History Of Lower Abdominal Surgery Research Articles

Surgeons' Approach to Intraoperative Complications in Total Extraperitoneal (TEP) Hernia Repair.

This study aimed to determine the frequency of laparoscopic inguinal hernia repair (LIHR) and how surgeons managed complications such as intraoperative bleeding, organ damage, and peritoneal injury that may develop during this procedure. The data for the study were collected through an electronic survey created using Google Forms and sent using WhatsApp in May 2024. The study included 220 of 250 surgeons (88%) working in 25 healthcare centers located in different regions where the survey was distributed. Fourteen respondents with missing data were excluded from the study. The mean age of the remaining 206 participants was 39.6 (27-69) years. The rate of surgeons using laparoscopic techniques in inguinal hernia surgery was 89.3%. The method most preferred by the surgeons performing LIHR was total extraperitoneal (TEP) repair (60.9%), followed by transabdominal preperitoneal (TAPP) repair (39.1%). The surgeons preferred open procedures in patients with a history of lower abdominal surgery, those with scrotal hernia, and elderly patients. Additionally, in cases of intraoperative complications that developed at different stages of TEP, it was observed that participants mostly convert to the TAPP technique (43.5-46%), and in some cases, almost all participants continued the procedure with the same technique, i.e., TEP repair (94.6%). This study revealed that surgeons preferred open procedures in some specific patient groups, but they mostly preferred LIHR in the remaining cases. Young surgeons, in particular, seem more inclined to employ laparoscopic methods. In cases of intraoperative complications, most surgeons chose to continue with laparoscopic techniques.

RETRACTED ARTICLE: Retrospective study of preservation and transection of the round ligament of uterus during laparoscopic transabdominal preperitoneal inguinal hernia repair in adult women

PurposeThe processing of the round ligament of uterus in laparoscopic transabdominal preperitoneal (TAPP) repair of inguinal hernia in women has contended. This study aimed to explore whether there is any difference in the surgical outcome and postoperative complications between the two processing modalities, preservation, and transection of the round ligament of uterus, in adult female inguinal hernia patients undergoing TAPP.MethodsRetrospective analysis of 84 female patients (117 sides) who underwent TAPP in XXX Hospital from July 2013 to August 2022. Patient characteristics and technical details of the surgical procedure were collected and divided into two groups according to whether the round ligament of uterus was severed intraoperatively or not. There were 52 cases (77 sides) in the group with preservation of the round ligament of uterus and 32 cases (40 sides) in the group with transection of the round ligament of uterus, comparing the general condition, surgical condition, and the occurrence of postoperative related complications between the 2 groups.ResultsThe operative time for unilateral primary inguinal hernia was (129.2 ± 35.1) and (89.5 ± 42.6) minutes in the preservation and transection groups, respectively. There were no statistical differences between the two groups in terms of age, length of hospital stay, ASA, BMI, history of lower abdominal surgery, type and side of hernia, intraoperative bleeding, and time to surgery for primary bilateral hernia (P > 0.05). In addition, there was likewise no statistical difference in the occurrence of postoperative Clavien–Dindo classification, VAS, seroma, mesh infection, labia majora edema, chronic pain or abnormal sensation in the inguinal region, and hernia recurrence in the two groups as well (P > 0.05).ConclusionThere is no evidence that the transection of the round ligament of the uterus during TAPP has an impact on postoperative complications in patients. However, given the important role of the uterine round ligament in the surgical management of patients with uterine prolapse and the high incidence of uterine prolapse in older women, hernia surgeons should also be aware of the need to protect the round ligament of uterus in older women.

OC-044 TOTAL EXTRAPERITONEAL ENDOSCOPIC INGUINAL HERNIOPLASTY (TEP) IN PATIENTS WITH PREVIOUS LOWER ABDOMINAL SURGERY. IS IT A WORRISOME INDICATION?

