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BMC Urology Jan 2021Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused...
BACKGROUND
Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused surgeons. The aim of this study was to describe the periprostatic neurovascular bundles and their relationship with the fascicles around prostate and provide the accurate morphologic knowledge of periprostatic tissue for prostate operation.
METHODS
The pelvic viscera were obtained from 26 adult male cadavers. They were embedded in celloidin and cut into successive slices. The slices were explored with anatomic microscopy. 3-Dimensional reconstruction was achieved with celloidin sections and series software.
RESULTS
The prostatic capsule which surrounded the dorsal, bilateral aspect of the prostate was attached ventrally to anterior fibrous muscular stroma (AFMS). The lower part of the striated sphincter completely embraced the urethral; the upper part of this muscle covered the lower ventral surface of prostate. The upper ventral surface of prostate is covered by the circular muscle of detrusor. The levator fascia and the capsule adhered on the most convex region of the lateral prostate, but separated on the other region. The pelvic neurovascular bundles (PNVB) divided into the anterior and posterior divisions. The anterior division continued as dorsal vascular complex (DVC). The distal part of DVC entered into penile hilum. The posterior division continued as neurovascular bundles, and then as the cavernous supply (CS). The distal part of CS joined into pudendal neurovascular bundles.
CONCLUSIONS
The capsule and AFMS formed a pocket like complex. There were anterior and posterior neurovascular approaches from PNVB to penile hilum.
Topics: Aged; Aged, 80 and over; Blood Vessels; Cadaver; Collodion; Humans; Male; Middle Aged; Nervous System; Prostate
PubMed: 33407368
DOI: 10.1186/s12894-020-00778-0 -
International Journal of Surgery Case... 2020A congenital diaphragmatic hernia (CDH) is rarely diagnosed in adults and can allow passage of abdominal viscera into the chest cavity. A particularly rare association...
INTRODUCTION
A congenital diaphragmatic hernia (CDH) is rarely diagnosed in adults and can allow passage of abdominal viscera into the chest cavity. A particularly rare association is a wandering spleen due to absence of its diaphragmatic and retroperitoneal attachment which predisposes to elongation of the vascular pedicle with risk of torsion, infarction and rupture.
PRESENTATION OF CASE
A 17-year-old girl presented with a two-day history of increasing abdominal pain. Examination identified an abdominal mass. Computer tomography (CT) chest, abdomen and pelvis revealed a significantly enlarged wandering spleen with signs of torsion and an associated large left CDH with viscera in the chest cavity. The patient proceeded to an open splenectomy and repair of CDH. Post-operatively the patient developed ileus and required a temporary chest tube for pneumothorax, but otherwise progressed well.
DISCUSSION
Untreated CDH with a symptomatic wandering spleen is an extremely rare diagnosis with only one similar previous case report. Clinical detection is unlikely, making CT scanning the diagnostic test of choice. Surgery is recommended given the high morbidity and mortality of associated complications of both conditions. Splenic preserving options are favoured, however the majority of identified cases require splenectomy because of associated torsion or splenomegaly. Reduction of the CDH should be performed with primary closure of the defect and mesh reinforcement where possible.
CONCLUSION
CDH with associated wandering spleen in adults presents an extremely rare but clinically important diagnosis. Prompt surgical management as reported in this case should be performed to minimise immediate and future complications.
PubMed: 33137668
DOI: 10.1016/j.ijscr.2020.10.049 -
EJVES Vascular Forum 2020Nutcracker syndrome refers to the clinical manifestations of left renal vein compression between the superior mesenteric artery and the abdominal aorta, causing urinary...
INTRODUCTION
Nutcracker syndrome refers to the clinical manifestations of left renal vein compression between the superior mesenteric artery and the abdominal aorta, causing urinary changes and low back pain.
REPORT
A 44 year old woman presented with low back and pelvic pain. Following the diagnosis of nutcracker syndrome, she underwent endovascular treatment with renal vein stent placement; however, the patient continued to complain of pain. Further examinations revealed left renal vein compression by the portal vein. The patient underwent a second procedure; however, improvement was temporary and her pain returned. Further investigation revealed previously undetected nephroptosis and hyperelasticity. A diagnosis of Ehlers-Danlos syndrome made, possibly explaining the mobility of viscera and unusual compression of the left renal vein by the portal vein.
CONCLUSION
Ehlers-Danlos syndrome can cause nutcracker syndrome and may give rise to visceral pain of mixed origin.
PubMed: 33078146
DOI: 10.1016/j.ejvsvf.2020.02.005 -
World Journal of Clinical Cases Sep 2020A pelvic floor hernia is defined as a pelvic floor defect through which the intraabdominal viscera may protrude. It is an infrequent complication following...
