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The American Journal of Case Reports Aug 2023BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and... (Review)
Review
BACKGROUND Tubal heterotopic pregnancy is an extremely rare complication of pregnancy, in which there is a simultaneous presence of a pregnancy in the uterine cavity and in an ectopic location, most commonly in the fallopian tube. The management of such cases is not clearly established. In the case of a desire to maintain an intrauterine pregnancy, the surgical procedure consisting of a salpingectomy or salpingostomy is the most common. Such a procedure is effective, but it involves potential complications typical of surgeries, so, in some cases, it seems reasonable to apply the expectant management. CASE REPORT A 31-year-old woman was admitted to the clinic due to pain in the right lower abdomen. An ultrasound examination revealed a gestational sac in the uterine cavity corresponding to 5 weeks of pregnancy with a yolk sac. A twin sac was found in the right fallopian tube. Due to the patient's mild symptoms, absence of bleeding into the peritoneal cavity, concerns about the safety of the embryo and the pregnant woman in case of surgery, conservative management was decided. On the 20th day, the patient was discharged from the clinic with a viable intrauterine pregnancy and a partially absorbed ectopic pregnancy. CONCLUSIONS In the case of an ectopic tubal pregnancy, if there are no symptoms of bleeding into the peritoneal cavity, it is possible to adopt a safe conservative approach with strict patient observation.
Topics: Pregnancy; Female; Humans; Adult; Pregnancy, Heterotopic; Conservative Treatment; Pregnancy, Tubal; Fallopian Tubes; Salpingostomy
PubMed: 37550961
DOI: 10.12659/AJCR.940111 -
Minimally Invasive Surgery 2021Totally extraperitoneal herniorrhaphy (TEP) is a therapeutic challenge because of its complex anatomical location in inguinal region. The aim of this study was to...
BACKGROUND
Totally extraperitoneal herniorrhaphy (TEP) is a therapeutic challenge because of its complex anatomical location in inguinal region. The aim of this study was to describe the related surgical anatomy through laparoscopic observation and share the lessons learned from a review of 250 primary inguinal hernia repair procedures performed at our hospital from January 2013 to November 2019. . There were 245 men and 5 women (median age: 63.2 years). Right hernia (60.2%) was the most common site. Indirect hernia (60.5%) was the most common abnormality. The classification of type II (65.0%) was the most common form. Surgical techniques comprised retromuscular approach using cauterized dissection, management of variations of arcuate line, Retzius space and Bogros space dissection, hernia sac reduction, and mesh positioning.
RESULTS
The incidence of peritoneum injury was in 27 (10.1%). No epigastric vessels were injured. There were 8 (3%) hematoma and 18 (6.8%) seroma. No mesh infection, chronic pain, and recurrence were found after follow-up of an average of 35 months.
CONCLUSION
A good understanding of the anatomically complex nature in the inguinal region can make it easier and safer to learn the TEP approach. Early and midterm outcomes after TEP are satisfactory.
PubMed: 33976937
DOI: 10.1155/2021/5524986 -
PloS One 2019Deep infiltrating endometriosis (DIE) is defined as an endometriotic lesion penetrating to a depth of >5 mm and is associated with pelvic pain, but the underlying...
PURPOSE
Deep infiltrating endometriosis (DIE) is defined as an endometriotic lesion penetrating to a depth of >5 mm and is associated with pelvic pain, but the underlying mechanisms are unclear. Our objective is to investigate whether plasminogen activator inhibitor-1 expression (PAI-1) in endometriotic tissues is increased in women with DIE.
METHODS
In this blinded in vitro study, immunohistochemistry and Histoscore were used to examine the expression of PAI-1 in glandular epithelium (GECs) and stroma (SCs) in a total of 62 women: deep infiltrating uterosacral/rectovaginal endometriosis (DIE; n = 13), ovarian endometrioma (OMA; n = 14), superficial peritoneal uterosacral/cul-de-sac endometriosis (SUP; n = 23), uterine (eutopic) endometrium from women with endometriosis (UE; n = 6), and non-endometriosis eutopic endometrium (UC; n = 6). The following patient characteristics were also collected: age, American Fertility Society stage, hormonal suppression, phase of menstrual cycle, dysmenorrhea score and deep dyspareunia score.
RESULTS
PAI-1 expression in GECs and SCs of the DIE group was significantly higher than that of SUP group (p = 0.01, p = 0.01, respectively) and UE group (p = 0.03, p = 0.04, respectively). Interestingly, increased PAI-1 expression in GECs and SCs was also significantly correlated with increased dysmenorrhea (r = 0.38, p = 0.01; r = 0.34, p = 0.02, respectively).
CONCLUSIONS
We found higher expression of PAI-1 in DIE, and an association between PAI-1 and worse dysmenorrhea.
