Use of plastic wound retractor at hysterotomy site in prenatal repair of myelomeningocele: a new technique.

Objective: To describe the use of a self-retaining thermoplastic polyurethane wound retractor for the management of hysterotomy during prenatal repair of myelomeningocele.Methods: The preliminary experience with 16 consecutive cases of open surgery for prenatal repair of myelomeningocele using a new technique is presented. Under general anesthesia, the gravid uterus was partially exteriorized through a low transverse abdominal incision and a high 3-4-cm midline vertical mini-hysterotomy was performed. After chorioamniotic membranes were opened with scissors, the internal ring of the retractor was placed into the amniotic cavity to compress the chorioamniotic membranes against the internal uterine wall and permit full retraction of the hysterotomy. Once the neurosurgical intervention was completed, the retractor was removed manually and uterine and abdominal incisions were closed using conventional techniques. Intra- and post-operative complications, as well as short-term pregnancy outcomes, were evaluated.Results: Intrauterine surgery was performed at a mean gestational age of 25.3 weeks and all except two of the interventions were completed within 3.0 h. When compared with the technique described in the Management of Myelomeningocele study (MOMS) trial, the use of the retractor was associated with a lower, although statistically nonsignificant, rate of chorioamniotic membrane separation (20/78 (26%) versus 2/16 (13%), respectively), preterm rupture of membranes (36/78 (46%) versus 4/16 (25%), respectively), and persistent oligohydramnios (16/78 (21%) versus 1/16 (6%), respectively) as well as higher gestational age at delivery (34.1 weeks ± 3.1 versus 36.0 weeks ± 1.93, respectively) and birthweight (2383 g ± 688 versus 2790 g ± 529, respectively). There were no intra- or post-operative complications associated with the use of the device. Only one (6%) of the hysterotomy scars was noted to be thin at the time of the cesarean delivery and no cases of dehiscence occurred.Conclusions: The use of a plastic wound retractor at the hysterotomy site provides a less traumatic approach than the conventional technique for the management of the uterine incision during open intrauterine surgery. Our experience with this technique was associated with short-term pregnancy outcomes that are similar and perhaps even superior to the technique reported in the MOMS trial. Because the device is inexpensive, easy to use, and widely available, its use during open intrauterine surgery should be considered. However, further clinical experience is required to reach a definitive conclusion regarding whether this technique should be incorporated into the protocol of prenatal repair of myelomeningocele.

Histerectomía vaginal asistida por laparoscopia / Laparoscopic assisted vaginal hysterectomy

Evaluar los resultados de las histerectomías vaginales asistidas por laparoscopia. Estudio descriptivo, evolutivo, en el cual se evalúa una población de 400 pacientes a quienes se les realizó histerectomía veginal asistida por laparoscopia, durante octubre de 1991 a octubre de 2003. Los datos se analizaron según técnicas de estadísticas descriptiva. Describimos en detalle nuestra técnica quirúrgica personal. Hospital Luis Blanco Gásperi. Cruz Roja Venezolana, Seccional Valencia. Estado Carabobo, Venezuela. La edad promedio de las pacientes fue de 42 años. Las principales patologías fueron leiomiomatosis y prolapso genital. El tiempo quirúrgico promedio fue de 148 minutos, aunque en el 70 por ciento de los casos se asoció a otra cirugía. El peso uterino promedio fue de 198 g con una longitud media de 12.6 cm. Las complicaciones transoperatorias se presentaron en menos del 5 por ciento de las pacientes, destacando lesiones vesicales e intestinales. Hubo complicaciones posoperatorias en el 2 por ciento de las pacientes, principalmente infecciones urinarias. El tiempo promedio de hospitalización fue de 1,8 días. La Técnica empleada es segura, más económica que las que utilizan engrapadoras y de facilidad para su uso en grupos poblacionales de bajos recursos económicos