Concurrent acute cystitis, pancolitis, and tubo-ovarian abscess following laparoscopic ovarian cystectomy: a case report.

BACKGROUND: Inadequate surgical interventions can lead to serious complications such as tubo-ovarian abscesses in the upper female genital system, often resulting from untreated pelvic inflammatory disease. Pelvic inflammatory disease, caused by infections like Chlamydia trachomatis and Neisseria gonorrhoeae, leads to scarring and adhesions in the reproductive organs, with common risk factors including intrauterine device use and multiple sexual partners. Pelvic inflammatory disease primarily affects sexually active young women and can manifest with varied symptoms, potentially leading to complications like ectopic pregnancy, infertility, and chronic pelvic pain if untreated. CASE PRESENTATION: This case report presents a unique scenario involving a 17-year-old sexually inactive female who experienced concurrent tubo-ovarian abscess, acute cystitis, and pancolitis following laparoscopic ovarian cystectomy. Pelvic inflammatory disease and its complications are well-documented, but the simultaneous occurrence of acute cystitis and pancolitis in this context is unprecedented in the medical literature. The patient's presentation, clinical course, and management are detailed, highlighting the importance of considering diverse and severe complications in individuals with a history of gynecological surgeries. CONCLUSIONS: Our case report highlights the need for healthcare professionals to remain vigilant for atypical presentations of gynecological complications and emphasizes the value of interdisciplinary collaboration for optimal patient care. We encourage further research and awareness to enhance understanding and recognition of complex clinical scenarios associated with gynecological procedures.

TWO-YEAR FOLLOW-UP ON SURGICAL OUTCOMES OF vNOTES HIGH UTEROSACRAL LIGAMENT SUSPENSION FOR THE PROPHYLAXIS AND TREATMENT OF PELVIC ORGAN PROLAPSE: A MULTICENTER PROSPECTIVE COHORT STUDY.

STUDY OBJECTIVE: We aimed to evaluate the medium-term outcomes of high uterosacral ligament suspension (HUSLS) with vaginal-assisted natural orifice transluminal endoscopic surgery (vNOTES) in patients either suffering from pelvic organ prolapse (POP) or undergoing routine prophylaxis to prevent post-hysterectomy vaginal vault prolapse. DESIGN: Multicenter prospective cohort study SETTING: Three tertiary care hospitals PATIENTS: Patients who received vNOTES-HUSLS between January 1, 2021 and January 1, 2023, were included in the study. INTERVENTIONS: vNOTES-HUSLS MEASUREMENTS AND MAIN RESULTS: The data collected included surgery duration, intraoperative and postoperative complications, postoperative Visual Analog Scores (VAS), and Female Sexual Function Index (FSFI) pain subdomain scores. The changes in prolapse levels were measured using modified POP-Q scores, including the C, Ba, and Bp scores recorded prior to surgery and during the postoperative follow-up examination. Patient satisfaction was assessed using the Patient Global Impression of Improvement (PGI-I) questionnaire. The final analysis included 55 women. Of these, vNOTES-HUSLS was performed in 43 patients (78.2%) to treat apical prolapse, while the remaining 12 patients (21.8%) underwent prophylaxis following hysterectomy to prevent vaginal vault prolapse. The median follow-up period was 23.5 months, with a range of 12-37 months. Ba,C, and Bp points significantly improved in patients who underwent surgery for prolapse (p<0.001). There was no recurrence in the apical compartment following vNOTES-HUSLS for both performed prophylactic and treatment purposes after hysterectomy. Two (3.6%) patients were diagnosed with stage 3 anterior compartment prolapse. The overall vNOTES-HUSLS success rate was 96.4% at approximately two years follow-up. Bladder injury was detected as an intraoperative complication in one patient (1.8%). The overall satisfaction rate was 98.1% at the final follow-up. CONCLUSION: vNOTES-HUSLS was effective in the treatment and prophylaxis of apical prolapse, demonstrating high anatomical success rates. The procedure demonstrated a low complication rate, with intraoperative and postoperative complications each observed in 1.8%(n=1) of patients. SYNOPSIS: The Medium-Term Outcomes of vNOTES High Uterosacral Ligament Suspension.

