Omental herniation through a 3-mm umbilical trocar site: unmasking a hidden umbilical hernia.

BACKGROUND: The incidence of umbilical hernia following laparoscopic surgery varies from 0.02-3.6%. The incidence of pre-existing fascial defects, however, may be as high as 18% in patients undergoing abdominal laparoscopic surgery. Previous recommendations have been made to close any fascial defect greater than or equal to 10 mm. Reported here is a case of herniation through a 3-mm trocar site incision and the discovery of a pre-existing fascial defect. CASE REPORT: A 32-year-old female underwent an uncomplicated laparoscopic tubal ligation using a 3-mm umbilical port. Prior to umbilical trocar removal at the completion of the case, the carbon dioxide was evacuated from the abdomen and the sleeve was withdrawn under direct vision. Neither the fascial nor skin incisions were sutured. On postoperative day two, the patient returned with omentum herniating from the 3-mm site. At surgery, a 1.5-cm pre-existing fascial defect was discovered adjacent to the trocar site. The hernia sac tracked laterally to the base of the umbilicus, and the omentum had slid into the sac and out the skin opening. CONCLUSION: As this report illustrates, herniation associated with laparoscopic trocar sites can occur with incisions as small as 3 mm. The presence of pre-existing fascial defects can cause increased morbidity in any laparoscopic surgery, and as illustrated in this report, may predispose the patient to site herniation. The detection and management of these defects is crucial in preventing postlaparoscopic complications.

Gender reassignment surgery and the gynecological patient(1).

With the increasing number of open transsexuals in the population and the advances in reconstructive surgical techniques, gender reassignment surgery has been increasing since the 1960s. Secondary to the increase in patients undergoing gender reassignment surgery, the practicing gynecologist is more likely to encounter a transsexual patient. A 49-year-old, nulligravid, white female presented to the gynecology clinic for her annual gynecological exam. Her past surgical history was significant for male to female gender reassignment surgery in 1991. Her hormonal medications included levothyroxine and estrogen. She described a strong family history of breast cancer for which she was being followed in our institutional Breast Watch Clinic. On physical examination, findings were notable for surgically constructed female external genitalia and a neovagina. The rectal exam was normal and failed to demonstrate any prostate pathology. It is important for the experienced gynecologist to be familiar with transsexualism, the reconstructive surgery involved, the surgical complications, and gender identity support groups and clinics available to these patients. Transsexuals should be treated to the extent possible like other female gynecological patients, while care is taken not to overlook underlying or preexisting medical conditions, including conditions unique to the prior and new genders.

Credentialing residents for intraoperative cystoscopy.

OBJECTIVE: To determine whether incorporation of routine intraoperative cystoscopy for evaluation of potential urinary tract injury into gynecologic residency training provides sufficient experience to justify hospital credentials after graduation. METHODS: We developed a curriculum to train residents in intraoperative cystoscopic evaluation of potential lower urinary tract injury. Cystoscopy was performed when indicated with hysterectomy and routinely in conjunction with pelvic reconstruction. Faculty members evaluated conceptual and technical proficiency by oral examination and direct observation in the operating room. Once the resident demonstrated a thorough understanding and proficiency in performing intraoperative cystoscopy, a competency certification document was issued by the Program Director. This certification was transmitted to the postresidency hospital credentials committee to justify granting privileges. RESULTS: Since 1994 over 400 transurethral cystoscopic evaluations have been done in conjunction with major gynecologic abdominal and vaginal surgeries, and since 1997 an additional 50 transvesical microcystoscopies have been done in selected abdominal cases. Twenty-five residency graduates have been certified as fully trained in intraoperative diagnostic cystoscopy. All these graduates have been granted intraoperative cystoscopy privileges at their subsequent hospital practice. CONCLUSION: Incorporation of cystoscopic urinary tract evaluation into routine gynecologic surgical training is good medical practice and provided a mechanism whereby obstetrics and gynecology residents could obtain intraoperative cystoscopy hospital privileges after graduation. (Obstet Gynecol 2000;96:1014-7.)

