Inguinal hernia following the use of fluid anti-adhesive agents in laparoscopic surgery: a literature review and case report.

Introduction and importance: Inguinal hernia is a rare complication in females occurring due to the use of common anti-adhesion agents, such as ADEPT. Some complications have been reported to date; however, there are no reported cases of ADEPT-induced inguinal hernia. Case presentation: A 39-year-old woman underwent laparoscopic ovarian cystectomy for a right ovarian endometrioma, using ADEPT as an anti-adhesion agent. Subsequently, she developed an inguinal hernia diagnosed using pelvic computed tomography. The inguinal mass gradually decreased in size and disappeared four months after, without intervention. Clinical discussion: While rare complications have been reported, no cases of inguinal hernias induced by anti-adhesion agents have been reported to date. To minimize the risk of this complication, avoiding excessive intra-abdominal pressure to prevent possible peritoneal fluid migration through small orifices into low-pressure areas is advised. Additionally, applying external pressure over the superficial/deep inguinal rings until CO2 is completely removed from the abdominal cavity might be helpful. Conclusion: Inguinal hernia is a rare anti-adhesion solution complication in females. Minimizing the risk involves avoiding excessive intra-abdominal pressure and applying external pressure over the superficial/deep inguinal rings.

Anti-NMDAR encephalitis with ovarian teratomas: Review of the literature and two case reports.

OBJECTIVE: Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is a paraneoplastic syndrome associated with ovarian teratomas. Anti-NMDAR encephalitis patients typically present with prominent psychiatric symptoms, seizures, and involuntary movements; further, they rapidly progress to unresponsiveness with central hypoventilation and dysautonomia. CASE REPORT: This paper presents two anti-NMDAR encephalitis cases with ovarian teratomas and reviews 13 anti-NMDAR encephalitis clinical case reports in Taiwan, of which six involved ovarian tumors, five being mature teratomas. Patients presented with acute onset of psychiatric symptoms and subsequently developed coma within a few days. Anti-NMDAR encephalitis usually occurs in young women and is often associated with ovarian tumors, specifically teratomas. Ovarian cystectomy or oophorectomy was performed, which markedly improved cognitive function. CONCLUSION: Paraneoplastic neurological conditions associated with ovarian teratomas represent a fascinating disease process. Identifying the gynecological cause of a neurological condition, particularly in young women, followed by prompt treatment can remarkably improve clinical conditions and, thus, be lifesaving.

Intraligamental Myomectomy Strategy Using Laparoscopy.

UNLABELLED: STUDY OBJECTIVE: Intraligamental myomas (IMs) represent 6% to 10% of all uterine myomas. An IM growing from the lateral uterine wall into the broad ligament often presents as a large pelvic mass without symptoms. Removing a large IM can be difficult because of the limited operative field and poses challenges during conventional laparoscopic surgical approaches. The risk of injury to the ureter and uterine artery during myomectomy is greater than that during other types of myoma. DESIGN: Retrospective study (Canadian Task Force classification III). SETTING: University-affiliated hospital. PATIENTS: IM was classified into 3 types according to the location: (1) anterior intraligamental myoma (AIM), (2) posterior intraligamental myoma (PIM), and (3) lateral intraligamental myoma (LIM). From April 2007 to July 2015, 83 consecutive patients with IM underwent laparoscopic myomectomy at National Taiwan University Hospital, Taipei, Taiwan, including 23 AIM, 27 PIM, and 33 LIM. INTERVENTIONS: Several techniques are described, and videos are supplied for performing laparoscopic myomectomy safely and easily in different types of IM. MEASUREMENTS AND MAIN RESULTS: Urinary frequency (31%) and a palpable abdominal mass (31%) were the 2 most common presenting symptoms. Most of the lesions were 33 LIM (40%) followed by 27 PIM (32%) and 23 AIM (28%). The mean myoma sizes were 11.0, 8.0, and 7.8 cm; the mean myoma weights were 478, 279, and 309 g; the mean operative times were 134, 108, and 104 minutes; and the mean blood loss during surgery was 224, 94, and 107 mL for LIM, PIM, and AIM, respectively. LIMs had relatively more blood loss because they were heavier and commonly rested alongside the uterine artery. The only complication was late postoperative hemorrhage in 1 case of LIM. Histopathology showed leiomyoma in all cases. Three patients were spontaneously conceived after myomectomy, and each had a successful pregnancy and cesarean delivery. CONCLUSION: Surgical treatment of IM is empirically difficult. It is important to use an approach that considers the location, size, and shape of the myoma. All types of IM presented with similar symptoms, and the highest blood loss occurred during laparoscopic myomectomy of a LIM.