Topics: Adult; Dysmenorrhea; Endometriosis; Epithelial Cells; Female; Humans; Immunohistochemistry; Middle Aged; Peritoneal Diseases; Plasminogen Activator Inhibitor 1; Rectal Diseases; Stromal Cells; Uterine Diseases; Vaginal Diseases; Young Adult
PubMed: 31315131
DOI: 10.1371/journal.pone.0219064 -
Gynecologic Oncology Reports Jun 2023Psammocarcinoma is a rare form of serous carcinoma of the ovary or peritoneum characterized by extensive psammoma body formation seen on histology. A 49-year-old obese...
Psammocarcinoma is a rare form of serous carcinoma of the ovary or peritoneum characterized by extensive psammoma body formation seen on histology. A 49-year-old obese woman, gravida 1 para 1 with poorly controlled type 2 diabetes, presented with a history of menorrhagia. She was diagnosed with both leiomyomata and simple endometrial hyperplasia without atypia in the office. Consultation with gynecological oncology and primary gynecologist resulted in a planned hysterectomy with bilateral salpingo-oophorectomy. Laparoscopic hysterectomy and bilateral salpingo-oophorectomy were performed by primary gynecologist. Intraoperative survey of pelvis found concerning nodular lesions seen in posterior cul-de-sac. Lesions were excised and sent for frozen section. Pathology showed invasive peritoneal epithelial implant with psammomatous calcifications. Gynecological oncologist stand-by was called in and proceeded with surgical debulking and staging procedure. Post operatively, the patient has been diagnosed with primary peritoneal low grade serous psammomacarcinoma stage III A2. Her case has been presented to tumor board for multidisciplinary management and is now undergoing adjuvant hormonal therapy utilizing letrozole with chest, abdomen, and pelvic CT scans every 6 months. Standardized protocols are hindered by the rarity of this tumor. Benefits for this oncologic diagnosis are not clearly understood due to the rarity of this tumor. The significance of this case presentation is to highlight the multidisciplinary approach to the workup, diagnosis, treatment (both surgical and medical) and follow up of a rare gynecologic oncologic case. While the surgical team was expecting to find at most significant pathology, an endometrial carcinoma, a rarer primary peritoneal carcinoma was found. Due to the pre surgical planning, and intraoperative teamwork of the pathology, gynecology and oncology teams, this patient received the individualized and disease specific needed surgical and medical care warranted by her unique diagnosis.
PubMed: 37122436
DOI: 10.1016/j.gore.2023.101176 -
Arquivos Brasileiros de Cirurgia... 2021Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as...
BACKGROUND
Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair.
AIM
To describe a robotic assisted surgical technique for incisional lumbar hernia repair.
METHODS
Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies.
RESULTS
Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days.
CONCLUSION
The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.
Topics: Hernia, Ventral; Herniorrhaphy; Humans; Incisional Hernia; Laparoscopy; Retrospective Studies; Surgical Mesh
PubMed: 34669888
DOI: 10.1590/0102-672020210002e1599 -
International Journal of Surgery Case... 2018Spigelian hernia is uncommon and frequently presents with features of intestinal obstruction. Clinical diagnosis is difficult in patients without obvious abdominal mass...
INTRODUCTION
Spigelian hernia is uncommon and frequently presents with features of intestinal obstruction. Clinical diagnosis is difficult in patients without obvious abdominal mass and a computed tomography scan is very helpful in making diagnosis. We report a patient who presented with a strangulated sliding left sided spigelian hernia who was pre-operatively diagnosed and successfully managed surgically.
PRESENTATION OF CASE
A 56-year-old woman was to referred to the surgical emergency unit of our institution with abdominal swelling and pain of three days. There was no abdominal distension or fever and had no history of recurrent abdominal pains, abdominal swelling or surgery. Examination revealed a middle aged woman with a tender mass measuring about 10 cm by 8 cm in the left iliac fossa region of the abdomen. Bowel sounds were hyperactive and digital rectal examination revealed an empty rectum consistent with the diagnosis of acute intestinal obstructions. Investigations done by the patient at the referring hospital included a computed tomography (CT) scan which was suggestive of an obstructed Spigelian hernia with the sac containing a small bowel loop and mesentery. She had emergency herniorrhaphy and findings were herniation through a facial defect of about 5 cm by 4 cm along the lateral border of the rectus sheath with the hernia sac containing sero-sanguineous peritoneal fluid, gangrenous ileal segment and part of herniated urinary bladder forming the lower wall of the sac. Resection of gangrenous bowel with an end to end anastomosis was carried out, viable contents of the sac were reduced and defect repaired with interrupted non absorbable sutures to approximate the internal oblique and transversus abdominis to rectus sheath. In addition, nylon darning from inguinal ligament to the rectus sheath was also done. Her post-operative recovery was satisfactory and she remained well six months after surgery.
