[Peritoneal serous borderline tumor discovered during a cesarean section. A case report]. / Tumeur séreuse borderline péritonéale découverte lors d'une césarienne. A propos d'un cas.

During a caesarean section performed in a 36-year-old woman, we discovered small granulations on the pelvic peritoneum. Biopsies were performed. The diagnosis of primitive borderline serous tumor was confirmed by pathologists. The patient was operated twice: once for diagnostic evaluation, and again six months later. A radical gesture was then decided for therapeutic purposes. The optimal attitude regarding these borderline peritoneal tumors in young women remains difficult and requires a multidisciplinary workout between pathologists and surgeons.

[Advantages of laparoscopic assisted vaginal hysterectomy in surgery of endometrial carcinoma]. / Avantages de la voie vaginale coelio-assistée dans la chirurgie des cancers de l'endomètre.

INTRODUCTION: In to respect the principles of oncological surgery and to reduce the operative morbidity, the authors of this study propose to find the proper place of the laparoscopic-assisted vaginal hysterectomy in the surgery of endometrial carcinomas. PATIENTS AND METHODS: Between the 1st of June 2002 and 31 of May 2005, we realize a retrospective and comparative study for 36 laparoscopic-assisted vaginal hysterectomy and 20 laparotomies concerning 56 patients. RESULTS: In primary stages (stages I and II of FIGO), laparoscopic assisted vaginal hysterectomy is as powerful as the laparotomy whereas in more advanced stages, laparotomy was more complete and effective (p=0,07). One conversion case was observed (2.8%) in a context of peritoneal carcinosis (stage IIIc). There was not statistically significant difference about the operatives complications (p = 0.51). On the other hand, the postoperative comfort was so far better in the laparoscopic-assisted vaginal hysterectomy group (p=0.0002). The average delay of followed without relapses was 22,3 months in the laparoscopic-assisted vaginal hysterectomy group versus 23 months in the laparotomy group (p=0.51). CONCLUSION: Considering these results, the authors retain that, in primary stages (I-II, FIGO), laparoscopic-assisted vaginal hysterectomy represents a real option in the surgery of endometrial carcinoma. On the other hand, the advanced stages should be reserved for laparotomy.

Avantages de la voie vaginale coelio-assistee

Introduction : Apres l'enjeu carcinologique et de survie de la chirurgie des cancers de l'endometre; les auteurs de cette etude se proposent d'evaluer l'impact reel de la voie coelio-vaginale dans la chirurgie des cancers de l'endometre. Patientes et methodes : Entre le 1er Juin 2002 et le 31 Mai 2005; nous avons effectue une etude retrospective; comparative portant sur 36 interventions par voie colio-vaginale et 20 laparotomies realisees chez 56 patientes. Resultats : Dans les stades precoces (I et II de la FIGO); la voie coelio-vaginale est aussi performante que la laparotomie (p =0;07) alors que dans les stades plus avances la laparotomie etait plus complete et efficace. Le cas de conversion observe (soit 2;8) etait du a une des adherences complexes dans un contexte de carcinose peritoneale chez une patiente au stade IIIc. Il n'y avait pas de difference significative dans les complications (p=0;51). Le confort post operatoire etait; par contre; de loin meilleur dans le groupe de coelio-vaginale (p=0;0002). Le delai moyen de suivi sans recidive etait de 22;3 mois dans le groupe de coelio-vaginale versus 23 mois dans le groupe de laparotomie (p = 0;51). Conclusion : Devant ces resultats; les auteurs retiennent que dans les stades precoces (I- II de la FIGO); la voie coelio-vaginale constitue une reelle option dans la chirurgie des cancers de l'endometre par contre les stades avances devraient etre reserves a la laparotomie

[Management of ovarian cysts]. / Prise en charge des kystes ovariens.

Ovarian cysts occur frequently in women of reproductive age. These are usually functional cysts which resolve spontaneously and whose evolution can be followed with ultrasound. Non-functional cysts have diverse histologic origins. The most common are serous and mucinous cystadenomas which arise from the epithelial wall of the ovary, endometriomas which arise in the setting of pelvic endometriosis, and dermoid cysts which arise from the germinal cells of the ovary. Endovaginal ultrasound with Doppler enhancement is the best imaging technique to establish the nature of cysts and to distinguish cysts suspicious for malignancy which require more invasive investigation. Pelvic laparoscopy is the surgical approach of choice for the treatment of non-functional benign ovarian cysts. Conservative treatment to shell out the cyst and preserve functional ovarian tissue should be reserved for women desirous of future pregnancies. The risk of ovarian cancer remains a major preoccupation of the surgeon. Where malignancy is suspected, laparoscopy is contraindicated and a median laparotomy is appropriate for radical extirpative surgery. This article describes the diagnostic techniques which allow a laparoscopic approach to presumably benign cysts and discusses surgical techniques specifically adapted to their different histologic nature of ovarian cysts.