Uterine perforation resulting in bowel infarction: sharp traumatic bowel and mesenteric injury at the time of pregnancy termination.

BACKGROUND: By law, elective terminations of pregnancy are not performed in U.S. military institutions. However, in the civilian sector, more than a million abortions are performed each year, some of which are on military beneficiaries. Although complications are relatively rare, patients not uncommonly present for follow-up care to their military installation. We report the case of a patient who presented after a second-trimester elective abortion and was found to have suffered uterine perforation with mesenteric and bowel injury that required bowel resection. CASE: An 18-year-old gravida 1 para 0 female presented from an outlying facility 1 week after elective termination at 18 weeks of gestation with complaints of severe abdominal pain, nausea, and vomiting. Exploratory laparotomy for presumed bowel obstruction revealed uterine perforation and bowel devitalization and necrosis, which required small bowel resection. Fetal bones were discovered within the surgical specimen. CONCLUSION: Morbid, even potentially fatal, complications can occur as a result of pregnancy termination. With second-trimester procedures, perforation can result in injury to abdominal viscera from the perforating instruments or even from sharp fetal bony structures. Military gynecologic surgeons, who are not in abortion practice, must nevertheless be cognizant of the potential for perforation leading to serious visceral injury.

Micro-hydrovaginoscopy in examining children.

BACKGROUND: The gynecologic evaluation of children is challenging and requires mastery of special examination techniques. TECHNIQUE: small-diameter endoscopic trocar sleeves and endoscopes (2 or 3 mm) were used in conjunction with hydrodistention with normal saline, to view atraumatically the entire vagina and cervix. EXPERIENCE: During the past 3 years we have used micro-hydrovaginoscopy (2-mm trocar sleeve and endoscope, with hydrodistention) for vaginal examination of young girls and in selected cases of young adolescents and virginal adults in whom traditional speculum examination proved difficult or impossible. This technique was effective for (1) confirming diagnosis of cribriform hymen and facilitated hymenotomy; (2) diagnosis of vaginal discharge unresponsive to medical treatment caused by an intravaginal foreign body (color crayon), which was removed under direct endoscopic view; (3) suspected müllerian agenesis and persistent vaginal discharge confirming absence of the cervix and ruling out foreign body in the urogenital portion of the vagina; and (4) a vulvar straddle injury and urinary retention in which vaginal laceration and hematoma were excluded. CONCLUSION: Micro-hydrovaginoscopy is simple, minimally invasive, and effective for vaginal examination in prepubertal girls. It permits precise and complete diagnosis, directs and assists treatment, and has potential for well- tolerated office use in cooperative patients.

Abdominal pregnancy in a 67-year-old woman undetected for 37 years. A case report.

BACKGROUND: Abdominal pregnancy is an exceedingly rare occurrence, but even more unusual is prolonged retention of an advanced abdominal pregnancy with lithopedion formation. We present the case of prolonged retention of an advanced abdominal pregnancy in an elderly women. CASE: A 67-year-old, white woman presented to the emergency department with abdominal pain. An acute abdominal series revealed a fetal skeleton extending from the patient's pelvis to her lower costal margins. Pelvic examination revealed a normal postmenopausal uterus, and human chorionic gonadotropin was negative. On further questioning the patient reported that she had become pregnant 37 years earlier and was diagnosed as having a "missed" pregnancy. She refused intervention at that time but suffered no untoward consequences. She reported having had later a healthy intrauterine pregnancy, delivered vaginally at term. No attempt was made to remove the prior missed abdominal pregnancy. The acute pain episode resolved, and there was no surgical intervention. CONCLUSION: Abdominal pregnancies can have a complex course, and management decisions can be difficult. This case presents an unusual outcome of an advanced abdominal pregnancy and illustrates a unique approach to management.

Decline in bone mineral density with stress fractures in a woman on depot medroxyprogesterone acetate. A case report.