Regulatory T Cells Suppress Natural Killer Cell Immunity in Patients With Human Cervical Carcinoma.

OBJECTIVE: To determine the functional attributes of CD4 CD25 regulatory T (Treg) cells by suppressing natural killer (NK) cell activity in human cervical cancer (CC). METHODS: Triple-color flow cytometry was used to study the phenotypic expression of CD4 CD25 Treg cells and NK cells in the peripheral blood lymphocytes (PBLs) and tumor-infiltrating lymphocytes (TILs). In vitro coculture assays were performed to illustrate the cytokine immunoregulations between Treg cells and NK cells. RESULTS: Significantly lower expression ratio of NK cells and higher expression ratio of Treg cells in TILs than PBLs were found. The NK cells displayed significantly higher expression ratio of inhibitory NK receptors (CD158a, CD158b, and NKG2A) and lower expression ratio of activating NK receptors (NKG2D, NKp46, and NKp30) as well as perforin in TILs than PBLs, suggesting the suppressed cytotoxicity of the NK cells in the CC tumor milieu. The expression ratio of transforming growth factor-ß1 (TGF-ß1) on Treg cells as well as TGF-ßRII on Treg cells and NK cells was significantly higher in TILs than PBLs. Further functional in vitro assays demonstrated that NK cell function was suppressed by Treg cells, mimicking the inhibition of TGF-ß on NK cells, and interleukin-2/interleukin-15 stimulation was able to restore the NK cell activity. CONCLUSIONS: These findings indicate that Treg cells in TILs may abrogate NK cell cytotoxicity through TGF-ß pathway, and therefore, Treg cell elimination may enhance NK cell activity and be a novel therapeutic strategy for CC.

The effects of narrow-band middle infrared radiation in enhancing the antitumor activity of paclitaxel.

Paclitaxel is used as an adjuvant to enhance the effectiveness of ionization radiation therapy; however, high-energy radiation often damages the healthy cells surrounding cancer cells. Low-energy, middle-infrared radiation (MIR) has been shown to prevent tissue damage, and recent studies have begun combining MIR with paclitaxel. However, the cytotoxic effects of this treatment combination remain unclear, and the mechanism underlying its effects on HeLa cells has yet to be elucidated. This study investigated the effectiveness of treating HeLa human cervical cancer cells with a combination of paclitaxel for 48 h in conjunction with narrow-band MIR from 3.0 to 5.0 µm. This combined treatment significantly inhibited the growth of HeLa cells. Specifically, results from Annexin V-FITC/PI apoptosis detection and cell mitochondrial membrane potential analyses revealed an increase in apoptotic cell death and a collapse of mitochondrial membrane potential. One possible mechanism underlying cellular apoptosis is an increase in oxidative stress. These preliminary findings provide evidence to support the combination of narrow-band MIR with paclitaxel as an alternative approach in the treatment of human cervical cancer.

Comparison of Laparoscopic Myomectomy in Large Myomas With and Without Leuprolide Acetate.

STUDY OBJECTIVE: To evaluate the efficacy of gonadotropin-releasing hormone analogue (GnRHa) use before laparoscopic myomectomy (LM) in large myomas. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: Ninety-one women with large myomas (≥10 cm) or more than 2 myomas ≥ 5 cm underwent LM between July 2011 and March 2014. INTERVENTIONS: Forty patients underwent LM after GnRHa use (group A) and 51 underwent LM only (group B). GnRHa was used for 3 doses every 4 weeks before LM in group A. MEASUREMENTS AND MAIN RESULTS: Group A had a significantly smaller maximum diameter of the largest myoma than group B (8.5 ± 2.1 vs 10.7 ± 2.4, p < .001) and fewer patients with myomas larger than 10 cm after GnRHa administration (33% vs 67%, p = .001). In group A, there was a decrease in 2 or more myomas ≥ 5 cm (20% vs 50%) after GnRHa use. Group A also had significantly smaller mean myoma weight (448 vs 567 g, p = .045) and significantly shorter mean operative time (129 ± 30 vs 152 ± 34 minutes, p = .001). Most patients in group A (40%) had an operative time < 119 minutes, whereas most patients in group B (37%) had an operative time between 150 and 179 minutes. Group A also had less intraoperative blood loss (84 ± 53 vs 137 ± 166 mL, p < .001), drop in hemoglobin (1.5 ± 0.8 vs 3.0 ± 1.7 g/dl, p < .001), excessive bleeding (5% vs 33%, p = .001), postoperative hematoma (2.5% vs 9.8%, p = .168), and blood transfusion (7.5% vs 35%, p = .001). CONCLUSION: GnRHa before LM in large myomas may be an effective adjuvant treatment for women with large and multiple myomas. This method is beneficial in decreasing operative time, intraoperative bleeding, postoperative hemorrhage, and need of blood transfusion.