Abstract Aim The purpose of the study is to analyze whether a previous medical history of lower abdominal surgery (or pelvic radiotherapy) involves a different postoperative outcome in TEP inguinal repairs. Material & Methods We performed a retrospective analysis of 1252 TEP procedures included from 2015 to 2019 at our institution. We compared the short-term intraoperative difficulties and the postoperative outcome in patients with and without previous lower abdominal surgeries. The postoperative data collected included variables such as comorbidities, hernia classification, intraoperative complications, rate of conversion to open surgery, admission status, postoperative follow-up, chronic pain, and hernia recurrence. We defined a “surgical success” dichotomous variable only for patients in an outpatient setting. It included cases with no complications during surgery, no need for conversión, and no chronic pain, no readmission or recurrence during followup. Results Out of the 1252 TEP procedures, 250 (19%) had previous lower abdominal surgery (or pelvic radiotherapy). At the time of applying the “surgical success” variable we found a statistically significant difference in the conversion to open surgery rate between both groups (0.7% versus 5.6% p value 0.005). No differences were found in complications, readmissions, chronic pain, functional recovery or recurrence rates. Conclusions TEP procedure in patients with previous lower abdominal surgery showed a higher rate of conversion to open surgery compared to previously non operated patientes. The fact of having previous surgery did not imply however a worse postoperative outcome after a TEP procedure.

Prevention and management of intraoperative complication during single incision laparoscopic totally extraperitoneal repair.

Serious complications related to hernia surgeries have rarely been reported. One meta-analysis comparing laparoscopic and open mesh repair reported that 0.4% of potentially serious operative complications were reported. Previous studies have reported that uncommon serious intraoperative complications more frequently occur during laparoscopic inguinal hernia repairs. One study has shown that patients with history of lower abdominal surgery are at an increased risk of visceral injury during laparoscopic hernia repair. Vascular injuries at dissection and mesh fixation or suturing in the preperitoneal space typically involve the epigastric or aberrant obturator vessels crossing the Cooper’s ligament. However, complications can occur at every step of the operation, although only few are reported. Therefore, we report our experiences of intraoperative complications during single-incision laparoscopic totally extraperitoneal hernia repair and how to prevent and manage intraoperative complications.

Prevalence and Associated Factors of Urinary Incontinence among Elderly in Pekanbaru, Indonesia

Background: The proportion of the elderly in Riau Province was 4.8% higher than that (4.2%) in 2011. Urinary incontinence (UI) is a common health problem among the elderly. This study aims to determine the prevalence and associated factors for UI among the elderly (≥60 years). Methods: This cross-sectional study was conducted in 20 public health centers in Pekanbaru City in 2018. A total of 351 elderly meeting the inclusion criteria were enrolled. Gender, age, education, occupation, marital status, obesity, depression, cognitive impairment, smoking status, history of chronic cough, and history of lower abdominal surgery served as the independent variables and UI as the dependent variable. Data were collected through interviews facilitated by staff trained by the research team. Data were analyzed using multiple logistic regression with a predictive factor model to assess the relationship between the independent and dependent variables. Results: The prevalence of UI was 6%, and the associated factors were chronic cough (prevalence odds ratio = 17.661; 95% CI: 6.380–48.884). Gender, age, education, and lower abdominal surgery were the confounding factors. Conclusions: Health workers at the public health center of Pekanbaru should educate the community and the elderly about the potential causes, prevention, and treatment of UI.

Evaluation of the Results and Complications of Transabdominal Preperitoneal Laparoscopic Inguinal Hernia Repair in Patients with a History of Radical Prostatectomy.

Radical prostatectomy is one of the most common urological surgeries. Inguinal hernia is a well-known complication of radical prostatectomy. There are many controversies about selection of surgical techniques for repair of inguinal hernia. Traditionally laparoscopic approach was contraindicated for patients with history of lower abdominal surgery, but recent studies showed that it could be safe and successful and even has some advantages over open repair. In this prospective study we evaluated outcomes of laparoscopic hernia repair in patients who previously underwent radical prostatectomy. In this prospective study, 34 consecutive patients diagnosed with inguinal hernia after radical retropubic prostatectomy underwent laparoscopic transabdominal inguinal repair and followed up for outcomes and complications. The surgery duration was 167.44 ± 52.85 min (75-230 min). No intraoperative complications occurred. Patients were discharged within 20.79 ± 4.76 hours (12-34 hours). 69.8% of cases (30 patients) needed analgesic administration. No conversion to open surgery occurred. There were 9.3% (4 hernias) hernia recurrences. We followed patients for 9.9 ± 5.33 months (2-19 months). It is concluded that TAPP for inguinal hernia repair after radical prostatectomy has good results and is effective. But according to rate of recurrence, its safeness is conflicting. We notice no major complication in our patients during the time of follow up. This may be due to safety of the operation in the proposed patients.

