New improvements in increasing trends of caesarean section: to compare the effectiveness of two techniques Misgav Ladach with Joel Cohen incision versus Munro Kerr with pfannenstiel incision for caesarean section

Background: Caesarean section (C-section) is the most common surgery among women worldwide, and the global rate of this surgical procedure has been continuously rising. Hence, it is significantly crucial to develop and apply highly effective and safe caesarean section techniques. In this study, we aimed at assessing the safety and effectiveness of the Joel-Cohen-based Misgav Ladach technique and comparing the results with the transverse Pfannenstiel incision (Munro Kerr) for C-section.Methods: It was a prospective randomised controlled trial conducted on 100 women undergoing caesarean section at Patna Medical College and hospital in 2017. Patients were randomly allocated in 2 groups  and intra operative  and postoperative findings (blood loss, duration of surgery, post op fever, wound complication, APGAR scores etc. were calculated.Results: The duration of surgery was significantly low in Misgav Ladach technique (19.9 minutes vs. 29.54 minutes p value <0.001) Misgav technique was found economically better method as only 1 suture was used in 43 patients (p value<0.001). Post operative recovery (ambulation and bowel transit time) was found much early in Misgav Ladach vs. Munro Kerr (p value <0.001).Post operative use of analgesics was significantly less in Misgav technique (p value <0.0001). However no significant difference was observed in incidence of postoperative fever, blood loss and mean APGAR scoring of neonates.Conclusions: From this study it can be concluded that Misgav ladach method of caesarean section is associated with better short time post operative outcomes, especially resulting in reduction of pain and postoperative hospital stay.

Continuous Ilioinguinal-iliohypogastric Nerve Block for Groin Pain in a Breast-feeding Patient after Cesarean Delivery

Ilioinguinal and iliohypogastric (II/IH) nerve injury is one of the most common nerve injuries following pelvic surgery, especially with the Pfannenstiel incision. We present a case of intractable groin pain, successfully treated with a continuous II/IH nerve block. A 33-year-old woman, following emergency cesarean section due to cephalopelvic disproportion, presented numbness in left inguinal area and severe pain on the labia on the second postoperative day. The pain was burning, lancinating, and exacerbated by standing or movement. However, she didn't want to take additional medicine because of breast-feeding. A diagnostic II/IH nerve block produced a substantial decrease in pain. She underwent a continuous II/IH nerve block with a complete resolution of pain within 3 days. A continuous II/IH nerve block might be a goodoption for II/IH neuropathy with intractable groin pain in breast-feeding mothers without adverse drug reactions in their infants.

Pfannenstiel incision for intact specimen extraction in laparoscopic transperitoneal radical nephrectomy: a longitudinal prospective outcome study

OBJECTIVES: To evaluate the intra- and postoperative outcomes of patients undergoing laparoscopic radical nephrectomy with intact specimen extraction through a Pfannenstiel transverse suprapubic incision. METHODS: Prospective follow-up of 26 laparoscopic transperitoneal radical nephrectomies for suspected renal tumors in which the kidneys were extracted via a Pfannenstiel lower abdominal transverse incision. RESULTS: The mean operating time was 152.3 (80-255) minutes, and the mean blood loss was 90 (20-300) ml. The mean extraction time was 20.4 (12-35) minutes. The mean weight of the removed specimen was 631.5 (190-1505) grams, and the mean longest diameter of the extracted specimen was 17.4 (9-25) cm. The mean extraction incision size was 10.7 (7-16) cm. No open surgical conversions were necessary. Pain control was excellent, with minimal intravenous morphine equivalent narcotic use by patients: 15.7 (0-31) mg in the recovery room, 33.8 (0-127) mg on the first postoperative day and 8.7 (0-60) mg in the first week after discharge. The patients experienced a short duration to full ambulation and normal dietary intake. Postoperative follow-up visits were recorded for at least six months. The patients reported a high cosmetic satisfaction rate of 97.7% (60-100). No late postoperative complications were observed related to the extraction site. CONCLUSIONS: The operative specimen can be extracted via a low transverse Pfannenstiel incision during radical laparoscopic nephrectomy. This incision ensures the extraction of large specimens while preserving the aesthetic and functional advantages of laparoscopy without increasing the cancer risk. The absence of muscle cutting maintains the integrity of the abdominal wall and elicits minimal pain. No postoperative incisional hernias or keloid formations were observed. .

