Preventive Effect of Neutral Positioning of Both Arms on Malposition-Related Hand Numbness after Gynecological Laparoscopic Surgery / 日本農村医学会雑誌

　　This retrospective study was carried out to clarify the preventive effect of neutral positioning of both arms on upper extremity neuropathy after gynecological laparoscopic surgery compared with right arm abduction positioning. In 93 cases of right arm abduction positioning >90°, with the left arm tucked in at the side, postoperative right hand numbness occurred in 6 cases (6.5%). In these 6 cases, symptoms disappeared in 4 cases after postoperative day (POD) 1, in 1 case after POD 21, and in the remaining case after POD 41. In 81 cases where both arms were in the neutral position tucked in at the sides with shoulder braces applied, upper extremity numbness was not experienced in any cases; however, shoulder pain developed in 4 cases (4.9%) and was thought to be related to using the shoulder braces. The pain disappeared in 2 cases after POD 1, in 1 case after POD 2, and in the remaining case after POD 3. In right arm abduction positioning without the use of shoulder braces, shoulder pain was not experienced in any cases. Neutral positioning of both arms in gynecological laparoscopic surgical patients was effective for the prevention of upper extremity neuropathy, but measures to alleviate the onset of shoulder pain after change in positioning need to be addressed in the future.

Vaginal Double Circular Incision-Closure Method: A New Technique for Vaginal Cuff Dehiscence after Total Laparoscopic Hysterectomy / 日本農村医学会雑誌

　　We report a case of vaginal cuff dehiscence after total laparoscopic hysterectomy that was successfully managed by a newly developed vaginal double-layer circular incision-closure method through a transvaginal approach. The nulligravid postmenopausal patient with cervical cancer received a diagnosis of vaginal evisceration on postoperative day 24. The eviscerated small intestine was pushed back after vaginal douching with normal saline before the procedure. The vaginal mucosa was incised circularly in two layers at the levels of 10 mm and 15 mm from the vaginal stump, and the edges apposed with double-layer closures. She was discharged on postoperative day 3 and followed up for 5 years, with no recurrence of cancer or vaginal dehiscence. This operative method is especially useful for a nulligravida with a small vagina.

Utility of Dynamic CT in the Management of Laparoscopic Port-site Hematoma / 日本農村医学会雑誌

　　We report a case of subcutaneous port-site hematoma developed on day 6 after laparoscopic left-sided salpingooophorectomy. To start the procedure, three ports were placed in the umbilicus and in each lower quadrant using bladeless trocars. No bleeding was observed at the trocar sites after insertion or withdrawal. The patient was discharged on postoperative day (POD) 3, but returned to the emergency outpatient department with acute left lower abdominal pain on POD 6. Dynamic CT revealed a port-site hematoma with active bleeding from a subcutaneous artery. Hemostasis was achieved easily by opening the trocar wound. Dynamic CT was useful to locate the bleeding vessel and enabled use of a minimally invasive procedure to control bleeding.

A Case of Deep Venous Thrombosis and Pulmonary Thrombosis during Week 29 of Pregnancy / 日本農村医学会雑誌

　　A major cause of pulmonary thromboembolism (PTE) is deep venous thrombosis (DVT). We report here a case of DVT in a 31-year-old woman during week 29 of her second pregnancy. At week 29, the patient noticed swelling of the left leg and pain in the groin after sitting. At almost week 30, walking became difficult due to pain and she was referred to hospital. Computed tomography (CT) revealed a thrombus from the left common iliac vein to the femoral vein and multiple thrombi in the right pulmonary artery. Blood testing showed elevated D-dimer (3.4μg/ml). Continuous intravenous unfractionated heparin was administered, and the dose was increased due to decreased activated partial thromboplastin time control. Despite conservative therapy for DVT, the thrombi showed no change since admission. At almost week 37, a temporary inferior vena cava filter (t-IVCF) was placed to prevent pulmonary thromboembolism, and she had an uneventful delivery of a baby by Caesarean section. Warfarin was administered postpartum. The t-IVCF was removed 4 days after delivery, and the patient was discharged 10 days after delivery. Within the field of obstetrics, the need for IVCF insertion should be considered on an individual case basis and should not be viewed as a standard option.