Effect of Previous Lower Abdominal Surgery on Outcomes Following Totally Extraperitoneal (TEP) Inguinal Hernia Repair.

Previous lower abdominal surgery is generally considered as a relative contraindication for laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. Our objective was to investigate the feasibility and safety of TEP repair in patients with a history of lower abdominal surgery. A retrospective analysis of 301 patients with inguinal hernia who underwent elective laparoscopic TEP repair between August 2010 and August 2014 was conducted. One-hundred five patients (34.9%) had previously undergone lower abdominal surgery. The main outcome measures included intraoperative and postoperative morbidity and mortality. Secondary outcomes were immediate postoperative pain, presence of chronic pain at follow-up, and hernia recurrence. Patient demographics and clinical variables were balanced between the 2 groups, with the exception of age. Intraoperative morbidity was similar between cases without previous lower abdominal surgery (nPS) and cases with history of lower abdominal surgery (PS) [nPS vs. PS: 0.5% (n=1) vs. 2.8% (n=3), P=0.09]. Overall 30-day morbidity was found to be significantly higher in the PS patient group [nPS vs. PS: 1.5% (n=3) vs. 6.6% (n=7), P=0.018]. Mortality was nil. There were no differences noted between the 2 groups with respect to early postoperative pain and chronic inguinal pain. Complete follow-up information was available for 149 of 301 patients (follow-up rate of 49.5%, range: 3 to 48 mo) with a mean follow-up time of 20.38 months (SD=7.7). There was no statistically significant difference noted in the recurrence rate between the 2 patient groups at follow-up [nPS vs. PS: 3.2% (n=3) vs. 1.8% (n=1), P=0.6]. The present work demonstrates higher incidence of postoperative scrotal hematoma after TEP repair in patients with history of previous lower abdominal surgery. All remaining outcomes of interest were found to be similar between the 2 patient groups. Further trials will be needed to verify our findings.

Meta-analysis of totally extraperitoneal inguinal hernia repair in patients with previous lower abdominal surgery

Previous lower abdominal surgery is considered a relative contraindication to laparoscopic totally extraperitoneal (TEP) inguinal hernia repair. This was a meta-analysis of studies comparing the feasibility and safety of TEP repair between patients with (PS), and without (NS) a history of lower abdominal surgery. A systematic literature search was undertaken for studies comparing the outcome of TEP inguinal hernia repair in patients with, and without previous lower abdominal surgery. Data on postoperative outcomes were extracted and compared by meta-analysis. Odds ratios (ORs) and mean differences with 95 per cent confidence intervals were calculated. Seven comparative cohort studies were identified, involving a total of 1657 procedures (PS 326, NS 1331). There was a statistically significant difference between PS and NS favouring the NS group with regard to both primary outcomes: intraoperative morbidity (OR 2·85, 95 per cent c.i. 1·19 to 6·80; P =0·02; 7 studies; I2 = 33 per cent), and postoperative morbidity in the multiport subgroup (OR 2·14, 1·28 to 3·58; P =0·004; 5 studies; I2 = 0 per cent). For the secondary endpoints conversion rate, peritoneal tears, major intraoperative bleeding, postoperative haematoseroma and delay in return to normal activities, there was a statistically significant difference favouring the NS group. This study suggests that patients with previous lower abdominal surgery who need hernia repair get less benefit from TEP repair than those with no history of surgery.

Safety and feasibility of laparoscopic gastrectomy for gastric cancer patients with a history of abdominal surgery.

To assess the safety and feasibility of laparoscopic gastrectomy (LG) for gastric cancer patients with a history of abdominal surgery (HAS). This retrospective study analyzed data collected from gastric cancer patients with HAS, who underwent LG between 2004 and 2015. We compared the clinicopathological features that correlated with conversion to open surgery and the development of severe postoperative complications (Clavien-Dindo classification of grade III or higher). Of the 41 patients identified, 6 (14.6%) required conversion to open surgery. The incidence of conversion to open surgery was associated with a history of lower gastrointestinal tract surgery (p = 0.009), attempted laparoscopic total gastrectomy (p = 0.002), and excessive blood loss (p < 0.001). Severe postoperative complications developed in six patients (14.6%). Although the development of complications was associated with high postoperative serum C-reactive protein, the type of past abdominal surgery was not significantly correlated with severe complications. LG was feasible for gastric cancer patients with a HAS, but for those with a history of lower abdominal surgery or those who require total gastrectomy, surgeons should carefully consider the indications for LG.