CONCLUSION
Pre-operative diagnosis of strangulated Spigelian hernia is difficult but can be aided by a CT. The use of nylon darning to re-inforce the repair can be rewarding where mesh cannot be used or unavailable.
PubMed: 30567073
DOI: 10.1016/j.ijscr.2018.10.043 -
The Pan African Medical Journal 2014Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal... (Review)
Review
Pregnancy, the implantation of a fertilized ovum outside the endometrial cavity, occurs in 1.5%-2% of pregnancies. It is one of the major causes (about 6%) of maternal death during the first trimester of pregnancy. The remaining 5% implant in the ovary, peritoneal cavity, within the cervix, and the omental pregnancy is the least common form of abdominal pregnancies. A review of the literature on Medline for the period 1958-2012 reported only 16 cases of omental pregnancy. Here we report a case of primary omental pregnancy in a nulliparous woman. A 24 year-old woman gravid 1, para 0, with lower abdominal pain. Her last menstrual period occurred 8 weeks before the visit. The physical examination revealed abdominal tenderness in the lower quadrants, she was not bleeding. Transvaginal ultrasound showed: a free anechoic/hypoechoic area of 30 x 57 mm in the pouch of Douglas and the endometrium was homogeneus with a thickness of 12 mm and no evidence of gestational sac in the uterine cavity. Laboratory data revealed a normal cell blood count and beta hcg levels of 8047 IU / L. Because of continuing abdominal pain and a diagnosis of ectopic pregnancy a diagnostic laparoscopy was performed, which showed hemoperitoneum. Further inspection of abdominal cavity revealed a bloody lesion that was tenaciously adherent to the omentum, using non traumatic laparoscopic forceps and bipolar scissors we carefully removed a friable mass of about 30 mm from the omental attachments. Histological examination showed the presence of blood clot material mixed with trophoblastic tissue. Ultrasound evaluation and and hCG assessment are important to determine the extrauterine location of the ectopic pregnancy but the early diagnosis of abdominal pregnancy requires also a laparoscopic evaluation and, as our case has highlighted, thorough abdominal exploration especially in the absence of adnexal findings when ectopic pregnancy is highly suspected. Early diagnosis of omental pregnancy is difficult but essential to reduce the high mortality risk for the mother.
Topics: Abdominal Pain; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Laparoscopy; Omentum; Pregnancy; Pregnancy, Abdominal; Young Adult
PubMed: 25852787
DOI: 10.11604/pamj.2014.19.244.3661 -
Surgical Case Reports Feb 2023The finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand's hernia. The reported incidence of Amyand's hernia and femoral...
BACKGROUND
The finding of a vermiform appendix within the peritoneal sac of an inguinal hernia is called Amyand's hernia. The reported incidence of Amyand's hernia and femoral hernia is 1% and 3.8%, respectively. To our knowledge, no cases have been reported in the literature that associate these two entities. We present the first case of incarcerated left-sided Amyand's hernia and synchronous ipsilateral femoral hernia found during emergency surgery.
CASE PRESENTATION
A 72-year-old woman was admitted to the Emergency Department for a complicated left inguinal hernia. An inguinotomy was performed that detected a large direct hernial sac and a synchronous femoral hernia. The opening of the inguinal hernia showed the presence of the cecum and the appendix, both without signs of inflammation. The femoral space was evaluated transinguinally, identifying the larger omentum that had slipped into the femoral canal. The primary closure of the posterior wall defect was performed with the McVay technique due to its large size, and then the hernioplasty was completed with a polypropylene mesh. No postoperative complications were reported.
CONCLUSIONS
In the context of an incarcerated Amyand's hernia, the decision to perform an appendectomy in addition to hernia repair with or without mesh will depend on intraoperative findings.
PubMed: 36723671
DOI: 10.1186/s40792-023-01597-9 -
Journal of Abdominal Wall Surgery : JAWS 2022Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended-Totally Extraperitoneal (E-TEP) technique of ventral hernia repair...
Hernia Sac Preservation for Prevention of Transversus Abdominis Release in Laparoscopic Extended-Totally Extra Peritoneal Repair of Ventral Hernia: A Minimalistic Solution for a Formidable Challenge.