[Femoral neuropathy after transversal suspubic laparotomies. Etiopathological explanation on the basis of an anatomical study]. / Paralysie du nerf fémoral dans les suites des laparotomies transversales sus-pubiennes: étude anatomique et hypothèses étiopathogéniques.

OBJECTIVES: Based on a case of transient troncular femoral neuropathy after the surgical treatment of a genital prolapse in a 46-year-old woman, a study was designed to better understand the mechanism of this postoperative complication. METHODS: The consequences of different varieties of transversal laparotomies were investigated in human cadavers. RESULTS: On the basis of the data from the anatomical evaluation, the most probable etiopathogenic explanation for the complication we observed is the compression of the femoral nerve, inside the psoas muscle, by the retractor lower edge. CONCLUSION: In the reported case, the outcome was simple with full sensory and motor recovery in the lower limb. The different mechanisms potentially involved in this kind of postoperative femoral neuropathies are reviewed and discussed.

[Peripartum dilated cardiomyopathies: is there a correlation with sexually transmitted diseases?]. / Cardiomyopathies dilatées du péripartum: existe-t-il une corrélation avec les maladies sexuellement transmissibles?

A revue of litérature about peripartum cardiomyopathy; a disease of unknown pathogenesis. Some retrospective studies suggest a relation with sexually transmitted diseases. Other risk factors were observed. Diuretics and digoxin are used in the treatment. Cardiac transplantation is the final solution but the affection could appear again. A database must be started with epidemiologic information to understand this disorder and its correlation with sexually transmitted diseases.

[Multidisciplinary management of aortic dissection complicating pregnancy]. / Prise en charge multidisciplinaire d'une grossesse compliquée de dissection aortique.

BACKGROUND: Most cases of aortic dissection observed in women under 40 years of age occur as a complication of pregnancy in patients with other risk factors. Case report. We report a case of dissection of the ascending aorta in a young primigravida at 35 weeks gestation. The risk factor was aortic regurgitation. Multidisciplinary management enabled fetal extraction followed by repair of the aorta. Outcome was favorable for both mother and child. DISCUSSION: A review of the literature shows a variety of etiological factors leading to this disease. Emergency diagnosis and management is mandatory. Obstetricians should be aware that pregnancy can be a triggering factor in patients with a predisposition, e.g. connective tissue disease. A complete cardiovascular evaluation should be conducted before conception and a suitable surveillance planned for the entire pregnancy. The aim of this careful follow-up it to avoid surgery in an emergency setting that could compromise prognosis for both mother and child.

[Laparoscopic surgery and "massive" obesity]. / Coeliochirurgie et obésité "massive".

OBJECTIVE: Massive obesity is an important risk factor in gynecology surgery. The traumatic effect of traditional laparotomy on the parietal wall is responsible for important per and postoperative morbidity. We evaluated the feasibility and advantages of the laparoscopic approach in these patients, both in terms of surgical procedure and anesthesia. METHODS: To evaluate the technique, we reviewed four patients with massive obesity (BMI > or =40 kg/m(2)) who underwent laparoscopic surgery in our department. For each patient, we studied the cardiovascular risk factors, indications for operation, surgical technique, anesthesia conditions and follow-up. RESULTS: From the surgical point of view, certain technical difficulties were noted such as the problem of exposure and coagulation difficulties for the vascular pedicles enveloped in a layer of fatty tissue. No conversion to laparotomy was necessary. From the anesthesiology point of view, unlike what was previously feared, there was a reduction in the high operative risk due to obesity, especially due to postoperative benefits. Follow-up in these four patients was uneventful. CONCLUSION: Patients who suffer massive obesity are in a high risk category for surgery and anesthesia. This high risk group can benefit most from the advantages of laparoscopic surgery compared with open surgery.

[Complications of cordocentesis associated with fetal therapy]. / Les complications des cordocentèses associées à un geste thérapeutique.

OBJECTIVES: To evaluate the technical and obstetrical risk factors of percutaneous umbilical blood sampling (PUBS) when associated with simultaneous fetal therapy. STUDY DESIGN: Retrospective study. One thousand PUBS have been performed in our department between 1984 and 1992. One hundred and forty one of them were done with another invasive fetal procedure. Technical and obstetrical circumstances were related to pregnancy follow-up and complications. RESULTS: Pregnancy complication rate increased when PUBS was associated with another invasive procedure (fetal losses: 12.9%, premature rupture of membranes (PROM): 11.6%). No chorioamnionitis nor perinatal infection was observed. As expected, previous fetal status was a main risk factor. Significant relationships have been found between fetal loss risk and therapy procedures such as amnioinfusion and severe IUGR and as well as abnormal post operative fetal tracing. The duration of cord bleeding after needle retrieval was the single risk factor pointed out for PROM. CONCLUSION: The study of the predictors of fetal complications is necessary to separate the genuine risk of previous fetal status and the risk of the invasive procedure itself.

