Laparoscopic removal of heterotopic cesarean scar pregnancy.

OBJECTIVE: To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DESIGN: Surgical video article. The Institutional Ethics Committee approved the video reproduction. SETTING: Tertiary referral to a university hospital PATIENT: A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar. INTERVENTIONS: Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures. MAIN OUTCOME MEASURES: Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. RESULTS: The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered. CONCLUSIONS: The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.

Cesarean scar ectopic partial molar pregnancy: A case report and a review of literature.

A scar ectopic pregnancy exhibiting hydatidiform features is an extremely rare and clinically challenging entity. Delayed diagnosis and failure to treat such cases promptly can lead to devastating consequences. In this report, we present a case of cesarean scar ectopic partial molar pregnancy in a 37-year-old woman who presented with complaints of vaginal discharge with streaks of blood and lower abdominal pain. Diagnostic laparoscopy revealed an abnormal mass of brown soft tissue in the anterior wall of the uterus, measuring 13.0 × 9.0 × 2.0 cm, raising suspicion (in the context of elevated serum human chorionic gonadotropin levels) of a scar ectopic pregnancy. Open laparotomy was performed, and the scar ectopic mass was successfully removed. The histologic examination of the tissue revealed a partial hydatidiform mole. The patient experienced a full recovery postoperatively, with serum human chorionic gonadotropin levels gradually declining to normal values. This report is unique in its presentation of the clinicopathological features of cesarean scar ectopic molar pregnancy and the successful management of the condition.

Current management of concomitant cholelithiasis and common bile duct stones.

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

Laparoscopic Management of Cornual Ectopic Pregnancy: A Step-by-step Approach.

Interstitial and cornual pregnancies are dangerous, yet rare, forms of ectopic pregnancy, accounting for 2%-4% of all ectopic pregnancies. A 38-year-old female, para 1, gravida 3 had undergone another in vitro fertilisation (IVF) cycle (a salpingectomy performed elsewhere for treating a hydrosalpinx before a previous IVF attempt). Duration of pregnancy is 6 weeks and 5 days, a transvaginal ultrasound revealed an embryo with a positive foetal heartbeat, located in the left cornuum. As no conservative treatment option could be followed, we proceeded with laparoscopic removal of ectopic pregnancy through cornual resection. Since a specific surgical methodology has not yet been established, presenting more step-by-step surgical approaches that can be used in clinical practice is of high importance. We present a step-by-step surgical approach that we have implemented in cases of cornual pregnancy in our department.

Successful Laparoscopic Management of Non-communicating Rudimentary Horn Pregnancy.

Unicornuate uteri are a type of Mullerian duct anomaly and the majority present with rudimentary horns. Rudimentary horn pregnancies are extremely rare and have a high risk of rupture. A high index of suspicion is needed to diagnose them early and unfortunately, the majority of cases are undetected until the patient presents with a ruptured uterus. Early diagnosis and management will reduce morbidities and mortality for patients. We present a case of a 29 year old who had a routine ultrasound scan in the first trimester that raised an index of suspicion for a rudimentary horn pregnancy. An MRI scan was performed and supplemented the ultrasound findings. The patient underwent laparoscopic management, and the non-communicating rudimentary horn, the foetus, and the attached tube were excised. The patient had a smooth recovery and had no complications.  Due to the rarity of rudimentary horn pregnancies, a high index of suspicion is needed for a diagnosis. Timely detection and intervention are crucial to prevent complications. Ultrasound scans and MRIs can aid in the diagnosis. Traditional management involved laparotomy, but with surgical advancements, laparoscopic surgery can be utilized as a less invasive alternative.

Laparoscopic management of a primary gallbladder hydatid cyst with daughter cysts in the common bile duct: Case report.

Introduction and importance: Primary Gallbladder hydatid cysts are a very rare phenomenon caused by Echinococcus granulosus. Hydatid cysts usually present as hepatic or pulmonary lesions, but in our case, it presented in the gallbladder with three symptomatic daughter cysts in the CBD. Echinococcus caused by E.granulosus Is the most common parasite causing the disease, accounting for 95% of the cases. Case presentation: 75 - year - old male presented with colic pain, jaundice, itching, vomiting, nausea, insomnia, Positive murphy's sign, and elevated AST and ALT. Total bilirubin was also elevated with no hepatomegaly or splenomegaly. Clinical discussion: This disease is endemic in Mediterranean countries due to high contact with the host of the parasite the lumen or on the external surface of the gallbladder. Which can come from the portal system or the spreading of brood capsules through the biliary tract. Conclusion: The method of investigation used was USG, CT, ERCP which are affordable and accessible in low-income countries including Syria. we would like to highlight this rare presentation and the possibility of using laparoscopic surgery.

