Laparotomy Research Articles

Diagnostic Performance of Ultrasound in Predicting the Extension of Disease in Advanced Ovarian Cancer

Aim: To assess the diagnostic performance of ultrasound in predicting the extension of disease in advanced ovarian cancer. Study design: Prospective observational study. Place and duration of study: Department of Obstetrics & Gynaecology, Islam Teaching Hospital, Sialkot from 1st July 2020 to 30th June 2021. Methodology: Fifty-nine patients were enrolled and each patient underwent ultrasonography preoperatively and was assigned a six Fagotti-score. Surgical removal of ovarian mass was done through laparotomy. Midline incision was given. Peritoneal washings were taken for cytology. Omental biopsies were taken from various sites. Total abdominal hysterectomy was performed with bilateral oophorectomy. The ultrasound results and intraoperative extent of the ovarian malignancy spread were compared. The Cohen’s Kappa results were interpreted. Results: The mean age was 51.5±5.2 years. The range of Cohens Kappa was 0.7 in cases of carcinomatosis presented on the smaller/larger bowel. The predictive agreement value between the ultrasound and surgical cases for Cohens Kappa was 0.75 and 0.73 with mean as 0.74. Conclusion: The ultrasonography can be used as an important tool in identifying the advancement extent of ovarian cancer. Keywords: Ovarian cancer, Ultrasound, Cohen’s Kappa

To Evaluate The Efficacy Of Bioresorbable Seprafilm Membrane In Avoiding Abdominal Adhesions

Aim: To evaluate the efficacy of bioresorbable Seprafilm membrane in avoiding abdominal adhesions.
 Material and methods: After obtaining approval from the appropriate institutional review board, this research was conducted within the department of General Surgery. Patients who needed a Hartmann procedure for diverticulitis or rectosigmoid blockage were randomly assigned to receive Seprafilm or to act as a control patient.
 Results: This research covered 100 patients in total. 50 patients were randomly assigned to receive Seprafilm while the other 50 served as controls. There were no significant variations in medical history or preoperative physical examination. At the midline incision, five patients got three Seprafilm membranes, 35 patients received two membranes, and ten patients received one membrane. In 40 patients, additional surgical operations were performed during the Hartmann procedure. In the Seprafilm group, 8 patients had appendectomy, 6 had surgical decompression of the small intestine, 3 had his peritoneal dialysis catheter removed, and 3 had ovarian cyst resection and partial small intestinal resection for unintentional bowel perforation. In the control group, 8 patients had further appendectomy, 6 patients had splenectomy, 3 patients had suturing for an iatrogenic bladder damage, and 3 patients had partial small bowel resection for a mesentery abscess. The median blood loss in the Seprafilm group was 352mL and 420mL in the control group. Postoperative wound healing was abnormal in 18 of the Seprafilm patients and 14 of the control patients. The time between the original operation and the follow-up surgery was not statistically different across groups. The median interval in the Seprafilm group was 6 months (range 2-17) and 4 months in the control group (range 1–31).
 Conclusion: we concluded a decrease in the degree of adhesion development following the application of Seprafilm in Hartmann procedure patients compared to controls.

A rare case of acute presentation of a chronic massive extraperitoneal abscess: a case report

Extra-peritoneal abscesses are uncommon entities encountered during general surgical practice. They occur in a plane present between the peritoneum and the deep fascia anteriorly, posteriorly or in the pelvis. These abscesses commonly occur as a result of supra-levator and pre-peritoneal extension of an ischiorectal abscess. Treatment includes antibiotics and drainage. Here we have described a case of an abscess in the anterior extra-peritoneal plane extending from perirectal and pararectal space, drained surgically through a midline incision.

