Total laparoscopic hysterectomy with posterior cul-de-sac obliteration: step-by-step procedures based on precise anatomical landmarks.

BACKGROUND: Dense adhesion due to severe endometriosis between the posterior cervical peritoneum and the anterior sigmoid or rectum obliterates the cul-de-sac and distorts normal anatomic landmarks. Surgery for endometriosis is associated with severe complications, including ureteral and rectal injuries, as well as voiding dysfunction. It is important to develop the retroperitoneal avascular space based on precise anatomical landmarks to minimize the risk of ureteral, rectal, and hypogastric nerve injuries. We herein report the anatomical highlights and standardized and reproducible surgical steps of total laparoscopic hysterectomy for posterior cul-de-sac obliteration. OPERATIVE TECHNIQUE: We approach the patient with posterior cul-de-sac obliteration using the following five steps. Step 1: Preparation (Mobilization of the sigmoid colon and bladder separation from the uterus). Step 2: Development of the lateral pararectal space and identification of the ureter. Step 3: Isolation of the ureter. Step 4: Development of the medial pararectal space and separation of the hypogastric nerve plane. Step 5: Reopening of the pouch of Douglas. CONCLUSION: Surgeons should recognize the importance of developing the retroperitoneal avascular space based on precise anatomical landmarks, and each surgical step must be reproducible.

Intranodal lymphangiography under microsurgery for refractory lymphatic ascites after pelvic lymphadenectomy.

Lymphatic ascites is a postoperative complication of lymph node dissection. Most symptomatic cases improve with conservative treatments. However, optimal management strategies for intractable lymphatic ascites remain controversial, and clinicians sometimes encounter intractable lymphatic ascites that does not respond to conservative management. We herein report a case of postoperative intractable lymphatic ascites that was successfully treated with intranodal lymphangiography (LG) from inguinal lymph nodes under microsurgery. A 56-year-old woman was diagnosed with stage II endometrial cancer and underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomies. On postoperative day (POD) 13, the patient presented with abdominal distention, and lymphatic ascites was diagnosed. Although the patient was treated with conservative management and lymphaticovenular anastomosis, her lymphatic ascites did not resolve. Finally, intranodal LG from the inguinal region was performed under microsurgery. A 2-cm incision was made on each side of the inguinal region. Once the lymph nodes were identified, a 23-gauge needle was inserted into the lymph node and lipiodol was injected. Extravasation of lipiodol into the abdomen from the left side of the lower pelvic region was confirmed. The postoperative course was uneventful. The ascites gradually decreased and disappeared within two weeks after LG.

Delayed Nonimmune Anaphylaxis Caused by Ropivacaine for Preoperative Nerve Blocks: A Case Report.

Ropivacaine is an amide local anesthetic with rare reports of anaphylaxis. To our knowledge, this is the first report of delayed nonimmune anaphylaxis induced by ropivacaine. A 70-year-old man underwent general anesthesia with a nerve block for a total knee arthroplasty. The patient developed symptoms of anaphylaxis 3.5 hours after receiving ropivacaine for femoral and tibial nerve blocks. A basophil activation test (BAT) revealed ropivacaine as the causative agent. Notably, anaphylaxis can be caused by medications even hours after their administration, and all administered drugs should be suspected of potentially causing anaphylaxis.

Impact of fentanyl on acute and chronic pain and its side effects when used with epidural analgesia after thoracic surgery in multimodal analgesia: a retrospective cohort study.

BACKGROUND: We investigated the effects adding opioids to epidural anesthesia on acute and chronic pain and its side effects in multimodal analgesia. METHODS: Retrospective cohort study. We retrospectively studied patients who received epidural anesthesia after thoracic surgery. Patients were divided into two groups: epidural anesthesia with fentanyl (group F) and without fentanyl (group N). Pain visual analog scale (VAS) scores at rest and after movement, use of non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, side effects (nausea, vomiting, pruritus, hypotension, urinary retention), and post-thoracotomy pain syndrome (PTPS) were compared between the two groups. A Mann-Whitney U test and chi-squared test were used for statistical analysis, with significance set at P<0.05. Values were presented as median [interquartile range]. RESULTS: A total of 282 patients received epidural anesthesia, 142 in group F and 140 in group N. Resting pain and movement pain were lower in group F than those in group N {resting pain: group F 12 [0-29], group N 20.5 [7-38.5], P=0.01; movement pain, group F 43 [17-65]; group N, 51.5 [39-72]; P<0.001}. Incidence of hypotension was 9.9% in group F and 2.1% in group N (P=0.01), and that of pruritus was 41.5% in group F and 10.7% in group N (P<0.001). There is no difference in the incidence of nausea and vomiting and PTPS. CONCLUSIONS: In multimodal analgesia management after thoracic surgery, the addition of fentanyl to epidural anesthesia reduced acute pain and increased the incidence of hypotension and pruritus but did not affect that of PTPS.

Acute vascular effects of carbonated warm water lower leg immersion in healthy young adults.

Endothelial dysfunction is associated with increased cardiovascular mortality and morbidity; however, this dysfunction may be ameliorated by several therapies. For example, it has been reported that heat-induced increases in blood flow and shear stress enhance endothelium-mediated vasodilator function. Under these backgrounds, we expect that carbon dioxide (CO2)-rich water-induced increase in skin blood flow improves endothelium-mediated vasodilation with less heat stress. To test our hypothesis, we measured flow-mediated dilation (FMD) before and after acute immersion of the lower legs and feet in mild warm (38°C) normal or CO2-rich tap water (1000 ppm) for 20 min in 12 subjects. Acute immersion of the lower legs and feet in mild warm CO2-rich water increased FMD (P < 0.01) despite the lack of change in this parameter upon mild warm normal water immersion. In addition, FMD was positively correlated with change in skin blood flow regardless of conditions (P < 0.01), indicating that an increase in skin blood flow improves endothelial-mediated vasodilator function. Importantly, the temperature of normal tap water must reach approximately 43°C to achieve the same skin blood flow level as that obtained during mild warm CO2-rich water immersion (38°C). These findings suggest that CO2-rich water-induced large increases in skin blood flow may improve endothelial-mediated vasodilator function while causing less heat stress.