Cul De Sac Research Articles

Tips and Tricks for Successful Resection of Cesarean Scar Ectopic With an Obliterated Anterior Cul De Sac

Tips and Tricks for Successful Resection of Cesarean Scar Ectopic With an Obliterated Anterior Cul De Sac

Efficacy and safety of estetrol (E4) 15 mg/drospirenone (DRSP) 3 mg combination in a cyclic regimen for the treatment of primary and secondary dysmenorrhea: A multicenter, placebo-controlled, double-blind, randomized study.

To evaluate the efficacy and safety of the estetrol (E4) 15 mg/drospirenone (DRSP) 3 mg combination in a cyclic regimen in Japanese women with primary and secondary dysmenorrhea. A 16-week, multi-center, randomized, double-blind, placebo-controlled, parallel-group study, followed by a 36-week, open-label, extension study. 162 Japanese women with primary and secondary dysmenorrhea. Participants were randomly allocated to either the E4/DRSP group or the placebo group. In the E4/DRSP group, participants orally received one tablet containing E4 15 mg and DRSP 3 mg daily for 24 days, followed by a placebo tablet for 4 days, constituting one cycle. The placebo group was given one placebo tablet daily for 28 days. After 16 weeks, participants in the placebo group were switched to receive E4/DRSP for 36 weeks. Absolute change in the most severe total dysmenorrhea score from baseline to the end of the 16-week double-blinded period. E4/DRSP reduced the most severe total dysmenorrhea score by 2.3 points from baseline at week 16. The between-group difference was significant (-1.4, two-sided 95% confidence interval: -1.8 to -1.0), showing superiority to placebo (p<0.001). The responder rate, the proportion of participants who achieved a ≥2.0-point reduction in the most severe total dysmenorrhea score from baseline, was 64.3% in the E4/DRSP group, significantly higher than in the placebo group, 28.4%, (p<0.05). In the E4/DRSP group, visual analog scale scores for pelvic pain and dysmenorrhea symptoms during the menstrual bleeding periods were decreased by 44.2 mm and 42.3 mm, respectively, from baseline at week 16, significantly more than in the placebo group (p<0.001). Objective gynecological examinations suggested amelioration of pelvic tenderness, uterine mobility, and cul-de sac induration in the E4/DRSP group. E4/DRSP improved the quality of life-related questionnaires (interference with daily activities and sleeping) and global impression scores. Intermenstrual bleeding was the primary treatment-emergent adverse event in the E4/DRSP group, similar to combined oral contraceptives. There were no cases of venous thromboembolism and less impact on hemostasis parameters in the E4/DRSP group. E4/DRSP is an effective treatment for dysmenorrhea, offering a safe, new treatment option with potentially reduced thromboembolic risk.

Diagnosis and management of a case of gestational trophoblastic neoplasia with lumbosacral metastases.

Gestational trophoblastic neoplasia (GTN) with spinal metastasis is rare with few documented cases worldwide. Few studies have explored chemotherapy combined with radiotherapy in the treatment of such cases. However, because of its rarity, there is still no standardized treatment regimen. A 34-year-old Gravida 1 Para 0 (0010) was diagnosed with GTN with metastasis to the lumbosacral spine, resulting in conus medullaris syndrome with lumbar radiculopathy. She presented with a 14-month history of amenorrhea, left lower extremity pain, and urinary and bowel retention. On examination, there was a 10.0 × 7.0 cm lumbosacral mass and atrophy of the left lower extremity. Transvaginal ultrasound showed a cul de sac mass, and diluted β-human chorionic gonadotropin (β-hCG) titer was markedly elevated at more than 1000 000 mIU/mL. Magnetic resonance imaging (MRI) of the lumbosacral spine showed an ill-defined sacral mass measuring 13.3 × 11.5 × 6.3 cm with spinal canal, bone, muscle, and nerve root involvement. She was treated with 10 cycles of EMACO and palliative radiotherapy with 10 sessions of 30 Gy of external beam radiation therapy directed toward the lumbosacral mass. Repeat MRI showed a decrease in size of the mass to 6.6 × 8.2 × 4.1 cm with concurrent decrease in β-hCG to 1.30 mIU/ml, and resolution of leg pain and urinary and bowel symptoms. She was declared to be in remission 3 months after the last cycle of EMACO.