Iatrogenic parasitic myoma: a case report and review of the literature.

OBJECTIVE: To investigate the possible causes of iatrogenic parasitic myoma and methods to prevent its occurrence. CASE REPORT: A 27-year-old nulliparous unmarried patient underwent laparoscopic myomectomy with morcellation for a submucosal myoma at the National Taiwan University Hospital (Taipei, Taiwan). Seven years later, an asymptomatic pelvic tumor was noted during a regular annual follow up. Two pelvic tumors were detected and excised by laparoscopic surgery. The masses were confirmed by histopathology to be cellular leiomyomas. CONCLUSION: In the past 7 years, the incidence of iatrogenic parasitic myomas has increased because of the increased use of minimally invasive surgery using a morcellator. Forty-one cases of iatrogenic parasitic myoma were reviewed from 23 published studies. Parasitic myoma frequently occurs in the dependent part of the abdominal cavity, which suggests seeding of myometrial tissues during morcellation. In situ morcellation and vigorous irrigation with concomitant changes in position may decrease the incidence of retained myoma tissue in the abdomen during surgery.

Comparison of laparoscopic myomectomy using in situ morcellation with and without uterine artery ligation for treatment of symptomatic myomas.

STUDY OBJECTIVE: To evaluate the efficacy of laparoscopic uterine artery ligation (LUAL) before in situ morcellation (ISM) compared with ISM alone. DESIGN: Prospective study (Canadian Task Force classification II-1). SETTING: University-affiliated hospital. PATIENTS: One hundred forty-four women with symptomatic uterine myomas, of whom 45 underwent LUAL and ISM and 99 underwent ISM only, from August 2007 through August 2009. INTERVENTIONS: Ligation or no ligation of the uterine arteries before ISM. MEASUREMENTS AND MAIN RESULTS: In the LUAL+ISM group compared with the ISM group, mean (SD) operative time was significantly longer (107 [34] minutes vs 93 [35] minutes; p = .03), and there was less intraoperative blood loss (84 [53] mL vs 137 [166] mL; p < .001). Eight patients in the ISM group (8.1%) required a blood transfusion, including 4 (4.0%) with excessive intraoperative bleeding and 4 (4.0%) with postoperative hematomas. Although myomas in the LUAL+ISM group weighed more (p < .001), none of the patients in that group had excessive intraoperative bleeding, postoperative hematomas, or required blood transfusion (p = .046). At 2 years of follow-up, in the LUAL+ISM group compared with the ISM group, the myoma recurrence rate was 7% vs 24%, and symptom improvement was reported by 98% of patients vs 86% (statistically significant). CONCLUSION: Laparoscopic myomectomy using an ISM technique with or without simultaneous LUAL may be used in the management of symptomatic uterine myomas; however, LUAL+ISM may result in a better surgical outcome.

Simultaneous laparoscopic uterine artery ligation and laparoscopic myomectomy for symptomatic uterine myomas with and without in situ morcellation.

BACKGROUND: To determine the optimal surgical approach for laparoscopic uterine artery ligation (LUAL) combined with myomectomy in the management of women with symptomatic uterine fibroids. METHODS: This is a prospective study. One hundred and six women with symptomatic uterine myomas underwent LUAL + laparoscopic morcellation after enucleation (enucleation group) (n = 51) or LUAL + laparoscopic in situ morcellation (ISM group) (n = 55). The outcome was measured by comparing surgical techniques, symptom control, recurrence and pregnancy during a 3-year follow-up in both groups. RESULTS: General characteristics of the patients were similar in both groups, except the myomas were larger in the ISM group. The operative time (mean ± SD) was significantly shorter in the ISM group than the enucleation group (107 ± 30 min versus 128 ± 49 min, P = 0.009). There were no differences in the therapeutic outcomes of the two groups at the 3-year follow-up, with low recurrence rates and good symptom control rates. Of the sexually active patients without contraception, the pregnancy and live birth rates were 87.5 and 100% in the ISM group and 66.7 and 83.3% in the enucleation group (all NS). CONCLUSIONS: The LUAL + myomectomy, either by enucleation or ISM, is acceptable in the management of symptomatic uterine fibroids. However, the LUAL + ISM technique might be more feasible, as it requires less operative time.