Laparoscopic Totally Extraperitoneal Hernia Repair after Radical Prostatectomy or Lower Abdominal Surgery Except for Appendectomy – Experience of 35 Cases

Purpose: Laparoscopic totally extraperitoneal (TEP) hernia repair is known to be relatively difficult in cases with a history of lower abdominal surgery. We assess the feasibility of laparoscopic TEP hernia repair in those patients. Methods: Thirty five patients with a previous history of radical prostatectomy or lower abdominal surgery who underwent laparoscopic TEP hernia repair for inguinal hernia were reviewed retrospectively. All operations were performed by a single experienced surgeon. Results: Thirty three out of the 35 patients (94%) were men. Laparoscopic TEP hernia repair was performed successfully in 30 out of 35 cases. Twenty five cases (71%) were right inguinal hernia, 6 cases (17%) were left hernias, and 4 cases (11%) had an inguinal hernia on both sides. Five cases were converted to transabdominal preperitoneal (TAPP) (n=3) or open methods (n=2). Mean operation time was 111 minutes. The patient group with previous radical prostatectomy was the largest (n=22, 63%) and required a longer operation time (124 minutes). Blood loss was less than 50 cc in all cases. Average hospital stay was 1.2 days after surgery. Voiding difficulties requiring catheterization were observed in 13 cases (37%). Conclusion: Laparoscopic TEP hernia repair for a patient with previous history of radical prostatectomy or lower abdominal surgery except for appendectomy can be safely performed by an experienced surgeon, but is not recommended as a standard choice because of a longer operation time and higher conversion rate.

Direct Application of Single-Port Laparoscopic Totally Extraperitoneal (TEP) Inguinal Hernia Repair by an Experienced Single-Port Laparoscopic Surgeon Who Was Inexperienced in Conventional TEP Hernia Repair: Initial Experience with 100 Cases

Single-port laparoscopic surgery (SPLS) has been introduced for totally extraperitoneal (TEP) inguinal hernia repair. The aim of this study was to report our initial experience with SPLS TEP inguinal hernia repair in 100 patients by a single-port laparoscopic surgeon who had no prior experience of conventional TEP hernia repair. Between October 2012 and December 2013, 100 patients underwent SPLS TEP inguinal hernia repair by a single surgeon. The procedures that were performed in the preperitoneal space did not differ from those in conventional TEP repair. Patient demographics, type of hernia, and operative and postoperative outcomes were analyzed. Also, we compared the results of current series with the data of the other studies for single-port TEP inguinal hernia repair. Among the 100 patients, SPLS TEP inguinal hernia repair was successful in 99 patients; 1 patient required additional incisions for inserting the trocar. The mean operative time and postoperative length of stay were 97.8 minutes (range, 55-185 minutes) and 1.3 days (range, 1-4 days), respectively. In the current series, the operation time was longer than those in the other studies for SPLS TEP repair. Recurrent hernia, history of lower abdominal surgery, and peritoneal tear during the operation were significantly associated with prolonged operation time. The other data, including perioperative complications, were similar. In our experience, the transition from standard hernioplasty to SPLS TEP inguinal hernia repair by an experienced SPLS surgeon was feasible. However, a learning curve is necessary.

Totally extraperitoneal repair under general anesthesia versus Lichtenstein repair under local anesthesia for unilateral inguinal hernia: a prospective randomized controlled trial