STATISTICAL OPTIMIZATION AND EVALUATION OF IN SITU GEL FOR THE OCULAR DELIVERY OF CROMOLYN SODIUM

Objective: The study aimed to develop and optimize cromolyn sodium-based ocular in situ gel to improve the ophthalmic contact period and provide sustained drug release for treating allergic conjunctivitis. Methods: Formulations were prepared using sodium alginate and HPMC K4M (Hydroxypropyl Methylcellulose) polymers and were characterized and evaluated for viscosity, gelling time, in vitro drug release, and optimized using a factorial 32 DOE design (Version 11; Design Expert® software). The resulting cromolyn sodium-based formulation was tested for hyperemia and eye-scratching behavior in Wistar albino rats. Results: Increased polymer concentrations resulted in higher viscosity with decreased gelling time and in vitro drug release. The optimized formulation achieved a viscosity of 15.350 cps, a gelling time of 55.137 s, and sustained drug release of 92.61% over 12 h. The in vivo pharmacodynamic study of the optimized formulation showed a significant decrease in the frequency of eye-scratching behaviour (7.525) at a significance level of (**p&lt;0.01) and hyperemia (1.125) (***p&lt;0.001, *p&lt;0.05) compared to negative and positive control indicating that the developed in situ formulation improved the drug's therapeutic effectiveness by extending its duration within the cul de sac. Conclusion: In light of these findings, this optimized cromolyn sodium in situ gel holds promise as a viable alternative to conventional eye drops

Successful pregnancy outcome with a large ruptured juvenile granulosa cell tumor: A case report

Background: Juvenile granulosa cell tumors (JGCTs) are rare sex cord stromal tumors diagnosedmainly in premenarchal girls and women younger than 30 years. Case presentation: A 19-year-old primigravida at 36 weeks of gestation presented to the labor ward withcomplaints of generalized abdominal pain, headaches, and reduced fetal movements for two days.Ultrasound revealed a left-sided 15.7 by 15 cm large cyst and a solid mass of increased vascularity withmaternal ascites. The biophysical profile of the fetus was 4/8 (no movement or tone but the presence ofrespiration and amniotic fluid). An emergency exploratory laparotomy was performed, and intraoperativefindings revealed a massive torsed right ovary with a ruptured ovarian mass with grossly edematous and necrosed fallopian tubes. Following a safe cesarean section delivery of the fetus, a right salpingo-oophorectomy with cystectomy was performed. The histopathological results confirmed the diagnosis of JGCT FIGO stage IC2. Postoperatively, the patient was treated with six sessions of chemotherapy(cisplatin and paclitaxel). Post-chemotherapy magnetic resonance imaging showed normal abdominalviscera with minimal free fluid in the posterior cul de sac and a normal left ovary. Inhibin B levels droppedto 3.17, and the patient is on follow-up for the next 5 years with repeated tumor marker testing andcomputed tomography scans.Conclusion: JGCT is a very uncommon pregnancy tumor, and aggressive treatment is necessary foradvanced-stage tumors such as the one in this case to prevent recurrence or even death.

Acute Intestinal Obstruction Due to a Foreign Body Migrated into the Abdomen after a Clandestine Abortion Almost 20 Years Ago

Acute intestinal obstruction caused by a foreign body is no longer a rare phenomenon, especially if the latter is found in the digestive tract. However, the migration of an extradigestive foreign body as a cause of obstruction is extremely rare. We report the case of a 60-year-old female patient seen urgently on September 5, 2023 at 3:00 p.m. at the District Hospital of Commune IV of Bamako with the diagnosis of acute intestinal obstruction. Intraoperatively we noted grélo-uterine, grélo-sigmoid adhesions and bands tying the terminal ileum with significant intestinal dilatation upstream without signs of necrosis. Also a foreign body (tubing of a serum infuser) rigid curved of approximately 40 cm was located between the loop. The procedures performed were: adhesiolysis, sectioning of the flanges, extraction of the foreign body, toileting and installation of a Redon drain in the Douglas cul de sac. The in-depth postoperative questioning revealed a notion clandestine abortion in 2003 by a nurse in a country in the sub-region, leaving an infusion tube in place for a few hours. And she was supposed to go in the next day for a check-up, but she didn't show up. Our medical team reviewed the ASP image where we noted in addition to the central hydroaeric levels, an inverted U-shaped image of a foreign body (infuser tubing) going from the left hypochondrium to the left iliac fossa. confirming the diagnosis intraoperatively. The postoperative course was simple. The patient returned home on postoperative day 5.

