Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence.

BACKGROUND AND OBJECTIVES: The aim of our study is to evaluate the role of electrosurgery and vaginal closure technique in the development of postoperative vaginal cuff dehiscence. METHODS: From prospective surgical databases, we identified 463 patients who underwent total laparoscopic hysterectomy (TLH) for benign disease and 147 patients who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. All TLHs and LAVHs were performed entirely by use of electrosurgery, including colpotomy. Colpotomy in the TLH group was performed with Harmonic Ace Curved Shears (Ethicon Endo-Surgery, Cincinnati, OH, USA), and in the LAVH group, it was performed with a monopolar electrosurgical pencil. The main surgical difference was vaginal cuff closure--laparoscopically in the TLH group and vaginally in the LAVH group. RESULTS: Although patients in the LAVH group were at increased risk for poor healing (significantly older, higher body mass index, more medical comorbidities, higher blood loss, and longer operative time), there were no vaginal cuff dehiscences in the LAVH group compared with 17 vaginal cuff dehiscences (4%) in the TLH group (P = .02). CONCLUSION: It does not appear that the increased vaginal cuff dehiscence rate associated with TLH is due to electrosurgery; rather, it is due to the vaginal closure technique.

Intervention rates for placental removal following induction abortion with misoprostol.

BACKGROUND: Second-trimester terminations can be performed via surgical or medical methods. It is essential to have the ability to safely and effectively perform induction terminations to offer a full range of services. Many studies of induction abortions report routine operative removal of the placenta after a set time period resulting in high rates of operative procedures. STUDY DESIGN: A retrospective chart review was performed for 233 women who underwent second-trimester induction abortions between November 2003 and November 2006. All women received intraamniotic injection of digoxin for feticide 1 day prior to induction. All inductions were performed using a schedule of 400 mcg of misoprostol initially followed by 200 mcg every 6 h for a maximum of 48 h. There were three methods of administering misoprostol: (1) vaginal administration for all doses, (2) vaginal and buccal used in combination and (3) buccal for all doses. Spontaneous expulsion of the placenta was expected. Operative intervention was performed for excessive bleeding or to expedite hospital discharge after a minimum of 4 h. No manual removal of placenta was done. RESULTS: The rate of operative intervention for retained placentas was 6% (14/233). Most (11/14) of the patients who underwent operative extraction for retained placentas did so to expedite discharge from the hospital. Overall, expectant management to allow spontaneous expulsion of the placenta for at least 4 h was not associated with serious morbidity. CONCLUSIONS: Our regimen of digoxin and misoprostol with a policy of expectant management of placental passage is associated with a very low rate of instrumented removal of the placenta. In the absence of bleeding, patients may be afforded intervals to at least 4 h for spontaneous expulsion of the placenta after fetal expulsion.

The subdominant status of Echinocereus viridiflorus and Mammillaria vivipara in the shortgrass prairie: The role of temperature and water effects on gas exchange.

The subdominant CAM species, Echinocereus viridiflorus and Mammillaria vivipara, collected from the shortgrass prairie in northeastern Colorado were pretreated and analyzed for gas exchange under cool temperatures (20/15°C) and warm temperatures (35/15°C). Well watered plants of both species under a 35/15°C thermoperiod fixed atmospheric CO2 during the night and early moring. Echinocereus viridiflorus grown and analyzed at 20/15°C fixed CO2 during the night, early morning and late afternoon but total carbon gain over a 24 h period is less than when grown and analyzed under the 35/15°C thermoperiod. Mammillaria vivipara grown and analyzed at 20/15°C assimilates CO2 at low rates during all parts of a 24 h period with the greatest CO2 fixation rates occuring from midday to late afternoon. The total carbon gain under the 20/15°C thermoperiod is less than that for this species under the 35/15°C thermoperiod. Decreasing the night temperature of plants grown under the warm conditions to 10°C or 5°C results in a depression of the night CO2 fixation in both species. E. viridiflorus from the cool growth conditions showed an enhancement of the CO2 uptake during the night, early morning and late afternoon when subjected to the cooler night temperatures (10°C and 5°C). The CO2 uptake of M. vivipara grown at 20/15°C shows an enhancement during the night and early morning while the CO2 fixation during midday and late afternoon is slightly depressed under cool night temperatures (10° and 5°C). Under the 35/15°C thermoperiod both species exhibit depressed rates of CO2 fixation during the night and early morning when water stressed. Plants of both species grown under the 20/15°C thermoperiod exhibit no net CO2 fixation following five weeks of water deprivation. Upon rewatering, E. viridiflorus begins to recover its capacity for CO2 fixation within 24 h under both the warm and cool temperature regimes. However, M. vivipara did not show recovery within 48 h following rewatering under the warm or cool temperature regime. Contrasting the patterns of gas exchange of the subdominant species, E. viridiflorus and M. vivipara, with a dominant CAM species of the shortgrass prairie, Opuntia polyacantha reveals significant differences that may well dictate the role of these species in this ecosystem. E. viridiflorus and M. vivipara have a lower capacity of carbon gain and recovery from water stress than O. polyacantha mainly due to their lack of late afternoon CO2 uptake. This study suggests that carbon gain plays an important role in limiting E. viridiflorus and M. vivipara in the shortgrass prairie ecosystem.