Efficacy of a local anesthetic gel infusion kit for pain relief after minimally invasive colorectal surgery: an open-label, randomized clinical trial

Continuous wound infusion with local anesthesia is an effective method for reducing postoperative pain after laparoscopic colorectal surgery. However, most subcutaneous local anesthesia is delivered through continuous injection, which can be inconvenient for patients. This study compared the effectiveness of postoperative pain relief from the application of a local poloxamer 407-based ropivacaine hydrogel (Gel) to the incision site with continuous infusion-type ropivacaine administration (On-Q) in patients undergoing laparoscopic colorectal surgery. This prospective, randomized, non-inferiority study included 61 patients who underwent laparoscopic colorectal surgery with an incision length of 3–6 cm. All 61 patients were randomly assigned to the Gel group (poloxamer 407-based 0.75% ropivacaine, 22.5 mg) or the On-Q group (0.2% ropivacaine, 4 mg/hour for two days). Postoperative analgesia was induced in all patients with intravenous patient-controlled analgesia (IV-PCA). The outcome measures, which were assessed for 72 h after surgery, included the total amount of fentanyl consumed via IV-PCA (primary endpoint), and the amount of rescue analgesia (pethidine) and postoperative pain intensity assessed using a numeric rating scale (NRS) [secondary endpoints]. The Gel was administered to 31 patients and On-Q was used for 30 patients. There was no significant difference in the total usage of fentanyl between the two groups (Gel group, 1623.98 mcg; On-Q group, 1595.12 mcg; P = 0.806). There was also no significant difference in the frequency of analgesic rescue medication use (P = 0.213) or NRS scores (postoperative 6 h, P = 0.860; 24 h, P = 0.333; 48 h, P = 0.168; and 72 h, P = 0.655) between the two groups. The Gel, which continuously delivers a local anesthetic to operative sites, can thus be considered an effective device for analgesia and pain relief for midline incisions in laparoscopic colorectal surgery.

A Study on the Presentation and Management of Nasal Dermal Sinus

Aim: Nasal dermal sinus is a relatively rare congenital condition. We have reviewed our experience in the presentation and managements of these cases. Patients and Methods: This is a retrospective study from June 2006 to January 2019. Patients presented with a nasal pit, with or without a hair in it were selected. They were studied for their various aspects before and after operation. Results: Out of eight patients studied one presented with infection and hence operation was done at a later date. One patient’s parents refused operation and hence seven patients were operated. Complete excision of dermal sinus by midline vertical incision under general anaesthesia was done. One patient had recurrence and was re-operated 14 years later. Follow-up was from 1 to 13years, with mean of 6 years. Conclusion: Nasal dermal sinus and dermal cyst without fistulae are two different entities. Most of these sinuses do not bear the intracranial extension. Excision can be done from the face and cranial exploration is rarely required.

Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation.

In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.

V-007 LESSONS LEARNED DURING THE ABDOMINAL WALL RECONSUTRCTION FOR A MULTIRECURRENT LUMBAR HERNIA AFTER BONE GRAFT HARVESTING

Abstract The best approach for lateral incisional hernia is not known. Among these difficult hernias, those arising from iliac crest harvesting can be particularly challenging. The objective of this video is to illustrate the surgical approach of a multirecurrent case with the need of adding a posterior component separation A 70 years old woman with 2 previous attempts of repair was referred to our center. With the patient in a 45 degrees lateral decubitus, a posterior lumbar approach was initiated through the previous scar. The retromuscular preperitoneal plane was accessed with difficulty due to previous meshes in the subdiaphragmatic, iliac and posterior areas. A big tear on the medial peritoneum changed our plan to add a posterior component separation. As we did not want to enlarge the lumbar incision to denervate more the lateral abdominal wall, we decided to make an accessory midline incision. Probably, an ETEP approach could have been better even before making the posterior incision. Once the retromuscular plane was dissected, the hole in the peritoneum could be closed. The reconstructive phase consisted in making a taco configuration using the combination of a permanent and absorbable mesh. We have learned from this case, that an eTEP dissection of the retromuscular plane could have helped to avoid the accessory midline incision. It is also important to consider the potential iatrogenic denervation we could add in case of enlargement of the incision.