Laparoscopic surgery in the Cameroon.

A new surgical section of operative laparoscopy was installed in General Hospital of Yaoundé, Cameroon, in April 1992 after many years of collaboration between the University of Clermont-Ferrand and the University of Yaoundé. A total of 735 laparoscopic operations were conducted in the first 5 years. Conditions facilitating such a project are discussed.

[Ursodeoxycholic acid: prospect for treatment of gravidic cholestasis? Report of 3 cases]. / L'acide ursodésoxycholique: perspective de traitement de la cholestase gravidique? A propos de 3 observations.

Ursodeoxycholic acid, employed in treatment of intrahepatic cholestasis as seen in primary biliary cirrhosis, primary sclerosing cholangitis, and chronic hepatitis; does not have marketing approval for prescription during pregnancy because of lack of data. In 3 cases of gravidic cholestasis, we administered oral ursodeoxycholic acid 1 g a day from the 34th week of amenorrhea to delivery. In each case, it took 3 days of treatment for the pruritus to regress incompletely and for plasma levels of biliary acid and transaminases to decrease. The infants, born between the 36th and 38th week of amenorrhea, presented with no problem. Forty-eight cases of gravidic cholestasis treated by ursodeoxocholic acid (0.4 to 1 g a day) have been reported in the literature; 18 cases belonging to 2 randomized studies. In 46 cases pruritus disappeared generally 3 days after treatment onset, and plasma level of biliary acid and transaminase decreased in one week. Only two patients experienced persisting pruritus despite biological improvement. No foetal adverse effect is reported. Ursodeoxycholic acid seems to be an efficient treatment of gravidic cholestasis. Long term observation of fetuses exposed in utero to this treatment is required to assess safety.

[Prevention and control of malaria in pregnant women in an urban setting (Yaoundé, Cameroun)]. / Prévention et lutte contre le paludisme chez les femmes enceintes en milieu urbain (Yaoundé, Cameroun).

The aim of this study was to evaluate the methods of preventing malaria (chemoprophylaxis, vector control) and of fever management (presumptive treatment of malaria) used for pregnant women in Yaounde, Cameroon and to identify the most important factors for assessing these practices. The 221 women studied were selected by cluster sampling. All had made extensive use of health services during pregnancy and 77% were using chemoprophylaxis. The number of febrile episodes in pregnant women who claimed to have used chemoprophylaxis was not significantly different to that in the women who did not use it. However, the mean birth weight of the babies of women who had used chemoprophylaxis was significantly higher. The women did not systematically use vector control measures; 21% used insect repellents (electric plaques, coil burners) and 20% used aerosol insecticides. Only 10% of the women slept under simple, untreated mosquito nets and none used mosquito nets impregnated with insecticide. Fifty per cent of the women had at least one episode of fever during pregnancy and 77% were treated for presumed malaria. However, the treatment was not standardized and was unsuitable in a third of cases. Possible changes in the chemoprophylaxis strategy are discussed.

Laparoscopic fimbrioplasty and neosalpingostomy. Experience of the Yaoundé General Hospital, Cameroon (report of 194 cases).

OBJECTIVE(S): To study the fertility results after laparoscopic distal tuboplasty and compare them with the data in the literature. STUDY DESIGN: 194 laparoscopic distal tuboplasties were carried out from May 1992 to May 1994 in the Yaounde General Hospital (Cameroon). The results were analysed according to the age of the patients, the type and duration of infertility, past history of abortion, laparotomy and Chlamydia trachomatis infection, the tube and adhesion scores, surgical procedures and achievement of pregnancy. The fertility rates were calculated according to Cramer's method [11]. The cumulative pregnancy rate curves were drawn up from the life table [12] and compared using the Log-Rank test. RESULTS: 53 patients obtained pregnancy (27.3%) of which 45 were inter-uterine (23.2%) and 8 ectopic (4.1%). Of the 45 intra-uterine pregnancies (IUP), 36 were obtained after fimbrioplasty (33.3%) and 9 after neosalpingostomy (10.5%). The monthly fertility rate at one year was 1.4%. The rate of IUP for tube stages I and II is significantly higher than that for stages III and IV (p<0.001). However the rate of ectopic pregnancies (EP) is proportional to damage to the tubes. Infection with Chlamydia trachomatis, and residual inflammation could have an effect on the achievement of pregnancy. CONCLUSION(S): Our results are similar to those found in the literature. The tube stage thus remains the decisive factor in terms of fertility (Cox: p<0.001). Operative laparoscopy is the best alternative in our countries compared with laparotomy for distal tubal pathology.

