Laparoscopic approach to fibroid torsion presenting as an acute abdomen in pregnancy.

Uterine leiomyomas (fibroids) are seen in up to 4% of pregnancies, and most commonly present with pain in pregnancy, which can be due to red degeneration or torsion. Most cases previously have been managed with open resection. We report the case of a 35-y-old primagravida woman, presenting with acute lower abdominal pain at 11 wk gestation. Ultrasound demonstrated an 8-cm fibroid only. She demonstrated features of lower abdominal peritonitis and was scheduled for a diagnostic laparoscopy. At operation, a torsed subserosal fibroid was found. She successfully underwent laparoscopic myomectomy with the endoGIA vascular stapler and subsequent Pfannenstiel delivery. The patient was discharged 48 h postoperatively to continue her pregnancy. This case demonstrates the safe application of laparoscopic excisional myomectomy in the first trimester of pregnancy. Previously reported cases in the literature have focused on open resection or bipolar diathermy enucleation and morcellation. A high degree of suspicion should be maintained for the diagnosis in patients presenting to the surgical service with acute lower abdominal peritoneal signs during pregnancy.

Why we are wasting time in the operating theatre?

OBJECTIVES: To determine reasons for delay during elective operating lists and suggest solutions. DESIGN: Prospective observational study. SETTING: A large under-graduate teaching hospital. PARTICIPANTS: Fifty-five consecutive women undergoing elective gynaecological surgery under general anaesthesia. INTERVENTIONS: Every time point of individual patient's passage through the operating theatre (patients sent for, arrival in the anaesthetic room, general anaesthetic commenced, transfer to the operating theatre, surgery started, surgery completed, anaesthetic reversed, patient taken to recovery area) was documented. MAIN OUTCOME MEASURES: Time intervals between the various time points with particular reference to wait by the anaesthetist and surgeon between cases. RESULTS: We monitored 55 operations carried out during 22 operating lists. Apart from the surgery itself (median 81 min per procedure), the longest interval was the time taken to get patients into the anaesthetic room from the ward (median 20 min). Although patients waited a median of 10 min before the start of anaesthesia, if the first procedure on the list was excluded, the anaesthetist was waiting for the patient to arrive in the anaesthetic room in 13/30 (43%) cases, wasting a median of 7 min per case. The surgeon had to wait a median of 22.5 min between operations. CONCLUSIONS: Considerable operating theatre time is wasted while patients are transferred to and from the operating theatre resulting in both anaesthetists and surgeons having to wait between patients in a high proportion of cases, averaging 1 h during a 4 h operating list. Surgery could be made more time efficient by ensuring that patients arrive in the operating theatre complex early enough (to reduce time wasted for anaesthetists and surgeons), and by having two anaesthetists available at the end of surgery, one to reverse the anaesthetic while the other starts the next induction (to reduce time waste for the surgeon), coupled to adequate recovery area capacity.