Minimally Invasive Management of Bile Leak Following Displaced Percutaneous Transhepatic Biliary Stent.

Biliary endoprosthesis plays a crucial role in the management of patients with obstructive jaundice. However, a biliary leak is a life-threatening complication of this procedure. A 52-year-old otherwise healthy man presented with obstructive jaundice and was found to have a stricture at the confluence of the right and left hepatic ducts, which was managed with the placement of an uncovered self-expanding metallic stent. He rapidly deteriorated, and an active bile leak in the peritoneum due to stent displacement through the liver was discovered, which was successfully managed in a minimally invasive manner via laparoscopy. The extrahepatic part of the metallic stent was cut and removed, the peritoneum was washed out, and multiple drains were placed. The patient improved clinically, and his biochemical parameters returned to normal.

Laparoscopic-assisted excision of a huge polycystic omental lymphangioma in a 3 year old patient presenting with acute abdomen: case report and review.

Lymphangioma is a rare benign neoplasm affecting mainly children. In this report we present a complicated case of polycystic omental lymphangioma in a 3 year old female presenting with acute abdomen. The patient underwent a laparoscopic-assisted excision of the lesion and had an excellent postoperative course. We discuss the effectiveness and advantages of this laparoscopic surgical approach in children and elaborate on the current literature.

Two cases of non-parasitic splenic cysts and spleen-preserving therapy.

We review two different presentations of non-parasitic splenic cysts, both of which are post-traumatic in aetiology. The first case was of slower onset and was managed electively. The second case was of acute onset and was managed as an emergency. Non-parasitic splenic cysts are uncommon and the optimal management strategy for them is not well defined. Historically, treatment has been with open splenectomy; however, infection rates following this surgery have been high, making it an unattractive management option. Both cases were managed successfully with laparoscopic fenestration with no recurrence at subsequent follow-up.

Live birth after treatment of a spontaneous ovarian heterotopic pregnancy: A case report.

Spontaneous heterotopic pregnancies occur in about 1/30000 pregnancies, with the ovarian subtype comprising 2.3% of the total. We report the case of a healthy 32-year-old woman, gravida 4, para 3, who presented to the emergency room with severe abdominal pain. Two weeks earlier, pelvic ultrasound had revealed a 6-week intrauterine pregnancy. She was hemodynamically stable, but had rebound tenderness on the right iliac fossa. Transvaginal ultrasound revealed an evolutive intrauterine pregnancy with a gestational age (GA) of 8 weeks, with a synchronous evolutive adnexal pregnancy of the same GA and some free fluid in the pouch of Douglas. She underwent an urgent laparoscopy which showed an intact gestational sac containing an embryo on the right ovary associated with mild hemoperitoneum. An ovarian wedge resection was performed to preserve ovarian tissue. The intrauterine pregnancy had no complications and the patient delivered vaginally at term. Heterotopic pregnancy is potentially life-threatening. Despite being extremely rare after natural conception, and even more so in the absence of major risk factors, it should be considered in any pregnant woman with abdominal pain. A high index of suspicion is important for a prompt diagnosis, selection of the appropriate surgical treatment and successful obstetric outcomes.

Isolated torsion of the fallopian tube in a 16-year-old girl: A case report and review of the literature.

Torsion of the fallopian tube is when the tube twists on the axis created between the infundibulopelvic ligament and the utero-ovarian ligament. It most commonly presents with appendicitis-like symptoms, such as abdominal pain, nausea and vomiting. Because of its rarity and non-specific symptoms, it is usually misdiagnosed initially, which delays therapy, at the expense of the preservation of fertility. This case report of a 16-year-old girl who had never had sexual intercourse presents an example of the misdiagnosis of fallopian tube torsion. The definitive diagnosis was based on laparoscopy. We summarize our experience and provide our conclusions after reviewing the literature.

Laparoscopic Management of Chylous Leakage Using a Direct Lymph Node Injection with Methylene Blue as a Leakage Point Location Strategy in a Patient with Retroperitoneal Extragonadal Seminoma.