[Laparoscopically extended hysterectomy for cervix cancer: technique, indications and results. Apropos of a series of 41 cases in Clermont]. / Hystérectomie élargie par laparoscopie pour cancer du col: technique, indications et résultats. A propos d'une série clermontoise de 41 cas.

We report a study of 41 radical hysterectomies performed through laparoscopic approach for carcinoma of the cervix uteri. According to the FIGO staging, the tumors were classified as 12 stages Ia2, 24 stages Ib, 4 stages IIa and 1 stage IIb. 17 patients were treated by exclusive surgical procedure. 24 patients received a combination of radiation therapy and surgery 2 patients had a tumor of the cervical stump after subtotal hysterectomy. The mean duration of the procedure was 270 minutes. The post-op stay was 6.5 days. There was no major operative and postoperative complication. Only one patient required a blood transfusion. The intravenous pyelogram control was correct in all cases. At this time, with a 4 to 76 months follow-up, no recurrence was observed. This experience suggests the faisability of the laparoscopic radical hysterectomy. This approach seems to be convenient in young and non obese women with a tumor less than 4 cm in the greatest diameter.

Laparoscopic management of adnexal abscesses: consequences for fertility.

OBJECTIVE: To study fertility of patients with adnexal abscesses treated by laparoscopy, antibiotic therapy, and second-look laparoscopy. DESIGN: A retrospective clinical study. SETTING: Department of Obstetrics Gynecology and Reproductive Medicine, University of Auvergne, University Hospital of Clermont Ferrand, France. PATIENT(S): Thirty-nine patients treated for adnexal abscesses between January 1983 and December 1992. INTERVENTION(S): Laparoscopic drainage of adnexal abscesses was performed in all patients; 35 patients underwent a second laparoscopy 3 to 6 months later. MAIN OUTCOME MEASURE(S): Immediate and long-term clinical results, anatomical data obtained at second-look laparoscopy, spontaneous fertility. RESULT(S): No immediate reoperation was necessary within the first 2 months after the initial laparoscopic surgery. At second-look laparoscopy, an adhesiolysis was necessary in all cases. A distal tuboplasty was performed in 17 patients and 6 patients were referred to IVF-ET. Subsequently, 12 of 19 patients not using any contraception obtained a spontaneous intrauterine pregnancy (63%). CONCLUSION(S): This study confirms that laparoscopic surgery is a safe and efficient technique for treating adnexal abscesses. Anatomical results observed at second-look laparoscopy suggest that this second surgical step is essential for patients desiring future pregnancy.

[Post-laparoscopic incisional hernia. Apropos of a case]. / Les hernies incisionnelles post-coelioscopiques. A propos d'un cas.

Incisional hernia occurred in a patient after laparoscopic hysterectomy. The greater omentum was incarcerated in the tract of the suprapubic trocar (12 mm diameter). Diagnosis and treatment were performed during a second laparoscopy procedure. The greater number of trocar instruments and their larger diameter increases the risk of parietal morbidity after laparoscopic procedures. Elective closures of trocar incisions is recommended when exceeding 10 mm. Prevention of extra-umbilical incisional hernias and dehiscences appears to be more effective when suture is performed under laparoscopic vision with the trocar inserted. Both the aponevrosis and the peritoneal membrane should be treated.

[Laparoscopic treatment of adnexal abscesses. A series of 39 patients]. / Traitement coelioscopique des abcès annexiels. A propos d'une série de 39 patientes.

OBJECTIVE: Evaluate short- and long-term follow-up of patients treated by laparoscopy and antibiotherapy for tubo-ovarian abscess. METHODS: We report a retrospective study of 39 patients treated from January 1983 to December 1992. Clinical files were examined and a questionnaire was mailed to patients. RESULTS: None of the patients needed to be reoperated for failure of the first laparoscopic treatment. A laparoscopic control after 3 month was done in 35 cases, which allowed complete adhesiolysis in every patients. We performed distal tubal surgery in 17 patients at that time and oriented 6 patients directly towards IVF. Subsequent fertility, in 19 patients followed without contraception, demonstrated a rate of spontaneous intra-uterine pregnancy of 63%. CONCLUSION: This study confirms that laparoscopy remains the technique of choice in initial management of adnexal abscesses.