnosis could not be made preoperatively in any of the cases. Although rare, a possible diagnosis of adenomyoma must be contemplated while dealing with extrauterine masses. Surgical excision is the mainstay of treatment. Since malignancy has been reported in extrauterine adenomyomas, this possibility must be kept in mind while offering treatment.

Measurement of Gross Photosynthesis, Respiration in the Light, and Mesophyll Conductance Using H218O Labeling.

A fundamental challenge in plant physiology is independently determining the rates of gross O2 production by photosynthesis and O2 consumption by respiration, photorespiration, and other processes. Previous studies on isolated chloroplasts or leaves have separately constrained net and gross O2 production (NOP and GOP, respectively) by labeling ambient O2 with 18O while leaf water was unlabeled. Here, we describe a method to accurately measure GOP and NOP of whole detached leaves in a cuvette as a routine gas-exchange measurement. The petiole is immersed in water enriched to a δ18O of ∼9,000‰, and leaf water is labeled through the transpiration stream. Photosynthesis transfers 18O from H2O to O2 GOP is calculated from the increase in δ18O of O2 as air passes through the cuvette. NOP is determined from the increase in O2/N2 Both terms are measured by isotope ratio mass spectrometry. CO2 assimilation and other standard gas-exchange parameters also were measured. Reproducible measurements are made on a single leaf for more than 15 h. We used this method to measure the light response curve of NOP and GOP in French bean (Phaseolus vulgaris) at 21% and 2% O2 We then used these data to examine the O2/CO2 ratio of net photosynthesis, the light response curve of mesophyll conductance, and the apparent inhibition of respiration in the light (Kok effect) at both oxygen levels. The results are discussed in the context of evaluating the technique as a tool to study and understand leaf physiological traits.

Phosphorus deficiency alters scaling relationships between leaf gas exchange and associated traits in a wide range of contrasting Eucalyptus species.

Phosphorus (P) limitation is known to have substantial impacts on leaf metabolism. However, uncertainty remains around whether P deficiency alters scaling functions linking leaf metabolism to associated traits. We investigated the effect of P deficiency on leaf gas exchange and related leaf traits in 17 contrasting Eucalyptus species that exhibit inherent differences in leaf traits. Saplings were grown under controlled-environment conditions in a glasshouse, where they were subjected to minus and plus P treatments for 15 weeks. P deficiency decreased P concentrations and increased leaf mass per area (LMA) of newly-developed leaves. Rates of photosynthesis (A) and respiration (R) were also reduced in P-deficient plants compared with P-fertilised plants. By contrast, P deficiency had little effect on the temperature sensitivity of R. Irrespective of P treatment, on a log-log basis A and R scaled positively with increasing leaf nitrogen concentration [N] and negatively with increasing LMA. Although P deficiency had limited impact on A-R-LMA relationships, rates of CO2 exchange per unit N were consistently lower in P-deficient plants. Our results highlight the importance of P supply for leaf carbon metabolism and show how P deficiencies (i.e. when excluding confounding genotypic and environmental effects) can have a direct effect on commonly used leaf trait scaling relationships.

Postoperative Pulmonary Complications Following Laparoscopy.

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

Leaf water 18 O and 2 H maps show directional enrichment discrepancy in Colocasia esculenta.

Spatial patterns of leaf water isotopes are challenging to predict because of the intricate link between vein and lamina water. Many models have attempted to predict these patterns, but to date, most have focused on monocots with parallel veins. These provide a simple system to study, but do not represent the majority of plant species. Here, a new protocol is developed using a Picarro induction module coupled to a cavity ringdown spectrometer to obtain maps of the leaf water isotopes (18 O and 2 H). The technique is applied to Colocasia esculenta leaves. The results are compared with isotope ratio mass spectrometry. In C. esculenta, a large enrichment in the radial direction is observed, but not in the longitudinal direction. The string-of-lakes model fails to predict the observed patterns, while the Farquhar-Gan model is more successful, especially when enrichment is accounted for along the radial direction. Our results show that reticulate-veined leaves experience a larger enrichment along the axis of the secondary veins than along the midrib. We hypothesize that this is due to the lower major/minor vein ratio that leads to longer pathways between major veins and sites of evaporation.

Laparoscopic Myomectomy for a Plethora of Submucous Myomas.

STUDY OBJECTIVE: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. DESIGN: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). SETTING: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. INTERVENTIONS: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. CONCLUSION: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.