Background: The first-line treatment in cases of chylous leakage is conservative, and operation should be considered only in patients who fail to respond to this treatment. The main clinical concern is the difficulty of intraoperative localization of the site of leakage that can affect surgical outcome. Case Presentation: A 33-year-old man presented with a 4-month history of abdominal pain and weight loss. CT scan revealed enlarged retroperitoneal lymph nodes. Retroperitoneal lymph node biopsy was performed owing to the suspicion of lymphoproliferative disease, with a pathological result of nonspecific adenitis. Because of persistence of pain, an abdominal CT scan showed a large left retroperitoneal fluid collection that was found to be compatible with chyle after drainage. Conservative treatment was established, but because of its failure, surgical management was attempted by the laparoscopic approach. Intraoperative direct lymph node injection of methylene blue was used as a leakage point location strategy that allows selective ligation of the site of leakage. Thereafter a gradual reduction in chyle output to zero was observed. Conclusion: The laparoscopic approach could be a feasible and successful method for the management of chyle leakage in patients refractory to conservative treatment. Intraoperative direct lymph node injection of methylene blue could be a useful technique to facilitate detection of the site of leakage during operation.

Is It the Time for Laparoscopic Management of Early-stage Ovarian Malignancies?

The laparoscopic management of early-stage ovarian cancer remains controversial. Some surgeons hesitate to perform laparoscopic staging due to concern with the adequacy of staging, the possibility of tumor spillage and risk of port-site metastasis. Previous studies and literature reviews have reinforced the argument and supported the use of laparoscopy. However, the results were drawn with limited sample size obtained from case-series and case-control studies which result in difficult to make definite conclusions. Till date, the list of laparoscopic procedures has grown at a pace consistent with improvements in technology and technical skill of the surgeon. The number of studies with larger sample size, more prospective data, and longer duration of follow-up has been increasing. This review serves as an update on safety, feasibility, surgical, and oncological outcomes in cases of early-stage ovarian cancer treated by laparoscopic surgery of the literature published since 2008. We aim to clarify whether laparoscopy is safe and effective enough to be considered as standard management. Rely on nonrandomize studies, the current clinical evidence supports the role of laparoscopy in the management of early-stage ovarian cancer. Laparoscopy appears to offer several perioperative benefits without compromise of surgical morbidity and oncological outcome.

Large Hemobezoar Causing Acute Small Bowel Obstruction After Roux-en-Y Gastric Bypass: Laparoscopic Management.

The present video shows the laparoscopic management of an acute small bowel obstruction (ASBO) after a Roux-en-Y Gastric Bypass (RYGBP), due to the development of an intraluminal hemobezoar involving the jejuno-jejunostomy (j-j). On the first postoperative day (POD), the patient presented persistent abdominal pain, sense of fullness, nausea, and vomiting with traces of blood. The abdominal tube drained a small amount of serous fluid, while blood tests revealed a mild leukocytosis and a slight decrease of the hemoglobin. A CT scan showed the dilation of the excluded stomach, duodenum, and both the alimentary and biliopancreatic limbs. The transition point was located in the common limb, just beyond the j-j, which was dilated by a fluid collection with the radiological aspect of a blood clot. The patient underwent an emergency laparoscopy which confirmed the preoperative radiological findings. An enterotomy was performed at the biliopancreatic stump, and the blood clot was pulled out by suction. The enterotomy was then closed by means of a linear stapler. Postoperative course was uneventful, except for the development of low-grade pneumonia. The patient was discharged on POD 8. ASBO is a worrisome postoperative complication of RYGBP. Although rare, the development of intraluminal hemobezoar should always be considered as a possible cause of ASBO. Laparoscopic management is feasible and effective and does not necessarily entail the complete revision of the j-j.

Laparoscopic management of hydatid cyst in the lesser sac.

Hydatid cyst is a disease caused by Echinococcus granulosus. Various anatomical location of hydatid cyst has been described in literature. Liver is the most common site of hydatid cyst and lungs are the second most common site. Hydatid cyst of lesser sac is a rare entity. Here we present a rare case report of laparoscopic management of hydatid cyst in lesser sac.

The laparoscopic management of simple hepatic cysts.

The hepatic polycystic disease represents a hereditary condition with a reduced prevalence in the general population, sometimes associated with polycystic kidney disease. We present a retrospective observational study applied to 49 patients. The study aimed to observe the laparoscopic surgery of simple hepatic cysts. Laparoscopic approach is a simple and successful surgery management of these types of cysts.

Combination injuries of diaphragm and urinary bladder resulting urinothorax.