P-127 E-TEP ASSISTED REVERSE-TAR FOR THE TREATMENT OF LARGE LUMBAR INCISIONAL HERNIAS ASSOCIATED TO MIDLINE DEFECTS

Abstract Aim To describe a new hybrid surgical approach of large lumbar incisional hernias (IH) associated to synchronic midline defects. Material and Methods Prospective multicentric study including patients with large lumbar hernias (L4W3) associated to midline abdominal wall defects. Surgical intervention starts with a bilateral retrorectus dissection performed through a minimally invasive extraperitoneal endoscopic approach (eTEP). Once this space has been dissected, the lumbar IH is treated with an overextended centrifugal preperitoneal open approach through the previous lumbar incision. Afterwards the dissected spaces are communicated performing a reverse transversus abdominis release (TAR) from lateral to medial. A prosthetic preperitoneal repair is performed with an absorbable and permantent meshes that cover the space dissected. Results Five patients were included in the study. All patients had lumbar hernias L4W3 associated to primary or incisional midline hernias M1–5 W1–2. Eighty percent of the patients were women, with a mean age of 62 years. Mean BMI was 32 (range 30–34), with a 60% of diabetic patients, and 80% of recurrent lumbar hernias (between 1 and 3 previous repair attempts). Mean surgical time was 198 minutes (range 160–250). Mean hospital stay was 5 days (range 4–8 days). Two lumbar hematomas which didn't required any interventional procedure took place as the only surgical site occurrences, without any systemic complications. No recurrence has taken place after 5 months mean follow up (range 2–9 months) Conclusion Hybrid eTEP and open approach of large lumbar hernias associated with small midline defects seem to be an efficient and safe approach.

Choice of specimen’s extraction site affects wound morbidity in laparoscopic colorectal cancer surgery

BackgroundThe choice for an ideal site of specimen extraction following laparoscopic colorectal surgery remains debatable. However, midline incision (MI) is usually employed for right and left–sided colonic resections while left iliac fossa or suprapubic transverse incision (STI) were reserved for sigmoid and rectal cancer resections.ObjectiveTo compare the incidence of surgical site infection (SSI) and incisional hernia (IH) in elective laparoscopic colorectal surgery for cancer and specimen extraction via MI or STI.MethodProspectively collected data of elective laparoscopic colorectal cancer resections between January 2017 and December 2019 were retrospectively reviewed. MI was employed for right and left–sided colonic resections while STI was used for sigmoid and rectal resections. SSI is defined according to the US CDC criteria. IH was diagnosed clinically and confirmed by CT scan at 1 year.ResultsA total of 168 patients underwent elective laparoscopic colorectal resections. MI was used in 90 patients while 78 patients had STI as an extraction site. Demographic and preoperative data is similar for two groups. The rate of IH was 13.3% for MI and 0% in the STI (p = 0.001). SSI was seen in 16.7% of MI vs 11.5% of STI (p = 0.34). Univariate and multivariate analysis showed that the choice of extraction site is associated with statistically significant higher incisional hernia rate.ConclusionMI for specimen extraction is associated with higher incidence of both SSI and IH. The choice of incision for extraction site is an independent predicative factor for significantly higher IH and increased SSI rates.

The study of morphofunctional changes in the gastrointestinal tract after various operations on the colon (an experiment in rats)

Objective : modeling various types of surgical procedure in an experiment in rats, assessing the effect of surgery on the motility of the gastrointestinal tract (GIT). Materials and methods : the study was carried out on 30 female Wistar rats weighing 200–250 grams, comparable in age, divided into 3 groups (10 animals each) in random order. group 1 — rats underwented to laparotomy (LT), group 2 — laparotomy, creation of a loop colostomy (LT + C), group 3 — laparotomy, a colonic single-row anastomosis (LT + A). Gastrointestinal motility was assessed using the gastrointestinal transit index (GTI), calculated by the formula: (length of the stained area of the intestine / total length of the intestine) x100, as well as by the results of a morphological study. Results : surgery has a depressing effect on the motility of the gastrointestinal tract, while the maximum decrease in IHT was noted in the Colostomy group: 1.08±1.4% versus 2.3±3.3% in the Laparotomy group and versus 3.8±1.8% in the Anastomosis group. Comparison of the groups “Colostomy” and “Anastomosis” showed a significant difference in this feature — p=0.002. Conclusion : modeling of various surgical procedure in rats made it possible to prove the relationship between the formation of a stoma and the inhibition of gastrointestinal motility, further study of this pattern will allow us to develop ways to prevent the development of postoperative ileus.