Implementing the transvaginal natural orifice transluminal endoscopic surgery (vNOTES) "first" strategy in benign gynecological surgeries.

PURPOSE: The use of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) as the first choice of surgical route for patients scheduled to undergo conventional laparoscopy is still being debated. We aimed to evaluate and compare the outcomes of the "vNOTES first" strategy in benign gynecological cases. METHODS: All benign gynecological surgeries were initiated using vNOTES during the study period, regardless of the difficulty. Surgical outcomes, short-term patient satisfaction and sexual pain were compared between hysterectomies, adnexal and diagnostic procedures. Visual Analog Score (VAS), Patients Global Impressions of Improvements scale (PGI-I) and Female Sexual Function Index (FSFI) were used to assess the postoperative pain, satisfaction and sexual pain, respectively. RESULTS: A total of 105 vNOTES procedures were performed during the study period: 63 (60.58%) adnexal procedures, 36 (34.62%) hysterectomies, 5 (4.81%) diagnostic procedures and one (0.96%) myomectomy. The median 24th hour VAS scores for adnexal, hysterectomy, and diagnostic procedures were 1.29 ± 1.41, 2.06 ± 2.08, and 2.6 ± 2.41, respectively. The satisfaction rate was 96.19% at the 1st postoperative week and 97.14% at the first month. There was either no change or a slight improvement in the patients' total score on the FSFI/pain domain before and after surgery. There were two conversions (1.9%) from vNOTES to laparoscopy and laparotomy, and two (5.56%) bladder injuries in hysterectomy cases. CONCLUSION: Implementing the vNOTES technique as an initial approach for all benign gynecological surgeries seems feasible, safe and satisfactory, even in those with a non-prolapsed or enlarged uterus and those that have previously undergone abdominal surgery. The pain scores were found to be low and patients stated a high satisfaction with no or better change in their sexual life.

[Emergency combined surgery for acute appendicitis and cystic lesions of small pelvis]. / Neotlozhnye sochetannye operatsii pri ostrom appenditsite i kistoznykh obrazovaniyakh malogo taza.

OBJECTIVE: To determine the optimal surgical approach for acute appendicitis and concomitant cystic lesions of small pelvis. MATERIAL AND METHODS: The authors report the results of emergency combined surgery on abdominal and pelvic organs in 995 patients for the period from 1990 to 2020 (30 years). Acute appendicitis was diagnosed in 698 (70.15%) patients. Cystic lesions of small pelvis were observed in 286 (28.7%) patients: follicular cyst - 133 (46.5%), serous cyst - 91 (31.8%), corpus luteum cyst - 42 (46.4%), dermoid cyst - 20 (7.0%), endometrioid cyst - 3 (1.0%) cases. Catarrhal appendicitis was diagnosed in 10 (1.4%) patients, phlegmonous appendicitis - 685 (98.1%), gangrenous appendicitis - 3 (0.4%) patients. All patients with pyoinflammatory diseases of small pelvis had long-term history of gynecological diseases. RESULTS: Cystic lesions of small pelvis can undergo malignant transformation. Therefore, surgical intervention is determined by surgeon together with gynecologist. Tree large endometrioid cysts (20-25 cm) were malignant. These patients also had adenocarcinoma of sigmoid colon. Malignant neoplasm resulted acute ileus, and the cysts were incorporated into pyogenic membrane. Extensive adhesive process was also observed. These aspects caused significant technical difficulties during resection of these cysts. Postoperative complications occurred in 2.31% of patients. CONCLUSION: Prolonged therapy and follow-up of patients with urgent concomitant inflammatory diseases of abdominal cavity and small pelvis (chronic nonspecific salpingitis, diffuse pelvic endometriosis, ovarian cysts, etc.) can lead to development and growth of cystic lesions of small pelvis. These cysts may be complicated by subsequent malignant transformation.

Impact of obesity on recovery and pulmonary functions of obese women undergoing major abdominal gynecological surgeries.