BACKGROUND: Depot medroxyprogesterone acetate is a popular contraceptive among young, physically active women. However, its administration has been linked to a relative decrease in estrogen levels. Since bone resorption is accelerated during hypoestrogenic states, there has been growing concern about the potential development of osteoporosis and fractures with the use of this contraceptive method. CASE: A physically active, 33-year-old woman demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), 6.4% drop in lumbar BMD and 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on depot medroxyprogesterone acetate. Bone mineralization rapidly improved, and the stress fracture resolved with discontinuation of the medication. CONCLUSION: The long-term effects of depot medroxyprogesterone acetate on bone mineralization in physically active women should be evaluated more thoroughly.

PIP: This case report illustrates the potential development of osteoporosis and fractures with the use of depot medroxyprogesterone acetate (DMPA), a popular contraceptive among young women. The case of a physically active 33-year-old woman who received 150 mg DMPA intramuscularly every 10 weeks, for a total of 3 injections, is presented. She demonstrated a 12.4% drop in femoral neck bone mineral density (BMD), a 6.4% drop in lumbar BMD, and a 0.8% drop in total BMD with the subsequent development of a tibial stress fracture while on DMPA. Bone mineralization rapidly improved, and stress fracture resolved with discontinuation of the medication. Women using DMPA are in a state of relative estrogen deficiency, which may not be adequate to maintain BMD in some patients. The long-term effects of DMPA on bone mineralization in physically active women should be evaluated more thoroughly.

Enhancing advanced surgical laparoscopy. Combined, routine use of microlaparoscopes and macrolaparoscopes.

OBJECTIVE: To describe a variety of techniques for using the microlaparoscope in conjunction with a standard-sized laparoscope for simplifying and enhancing advanced laparoscopic surgery. STUDY DESIGN: Descriptive study of microlaparoscopic techniques for enhancing macrolaparoscopic procedures. RESULTS: The microlaparoscope facilitates macrolaparoscopy by permitting: (1) specimen removal and use of 10-mm instruments without secondary, large ports; (2) performance of laparoscopic vaginal hysterectomy with the endoscopic stapler using only one 12-mm port; (3) lysis of difficult pelvic and periumbilical adhesions; (4) enhancement of visual access to difficult operative sites; (5) closure of large umbilical and secondary port sites under direct monitoring; (6) visualization from the left upper quadrant when umbilical adhesions are suspected; and (7) use as the initial entry laparoscope when extensive surgery is not anticipated. CONCLUSION: The routine, combined use of the microlaparoscope and 10-mm laparoscope significantly expands the capabilities of the advanced laparoscopic surgeon. Procedures are simplified, facilitated and made less invasive.

Combined tubal and cornual pregnancy in a patient without risk factors. A case report.

BACKGROUND: Ectopic pregnancy is the leading cause of pregnancy-related death during the first trimester. Bilateral ectopic pregnancy is a rare phenomenon, varying in frequency between 1 per 725 and 1 per 1,580 ectopic pregnancies. We report the case of a bilateral ectopic pregnancy (ruptured right cornual and intact left ampullary) in a patient with no known risk factors for extrauterine gestation. CASE: A 33-year-old, black woman, gravida 2, para 1001, presented at approximately 7 weeks' gestation with the acute onset of abdominal pain. She had a rigid surgical abdomen but was hemodynamically stable. Her beta-human chorionic gonadotropin level was 6,398 mIU/mL, and transvaginal ultrasound failed to reveal an intrauterine gestation, adnexal mass or cul-de-sac fluid. Findings at laparotomy included a 500-mL hemoperitoneum and a ruptured right cornual and intact left ampullary pregnancy. Pathology of both specimens confirmed the presence of chorionic villi. CONCLUSION: Although rare, heterotopic pregnancies can occur even in patients without risk factors.

A microlaparoscopic technique for Pomeroy tubal ligation.