BACKGROUND
A pelvic floor hernia is defined as a pelvic floor defect through which the intraabdominal viscera may protrude. It is an infrequent complication following abdominoperineal surgeries. This type of hernia requires surgical repair by conventional or reconstructive techniques. The main treatments could be transabdominal, transperineal or a combination.
CASE SUMMARY
In this article, we present the case of a recurrent perineal incisional hernia, postresection of the left side of the pelvis, testis and lower limbs resulting from a mine disaster 18 years ago. Combined laparoscopic surgery with a perineal approach was performed. The pelvic floor defect was repaired by a biological mesh and one pedicle skin flap. No signs of recurrence were indicated during the 2 years of follow-up.
CONCLUSION
The combination of laparoscopic surgery with a perineal approach was effective. The use of the biological mesh and pedicle skin flap to restructure the pelvic floor was effective.
PubMed: 33024783
DOI: 10.12998/wjcc.v8.i18.4228 -
Cureus Jul 2020This is a case report of a ruptured gastrointestinal stromal tumor (GIST) presenting as spontaneous hemoperitoneum. The patient was a 63-year-old female with a past...
This is a case report of a ruptured gastrointestinal stromal tumor (GIST) presenting as spontaneous hemoperitoneum. The patient was a 63-year-old female with a past medical history of hypertension and ulcerative colitis who presented to the emergency department with worsening epigastric pain. The patient denied history of trauma, previous surgeries, or forceful vomiting. She was not on anticoagulation. Vital signs at presentation were stable. A CT scan of abdomen/pelvis revealed a large amount of fluid in the upper abdomen with high attenuation material adjacent to the greater curvature of the stomach concerning for hemoperitoneum. Diagnostic laparoscopy revealed a significant amount of blood along the upper abdominal viscera. The procedure was converted to an upper midline laparotomy after identifying a necrotic, extremely friable 7 x 6 x 3 cm pedunculated mass with active hemorrhage on the posterior aspect of the greater curvature. A wedge resection was performed to remove the mass with grossly negative margins. An intraoperative frozen section revealed a stromal tumor with spindle cells. Final pathology revealed a pT3N0M0 stromal tumor with histologic spindle cells and a high mitotic rate (24/5 mm) consistent with a high-grade GIST. Given tumor rupture at presentation, the patient was started on imatinib therapy for a minimum duration of three years. GISTs are often asymptomatic or cause mild abdominal pain or GI bleeding. Rarely, an exophytic GIST may rupture leading to intraperitoneal bleeding. Surgical resection with negative margins is the mainstay of treatment although patients presenting with tumor rupture are at higher risk of dissemination and recurrence.
PubMed: 32850212
DOI: 10.7759/cureus.9338 -
Animals : An Open Access Journal From... Jul 2020The present study was designed to evaluate the relationship between the body measurements (BMs) and carcass characteristics of hair sheep lambs. Twenty hours before...
The present study was designed to evaluate the relationship between the body measurements (BMs) and carcass characteristics of hair sheep lambs. Twenty hours before slaughter, the shrunk body weight (SBW) and BMs were recorded. The BMs involved were height at withers (HW), rib depth (RD), body diagonal length (BDL), body length (BL), pelvic girdle length (PGL), rump depth (RuD), rump height (RH), pin-bone width (PBW), hook-bone width (HBW), abdomen width (AW), girth (GC), and abdomen circumference (AC). After slaughter, the carcasses were weighed and chilled for 24 h at 1 °C, and then were split by the dorsal midline. The left-half was dissected into total soft tissues (muscle + fat; TST) and bone (BON), which were weighed separately. The weights of viscera and organs (VIS), internal fat (IF), and offals (OFF-skin, head, feet, tail, and blood) were also recorded. The equations obtained for predicting SBW, HCW, and CCW had an ranging from 0.89 to 0.99, and those for predicting the TST and BON had an ranging from 0.74 to 0.91, demonstrating satisfactory accuracy. Our results indicated that use of BMs could accurately and precisely be used as a useful tool for predicting carcass characteristics of hair sheep lambs.
PubMed: 32727056
DOI: 10.3390/ani10081276 -
International Journal of Surgery Case... 2020Gossypiboma denotes a mass of cotton retained in the body following surgery. Migration of gossypiboma from initial site is a rare entity and could pose some diagnostic...
INTRODUCTION
Gossypiboma denotes a mass of cotton retained in the body following surgery. Migration of gossypiboma from initial site is a rare entity and could pose some diagnostic difficulties. Migration of gauze sponge has been reported to occur in several organs of the body. There have been few reported cases but the true incidence may be much higher due to under reporting for fear of litigation.
