Pneumopericardium and severe subcutaneous emphysema after laparoscopic surgery.

Subcutaneous emphysema is a known complication of laparoscopic surgery. Occasionally, subcutaneous emphysema is severe enough to cause pneumopericardium. This case report describes a rare but potentially serious complication of pneumopericardium occurring after laparoscopy. Contributing factors and possible etiologies are discussed.

An adhesion barrier may induce peritonitis and abscess after laparoscopy-assisted myomectomy with vaginal extraction: report of a case.

Following a myomectomy, postoperative adhesions occur in many patients. Although laparoscopy has been shown to decrease the development of adhesions compared to laparotomy, adhesions still occur. There are several commercially available adhesion barriers but these are not designed to be easily applied during laparoscopic surgery. In this study, we report a case involving a 34-year-old patient who developed pelvic peritonitis and abscess without an obvious etiology; this might have been related to the off-label use of a bioabsorbable membrane converted into a slurry during recent surgery. Surgeons should be aware of such complications, which might be attributed to this product.

Laparoscopic management of complicated adnexal masses in the first trimester of pregnancy.

OBJECTIVE: To describe our experiences with laparoscopic management of complicated adnexal masses in the first trimester of pregnancy. DESIGN: Retrospective clinical study. SETTING: A teaching hospital. PATIENT(S): Eleven patients with singleton pregnancy who underwent laparoscopic operation for complicated benign adnexal mass during their first trimester. INTERVENTION(S): Laparoscopic surgery for complicated adnexal masses. MAIN OUTCOME MEASURE(S): Technical feasibility and safety. RESULT(S): All of the patients had an uneventful recovery. Pregnancy was continued to term in nine patients (81.1%). Two patients (18.2%) had ongoing pregnancy at the time of writing. CONCLUSION(S): Operative laparoscopy for complicated adnexal masses performed during early pregnancy is safe and feasible.

Total laparoscopic hysterectomy (TLH) versus coagulation of uterine arteries (CUA) at their origin plus total laparoscopic hysterectomy (TLH) for the management of myoma and adenomyosis.

We tried to evaluate the relative feasibility, surgical duration and complications of total laparoscopic hysterectomy (TLH) versus coagulation of uterine arteries at their origin (CUA) plus total laparoscopic hysterectomy for the management of myoma and adenomyosis, and to compare the estimated blood loss for both procedures. A total of 123 patients underwent TLH or CUA plus TLH for the treatment of symptomatic myoma and adenomyosis. Sixty-four women underwent TLH, whilst 68 women underwent coagulation of uterine arteries at their origin plus TLH. The mean weight and volume of the uterus as determined following TLH was 288.1+/-102.4 gm (range 182.1 approximately 396.2 gm.) and 451+/-340.6 cm(3) (range 107.4 approximately 792), respectively. The mean weight of the uterus following CUA plus TLH was 269.1+/-151.7 gm (range 215.8 approximately 430.1) whilst the mean uterine volume was 472.7+/-377.8 cm(3) (range 93.7 approximately 851.2). No significant differences with respect to surgical duration (95 vs. 96.5 minutes TLH vs. CUA + TLH; p>0.05), blood loss (177.2+/-80.1 ml for TLH and 154.9+/-30.21 ml for CUA+TLH; p>0.05) and mean+/-SD preoperative (12.05+/-1.70 gm/dl for TLH and 12.14+/-1.38 gm/dl for CUA+TLH; p>0.05) and post-operative hemoglobin level (11+/-1.03 for TLH and 11+/-1.49 for CUA + TLH; p>0.05) were observed between the two study groups. The blood loss for TLH is comparable to that for the CUA plus TLH procedure.

Should cystoscopy be routinely performed after laparoscopy-assisted vaginal hysterectomy?

This study was undertaken to determine the usefulness of routine intra-operative cystoscopy in documenting ureteral patency after laparoscopy-assisted vaginal hysterectomy (LAVH). There were eighty patients who underwent LAVH for benign tumors of the uterus (adenomyosis and myoma), uterine prolapse, persistent intraepithelial neoplasm of the cervix (CIN3) and cervical carcinoma in situ (CIS). Intra-operative cystoscopy with ureteral stenting was performed at the time of LAVH to evaluate the urinary tract. From among the 80 patients who underwent LAVH, 52 had myoma, 19 had adenomyosis, six patients had uterine prolapse, one had CIS and seven patients were diagnosed to have CIN3. Cystoscopy discovered one unsuspected bladder injury. Hematuria was the immediate complication caused by intraoperative cystoscopy. It was observed in ten patients. Urinary tract evaluation, including cystoscopy and ureteral stenting at the time of complex gynecologic surgery such as LAVH could be incorporated in the whole surgical procedure. It decreases morbidity associated with unrecognized injury.

Identical twins with ovarian endometriosis and mucinous borderline tumor: an unusual association.

OBJECTIVE: To report a case of monozygotic twins with unilateral ovarian tumors of different histology and character. DESIGN: Case report. SETTING: Medical center and teaching hospital. PATIENT(S): A 22-year-old woman with ruptured ovarian endometrioma and her twin with mucinous borderline tumor of the ovary. INTERVENTION(S): Ultrasonography, laparoscopic ovarian cystectomy, and salpingo-oophorectomy. MAIN OUTCOME MEASURE(S): Ovarian cystectomy for the twin with endometrioma and examination of the asymptomatic twin. RESULT(S): Diagnosis and treatment of the asymptomatic twin. CONCLUSION(S): Ovarian tumors present in monozygotic twins may not always be of the same histologic type.