Lichtenstein repair (preferably under local anesthesia) or totally extraperitoneal repair (TEP) are both good options for treating uncomplicated unilateral inguinal hernia. We performed a prospective randomized trial to compare the outcome of TEP repair under general anesthesia versus open Lichtenstein inguinal hernioplasty under local anesthesia. Adult men with primary unilateral inguinal hernia without any history of lower abdominal surgery were assessed for inclusion in the study. Of the 194 patients assessed for eligibility for recruitment in the trial, 72 were recruited in the trial and randomized into two groups of 36 patients each. A per-protocol analysis was performed. Patients were followed for a period of 3 months. Pain was assessed by a visual analog scale, and quality of life was assessed by the SF-36 Health Survey Questionnaire, version 2. A total of 59 patients were analyzed at the end of the study, 30 in the Lichtenstein group and 29 in the TEP group. The operating time (75.93 ± 13.68 vs. 64.77 ± 12.66 min, p = 0.002) and total operating room time (102.66 ± 15.676 vs. 72.64 ± 12.25 min, p < 0.001) were significantly longer in the TEP group. Postoperative pain scores in the TEP group were lower than the scores in Lichtenstein group, but the difference was not statistically significant. There was significantly more use of analgesics and higher C-reactive protein levels in the Lichtenstein group. Quality of life and patient satisfaction were similar in both groups. Lichtenstein repair under local anesthesia is as good as TEP under general anesthesia. The shorter operating room time, smaller mesh size, and lower cost of local anesthetic drugs all contribute to make Lichtenstein repair the better choice for repair of uncomplicated unilateral inguinal hernia, especially in developing nations with scarce resources.

Didelphys uterus: misleading as ovarian cyst

Mullerian duct anomalies are not uncommon. Anomalies may be diagnosed in infancy, adolescene or young adulthood. Female patient may present with a mass resulting from mucocolpos, haematocolpos, haematometra or primary amenorrhoea, delayed menarche, infertility and repeated pregnancy loses. A 14 years unmarried girl came with lower abdominal pain and mass with severe dysmenorrhoea with a history of lower abdominal surgery 5 months back. Clinically it was diagnosed as ovarian cyst but after laparotomy it was detected didelphys uterus. Left uterus was non-communicated with vagina forming haematometra. Right uterus well developed with one tube and healthy ovary. DOI: http://dx.doi.org/10.3329/bmjk.v45i1-2.13627 Bang Med J (Khulna) 2012; 45 : 30-32

A Walk along the Learning Curve of Totally Extra-Peritoneal (TEP) Repair of Inguinal Hernia

Objectives/Background: Laparoscopic repair of inguinal hernia is a recent advancement gaining global popularity. It supposedly has a very steep learning curve due to various reasons. This study highlights an initial experience with totally extra-peritoneal repair of inguinal hernias with respect to difficulties, the learning curve, and outcome of this experience. Methods: It’s a prospective descriptive analysis of first 78 consecutive TEP repairs of inguinal hernias performed in 67 patients in a teaching hospital as well as private hospitals during one and a half year. Patients less than 15 years, morbidly obese, old unfit patients and patients with previous history of lower abdominal surgery, recurrent hernias, complicated and complete scrotal hernias were excluded. All the patients were explained the new technique and were informed of the likely complications and all the known benefits. Those who gave consent were registered as study subjects. Variables studied included demographics, difficulties/complications during surgery, early post-operative complications, chronic pain and recurrence of hernia. A detailed pro forma was duly filled in by one of the authors and attached with history chart of every patient. The patients were reviewed after 15 days and then every three months for a period of one year. The data collected was then statistically analyzed on SPSS version 16. Results: This study took one and a half years to complete from Jan 2009 to Jun 2010 during which we operated 67 patients with 78 primary inguinal hernias with a mean age of 40.27, Std 9.724 and a range of 38(20-58) years. All the patients were males with 56 (83.58%) unilateral and 11 (16.41%) bilateral inguinal hernia. The mean operative time of the initial 30 cases was reduced by 50% in the last cases. A number of early post-operative complications occurred during the same hospitalization. Results of three years of follow up are quite promising and encouraging. Conclusion: TEP is a safe and reliable method of inguinal hernia repair. Initial problems and fear due to a totally different anatomy soon overcome by repeated attempts at repair by this technique and sticking to the rules laid down by experts in this field.

Feasibility and safety of total extraperitoneal inguinal hernia repair after previous lower abdominal surgery: a case–control study