Infiltración con bupivacaína de la incisión de Pfannenstiel para la analgesia pos cesárea / Bupivacaine infiltration of the Pfannenstiel incision for post-caesarean section analgesia

OBJETIVO: Comparar la efectividad analgésica de la infiltración con Bupivacaína de la incisión de Pfannens-tiel respecto a un placebo para la analgesia posoperatoria de gestantes llevadas a cesárea segmentaria en el Hospital "Dr. Adolfo Pons" de Maracaibo, estado Zulia, Venezuela. MÉTODOS: Investigación comparativa y aplicada, con diseño cuasi-experimental, de casos y controles, contemporáneo y de campo, donde se incluyeron 60 gestantes planificadas para cesárea segmentaria electiva, divididas aleatoriamente en dos grupos pareados para infiltrarles la incisión de Pfannenstiel con 30 mL de Bupivacaína al 0,25% (75 mg) o solución salina. La intensidad del dolor se evaluó mediante la escala visual análoga (EVA). RESULTADOS: En cuanto a la intensidad del dolor, tanto en reposo como en movimiento, se encontraron diferencias altamente significativas a favor del grupo que recibió la infiltración incisional con Bupivacaína durante las primeras seis horas del postoperatorio (p<0,001); posterior a las 8 horas del posoperatorio no hubo diferencias significativas entre los dos grupos evaluados. De igual manera, estas pacientes presentaron un mayor tiempo libre de dolor, que sobrepasaba las 4 horas (251 ± 14 minutos vs. 220 ± 11 minutos; p<0,001), menores requerimientos analgésicos (199,37 ± 0,15 mg vs. 298,04 ± 1,96 mg; p<0,001) y con menos efectos adversos (p<0,05). CONCLUSIÓN: La infiltración de la incisión de Pfannenstiel es efectiva para la analgesia postoperatoria de la cesárea segmentaria, prolongado el tiempo libre de dolor y disminuyendo los requerimientos de analgésicos.

AIM: To compare the analgesic effectiveness of Pfannenstiel incision infiltration with bupivacaine over a placebo for post-operative analgesia in cesarean section in pregnants attending at the Hospital "Dr. Adolfo Pons" in Maracaibo, Zulia state, Venezuela. METHODS: A comparative and applied research, with quasi-experimental, case-control, contemporary and field design, which included 60 pregnant women scheduled for elective cesarean section, divided randomly into two groups matched for Pfannestiel incision infiltration with 30 mL Bupivacaine 0.25% (75 mg) or saline solution. Pain intensity was assessed by visual analog scale (VAS). RESULTS: In terms of pain intensity at rest and in motion, were found highly significant differences in favor of the group receiving the incisional infiltration with bupivacaine during the first six hours after surgery (p<0.001); not later than 8 hours after surgery where in all measurements, were found no significant differences between the two tested groups. Similarly, these patients had higher pain free time, surpassing the 4 hours (251 ± 14 minutes vs. 220 ± 11 minutes; p<0.001), lower analgesic requirements (199.37 ± 0.15 mg vs. 298.04 ± 1.96 mg; p<0.001) and fewer adverse effects (p<0.05). CONCLUSION: The infiltration of the Pfannenstiel incision is effective for postoperative analgesia in cesarean section, prolonged pain-free time and decreasing analgesic requirements.