Ventral hernia repair has always been an extensive and challenging surgery. The laparoscopic extended-Totally Extraperitoneal (E-TEP) technique of ventral hernia repair is gaining popularity due to the advantage of placing a large mesh in the retro rectus plane. When done through a Laparoscopic approach, the difficulty of the procedure is compounded by multiple factors such as obtaining retro muscular access, maintaining the retro muscular plane, crossing over to the contralateral retro muscular plane without entering intraperitoneally, suturing in a limited space, and manipulation of a large mesh in a constricted space for placement. In cases of large midline incisional hernias, dense adhesions to the previous surgical scar are often present. Despite having extremely satisfying outcomes, the aforementioned factors make the laparoscopic extended-total extraperitoneal repair of large midline ventral and incisional hernias an exceptionally challenging procedure. A tension-free midline approximation is the benchmark of ventral/incisional hernia surgery. In certain cases, this can be difficult to achieve due to multiple factors. For the purpose of attaining tension-free midline closure, component separation techniques (CST) have been explored and implemented. Of these, the posterior component separation technique of Transversus Abdominis Release (TAR) has gained popularity for reducing the tension of posterior rectus sheath during posterior midline closure in retro muscular repairs by adding a few centimetres of medial advancement. The main pitfall of TAR is its technical complexity, which may result in morbid complications when implemented incorrectly. Performing TAR laparoscopically compounds the complexity manyfold. Hence, to obviate the necessity to perform Laparoscopic TAR in cases of Laparoscopic E-TEP repair of large midline ventral and incisional hernias, we present that the technique of hernial sac preservation should be pre-emptively carried for all Laparoscopic ETEP repairs so that the necessity of performing TAR in select cases is reduced by aiding in the addition of final crucial centimetres of lengthening to the posterior rectus sheath for achieving posterior midline closure. This aids in the success of the procedure by preventing an additional complex procedure of TAR from being performed in an already challenging hernia repair technique of Laparoscopic E-TEP repair. We hereby report three cases of Ventral hernia repair in which Laparoscopic E-TEP repair was carried out and Hernial sac preservation technique was implemented successfully. Midline closure of the posterior rectus sheath was attained under reduced tension and a medium-weight macroporous polypropylene mesh was placed in the retro-rectus plane after measurement of the potential space. Patients were discharged uneventfully. Patients were followed up for up to 6 months postoperatively and were found to have no complications. In Laparoscopic E-TEP repair of midline ventral hernias, preservation of the hernial sac along with the posterior rectus sheath might aid in the prevention of performing a TAR in selected cases where posterior layer tension is present. Hernia sac preservation thereby aids in reducing operative time and preventing potential morbid complications.
PubMed: 38314153
DOI: 10.3389/jaws.2022.10634 -
African Journal of Paediatric Surgery :... 2023Inguinal hernia is a common surgical condition in children. Conventionally, the open approach for inguinal hernia repair has been considered the gold standard. However,... (Observational Study)
Observational Study
INTRODUCTION
Inguinal hernia is a common surgical condition in children. Conventionally, the open approach for inguinal hernia repair has been considered the gold standard. However, in the past two decades, laparoscopic inguinal hernia repair has gained popularity among paediatric surgeons as an alternative to the open approach. Apart from good cosmesis and shorter stay at hospital, laparoscopy offers clear-cut advantages of visualising contralateral site and simultaneous repair if it is patent. Many techniques for laparoscopic inguinal hernia repair have been proposed. In this retrospective observational study, we are comparing outcomes between proximal and distal disconnection of hernia sac.
MATERIALS AND METHODS
Ninety-five patients with inguinal hernia were studied in two groups. Group A included 50 patients in which hernia sac was disconnected from the peritoneal cuff proximal to deep inguinal ring (DIR). Group B included 45 patients in which hernia sac was disconnected distal to DIR. Various sociodemographic parameters and intraoperative findings were compared. Outcomes were analysed in terms of post-operative pain, duration of stay at the hospital and recurrences.
RESULTS
In group A, there were 46 males and four females with mean age of 4.01 years with standard deviation (SD) of 2.96. Group B included 37 males and eight females with mean age of 5.09 years with SD of 3.56. Excess post-operative pain was observed in 33 patients in Group A with proximal disconnection of hernia sac whereas it was seen in only three patients in Group B with distal disconnection of sac. The P was 0.001 which was highly significant. The duration of stay in the hospital was more in Group A (2.36 ± 1.22 days) as compared to Group B (1.8 ± 0.66 days) with a P of 0.0076 which was significant. Hernia recurrence was seen in four out of 50 patients in Group A (8%) as compared to no recurrence in Group B. However, the difference was not significant.
CONCLUSION
The disconnection of hernia sac distal to DIR is associated with less post-operative pain and shorter duration of hospital stay. There is less recurrence seen in distal disconnection of hernia sac as compared to proximal disconnection; however, to achieve the level of significance, a large cohort study is required.
Topics: Male; Female; Child; Humans; Child, Preschool; Hernia, Inguinal; Laparoscopy; Pain, Postoperative; Herniorrhaphy; Retrospective Studies; Recurrence; Treatment Outcome
PubMed: 37470556
DOI: 10.4103/ajps.ajps_98_21