This study aimed to evaluate the feasibility and safety of totally extraperitoneal (TEP) endoscopic hernia surgery after previous lower abdominal surgery, which may preclude preperitoneal dissection. All 331 consecutive patients undergoing TEP surgery between January 2008 and December 2010 were included in a prospective cohort study. This case-control study included a study group and a comparison group. The study group consisted of 23 patients with a history of previous lower abdominal surgery before undergoing TEP endoscopic hernia repair. For the comparison group, 46 patients were randomly selected (two for every patient in the study group) and matched with the study cohort in terms of age, gender, and laterality of inguinal hernia. Perioperative data were obtained for all the patients including demographic data, operation time, length of hospital stay, narcotic dose, conversions, and complications. A total of 69 patients with inguinal hernias underwent TEP surgery: 23 patients with previous abdominal surgery (study group) and 46 patients without such surgery (control group). No conversions were necessary in the control group, but one case (4.4%) in the study group was converted to transabdominal preperitoneal hernia repair (TAPP) (P = 0.33). Peritoneal injury requiring intracorporeal repair was encountered in six study group patients and eight control group patients (P = 0.53). No differences were observed between the two groups in terms of operative times, analgesic use, hospital stay, return to daily activities, or postoperative complications. In experienced hands, TEP hernia repair for patients with previous lower abdominal surgery can be performed safely. In this study, the operative outcomes were comparable with those for patients who had no history of lower abdominal surgery.

Impact of previous abdominal surgery on laparoscopic appendectomy for acute appendicitis

Laparoscopic appendectomy is one of the most commonly performed laparoscopic procedures. Impact of previous abdominal surgery on laparoscopic appendectomy has not been previously reported. From January 2001 to December 2005, 2029 patients with clinically suspected acute appendicitis underwent laparoscopic surgery in our hospital. Of these, 234 patients (11.5%) were found to have other pathology by intraoperative or histologic findings and were excluded from the study. The 1795 patients who underwent laparoscopic appendectomy for acute appendicitis were divided into three groups: group 1, patients without a history of previous abdominal surgery (n = 1652, 92%); group 2, patients with a history of upper abdominal surgery (n = 20, 1.1%); group 3, patients with a history of lower abdominal surgery (n = 123, 6.8%). Data were collected retrospectively by chart review and analyzed for conversion rate, operative time, intraoperative and postoperative complications, and hospital stay. Of the 1795 patients, 13 (0.7%) were converted to open appendectomy because of technical difficulty. Overall mean operative time was 57.2 (range, 20-225) min. There was no mortality or intraoperative complications. Overall postoperative complication rate was 10.7% (n = 193): rate of surgical wound infection was 8.2% (n = 147), surgical wound seroma 1.3% (n = 24), and intra-abdominal abscess 0.8% (n = 14). Overall postoperative hospital stay averaged 3.2 (range, 0-39) days. There were no significant differences between the three groups regarding the conversion rate (0.8% vs. 0% vs. 0%, p = 0.567), operative time (57.3 vs. 55.8 vs. 56.9 min, p = 0.962), postoperative complication rates (10.7 vs. 10 vs. 12.2%, p = 0.863), and hospital stay (3.2 vs. 3.6 vs. 3.1 days, p = 0.673). Previous abdominal surgery, whether upper or lower abdominal, has no significant impact on laparoscopic appendectomy for acute appendicitis.

Fetal echocardiography: factors that influence imaging of the fetal heart during the second trimester of pregnancy

The four-chamber view of the heart is an important component of the ultrasonographic examination of the fetus. However, during the second trimester of pregnancy the fetal heart cannot always be imaged in every patient. The purpose of this study was to ascertain the rate of successful imaging of the fetal heart during the second trimester and to determine factors that may influence imaging. Seven hundred and nine second trimester fetuses were examined and an attempt was made to obtain the four-chamber and outflow tract views of the heart. Analysis included multiple logistic regression models of the main effects and interactions of ten candidate variables. The four chambers and outflow tracts were imaged in 643 fetuses (90.7%) and not imaged in 66 (9.3%). Fifty-two of 709 patients (7.3%) had had previous surgery. In the 52 patients with a history of previous surgery, the heart could not be imaged in 18 (34%). Six hundred and fifty-seven patients (92.7%) did not have previous surgery. Of this group, the fetal heart could not be imaged in 48 (7.3%). In only one fetus in which the heart could not be imaged was it because of fetal position. Three independent risk factors that influenced imaging of the fetal heart were gestational age, maternal adipose tissue thickness, and previous lower abdominal surgery. Increasing gestational age increased the probability of imaging the heart, whereas increasing adipose tissue thickness and a history of previous surgery decreased the probability of imaging the heart. When the fetal heart cannot be imaged during the second trimester, these factors should be identified. Using data from this study, the gestational age at which the highest probability of imaging the heart can be determined if the thickness of the adipose tissue and a history of lower abdominal surgery are known.