To determine impact of obesity on recovery parameters and pulmonary functions of women undergoing major abdominal gynecological surgeries. Eighty women undergoing major gynecological surgeries were included in this study. Anesthesia was induced by remifentanil bolus, followed by propofol and cisatracurium to facilitate oro-tracheal intubation and was maintained by balanced anesthesia of remifentanil intravenous infusion and sevoflurane in oxygen and air. Time from discontinuation of maintenance anesthesia to fully awake were recorded at 1-min intervals and time from discontinuation of anesthesia until patient was transferred to post-anesthesia care unit (PACU) and discharged from PACU was also recorded. Pulmonary function tests were performed before surgery and repeated 4 h, days 1, 2 and 3 post-operative for evaluation of forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate. Occurrence of post-operative complications, re-admission to ICU, hospital stay and morbidities were also recorded. Induction of anesthesia using remifentanil bolus injection resulted in significant decrease of heart rate and arterial pressures compared to pre-operative and pre-induction values. Recovery times were significantly shorter in obese compared to morbidly obese women. Post-operative pulmonary function tests showed significant deterioration compared to pre-operative measures but showed progressive improvement through first 3 post-operative days. Hospital stay was significantly shorter for obese compared to morbid obese women. Obesity delays recovery from general anesthesia, adversely affects pulmonary functions and increases post-operative complications. Remifentanil infusion and sevoflurane could be appropriate combination for obese and morbidly obese women undergoing major surgeries.

Power morcellation for women undergoing laparoscopic supracervical hysterectomy - safety of procedure and clinical experience from 426 cases.

OBJECTIVES: Minimally invasive gynaecological surgeries are performed for several malignant and nonmalignant indications. The aim of our study was to evaluate the rate of unexpected malignancies among women who underwent laparoscopical supracervical hysterectomy (LASH) with power morcellation. MATERIAL AND METHODS: The retrospective analysis included clinical data of 426 consecutive female patients who underwent LASH with power morcellation due to presumed benign disorders (78.4% - symptomatic uterine fibromas, 12.7% - abnormal uterine bleeding, 8.9% - suspicion of uterine adenomyosis) between January 2011 and December 2015. Pre-malignant or malignant preoperative abnormalities in the cervix and the uterine corpus were contraindications for LASH. RESULTS: The unexpected malignancies were found in four patients from study group: one ovarian cancer located on the inner part of simple ovarian cyst and 3 endometrial carcinomas (0.9%) were documented. All these patients underwent abdominal reoperations and no histological abnormalities were detected in the extirpated cervix and adnexa. CONCLUSIONS: The incidence of unintended endometrial carcinoma in morcellated uterus after LASH was relatively small. However, careful pre-operative counseling should be undertaken in order to exclude the possibility of any malignant disease in uteri among women scheduled to power morcellation.

A Randomized Controlled Trial Comparing Two Wound Dressings Used in Obstetric and Gynecological Surgeries: Trushield NXT vs. Tegaderm.

Background Surgical site infection (SSI) is considered as a healthcare-associated infection. Wound dressings play an imperative role in altering the risk of SSI. In this study, we compared the efficacy and safety of Trushield NXT Non-adherent dressing (Healthium Medtech Limited, Bangalore, India) to the traditional Tegaderm HP+ Pad Film Dressing with Non-Adherent Pad (3M, Bangalore, India) in post-operative wound management of obstetrics and gynecological surgeries. Methodology This was a single-centre, prospective, two-arm, parallel-group, randomized, single-blind study conducted between January 2022 and May 2022. One hundred two subjects were enrolled and randomized to receive Trushield or Tegaderm dressing (n=51 each). The incidence of SSI, adverse events (AEs), comfort and performance of the dressings, subject satisfaction, and pain score were assessed in both groups. Results The baseline demographics and clinical and physical data were comparable among the groups. During the follow-up study, no SSI or AEs were reported. On the product usage assessment scale, surgeons rated both dressings "good" to "excellent" and favored Trushield for comfortable usage and removal, while Tegaderm was favored for ease of application and flexibility. On the wound pain assessment scale, the proportion of patients reporting "no pain" after surgery was 5.9% in the Trushield group and 4.2% in the Tegaderm group, which increased to 87.8% and 88.6%, respectively, at the end of the follow-up. The subject satisfaction for the comfort and wound healing properties was similar for both products. Conclusion Both dressings were equally safe, efficient, and beneficial in the post-operative wound management of obstetric and gynecological surgeries.