PRESENTATION OF CASE
We present an unusual case of a 58-year-old grand multiparous woman who had gauze retention for 5 years following a hysterectomy and presented with acute urinary symptoms. The gauze sponge transmigrated from the peritoneal cavity to the bladder and was partially extruded through the external urethral meatus. She had laparotomy for the removal of gauze sponge with good outcome.
DISCUSSION
Retained foreign body especially surgical sponges (gossypiboma) infrequently occurs and can be a source of great concern to the surgeon and patient. Foreign bodies inside the body cavities and organs can present with several non-specific clinical features that can make diagnosis difficult. Migration of surgical sponge (gauze, mops) into the urinary bladder is uncommon when compared to other abdominal and pelvic viscus. A gossypiboma in the peritoneal cavity creates a fistulous tract through the thick wall of the urinary bladder from long period of chronic inflammation as seen in the index case where the previous surgery was performed 5 years prior to onset of symptoms. Due to the non-specific presentations of gossypiboma, especially those in the bladder, several investigative modalities need to be employed to help make a prompt diagnosis. Most long-standing cases would require laparotomy due to the dense adhesions that occur around the site of the gossypiboma. Lack of appropriate diagnosis leaves the patient with recurrence of distressful symptoms and the consequent morbidities.
CONCLUSION
Transmigration of a gauze sponge over 5 years from the peritoneal cavity into the urinary bladder and through the external urethral meatus following a hysterectomy is a rare occurrence and can present diagnostic difficulties. High index of suspicion, prompt diagnosis and management will help reduce the high morbidity that is associated with the condition as in the case reported.
PubMed: 32470912
DOI: 10.1016/j.ijscr.2020.04.104 -
The Cochrane Database of Systematic... May 2020Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments.
OBJECTIVES
To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation.
SEARCH METHODS
On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials.
SELECTION CRITERIA
We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women.
DATA COLLECTION AND ANALYSIS
We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow.
MAIN RESULTS
We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events.
AUTHORS' CONCLUSIONS
There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.
Topics: Adult; Female; Humans; Intraoperative Complications; Laparoscopy; Leiomyoma; Length of Stay; Middle Aged; Morcellation; Operative Time; Postoperative Complications; Randomized Controlled Trials as Topic; Specimen Handling; Uterine Myomectomy; Uterine Neoplasms; Young Adult
PubMed: 32374421
DOI: 10.1002/14651858.CD013352.pub2 -
Journal of Surgical Case Reports Mar 2020An internal hernia is a protrusion of viscera through a congenital or acquired defect in the mesentery of peritoneum. They account for <0.9% of all small bowel...
An internal hernia is a protrusion of viscera through a congenital or acquired defect in the mesentery of peritoneum. They account for <0.9% of all small bowel obstructions [1] and ~4% of obstructions due to hernias [2]. We present a rare case of closed loop obstruction secondary to a band adhesion traversing the lower abdomen from a sigmoid colon appendage epiploicae to the right pelvic wall. A 82-year-old woman presented to the emergency department with nausea, vomiting and worsening right sided abdominal pain for 24 h, on the background of previous pelvic radiation and hysterectomy for uterine cancer. She was subsequently found to have a closed loop obstruction with 30 cm of ischemic bowel strangulated by a band adhesion from a sigmoid colon appendage epiploicae to the right abdominal wall. The patient underwent a successful small bowel resection with primary anastomosis and made an uneventful recovery.
PubMed: 32153757
DOI: 10.1093/jscr/rjaa008 -
Case Reports in Women's Health Apr 2020Pneumoperitoneum seen on an X-ray or computed tomography (CT) image points to a diagnosis of ruptured viscus and immediate surgery is warranted. A case of tubo-ovarian...
Pneumoperitoneum seen on an X-ray or computed tomography (CT) image points to a diagnosis of ruptured viscus and immediate surgery is warranted. A case of tubo-ovarian abscess (TOA) presenting with pneumoperitoneum is unusual. Very few cases have been reported where the pneumoperitoneum is caused by an abscess involving the adnexa. We present the case of a 17-year-old patient who presented with acute abdomen and raised inflammatory markers and had laparoscopy for suspected bowel perforation based on the finding of pneumoperitoneum on CT scan. Bowel perforation was ruled out and the findings were consistent with TOA. She had drainage of the abscess, subsequently received intravenous antibiotics and postoperatively recovered well. The pneumoperitoneum could have been due to coinfection with , as the patient had had a urinary tract infection due to three weeks before presentation, or slow leakage of the TOA. In conclusion, gas under the diaphragm can be related to non-bowel-related gynaecological pathology, but it vital to rule out sinister causes.
PubMed: 32082993
DOI: 10.1016/j.crwh.2020.e00181