S2841 Ileo-Rectal Anastomotic Defect Treated Twice With Endoscopic Tack Suture System and Stenting

Introduction: The endoscopic tack suture system is a novel technique that includes a through the scope (TTS) suture-based device that was recently designed for the closure of large and irregular defects in the gastrointestinal tract. Choice of closure device depends on the location, size, and working space around the defect. Over-the-scope clips (OTSC) and endoscopic suturing devices require withdrawal of the scope to load and are harder to maneuver through smaller spaces such as strictures. The TTS tack suturing system prevents the need to withdraw the scope and can be deployed in very small spaces. We present a case of a recurrent post-surgical leak leading to wound dehiscence and enterocutaneous fistula of an ileorectal anastomosis associated with a stenosis requiring the tack suture device and stenting for closure. Case Description/Methods: A 60-year-old woman was admitted after a recent subtotal colectomy with ileo-colonic anastomosis for a large adenoma that was unable to be resected endoscopically. She developed a pelvic abscess and wound dehiscence. She underwent exploratory laparoscopy with resection of the anastomosis with end-ileostomy creation. She later underwent open ileostomy reversal with ileo-rectal anastomosis and drain placement. Output continued from both the drain and the midline incision. Colonoscopy showed a large defect in the ileo-rectal anastomosis that was 40% circumferential with significant stenosis. The tack suturing system was employed after argon plasma coagulation (APC) and a fully covered esophageal stent was deployed across the defect (Figure A). During repeat colonoscopy, the initial tack and suturing device was found to be in place on the ileal mucosa, but two tacks had dislodged from the colonic mucosa. An improved small, well defined, round defect was found at the anastomosis (Figure B). The defect was again treated with APC, tack suturing, and stent placement with subsequent resolution of symptoms (Figure C). Discussion: This case highlights the novel tack suturing system which ultimately prevented this patient from undergoing further operations and requiring a colostomy. The tack suture system is an ideal tool for defect closure in tight spaces where OTSC or endoscopic suturing are too bulky. Mahmoud et al. conducted the first and only multi-center study describing the feasibility and safety of the endoscopic tack suturing device in the clinical setting and found successful closure of defects in approximately 90% of cases.Figure 1.: (A) Tack placement following APC at anastomotic defect. (B) Initial tack suture with 2 tacks dislodged from colonic mucosa and small improved defect in anastomosis. (C) Tack placement for closure of persistent defect.

Multiple Points of Pelvic Fixation: Stacked S2-Alar-Iliac Screws (S2AI) or Concurrent S2AI and Open Sacroiliac Joint Fusion with Triangular Titanium Rod.

Multiple Points of Pelvic Fixation: Stacked S2-Alar-Iliac Screws (S2AI) or Concurrent S2AI and Open Sacroiliac Joint Fusion with Triangular Titanium Rod.

