Use of Palmer’s Point in Creation of Pneumoperitoneum in Patients of Previous Abdominal Surgeries and To Check Efficacy of the Visceral Slide Technique for Detection of Abdominal Wall Adhesions

In patients with history of previous abdominal surgery, creation of pneumoperitoneum during laparoscopicprocedure involves risk of complications as there is association of underlying adhesions at the umbilicus site.Palmer’s point is alternative site of primary port insertion. For creating pneumoperitoneum, visceral slidetechnique is used to detect the movement of viscera immediately deep to the abdominal wall. This techniqueis reliable in identifying adhesion-free areas of the abdominal wall. This study was undertaken to evaluate useof Palmer’s point in creation of pneumoperitoneum in patients of previous abdominal surgeries and to checkthe efficacy of the visceral slide technique for detection of umbilical adhesions in these patients. This one-yearstudy was conducted on 30 patients with previous history of abdominal surgery in the Government MedicalCollege, Jammu. Visceral slide test was conducted using a real time ultrasonography machine with a 7.5 MHzabdominal transducer placed in a sagittal plane at the umbilicus and the ultrasound scan focused on theinfraumbilical region between the anterior abdominal wall and the aortocaval complex. A normal visceral slide(positive test) is movement of the viscera more than 1 cm. An abnormal visceral slide (negative test) is definedas movement of the viscera less than 1 cm. At the end of the surgery, intra-operative, early and late complicationswere evaluated. Adhesions under the umbilicus were present and absent in 15 (50%) patients each. Thevisceral slide technique was negative in 9 (30%) and positive in 21 (70%) patients. Sensitivity, specificity,positive predictive value, negative predictive value and accuracy of visceral slide technique was 60%, 100%,100%, 72% and 70% respectively. Definitive evidence of the efficacy of Palmer’s point in creation ofpneumoperitoneum could not be established due to the small sample size and patients with limited spectrum ofabdominal surgeries. Further studies in the form of multicenter randomized control trials are needed to verifythe utility of Palmer’s point for creation of pneumoperitoneum and to evaluate the role of visceral slidetechnique in diagnosing intra-abdominal adhesions preoperatively.

Manejo laparoscópico de masas anexiales gigantes en el embarazo, con abocamiento externo umbilical: Reporte de casos

Antecedentes: Los avances en laparoscopia tanto tecnológicos como médicos han hecho posible ampliar el espectro de patologías ginecológicas susceptibles de ser manejados por esta vía. Condiciones médicas consideradas previamente como una contraindicación a esta vía, como el embarazo, son susceptibles de ser manejadas con seguridad y eficacia manteniendo los beneficios que esta técnica ofrece. La patología anexial significa la principal causa intervención ginecológica con la cirugía mínimamente invasiva. Objetivo: Revisar el manejo de quistes anexiales gigantes, durante el embarazo, con abordaje laparoscópico y abocamiento externo umbilical. Diseño: Estudio retrospectivo y descriptivo. Institución: Servicio de Ginecología Especializada, Hospital Nacional Edgardo Rebagliati Martins (HNERM), Lima, Perú. Participantes: Gestantes con tumoración anexial gigante. Métodos: Cinco gestantes fueron ingresadas al Servicio por tumoración anexial gigante e intervenidas por laparoscopia. Principales medidas de resultados: Características y resultados de las intervenciones. Resultados: La edad promedio de las pacientes fue 22,8 años, la edad gestacional promedio fue 14,4 semanas, el promedio del tamaño de la tumoración anexial 15 cm, el tiempo promedio de cirugía 52 minutos. No se registraron complicaciones posquirúrgicas inmediatas. Todos los embarazos evolucionaron normalmente. Conclusiones: La técnica de laparoscopia con abocamiento umbilical disminuye la desventaja del aumento de la presión intraabdominal por el neumoperitoneo, además que, disminuye el tiempo operatorio y minimiza la falencia de la pericia laparoscópica.

Background: Technical and medical advances in laparoscopic surgery have made feasible to extend its use to a wide variety of gynecological pathologies. Clinical conditions considered earlier as a contraindication for its use, such as pregnancy, are now susceptible to be managed securely and efficiently with this technique and maintaining all advantages. Objective: To review the experience in managing giant adnexal mass during pregnancy via laparoscopy. Design: Retrospective, descriptive study. Setting: Specialized Gynecology Service, Hospital Nacional Edgardo Rebagliati Martins (HNERM), Lima, Peru. Participants: Pregnant women with giant adnexal tumors. Interventions: Five pregnant women admitted to the Service underwent laparoscopy. Main outcome measures: Characteristics and outcome of interventions. Results: Patients age average was 22.8 years, gestational age average was 14.4 weeks, tumor size average was 15 cm, and average surgical time was 52 minutes. There were no post surgical complications. All pregnancies had normal outcome. Conclusions: The external abouchement technique decreases the disadvantage of increased intra-abdominal pressure by pneumoperitoneum, decreases the surgical time, and minimizes the failure of laparoscopic expertise.

Laparoscopic procedures for adnexal cyst torsion in pregnant women:An analysis of 12 cases / 中国微创外科杂志

Objective To evaluate the feasibility of laparoscopic procedures in pregnant women. Methods A retrospective analysis was made on 12 pregnant women with an acute abdominal emergency resulted from adnexal mass from 1997 to 2002.Results All the 12 patients were laparoscopically diagnosed as having pregnancy associated with torsion or necrosis of adnexal mass. There were 2 cases of unwinding of the twisted fallopian tube and oophorocystectomy, 3 cases of oophorocystectomy, and 7 cases of adnexectomy. All the patients were cured. No miscarriage or infant malformation happened. Follow-up for 8～12 months in 11 infants revealed normal development. Conclusions In pregnant patients the laparoscopic procedure is relatively contraindicated. Satisfactory curative effects can be obtained if the patients are properly selected.

Analysis of the Immune Response of a Laparoscopic Surgery between Gas and Gasless Techniques

PURPOSE: To investigate the immunologic effect of the gasless laparoscopic procedure, we compared it with an immunologically effective, gas insuffulated (pneumoperitoneal) laparoscopic procedure. METHODS: The temporal immune responses in two similar groups of patients randomized to gas vs gasless laparo scopic cholecystectomy were analyzed. The patients were matched by age, weight, and operation time. Immune parameters, including serum white blood cell count and TNF-alpha, INF-gamma, IL-6, IL-8, cortisol and ESR levels, were assessed preoperatively and on postoperative days 1 and 3 between the two groups. Also during the operations, cytokines were checked in cultured peritoneal macrophages. RESULTS: The results were as follows: 1) Serum cortisol and ESR levels were not statistically different between the two groups. White blood cell counts were also not statistically different. 2) The preoperative and postoperative day 1 and days 3 serum TNF-alpha, INF-gamma, IL-6, and IL-8 levels in the two group were not statistically different. However, an immediate decrease cytokine levels was significant in both groups after postoperative day 1. 3) Especially cytokine levels were more increased in cultured peritoneal macro phages than in serum, but difference between the two groups was not statistically significant. CONCLUSION: From our results the beneficial effects of immunology in a gasless laparoscopic procedure were not different from those in a gas laparoscopic procedure. Rather, immediate preservation of the immune function during the postoperative period was detected in both groups.