When to MRI

MRI is a non-invasive second line tool which can make a valuable contribution to the diagnosis and pre surgical mapping of pelvic endometriosis. It is validated and serves as an adjunct to high quality ultrasound. It has particular strengths in the mapping of complex obliterative deep cul de sac disease and adjacent organ involvement. It has high sensitivity and specificity in diagnosing pelvic endometriosis and can upstage the degree of endometriosis compared to diagnostic laparoscopy. The use of MRI for endometriosis in Australia has significantly increased in the last 5 years and there is growing national and international research occurring in this space. Access has also improved dramatically for patients since the allocation of $25m of funding to make available Medicare funding for MRI imaging of suspected significant endometriosis by the Federal Government in mid-2022. As clinician and community awareness of improved MRI access grows, it is even more important to have a working knowledge of the strengths and weaknesses of MRI for anyone involved in the diagnosis, workup, and management of patients with suspected or proven endometriosis.

Ultrasound Integrated Robotic Identification of Sigmoid Colon Deep Endometriosis in the Absence of Posterior Cul De Sac Obliteration

Ultrasound Integrated Robotic Identification of Sigmoid Colon Deep Endometriosis in the Absence of Posterior Cul De Sac Obliteration

Update on the Geographic Distribution of the Intermediate Host Snails of Schistosoma mansoni on St. Lucia: A Step Toward Confirming the Interruption of Transmission of Human Schistosomiasis.

To provide information to guide considerations of declaring interruption of transmission of human schistosomiasis due to Schistosoma mansoni on St. Lucia, we undertook an island-wide survey in June-July 2022 to determine the presence of Biomphalaria snails, the intermediate hosts of S. mansoni, and their infection status. Snail surveys were carried out at 58 habitats to determine presence of Biomphalaria snails followed by examination of the collected snails for evidence of infection with S. mansoni. Furthermore, water samples were collected at the snail habitats and screened for presence of S. mansoni DNA using an eDNA approach. We found B. glabrata present in one habitat (Cul de Sac) where it was abundant. Specimens provisionally identified as Biomphalaria kuhniana were recovered from 10 habitats. None of the Biomphalaria specimens recovered were positive for S. mansoni. None of the eDNA water samples screened were positive for S. mansoni. Experimental exposures of both field-derived and laboratory-reared St. Lucian B. glabrata and B. kuhniana to Puerto Rican and Kenyan-derived S. mansoni strains revealed B. glabrata to be susceptible to both and B. kuhniana proved refractory from histological and snail shedding results. We conclude, given the current rarity of B. glabrata on the island and lack of evidence for the presence of S. mansoni, that transmission is unlikely to be ongoing. Coupled with negative results from recent human serological surveys, and implementation of improved sanitation and provision of safe water supplies, St. Lucia should be considered a candidate for declaration of interruption of human schistosomiasis transmission.

Clinical, Diagnostic and Therapeutic Aspects of Acute Appendicitis at the Reference Health Center of Commune I-Bamako