A Case of Erythropoietin-secreting Large Uterine Leiomyoma / 日本農村医学会雑誌

　　A 59-year-old woman, para 2, attended our hospital for an abdominal mass and atypical genital bleeding. Magnetic resonance imaging revealed a 30×25cm uterine myoma. A preoperative blood examination showed the following results: hemoglobin, 21g/dl; hematocrit, 71.5%; erythropoietin, 38.5mIU/ml; and estradiol, 29.9pg/ml. Abdominal total hysterectomy and bilateral salpingo-oophorectomy were performed, with an estimated blood loss of 1650ml. The weight of the uterus, including the myoma nodule, was 4740g, and the results of histology confirmed the diagnosis of leiomyoma. By postoperative day 28, her hemoglobin, erythropoietin, and estradiol levels had fallen to levels of 15.1g/dl, 6.0mIU/ml, and 5.8pg/ml, respectively, which are normal for a postmenopausal woman. The findings suggest that the leiomyoma secreted erythropoietin and induced erythrocytosis. Estradiol stimulates erythropoietin secretion and enlargement of the leiomyoma. Some studies have shown that erythropoietin is also a growth factor for leiomyoma. More than half of the erythropoietin-producing leiomyomas are detected after menopause. It was discovered that leiomyoma cells can produce aromatase, which transforms androstenedione into estradiol. Although estradiol secretion from the ovaries decreases in the postmenopausal period, the estradiol and erythropoietin autocrine/paracrine system in leiomyoma might promote its own growth after menopause.

Laparoscopic Round Ligament Psoas Minor Tendon-Hitching: Newly Developed Uterine Prolapse Operation / 日本農村医学会雑誌

　　We have developed a new surgical procedure for uterine prolapse of round ligament suspension to the psoas minor tendon by the use of a laparoscope. Here, we describe the new technique and report the outcome of surgery in three cases.　　Operative procedure: The fundus of the uterus is lifted back up to its natural position by fixing the round ligament of the uterus to the psoas minor tendon after incising the peritoneum covering psoas. It is important to use the tendon as a stronger reattachment site in addition to the psoas major muscle. The round ligament is tacked to the tendon by a 2-0 nonabsorbable suture on bilateral sides. The second suture may be added if the uterus is not appropriately lifted up by the first suture. The retroperioneum is closed by a continuous 3-0 absorbable suture after fixation.　　Cases: Two patients with severe uterine prolapse and one patient with a mild condition went through the operation safely and have experienced no recurrence for 10 to 24 months. One severely ill patient complained about post -operative right inguinal pain early and another with the severe condition complained that something felt wrong with the right thigh.　　We propose the operation of laparoscopic round ligament psoas minor tendon-hitching as a safe and effective surgical treatment for uterine prolapse.

Our Experience with Hyaluronic Acid-Carboxymethylcellulose Membrane in Cesarean Sections / 日本農村医学会雑誌

　　Adhesion formation after abdominal surgery is a commonly recognized entity. Many studies have shown that women giving birth by cesarean section are at the risk of developing complications related to the postoperative formation of adhesions including ileus, bowel obstructions, impaired fertility, and chronic abdominal pain. Among several adhesion barriers, one that has been tested in randomized, controlled trials is the hyaluronic cid-carboxymethylcellulose (HA/CMC) membrane (Seprafilm®: Genzyme, Cambridge, MA, USA). This bioresorbable membrane serves as a mechanical barrier between surgically damaged tissues and resorbs afterwards. At our institution, we have used HA/CMC in cesarean sections. We report our experience with this patient population using placement of HA/CMC.　　This study enrolled 45 women who had undergone cesarean sections twice or more who had received HA/CMC during the previous cesarean section between January 2013 and November 2014. The incidence of adhesions to the area of abdominal wall incisions and uterine surface, intestinal obstructive symptoms, and adverse events were studied. The incidence of adhesions to midline incisions was 4.4% (n＝2). The filmy adhesion by major omentum was detected in these two cases. The incidence of adhesions to uterine surface was 2.2% (n＝1). The moderate thickness adhesion was detected at the left side of the vesico-uterine peritoneal incision by pelvic peritoneum which did not affect the operative procedure. No symptoms related to intestinal obstructions such as abdominal pains, nausea and vomiting were observed. No adverse events were observed. These three cases had fever which had nothing to do with HA/CMC applications but was attributable respectively to influenza infection, mastitis, phlebitis associated with a needle procedure.　　HA/CMC was considered a useful adhesion barrier membrane for use in cesarean sections as an adjunct intended to reduce the incidence of postoperative adhesions between the abdominal wall and the underlying viscera such as omentum, small bowel, and between the uterus and surrounding structures.