Isolated diaphragmatic or urinary bladder injuries are uncommon, but rare are combination of these injuries. We report a rare case of urinothorax occurred as a result of combination injury of diaphragm and urinary bladder and our successful laparoscopic only management. A 26-year-old male presented with a history of trauma and features suggestive of bilateral pleural effusion. Radiological investigations revealed diaphragmatic and urinary bladder rupture. Laparoscopic examination of the abdomen confirmed the presence of ruptures and successful repair of both defects were done laparoscopically. High index of suspicion and early diagnosis are crucial for a better outcome in the management of diaphragmatic rupture. Laparoscopic management is a feasible and successful method in trained hands.

Transcystic approach to laparoscopic common bile duct exploration.

BACKGROUND AND OBJECTIVES: One-stage laparoscopic management for common bile duct stones in patients with gallbladder stones has gained wide acceptance. We developed a novel technique using a transcystic approach for common bile duct exploration as an alternative to the existing procedures. METHODS: From April 2010 to June 2012, 9 consecutive patients diagnosed with cholelithiasis and common bile duct stones were enrolled in this study. The main inclusion criteria included no upper abdominal surgical history and the presence of a stone measuring <5 mm. After the gallbladder was dissected free from the liver connections in a retrograde fashion, the fundus of the gallbladder was extracted via the port incision in the right epigastrium. The choledochoscope was inserted into the gallbladder through the small opening in the fundus of the gallbladder extracorporeally and was advanced toward the common bile duct via the cystic duct under the guidance of both laparoscopic imaging and endoscopic imaging. After stones were retrieved under direct choledochoscopic vision, a drainage tube was placed in the subhepatic space. RESULTS: Of 9 patients, 7 had successful transcystic common bile duct stone clearance. A narrow cystic duct and the unfavorable anatomy of the junction of the cystic duct and common bile duct resulted in losing access to the common bile duct. No bile leakage, hemobilia, or pancreatitis occurred. Wound infection occurred in 2 patients. Transient epigastric colic pain occurred in 2 patients and was relieved by use of anisodamine. A transient increase in the amylase level was observed in 3 patients. Short-term follow-up did not show any recurrence of common bile duct stones. CONCLUSION: Our novel transcystic approach to laparoscopic common bile duct exploration is feasible and efficient.

Ovarian preservation in children for adenexal pathology, current trends in laparoscopic management and our experience.

AIMS: Primary cysts and tumors of the ovary alongwith torsion are often regarded as an indication for open oophorectomy because of the fear of leaving an ischemic organ inside and chances of recurrence. We wish to report our experience of both modalities of management where we initially removed adenexal torsion by either laparoscopic salpingo-oophorectomy or oophorectomy, but later followed a more conservative approach of adenexal lesion removal with ovarian preservation. MATERIALS AND METHODS: Retrospective review of clinical records of patients with ovarian pathology who were managed laparoscopically. RESULTS: 46 cases of pediatric ovarian pathology were managed between March 2006 and March 2013 in two centers by a team of surgeons. The age ranged from 1 days to 18 years (average 14.3 years) and the pathology varied from 30 cases of a simple ovarian cyst with torsion, 3 cases of ovarian torsion without any cyst, 7 cases of a dermoid cyst with torsion in all, 1 case of secreting ovarian tumor and 5 cases of a paraovarian cyst with torsion. All patients had a normal tumor marker except 1 girl with a functional ovarian tumor who had elevated LDH and estrogen levels alongwith suppressed LH and FSH. In the initial period of our study we did 1 salpingo-oophorectomy for a suspected complex lesion and two oophorectomies for torsion with a simple cyst. In the later part of our study we performed laparoscopic cystectomy and ovarian preservation in 40 cases, including 7 cases of dermoid, where we performed laparoscopic detorsion with dermoid cystectomy and ovarian preservation in the same sitting. In three cases of chronic torsion who presented to us late, we could not preserve the ovary and had to resort to salpingo-ophorectomy. Histology showed a simple corpus luteal and follicular ovarian cyst in 31 cases, a paraovarian cyst in 5 cases with mature teratoma in 7 cases. Twenty-five patients with ovarian preservation following detorsion were subjected to follow-up ultrasound, who were found to have normal shape, size and blood flow compared to the contra lateral side. CONCLUSION: We outline our experience from the management of 46 cases of various ovarian pathologies with and without ischemia and found that ovarian torsion with a benign pathology and ischemia is not a contraindication for ovarian preservation, as pointed out in the current literature.

Laparoscopic management of a large torted ovarian cyst in an adolescent virgin: a case report.

We report a case of a torted mature cystic teratoma in a 23-year-old, sexually inactive, virgin female which necessitated immediate laparoscopy. The patient and her family stressed that the integrity of the hymen must be maintained at any cost, for cultural reasons. We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient's request to maintain the integrity of the hymen. Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag. Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.