Acute appendicitis is the most frequent abdominal surgical emergency in the world. The aim of this study was to analyse the results of surgical management of acute appendicitis. Methodology: This was a prospective study from January 2020 to December 2020 in the reference health centre in Commune I of Bamako. Results: During this period, we operated on 108 patients for acute appendicitis, including 78 men and 30 women, for a sex ratio of 2.5. The mean age was 26.92 years, ranging from 5 to 70 years. Abdominal pain was the main reason for consultation. Physical signs were dominated by a positive Blumberg's sign in 99.1% of cases, right iliac fossa defensiveness in 97.2% of cases, Rovsing's sign in 50% of cases, psoitus (Psoitis) in 18.5% and pain on the right in the cul de sac of Douglas in 69.4%. This physical examination enabled the diagnosis to be made in the majority of cases. In some doubtful cases, we requested an abdominal ultrasound scan. Locoregional anaesthesia was the most commonly used anaesthetic technique (63.9%). Classic Mac Burney appendectomy with burial of the stump was the surgical technique most frequently used. Postoperative recovery was straightforward in 97.2% of cases. However, we recorded one case of death. Conclusion: Acute appendicitis remains the most frequent abdominal surgical emergency in the community. Early diagnosis and rapid management improve prognosis. Treatment is essentially surgical.

An Autoethnography of Hybrid IR Scholars: De-Territorializing the Global IR Debate

Abstract Who can speak from the perspective of the Global South? In answering this question, Global International Relations (IR) finds itself in a cul de sac: rather than globalize IR, Global IR essentializes non-Western categories by associating difference and knowledge to place (countries, regions, and civilizations) which occludes de-territorialized forms of knowledge production. To reach out for these forms of knowledge, we develop the concept of “hybrid subjectivity,” and propose a shift from the macro to the micro. We propose autoethnography as a method to proceed with this move and present two case studies based on our experiences as hybrid IR scholars to illustrate it. In doing so, we demonstrate the relevance of our self-reflexive exercise in deconstructing reified categories and rendering visible new forms of knowledge in the Global IR debate. This article’s conceptualization of hybrid subjectivity enables the recasting of Global IR in a relational, hybrid, and truly global framework for analysis. The argument goes beyond the confines of Global IR and adds essential analytical value to critical, decolonial, and pluriversal critiques of wester-centrism in IR; in the sense of opening new theoretical and empirical possibilities, as an alternative to current intellectual efforts to recover non-colonial or pre-colonial forms of non-Western authenticity.

Tuberculous PYO-Pneumothorax: A Rare and Severe form of Tuberculosis

Introduction: Tuberculosis is still a public health problem in Morocco. Tuberculous pyopneumothorax is a rare but serious complication secondary to the rupture of a tuberculous cavern in the pleural cavity. It is a well-known clinical form occurring mainly in extensive forms of tuberculosis and in frail patients. In our context, it poses a management problem. We report the case of a young man, chronic smoker, who presented with dyspnea and productive cough revealing a tuberculous pyopneumothorax. Case Report: The patient was a 28 year old male, chronic smoker with 10 PA always active, without any particular pathological history, who had been presenting for 2 months with a productive cough bringing back yellowish sputum with Sadoul stage III dyspnea, and progressive chest pain, all evolving in a context of altered general condition and feverish feeling. The clinical examination found a conscious patient, polypneic at 26 cpm, febrile at 38C°, hemodynamically stable, with objective pleuro pulmonary examination of a left aerial pleural effusion syndrome. A chest X-ray was requested in first intention, objectifying an opacity occupying the internal 2/3 of the left pulmonary hemichamp, not very dense, heterogeneous, seat of some cartées within it in connection with bronchograms with a clear external and internal limit drowned in the mediastinum, a left pneumothorax of great abundance made of an axilobasal parenchymatous hyperclarity without vascular framework with enlargement of the EICs and refoulement of the elements of the mediastinum towards the counter lateral side, and a filling of the left costo diaphragmatic cul de sac. A complementary thoracic CT scan noted a left hydropneumothorax of great abundance associated with pneumonic foci complicated by abscesses and multiple branching micronodules of the right upper lobe and middle lobe suggestive of a tuberculous origin. A drainage of the pyo-pneumothorax was performed with a bacteriological, cytological and ..........