Laparoendoscopic pfannenstiel nephrectomy using conventional laparoscopic instruments - preliminary experience

PURPOSE: To confirm the feasibility of the laparoendoscopic Pfannenstiel nephrectomy using conventional laparoscopic instruments. MATERIALS AND METHODS: Since March 2009, laparoscopic nephrectomy through a Pfannenstiel incision has been performed in selected patients in our service. The Veress needle was placed through the umbilicus which allowed carbon dioxide inflow. One 5 mm (or 10 mm) trocar was placed at the umbilicus for the laparoscope, to guide the placement of three trocars over the Pfannenstiel incision. Additional trocars were placed as follows: a 10 mm in the midline, a 10 mm ipsilateral to the kidney to be removed (2 cm away from the middle one), and a 5 mm contralateral to the kidney to be removed (2 cm away from the middle one). The entire procedure was performed using conventional laparoscopic instruments. At the end of the surgery, trocars were removed and all three incisions were united into a single Pfannenstiel incision for specimen retrieval. RESULTS: Five nephrectomies were performed following this technique: one atrophic kidney, one kidney donation, two renal cancers and one bilateral renal atrophy. Median operative time was 100 minutes and median intraoperative blood loss was 100 cc. No intraoperative complications occurred and no patients required blood transfusion. Median length of hospital stay was 1 day (range 1 to 2 days). CONCLUSIONS: The use of the Pfannenstiel incision for laparoscopic nephrectomy seems to be feasible even when using conventional laparoscopic instruments, and can be considered a potential alternative for traditional laparoscopic nephrectomy.

Incisiones transversas en oncología ginecológica / Transverse incisions in gynecologic oncology

OBJETIVO: Determinar si el tipo de laparotomía influye en la etapificación de pacientes con cáncer de cuerpo y cuello uterino. MÉTODO: Se revisaron todas las fichas clínicas de pacientes con cáncer de cuerpo y cuello uterino que fueron operadas en el Hospital Clínico de la Universidad de Chile y el Hospital Clínico de la Fuerza Aérea Chilena, entre enero de 1999 y mayo de 2005. Se recopiló la siguiente información: tipo de laparotomía, índice de masa corporal (IMC), comorbilidades médicas, tiempo operatorio, histología, número total y distribución de linfonodos, pérdida sanguínea, complicaciones, duración de la cirugía y hospitalización. Se aplicaron análisis estadísticos con t student y c². RESULTADOS: Se identificaron 51 pacientes. Se usó laparotomía media (LM) y transversa (LT) en 16 (31%) y 35 (69%) de las pacientes, respectivamente. No hubo diferencias significativas en índice de masa corporal, estadio FIGO, histología, comorbilidades, estimación de pérdida sanguínea ni complicaciones intra o post operatorias entre el grupo de LM y LT. Se encontraron diferencias significativas en pacientes con IMC 25 sometidas a laparotomías verticales comparadas con las transversas, donde ocurrió mayor sangrado intraoperatorio, se recolectó mayor número de ganglios para-aórticos y tuvieron hospitalizaciones más prolongadas. CONCLUSIONES: La etapificación quirúrgica de pacientes con cáncer de cérvix o cuerpo uterino se puede realizar adecuadamente a través de incisiones transversas, sin mayor morbilidad. Previa adecuada selección, pacientes con cánceres cervical y uterino pueden beneficiarse de las ventajas ya descritas para las laparotomías transversas.

OBJECTIVE: To determine if the type of abdominal incision influences the adequacy of surgical staging in patients with uterine and cervical cancer. METHODS: A retrospective review of all uterine and cervical cancer patients operated on by the same surgeon at the Universidad de Chile Clinical Hospital and the Chilean Air Force Clinical Hospital between January 1, 1999, and May 1, 2005, is presented. Data on type of incision, body mass index (BMI), medical comorbilities, histology, total number and distribution of lymph nodes, estimated blood loss, complications, length of surgery and hospital stay were abstracted. Statistical analysis with two-tailed Student t test and c² were performed. RESULTS: 51 patients were identified. A vertical incision (VI) was used in 16 (31%) while 35 (69%) received a transverse incision (TI). There were no statistically significant differences in BMI, FIGO stage, histology, comorbilities, estimated blood loss or intraoperative and postoperative complications between the VI and TI groups. Compared patients with BMI 25, VI was associated with significantly more intraoperative blood loss, number of para-aortic lymph nodes harvested and length of hospital stay. CONCLUSION: Comprehensive surgical staging for uterine and cervical cancer can be adequately performed through a TI without greater morbidity. After appropriate selection, patients with uterine and cervical cancer can benefit from the inherent benefits previously described for TI.