OBJECTIVE: To evaluate the efficacy of performing Pomeroy tubal ligation using microlaparoscopic techniques. METHODS: Thirty-eight consecutive women desiring permanent sterilization underwent laparoscopic Pomeroy tubal ligation using small (2 or 5 mm) transumbilical laparoscopes and secondary midline sites (5 mm and 14 gauge). The procedures were performed under general anesthesia (n = 28) or local anesthesia with conscious sedation (n = 10). RESULTS: The mean operative time +/- standard deviation (SD) in minutes was 33.0 +/- 10.3. The mean recovery time +/- SD in minutes was 104.3 +/- 41.6. There were no operative complications, and no cases required conversion from the microlaparoscopic technique to a traditional method. CONCLUSION: The results of this study indicate that the Pomeroy tubal ligation may be performed using microlaparoscopic techniques. Furthermore, in selected cases, this technique can be performed under local anesthesia in an outpatient setting.

Midcycle administration of a progesterone synthesis inhibitor prevents ovulation in primates.

Progesterone receptors appear in granuloma cells of preovulatory follicles after the midcycle gonadotropin surge, suggesting important local actions of progesterone during ovulation in primates. Steroid reduction and replacement during the gonadotropin surge in macaques was used to evaluate the role of progesterone in the ovulatory process. Animals received gonadotropins to induce development of multiple preovulatory follicles, followed by human chorionic gonadotropin (hCG) administration (day 0) to promote oocyte (nuclear) maturation, ovulation, and follicular luteinization. On days 0-2, animals received no further treatment; a steroid synthesis inhibitor, trilostane (TRL); TRL + R5020; or TRL + dihydrotestosterone propionate (DHT). On day 3, ovulation was confirmed by counting ovulation sites and collecting oviductal oocytes. The meiotic status of oviductal and remaining follicular oocytes was evaluated. Peak serum estradiol levels, the total number of large follicles, and baseline serum progesterone levels at the time of hCG administration were similar in all animals. Ovulation sites and oviductal oocytes were routinely observed in controls. Ovulation was abolished in TRL. Progestin, but not androgen, replacement restored ovulation. Relative to controls, progesterone production was impaired for the first 6 days post-hCG in TRL, TRL + R5020, and TRL + DHT. Thereafter, progesterone remained low in TRL but recovered to control levels with progestin and androgen replacement. Similar percentages of mature (metaphase II) oocytes were collected among groups. Thus, steroid reduction during the gonadotropin surge inhibited ovulation and luteinization, but not reinitiation of oocyte meiotic maturation, in the primate follicle. The data are consistent with a local receptor-mediated role for progesterone in the ovulatory process.

A program of instruction in operative laparoscopy in a residency in obstetrics and gynecology.

Operative laparoscopy has found an increasingly innovative role in contemporary gynecologic practice. Residency programs must now formulate protocols for training in laparoscopic surgery on which subsequent credentialling may be safely recommended. This report describes a program of instruction in operative laparoscopy and the number of procedures required to develop technical skills at each year level of a 4-year residency. The objective of the program was to develop clinical judgment and technical skills in operative laparoscopy during the first 3 resident years. The main outcome measurement was the safe performance of complicated operative laparoscopy during the fourth resident year. This program emphasized progressive, graded responsibility in operative laparoscopy to develop skills in both the principles and practice of laparoscopic surgery. Principles were taught through didactic sessions in laparoscopic instruments and techniques, assignment of reading lists for each year level, and a review of videotapes to assist in decision making for each procedure. Skills in technique and development of manual dexterity were taught over 4 years as follows. Postgraduate year (PGY) 1: restricted to diagnostic procedures emphasizing the development of basic eye-hand coordination using a video monitor system; PGY2: incorporation of principles of laparoscopic hemostasis and laparoscopic tubal ligation; PGY3: operative laparoscopy using multiple puncture sites, sharp dissection, and suture techniques; PGY4: progressively more complicated procedures to include salpingectomy, salpingostomy, and segmental resection for ectopic pregnancies; oophorectomy for benign disease, appendectomy, and adhesiolysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Endometrial histology after electrocoagulation using different power settings.