Game Theory and Demonstratives

This paper argues, based on Lewis’ claim that communication is a coordination game (Lewis in Minnesota studies in the philosophy of science, University of Minnesota Press, Minneapolis, pp 3–35, 1975), that we can account for the communicative function of demonstratives without assuming that they semantically refer. The appeal of such a game theoretical version of the case for non-referentialism is that the communicative role of demonstratives can be accounted for without entering the cul de sac of trying to construct conventions of ever-increasing complexity. Instead communication via demonstratives is explained with reference to the general, non-domain specific ability of human beings to solve games of coordination. Furthermore, there is empirical support for such a view. Judgments concerning demonstrative reference have been shown to be sensitive to judgments concerning common ground (Clark et al. in J Verb Learn Verb Behav 22:245–258, 1983), which is exactly what the non-referentialist account would predict. The game theoretical account also allows for an intuitively plausible, non-referentialist treatment of Speaks’ ‘trumping argument’ (Speaks in Philos Stud 174:709–734, 2017), as well as the Carnap/Agnew puzzle (Kaplan in Syntax Semant 9:221–43, 1970).

Development of a prey-predator species distribution model for a large piscivorous fish: A case study for Japanese Spanish mackerel Scomberomorus niphonius and Japanese anchovy Engraulis japonicus

One of the major challenges of species distribution models (SDMs) is incorporating the influence of prey on the predator. An ensemble modeling approach, the prey-predator species distributabion model (PPSDM), uses environmental variables (sea surface temperature, bathymetry, sea surface salinity, and sea surface current) and a biotic variable (predicted prey distribution: Japanese anchovy) to predict a piscivorous fish (Japanese Spanish mackerel) habitat in the China Seas. PPSDM comprised selected preferable single algorithms from nine algorithms, including tree-based models, machine learning models, regression models, an envelope-style method, and a classification model. Compared with that obtained when using habitat without the Japanese anchovy distribution, the regression models, machine learning models and a classification model have significant improvements. However, tree-based models have only slightly improved. The PPSDM results well reflected the ontogenetic migration of Japanese Spanish mackerel. We found that the wintering ground was distributed in regions with temperatures between 11 and 17 °C and salinities between 33.6 and 34.1. The bottom topography was also closely correlated with Japanese Spanish mackerel, and the suitable habitat was at 50–100 m isobaths as topography determined the position of isotherms (11, 17 °C), salinity isolines (33.6, 34.1), and fronts (temperature, salinity) in winter. The relationships among different climatic indices, temperature, and Japanese Spanish mackerel were analyzed. We found that the East Asian monsoon significantly influenced the Japanese Spanish mackerel habitat by affecting temperature variation. In the future, the suitable habitat of Japanese Spanish mackerel is projected to decrease by 21%, 28%, 36%, and 42% under RCP2.6, RCP4.5, RCP6.0, and RCP8.5, respectively. The Japanese Spanish mackerel in the northern Yellow Sea is projected to experience the ‘cul de sac’ effect, which would drive this species toward local extinction. The Japanese Spanish mackerel in the China Seas will probably shift northeastward through the Tsushima Strait, and the Sea of Japan may form the main habitat at the end of the century.

8574 Robotic-Assisted Correction of Sacrocolpopexy Mesh Erosion

<h3>Study Objective</h3> This video highlights the technique for robotic-assisted laparoscopic correction of sacrocolpopexy mesh erosion into the vaginal cuff. <h3>Design</h3> N/A. <h3>Setting</h3> This surgery is performed at a tertiary teaching hospital. <h3>Patients or Participants</h3> 56-year-old gravida 1 para 1 with persistent vaginal discharge and intermittent bleeding, noted to have a retained foreign body eroding into the vaginal cuff ten years after undergoing abdominal hysterectomy due to pelvic organ prolapse. <h3>Interventions</h3> The patient underwent a robot-assisted laparoscopic excision of an eroded sacrocolpopexy mesh. After extensive adhesiolysis was performed, the pelvic sidewalls were opened, and bilateral ureterolysis was performed. The bladder was carefully dissected away from the vaginal cuff. Colpotomy was performed, and the eroded foreign body was visualized and identified as a mesh. Intraoperative cystoscopy confirmed there was no bladder erosion. The colpotomy was extended laterally, and the mesh was dissected using monopolar scissors. The presacral peritoneum was incised, and the presacral space was developed towards the cul de sac. The mesh was densely adhered to the right uterosacral ligament (USL) and extended cranially towards the sacral area. The mesh was transected at the level of the right USL and removed vaginally. The vaginal cuff was closed with a 0 polydioxanone suture in two layers. The left USL was then transfixed to the vaginal cuff. <h3>Measurements and Main Results</h3> The mesh was successfully removed, and the patient's symptoms resolved. <h3>Conclusion</h3> This approach offers optimal exposure and ease of access for excision in cases of vaginal mesh erosion. This can be especially beneficial in patients with dense adhesions from prior surgery. There are limited case reports describing laparoscopic correction of sacrocolpopexy mesh erosion, and further studies are necessary to compare this to the vaginal approach.