A Comparison of the Pfannenstiel Incision and Vertical Midline Incision for Radical Hysterectomy and Pelvic Lymphadenectomy / 대한산부인과학회잡지

OBJECTIVE: Our purpose was to review patients undergoing radical hysterectmy and pelvic lymphadenectomy, comparing Pfannenstiel and Vertical midline incisions for operative feasibility and perioperative outcome. METHODS: Between January 2001 and February 2003, 123 patients underwent radical hysterectomy and pelvic lymphadenectomy for cervical cancer at Busan Paik hospital. All procedures were performed by a gynecologic oncologist. Prospectively, all data were collected from review of each patient's medical record, including age, body mass index (BMI), stage, histology, nodal counts, operative time, estimated blood loss, surgical pathologic margin positivity, complications, and length of hospital stay. Associations between variables were studied using X2 test, t-test, and Fisher Exact test. RESULTS: Radical hysterectomy was performed through a Vertical midline (n=62) and Pfannenstiel (n=61) incision. There were no significant differences in age, BMI, stage, histology, nodal counts, estimated blood loss, surgical pathologic margin positivity, complications, and length of hospital stay. But, patients with a Pfannenstiel incision had shorter operative time than those with Vertical midline incision (169 min vs 197 min, P<0.0001). CONCLUSION: Radical hysterectomy and pelvic lymphadenectomy can be safely performed through a Pfannenstiel incision without increased operative morbidity and equal nodal removal as compared with Vertical midline incision. Pfannenstiel incision may offer the benefits of improved cosmesis and shorter operative time without compromising surgical exposure or increasing the risk of surgical complications.

Bloqueo de los nervios iliohipogástrico e ilioinguinal para analgesia posquirúrgica en cesárea tipo Pfannenstiel realizada bajo anestesia general ¿Qué concentración del anestésico local usar? / Iliohypogastric ano ilioinguinal block for postsurgical analgesia after Pfannenstiel cesarean section performeo unoer general anaesthesia

El bloqueo bilateral de los nervios Iliohipogástrico e Ilioinguinal con bupivacaína al 0.5 por ciento puede proveer analgesia luego de cesárea con incisión de Pfannenstiel aunque la cantidad de droga usada está cerca de la dosis máxima segura. Diseñamos este estudio para comparar el efecto analgésico de la bupivacaína al 0.5 por ciento y diluida al 0.25 por ciento. Se incluyeron treinta pacientes aleatoriamente asignadas a un grupo de estudio (bupivacaína 0.25 por ciento, n= 15) y uno de control (bupivacaína 0.5 por ciento, n=15). Se evaluaron las pacientes con una Escala Visual Análoga (EVA) a las O, 4, 8, 12 y 24 horas posoperatorias por médicos que no sabían a qué grupo pertenecían y sólo en caso de necesidad se prescribió analgesia IM con Diclofenaco. Los puntajes de analgesia y los requerimientos de analgesia complementaria fueron notoriamente similares en ambos grupos y no hubo diferencias estadísticamente significativas. Concluimos que el bloqueo de estos nervios es una técnica analgésica efectiva (el dolor siempre estuvo en promedio por debajo de 4 en la EVA), que no es afectada por la dilución del anestésico y que además es segura pues no se presentaron complicaciones

The Iliohypogastric and Ilioinguinal bilate. ral block with 0.5% bupivacaine can provide analgesia after Pfannenstiel cesarean section although the required amount of the drug is near the maximum secure dose. We designed this study in order to compare the analgesic effect of 0.5% bupivacaine and diluted 0.25% bupivacaine. Thirty patients were included in the study and asigned in aleatory form to either a study (0.25% bupivacaine n=15) or a control group (0.5% bupivacaine n=15). They were evaluated with the Visual Analogue Scale (VAS) at 0,4,8,12,24 postoperative hours by physicians who did not know the group of the patient and prescribed intramuscular analgesia with Dicofenac only if required. The analgesia scores and the complementery analgesia requirements were similar in both groups and there were no significative differences. We conclude that this nerve block is an effective analgesic technique (pain was always under 4 in the VAS), unaffected by the anesthetic dilution and furthermore that it is a safe technique since there were no complications derived from the procedure.