Transvaginal ultrasound-guided treatment of cervical pregnancy.

OBJECTIVE: To describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early cervical pregnancy. METHODS: We prospectively reviewed all cases of cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified, from 1993 through 2004. All cases were managed with transvaginal intra-amniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum beta-hCG measurements were performed twice weekly for 2 weeks after the procedure, then weekly. RESULTS: The mean initial beta-hCG level was 38,948 milli-International Units/mL and ranged from 5,608 to 103,256 milli-International Units/mL for 22 cases with fetal heart activity and from 2,765 to 18,648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All cervical pregnancies were successfully aborted, with an average resolution of the cervical mass in 49 days. Postoperative beta-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that, of 21 patients who desired pregnancy, 18 had achieved subsequent successful pregnancies. CONCLUSION: Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic pregnancy but also preserves the uterus for subsequent pregnancies.

Laparoscopic electrodessication of an interstitial pregnancy.

OBJECTIVE: To report on the case of a woman who presented with lower abdominal pain and vaginal bleeding, and who was diagnosed with early interstitial pregnancy. DESIGN: Case report. SETTING: Medical center and teaching hospital. PATIENT: A 32-year-old woman with a previous history of ectopic pregnancy. INTERVENTION(S): Imaging study with ultrasonography and laparoscopy. MAIN OUTCOME MEASURE(S): Complete resolution of the ectopic pregnancy at the interstitial site of the amputated fallopian tube, and resumption of menstruation. RESULT(S): Other causes of internal bleeding were ruled out. Menstruation resumed 30 days after the procedure. CONCLUSION: An early interstitial pregnancy may be successfully managed with laparoscopic electrodessication.

Large cell neuroendocrine carcinoma of the uterine cervix associated with adenocarcinoma.

OBJECTIVE: Large cell neuroendocrine carcinoma (LCNEC) is a rare and aggressive cervical neoplasm. In the present study, we present a 45-year-old woman with large cell neuroendocrine uterine cervical carcinoma with coexisting adenocarcinoma. CASE REPORT: A 45-year-old G2 P0 presented with vaginal bleeding for 7 months. On pelvic examination, a polypoid mass of the cervix was discovered. Biopsy of the lesion revealed large cell neuroendocrine carcinoma of the cervix. The patient underwent a radical hysterectomy, and then received concurrent chemotherapy and radiation therapy. She has remained disease free until the time of this writing. CONCLUSION: Patients with LCNEC of the cervix have had poor prognoses; hence aggressive multimodality treatment is recommended.

Prevalence of cervical human papillomavirus in Taiwanese women.

PURPOSE: To define the prevalence rate of cervical human papilloma virus (HPV) using DNA oligonucleotide microarray and its correlation with risk factors in Taiwanese women in metropolitan Taipei. METHODS: Thirteen hundred and twenty healthy women, aged 21 - 65 yr without history of cervical intraepithelial neoplasia (CIN) or carcinoma were included in this prospective study. Pap smear and HPV typing using oligonucleotide microarray were performed for each woman. They were given a standardized questionnaire to obtain information about the risk factors of cervical cancer in Taiwan. RESULTS: The overall HPV positivity was 19.85% and multiple infections were found in 35.84% of the infected group, 7.92% of the whole study population. The younger the subject, the higher was the infection rate and multiple infection rates. The most common HPV types were 16, 18, 58, 52, 51 and 56, which is different from the western world. The sensitivity of the HPV DNA chip in detecting CIN and cervical carcinoma is 97.06%, and 100% in detecting CIN 2 or more lesions. Risk factors for HPV infection include earlier coitarche (P < 0.01), multiple sexual partners (P < 0.05), history of sexually transmitted disease (P < 0.05), two or more vaginal deliveries (P < 0.05) and infrequent use of condoms (P < 0.05). The association between oral contraception or cigarette smoking and HPV infection could not be determined because few women smoke or used oral contraception. There was no relationship between induced abortion and HPV infection. CONCLUSIONS: About one-fifth of adult women in metropolitan Taipei were cervical HPV positive. The popular HPV types and the risk factors of HPV infection in metropolitan Taipei are not the same as those in the western world. The sensitivity of the HPV DNA chip in detecting cervical neoplasia is very high.

Sonographic appearance of fallopian tube carcinoma.

Fallopian tube carcinoma is the least common of gynecological malignancies. We report the case of a 56-year-old woman who presented with a 2 1/2-year history of intermittent vaginal bleeding and lower abdominal pain. Transvaginal sonography revealed a cystic lesion of the fallopian tube with papillary projections, distinct from the ovary and uterus. Doppler examination showed low vascular impedance (resistance index 0.50, pulsatility index 0.80). The suspicion of tubal malignancy was confirmed at surgery.

Primary peritoneal carcinosarcoma (malignant mixed mullerian tumor): Report of a case with five-year disease free survival after surgery and chemoradiation and a review of literature.

Malignant mixed mullerian tumors (MMMTs), also known as carcinosarcoma because they contain both carcinomatous and sarcomatous elements are aggressive tumors, which usually arise in the uterus and ovary. Extragenital carcinosarcomas are extremely rare and most cases develop from the peritoneum. To our knowledge, only 29 cases have been described in English literature. Here we report a case of a primary carcinosarcoma of the pelvic peritoneum with five-year disease-free survival after managing the patient with surgery, chemotherapy and radiotherapy.