Assessing The Role and Accuracy of Ultrasonographic Imaging in The Diagnosis of Deep Infiltrating Endometriosis: A Cross-Sectional Study.

Deep infiltrating endometriosis (DIE) is described as an endometriotic tissue that penetrates more than 5 mm under the peritoneal surface. It's suggested that trans vaginal sonography (TVS) is 79% sensitive and 94% specific in the assessment of intestinal DIE. Considering the possibility that DIE ultrasonography (rectal and\or vaginal ultrasonography) might be more accurate, we designed this study to assess this study to evaluate the accuracy of DIE ultrasonography. In this retrospective cross-sectional study, we designed and conducted this study from 2019 to 2020 on patients suspected of severe endometriosis. Our patients underwent ultrasonographic imaging and based on the results became candidates for surgery. We compared histopathological results with sonographic findings using crosstabulation and chi-square tests were used to measure accuracy. P<0.05 were considered statistically significant. Following pathological assessments of 109 cases, 97 cases had ovarian endometrioma, 42 cases had intestinal involvement and 56 cases had uterosacral DIE. The results for accuracy were as the following; uterosacral ligament (USL) involvement SE: 96.4% and SP: 59.1%; intestinal involvement SE: 97.6% and SP: 73.8%; and Cul de sac involvement with SE: 100% and SP: 50.8%. With regards to ovarian endometrioma, ultrasonographic imaging was 99.0% sensitive and 84.6% specific. With regards to intestinal involvement, ultrasonography performed a reliable overall diagnosis (97.6% sensitive and 73.8% specific). However, the results showed lower accuracy regarding the level of intestinal involvement. The accuracy for other sites and cavities was low except for ovarian endometrioma. The results of the present study demonstrated that pre-operative TVS and Transrectal ultrasound (TRUS) can be a helpful paraclinical tool in the assessment and diagnosis of DIE and endometriosis in general and particularly with adnexal and bowel lesions, it can have some shortcomings with respect to cul de sac and USLs.

Treatment of a stallion for penile deviation caused by haemorrhage into the corpus cavernosum penis

SummaryA 19‐year‐old Thoroughbred stallion developed severe curvature of its penis, preventing intromission, after breeding a mare. The cause of the curvature was found, during ultrasonographic examination of the penis, to be rupture of the trabeculae on the left side of the corpus cavernosum penis (CCP) between the cul de sac of the external preputial cavity and the scrotum, resulting in the formation of a seroma. Aspiration of the seroma performed 13 days after injury, with the horse anaesthetised, largely resolved the deviation. A complication of treatment was excessive belling of the glans penis during erection, which may have been the result of a temporary shunt created between the CCP and the corpora spongiosum penis (CSP) by inadvertently passing the spinal needle used to aspirate the seroma through the CSP. Excessive belling resolved after 3 weeks.

Stuck in a cul de sac of care: Therapy Assistance Online and the platformization of mental health services for college students

Many reports indicate higher education counseling centers are finding it difficult to keep pace with the growing rates of stress, anxiety, depression, and sleeping difficulties in undergraduate populations. Some universities are turning to telepsychology, or means of providing mental health care through videoconferencing, software, and other digital tools. This article analyzes one such platform, therapy assistance online (TAO), through a critical walkthrough of the platform’s self-help modules to consider how they communicate and construct care as individual labor which generates data for the platform. We argue that by removing traces of the therapist’s body and, in turn, dialogic communication, the platform produces modes of neoliberal self-care operationalized through data extraction, where the individual user works through modules while providing personal information to the platform. While TAO is offered as a solution to overcrowded and understaffed care facilities, it demonstrates some limitations of relying on third-party platforms to care for students.