Incidence and risk factors for surgical site infections in obstetric and gynecological surgeries from a teaching hospital in rural India.

BACKGROUND: Surgical site infections (SSI) are one of the most common healthcare associated infections in the low-middle income countries. Data on incidence and risk factors for SSI following surgeries in general and Obstetric and Gynecological surgeries in particular are scare. This study set out to identify risk factors for SSI in patients undergoing Obstetric and Gynecological surgeries in an Indian rural hospital. METHODS: Patients who underwent a surgical procedure between September 2010 to February 2013 in the 60-bedded ward of Obstetric and Gynecology department were included. Surveillance for SSI was based on the Centre for Disease Control (CDC) definition and methodology. Incidence and risk factors for SSI, including those for specific procedure, were calculated from data collected on daily ward rounds. RESULTS: A total of 1173 patients underwent a surgical procedure during the study period. The incidence of SSI in the cohort was 7.84% (95% CI 6.30-9.38). Majority of SSI were superficial. Obstetric surgeries had a lower SSI incidence compared to gynecological surgeries (1.2% versus 10.3% respectively). The risk factors for SSI identified in the multivariate logistic regression model were age (OR 1.03), vaginal examination (OR 1.31); presence of vaginal discharge (OR 4.04); medical disease (OR 5.76); American Society of Anesthesia score greater than 3 (OR 12.8); concurrent surgical procedure (OR 3.26); each increase in hour of surgery, after the first hour, doubled the risk of SSI; inappropriate antibiotic prophylaxis increased the risk of SSI by nearly 5 times. Each day increase in stay in the hospital after the surgery increased the risk of contacting an SSI by 5%. CONCLUSIONS: Incidence and risk factors from prospective SSI surveillance can be reported simultaneously for the Obstetric and Gynecological surgeries and can be part of routine practice in resource-constrained settings. The incidence of SSI was lower for Obstetric surgeries compared to Gynecological surgeries. Multiple risk factors identified in the present study can be helpful for SSI risk stratification in low-middle income countries.

Ideal anesthetic agents for day-care gynecological procedures: A clinical trial comparing thiopentone with ketamine as adjuncts to propofol.

BACKGROUND: Day-care gynecological procedures require the use of anesthetic agents, which ensure rapid induction and recovery. Although propofol is the gold standard drug in day-care procedures, it has its own side effects like apnea, cardiovascular instability, pain on injection, as well as its cost. The ideal drug combination to achieve this end remains elusive. Therefore, a combination of propofol, thiopentone, and ketamine may be a better alternative. MATERIALS AND METHODS: This prospective, double-blind, randomized study was conducted on 60 women, aged 18-50 years, American Society of Anesthesiologists (ASA) physical status 1 and 2, undergoing day-care gynecological surgeries. The patients were allocated to two groups. Group T received an admixture containing 10 ml of 1% propofol and 10 ml of 1.25% thiopentone. Group K received an admixture containing 10 ml of 1% propofol and 10 ml of 0.5% ketamine. RESULTS: There was less variation in the mean systolic blood pressure of patients in Group K as compared to patients in Group T. The mean total dose of propofol required in Group K (0.85 mg/kg) was significantly less than that required in Group T (1.12 mg/kg) (P = 0.0004). The mean recovery time in Group T (3.67 minutes) was significantly less than in Group K (6.27 minutes; P = 0.0001). However, the mean discharge time in both the groups was similar. (P = 0.7392). The results were analyzed statistically using the Student's t-test and the Fisher's exact test. CONCLUSIONS: Both the propofol-thiopentone and propofol-ketamine admixtures provided adequate anesthesia. Propofol-ketamine proved superior to propofol-thiopentone in terms of hemodynamic stability and requirement of a lesser total dose of propofol. However, the patients in the propofol-thiopentone group had faster recovery.

