A novel extraperitoneal cesarean section of supravesical approach: Operative techniques.

AIM: We have established a novel extraperitoneal cesarean section technique by supravesical approach. An advantage of this technique over the conventional paravesical approach is that the lower uterine segment is broadly exposed and that all operative procedures can be performed under direct vision. We present the details of this novel technique. METHODS: The bladder and the peritoneum are exposed by removing the transversalis and extraperitoneal fasciae. Subsequently, a triangular area between the median umbilical ligament, the peritoneum, and the bladder is exposed. The median umbilical ligament is dissected at this site. Bladder dissection from the peritoneum is also initiated from this area and proceeds toward the lower uterine segment. RESULTS: Operative times for pelvic fascia dissection and bladder removal from the peritoneal surface are currently around 15-25 min. During the process of development of this technique, there have been no bladder injuries in 501 patients that caused urine leakage. DISCUSSION: The supravesical approach has been considered difficult due to the strong adhesion between the perivesical fascia and the peritoneum at the bladder fundus. In this paper, we show how to safely remove the bladder fundus from the peritoneum. The bladder can then be easily lowered down toward the lower uterine segment. Although this technique allows the lower uterine segment to be broadly exposed and all operative procedures can be performed under direct vision, a disadvantage is the comparatively long time currently required to perform it. CONCLUSIONS: This technique could be a valuable option for extraperitoneal cesarean section, but disadvantages must also be considered.

Potential effect of intravenous immunoglobulin against paraneoplastic cerebellar degeneration in progressive ovarian cancer.

We report the effect of intravenous immunoglobulin (IVIG) against paraneoplastic cerebellar degeneration (PCD) in a case of progressive ovarian cancer. Our patient developed PCD soon after postoperative chemotherapy and became bedridden. After undergoing IVIG, however, symptoms dramatically improved, and unexpectedly the remaining tumors were confirmed to have completely disappeared. When PCD is diagnosed, IVIG treatment should be attempted to reduce neuropathy regardless of its degree and the state of the cancer. It may also have further potential benefits that should be considered.

Complete rupture of unscarred uterus with delayed symptoms: Case report and possible mechanism.

Uterine ruptures typically occur suddenly, have obvious symptoms, and may require urgent treatment. We experienced a case of complete rupture of an unscarred uterus that was undetected for 9 days. We report the clinical course and possible factors that led to it. Nine days after delivery, complete rupture of the posterior uterine wall was diagnosed by magnetic resonance imaging. The colon and ovaries were tightly adhered to the posterior uterine body. When this adhesive lesion was detached, 7 cm horizontal defects of the muscular layer were revealed. The ruptured wound was repaired. Magnetic resonance imaging 1 year postoperatively showed no thinning of the repaired lesion and suggested successful reperfusion. Mild clinical course despite complete uterine rupture was presumably because of adhesion of the ovaries and intestines to the rupture site.

A disadvantage of cesarean section en caul: Umbilical velamentous insertion, a risk factor and proposed mechanism of neonatal anemia.

Cesarean section en caul could cause neonatal anemia, but the mechanism remains unknown. We demonstrate an association between neonatal anemia and velamentous insertion of the umbilical cord in cesarean section en caul, and suggest a way to make this procedure safer. We performed cesarean section en caul, but the placenta and the membrane sac were delivered separately. The neonate was severely anemic. The umbilical cord was attached to the membrane and the blood vessel connecting the umbilical cord and placenta was torn. The amniotic membrane covering the placental surface had peeled away. Velamentous insertion of the umbilical cord could be a cause of neonatal anemia associated with cesarean section en caul.