OBJECTIVE: To study endometrial histology after electrocoagulation in an in vitro model using 50 watts (W) and 100 W of coagulation current and determine the depth of endometrial destruction and survival, if any, of glands beneath this zone. DESIGN: Twenty fresh uteri of similar weights and dimensions were obtained from patients undergoing hysterectomy for benign disease. Specimens were bivalved into anterior and posterior walls and each wall divided in half. Endometrial electrocoagulation was carried out with a 5-mm probe at 50 W and 100 W applied to anterior and posterior quarters of the specimen, respectively. The adjacent untreated endometrial surfaces served as controls. Specimens were formalin-fixed, embedded in paraffin, and sections stained with hematoxylin and eosin. MAIN OUTCOME MEASURES: The number and morphology of the endometrial glands were counted and classified manually for each section and compared between each power setting and controls. RESULTS: Histologic examination revealed morphologically normal glands in all specimens beneath the zone of destruction regardless of power setting. Both power settings produced significant focal and diffuse glandular and stromal destruction when compared with controls. Significant differences were noted in the number of normal glands after treatment with 50 W (71.33 glands +/- 76.44 [mean +/- SD]), 100 W (21.11 +/- 35.71) and untreated controls (240.16 +/- 110.81). Tissue destruction increased with increasing power, and there were significant differences in the percentage of morphologically normal, surviving glands between 50 W (11.7% +/- 11.4% [mean +/- SD]) and 100 W (4.9% +/- 10.9%). CONCLUSION: These data suggest that electrocoagulation may result in a variable degree of endometrial destruction dependent on power. Viable glands and stroma may survive beneath the zone of destruction regardless of power. Such variations in endometrial insult in an in vitro model may explain, in part, the variable clinical results of endometrial electrocoagulation. The survival of glands beneath the zone of destruction in this model raises the theoretical concern for occult malignant changes and leaves open to question the exact role and mode of hormonal therapy during the menopause after endometrial ablation.

Laparoscopic orchiectomy in a patient with complete androgen insensitivity.

Many procedures that were once approached exclusively through large abdominal incisions are now accomplished using operative laparoscopic techniques with shorter, less expensive hospital stays and significantly reduced convalescence. This report describes a laparoscopic orchiectomy in a patient with complete androgen insensitivity and discusses the indications for gonadectomy in phenotypic females with an XY karyotype.

A technique for laparoscopic pomeroy tubal ligation with endoloop sutures.

A laparoscopic technique of Pomeroy tubal ligation using endoloop sutures was compared with the conventional technique of laparoscopic tubal ligation with Silastic rings. Fifty-three patients selected from a population undergoing tubal ligation were randomized to either the Pomeroy (N = 28) or ring (N = 25) group. Mean (+/- standard deviation) operative time for the Pomeroy group was 27.39 +/- 5.95 minutes, with a range of 18-40; for the ring group, the time was 23.11 +/- 11.53 minutes, with a range of 12-58. These times were not statistically different. Operative complication were encountered only in the ring group and included two lacerations of the mesosalpinx. There were no technical or method failures over a follow-up interval of 12-18 months. Specimens confirmed tubal histology in all cases in the Pomeroy group. Laparoscopic Pomeroy tubal ligation using endoloop sutures was easily performed, comparable to laparoscopic application of Silastic rings, and provided a surgical specimen to confirm tubal histology. This aspect may represent a medicolegal advantage of documentation not available with other laparoscopic techniques of tubal ligation.

Expectant management of abnormal concentrations of human chorionic gonadotropin during the first trimester of pregnancy.

Abnormal serum human chorionic gonadotropin (hCG) levels during the first trimester may be associated with a nonviable intrauterine pregnancy or ectopic pregnancy. With the availability of sensitive hCG assays, expectant management of these patients may provide a viable alternative to surgery. To evaluate this approach, we managed 20 patients with low levels of serum hCG expectantly using serial hCG monitoring and clinical examination only. Serum hCG concentrations were followed to levels of less than 10 mIU/ml. Peak levels of serum hCG ranged from 72 to 5,685 mIU/ml. Duration of expectant management ranged from 7 to 97 days. No patient required intervention due to acute symptoms. These data suggest that a select group of patients with decreasing hCG concentrations may be managed expectantly without undue morbidity thereby avoiding surgical intervention.