Blood transfusion practice in obstetric and gynecology: impact of educational programs to create awareness for judicious use of blood components.

The study presents the data analysis (1) To find out the trend of blood component use during the period 2003-2010 and to determine impact of component awareness programs on reduction in whole blood (WB) and single unit transfusions. (2) To determine Hb trigger. The details about blood units issued were entered in the integrated blood bank management software as well as in Microsoft Excel. The data of 4,838 cases of pregnancy anemia; 2,244 receiving blood for obstetric (Ob) hemorrhage including 270 cases of disseminated intravascular coagulation; 1,413 women having Gynecological (Gy) bleeding; 911 Ob, 2,032 Gy and 740 surgeries for Gy malignancy were analyzed. During the years 2003-2010 there was gradual increase in component utilization for pregnancy anemia, Ob/Gy surgeries and Ob/Gy bleeding and significant reduction in WB transfusions due to component awareness programs. But single unit transfusions showed comparatively lower trend of reduction. The mean Hb was 6.4 g/dL for pregnancy anemia, 8.1 g/dL for surgeries and 7.3 g/dL for Ob/Gy bleeding.

Determinants of decision-to-intervention time in the management and therapeutic outcome of emergency gynecological surgeries in south east Nigeria.

BACKGROUND: Prompt and timely response in the management of gynecological surgical cases can significantly affect the therapeutic surgical outcome of patients in emergency situations. The aim of this study was to evaluate the decision-to-intervention time (DIT), its determinants, and the significance in the therapeutic outcome of emergency gynecological surgeries managed at a federal teaching hospital in south east Nigeria over an 18-month period. METHODS: This was a prospective descriptive study of 105 emergency gynecological cases managed at a federal teaching hospital over an 18-month period. Patients were recruited at the point of admission and followed up until discharge for outcome. Data were abstracted with a data entry pro forma and then analyzed with the Epi Info™ statistical software version 7.0. RESULTS: The incidence of gynecological surgical emergencies was 5.1% of the total gynecological cases managed during the study period. The mean DIT was 4.25 (range 1.45-5.50) hours with delay in intervention, mainly due to delays in securing blood/blood products and other materials for resuscitation (46.7%) and a lack of finance (15.2%). Six maternal deaths were recorded, giving a case fatality ratio of 5.7%, while the commonest maternal complications associated with the delays were hemorrhage (61.9%) and the need for blood transfusion (57.1%), respectively. The risk ratio of losing ≥1,000 mL of blood, anemia, hemorrhagic shock, and wound infection in those with DIT ≥120 minutes was statistically greater and significant at 95% confidence interval. CONCLUSION: Inadequacies in health care services and policies due to poor infrastructure, organizational framework, and financing were the major determinants of the prolonged DIT and therapeutic outcomes.

Hemodynamic responses with different dose of ketamine and propofol in day care gynecological surgeries.

BACKGROUND: Day care gynaecological surgeries mandate use of hemodynamically stable combination of commonly used intravenous agents, propofol & ketamine. Hence we proposed to evaluate the hemodynamic profile of different dose combination of propofol & ketamine as induction agents in ambulatory gynecological surgeries. MATERIAL & METHODS: Thirty adult patients scheduled for day care gynecological surgeries were randomly divided into five Groups. Group I received inj. propofol 2mg/kg i.v + inj. Normal saline (NS); Group II received ketamine 2mg/kg i.v + inj. NS; Group III was given inj. Propofol 2mg/kg i.v followed by inj. Ketamine 1 mg/kg i.v.; Group IV received inj. Ketamine 2 mg/kg i.v followed by inj. propofol 1 mg/kg i.v; Group V received combination of inj. Propofol 1 mg/kg i.v and inj. Ketamine 1 mg/kg i.v. After administration of the drug, non invasive systolic, diastolic and mean arterial pressures, heart rate, respiratory rate, arterial oxygen saturation and ECG were recorded every minute for five minutes. RESULTS: Statistically significant hemodynamic alterations were observed in Group I & II, with Group I having the highest incidence of apnea (23.3%). No significant changes in hemodynamics were seen in Group V. CONCLUSION: We conclude that the combination of 1mg Propofol and 1mg ketamine produced better hemodynamic stability in comparison to other Groups.