Gastrointestinal symptoms as a predictor of deep endometriosis of the pelvic posterior compartment on magnetic resonance imaging

Objective: To determine if gastrointestinal (GI) symptoms can predict deep endometriosis (DE) of the posterior pelvic compartment on magnetic resonance imaging (MRI). Methods: Patients with suspected endometriosis undergoing endometriosis protocol MRI at an academic center between 9/1/2015 and 7/31/2018 were identified. Presenting GI symptoms were collected via a standardized survey instrument prospectively at initial presentation. MRI and interdisciplinary conference notes were reviewed to identify posterior compartment DE (rectosigmoid, uterosacral ligaments, posterior cul de sac, and pelvic side walls). Associations between symptoms and DE were evaluated. Results: A total of 104 patients met inclusion criteria, and 89 (85.6%) presented with at least one GI symptom. Posterior compartment DE was identified on MRI in 47 patients (45.2%). The GI symptom that most strongly predicted DE was a bowel movement resulting in pain relief (OR 3.36, 95% CI 1.31–8.61, p = 0.012), with sensitivity, specificity, positive and negative predictive values 0.42, 0.82, 0.67, and 0.63, respectively. Other GI symptoms such as nausea, vomiting, rectal bleeding, change in frequency of bowel movements, and pain exacerbation by bowel movements did not significantly correlate to having DE. Of the 15 patients with no GI symptoms, 5 were found to have posterior compartment DE. Conclusion: In patients with suspected endometriosis, those who noted that bowel movements relieved their pain had more than three times the odds of having DE of the posterior compartment on MRI. Preoperative evaluation with MRI may be of value in these patients; however, lack of gastrointestinal symptoms does not exclude the possibility of posterior compartment DE.

Robotic Management of Diaphragmatic Endometriosis in 10 Steps

To present 10 standardized steps of the surgical management of diaphragmatic endometriosis using Da Vinci robotic assistance. Surgical education video. The local institutional review board confirmed that the video met ethical criteria required for publication. Patient consent was obtained. Tertiary referral center. The film presents a standardized way of performing excision of diaphragmatic endometriosis using the following 10 steps: (1) The patient is placed in left lateral decubitus and 10° proclivity [1,2]. (2). Three 8-mm wide incisions are made, including on the right medio-clavicular line for the endoscope, on the medio-axillar line for the bipolar forceps, and 2 cm below the xiphoid appendix for the scissors. A 10-mm incision is made 3 cm above the umbilicus for the assistant trocar. (3) The procedure starts by an inspection of the right diaphragmatic surface; the falciform ligament is sectioned to allow exploration of the left diaphragm and supplementary mobilization of the liver. (4) Adhesions are completely sectioned, down to the hepato-phrenic cul de sac, tangentially to the liver surface. (5) Small lesions, which do not require full thickness excision, are first removed, before creating a pneumothorax, using a low monopolar setting at 20 watts [3]. (6) Full thickness excision of transfixing lesions or holes is carried out using monopolar scissors and results in an immediate complete right pneumothorax [2,4]. (7) The pleural cavity is inspected to identify disseminated lesions in the chest, located far from the diaphragm. (8) Repairing of the diaphragm is carried out by performing a unidirectional barbed suture. (9) Before performing the final knot, the laparoscopic suction irrigation canula is introduced into the chest cavity, and the CO2 used for inflation is fully aspirated, leading to the creation of the diaphragm concavity; the use of a chest drain is therefore not necessary. (10) Despite the lack of high-level of evidence data, we routinely use an antiadhesion agent, with an aim to reduce postoperative adhesions. Operative time varies from 30 min to 1 hour. Chest X-ray is routinely performed at postoperative day 1. To date, in 76 patients, X-ray did not reveal postoperative relevant pleurisy requiring chest drainage. The robotic-assisted laparoscopic excision of deep endometriosis involving the diaphragm is a standardized 10-step procedure that allows a complete removal of diaphragmatic lesions with good clinical outcomes.