Clinical Study of Catamenial Pneumothorax / 日本農村医学会雑誌

　　Catamenial pneumothorax (CP) is defined as a form of thoracic endometriosis syndrome (TES) and the clinical manifestations and management of this disease are not consensual. Successful treatment depends on how closely pulmonary specialists and gynecologists work together. Such being the circumstances, we reviewed our experience with CP in terms of treatment and follow-up. We treated surgically many patients with pneumothorax during the period from 1989 to 2014, of which eight cases had endometriosis on the diaphragm, lung or pleura histologically. The median age at the time of operation was 37 (range, 17 to 41). CP was right-sided in seven of the eight patients (87.5%). Six patients underwent an examination with diagnostic laparoscopy and five had positive findings. The median period of follow-up after surgery was 33.5 months (range, 4 to 129 months). Two patients had no recurrence without hormonal therapy. Six other patients experienced a recurrence of pneumothorax, although two patients received dienogest after surgery. The use of only dienogest or both GnRHa and dienogest prevented recurrence in all patients. CP is a critical condition that requires prompt action, so after surgical treatment, the choice of hormonal therapy with a high rate of patient compliance are needed. No recurrence occurred in young patients who had only surgical treatment, suggesting that there were some associations between age and recurrence. Since we succeeded in preventing recurrence after using GnRHa in all cases, we recommend GnRHa or dienogest following GnRHa for the first choice of hormonal therapy after surgery. However, treatment with only dienogest could achieve successful results with no recurrence, so more case studies need to be done to make the best treatment choice for each case.

Clinical Study of Placental Abruption / 日本農村医学会雑誌

　　Placental abruption occurs suddenly and may cause maternal and fetal mortality. Forced delivery is the only way to improve perinatal outcome, but the aftereffects could be severe despite a high survival rate.　　Our hospital manages approximately 170 cases of maternal transport annually, including cases of severe placental abruption. Longer transport time can lead to undesirable maternal and fetal outcome. Hence this study, we compared the perinatal backgrounds and outcome of placental abruption retrospectively between the cases managed by maternal transport and by the local hospital (our hospital). The study included 54 cases of placental abruption during the period from January 2008 to December 2012, of which 27 cases were managed by our hospital, the other halves were managed by maternal transport. There were 6 intrauterine fetal deaths but not a single maternal death. There were no significant differences in the amount of blood lost and obstetric DIC (disseminated intravascular coagulopathy) score between two groups (p＝0.342, p＝0.649), and the number of cases that needed anti-DIC therapy and blood transfusion in each group was statistically similar (p＝0.807, p＝0.115). The time taken from the on-set of placental abruption to delivery was significantly shorter for the cases managed by our hospital (in-hospital management 143±133 minutes, maternal transport management 265±176 minutes, p‹0.05), while obstetric DIC score and Apgar score showed no significant differences (p＝0.336, p＝0.780) between the two groups. Thus, it could be said there were no correlations between the time taken from onset to delivery and perinatal outcome. It should be noted, however, maternal and fetal outcome of placental abruption could be fatal even with the rapid intervention, so quick diagnosis and management at the first contact are crucial. Thus, we concluded that forced delivery managed by the local hospitals is necessary for the potential better perinatal outcome, and an ideal system to manage maternal and/or neonate transport after the delivery should be established immediately.

The evaluation of twelve years experiences of the practice of medical team care at the university of Tsukuba, school of medicine / 医学教育

For the purpose of learning the comprehensive medical team care. we tried for the fourth year medical students at University of Tsukuba to exercise the nursing service and the team care system in the Hospital of University of Tsukuba.<BR>These practice were already undergone during past twelve years.<BR>In this practice, students are expected to comprehend about the significance of team work in medical care, to understand the meaning of medical care, to learn especially the roles of nursing and rehabilitation medicine (in total medical care system), to practice in the work of nurses and co-medical workers for understanding their roles, to study the basic science and contribution in medical team care of rehabilitation medicine, to comprehend about the outline of the health, medical care system, and medical economics.<BR>As the items of this practical exercise, all students must work as follows:<BR>1. collection of venous blood and check of vital signs.<BR>2. practical work of nursing service.<BR>day time service: 8:00 a.m.-11:30 a.m.(fourtimes)<BR>1:00 p.m.-4:30 p.m.(once)<BR>early night service: 5:00 p.m.-0:00 a.m.(once)<BR>midnight service: 0:00 a.m.-8:30 a.m.(once)<BR>Moreover 15 corelative lectures are prepared.<BR>For these twelve years, we researched motivating effects and impression of this exercise about both medical students and nurses by method of using questionnaire. We hope to grow kindly doctors having the mind of humanity.

The role of the practice of medical team carc and introductory medical training system / 医学教育

This paper discussed the introductory medical training system and medical team care problems at University Hospital of Tsukuba.<BR>The characteristics of this training system are that the duration of training is the fourth year medical students at the University of Tsukuba and to exercise the roles of nursing service at University Hospital.<BR>In this practice, medical students are expected to comprehend about the significance of team work in medical care, to practice in the work of nurses and c-medical workers for learning their roles. We introduce our purpose and practice of this medical team care. Problems of this trial are discussed in this paper. But we have confirmed that this experimental. Trial is useful experience to all medical students and the items of this practical exercise are one of the most effective training method for them.