Comparison of combinations of ciprofloxacin-metronidazole and ceftriaxone-metronidazole in controlling operative site infections in obstetrics and gynecological surgeries: A retrospective study.

OBJECTIVE: To compare the effectiveness of the ciprofloxacin-metronidazole (CIP-MET) regimen with the ceftriaxone-metronidazole (CEF-MET) regimen for operative site infection control in women undergoing obstetrical and gynecological surgeries. MATERIALS AND METHODS: One thousand and eighty-four case records of women who had undergone various obstetrical and gynecological surgeries who were given CIP-MET regimen and CEF-MET regimen were analyzed in predesigned and pretested proforma. Patients who were given CIP-MET regimen and CEF-MET regimen were classified as Group 1 and Group 2 respectively. The mode of administration of both the regimens was noted. Numbers of wound infections were recorded in the respective groups. Socioeconomic status and hemoglobin level of the patients were noted. Other data such as hospital stay, duration of operation were also noted. RESULTS: Out of a total of 1084 case records, 31 (5.8%) and eight (0.7%) patients contracted wound infections in Group 1 and Group 2 respectively (P = 0.0001). CONCLUSION: The CEF-MET regimen was found superior to the CIP-MET regimen to control operative site infection in obstetrical and gynecological surgeries.

Preventing adhesions in obstetric and gynecologic surgical procedures.

Adhesive disease represents a significant cause of morbidity for postoperative patients. Most surgical procedures performed by obstetrician-gynecologists are associated with pelvic adhesions that cause subsequent serious sequelae, including small bowel obstruction, infertility, chronic pelvic pain, and difficulty in postoperative treatment, including complexity during subsequent surgical procedures. The technology of adhesion prevention has significantly progressed. There are 3 methods approved by the US Food and Drug Administration for the prevention of postoperative adhesions, including Adept((R)), Interceed((R)), and Seprafilm((R)). The latter barrier is the most widely studied. This article reviews the current choices available for adhesion prevention barriers as well as surgical adjuncts that traditionally have been studied for that purpose.

Intrathecal tramadol added to bupivacaine as spinal anesthetic increases analgesic effect of the spinal blockade after major gynecological surgeries.

The analgesic effect of the centrally acting opioid, tramadol, is well-known. It has been shown in clinical studies that using tramadol epidurally can provide longer duration of analgesia, without the common side effects of opioids. The study was undertaken to evaluate the duration of analgesia and/or pain free period produced by intrathecal tramadol added to bupivacaine in patients undergoing major gynecological surgery in a randomized double blind placebo controlled protocol. Fifty patients ASA I & II scheduled for Wardmayo's operation and Fothergill's operation were randomly allocated to two equal groups. Group A (n=25) received 3 ml of 0.5% hyperbaric bupivacaine (15 mg) with 0.2 ml of normal saline and Group B (n=25) received 3 ml 0.5% hyperbaric bupivacaine and 0.2 ml (20 mg) tramadol by intrathecal route at L3-4 inter space. Standard monitoring of the vital parameters was done during the study period. Levels of sensory block and sedation score were recorded every two minutes for the first 20 minutes, and then every ten minutes for the rest of the surgical procedure. Assessment of pain was done using Visual Analogue Scale (VAS). The study was concluded when the VAS was more than 40 mm, postoperatively. The patient was medicated and the time was recorded. Duration of analgesia or pain free period was estimated from the time of completion of spinal injection to administration of rescue analgesic or when the VAS score was greater than 40 mm. In Group B patients, the VAS score was significantly lower, as compared to Group A patients. The duration of analgesia was 210 +/- 10.12 min in Group A; whereas, in Group B, it was 380 +/- 11.82 min, which was found to be significant.