S3357 Achalasia Cardia in Child With Severe Malnutrition: A Case Report

Introduction: Achalasia cardia is an esophageal motility disorder due to the failure of the lower esophageal sphincter to relax. It is extremely rare in the pediatric population with an incidence of 0.11 per 100,000 children. In children, it is usually associated with other conditions like Adrenal glucocorticoid deficiency and Down’s syndrome. The symptoms include vomiting, regurgitation, and weight loss. Its exact etiology is still unclear. It is considered to be due to degeneration of the myenteric plexus that innervates the lower esophageal sphincter leading to difficulty with swallowing and absence of peristalsis. Case Description/Methods: We present the case of a 3-year-old girl with a history of recurrent vomiting and poor weight gain. Her symptoms have been progressive for over 2 years. The child was initially treated at multiple local hospitals for Gastroesophageal reflux disease with no improvement. At presentation, she was severely malnourished and weighed 6 kgs. On evaluation, she was also found to be anemic. After admission to our pediatric unit, she underwent a barium study which showed tapering of the distal esophagus, representing the classic bird-beak sign, and the diagnosis of achalasia cardia was confirmed. She was treated surgically by Heller’s Cardiomyotomy and Fundal Wrap. Her post-operative phase was uneventful and she was discharged with follow-up advice. She exhibited excellent recovery with good weight gain and resolution of her symptoms. Her weight at the 1-month follow-up visit was 9kgs and at 3 months it was 12kgs. (Figure) Discussion: Achalasia cardia is a rare presentation in children but can lead to major health concerns if left untreated. Due to the nonspecific symptoms, it is mostly misdiagnosed as gastroesophageal reflux disease which leads to delayed diagnosis and severe malnutrition. Diagnosis is with barium swallow study and manometry. It is followed by endoscopic biopsy in adults to rule out malignancy, however, it is not a consideration in children. Medical management has often shown recurrence of symptoms, particularly in children, and is not considered an effective choice of treatment. Surgery is the definitive treatment and includes Heller’s esophagomyotomy with or without anti-reflux procedures. Prompt diagnosis and treatment have an excellent prognosis. Peroral endoscopic myotomy is a promising new therapy in adults with achalasia but has limited studies in children. Persistent undiagnosed cases can lead to severe malnutrition and failure to thrive.Figure 1.: 1: At presentation, weight 6kgs; Fig2:At 3months, weight 12kgs; Fig.3,4,5: Barium Study; Fig6: Supraumbilical midline incision; Fig7:Cardiomyotomy; Fig8:Approximation of Crura; Fig9:Fundal Wrap.

The distance between new and previous incisions does not affect skin necrosis in total knee arthroplasty: a parallel-randomized controlled clinical trial.

BackgroundTo avoid skin necrosis, an 8 cm distance between the new and previous incision is recommended in patients undergoing total knee arthroplasty (TKA). It was hypothesized that making a new incision less than 8 cm of the prior scar does not increase the risk of skin complications, and the new incision can be made anywhere, regardless of the distance from the previous scar. This study investigated how making a new incision, irrespective of the previous scars, affects skin necrosis.MethodsIn this parallel, randomized clinical trial, by simple randomization method using a random number table, 50 patients with single longitudinal knee scars were randomly assigned to two groups with a 1:1 ratio and 25 participants in each group. Patients with a minimum age of 60 and a single longitudinal previous scar on the knee were included. The exclusion criteria were diabetes mellitus, hypertension, morbid obesity, smoking, vascular disorders, cardiopulmonary disorders, immune deficiencies, dementia, and taking steroids and angiogenesis inhibitors. TKA was performed through an anterior midline incision, regardless of the location of the previous scar in the intervention group. TKA was performed with a new incision at least 8 cm distant from the old incision in the control group. Skin necrosis and scar-related complications were evaluated on the first and second days and first, second, and fourth weeks after the surgery. Knee function was assessed using the Knee Society Score (KSS) six months after the surgery.ResultsThe baseline characteristics of the groups did not differ significantly. The average distance from the previous scar was 4.1 ± 3.2 cm in the intervention group and 10.2 ± 2.1 cm in the control group. Only one patient in the control group developed skin necrosis (P-value = 0.31). Other wound-related complications were not observed in both groups. The mean KSS was 83.2 ± 10.2 and 82.9 ± 11.1 in the intervention and control groups, respectively (P-value = 0.33).ConclusionsIt is possible that in TKA patients, the new incision near a previous scar does not increase the risk of skin necrosis and other complications.

614. SIGNIFICANCE OF LAPAROSCOPIC SURGERY IN OPEN THORACOTOMY ESOPHAGECTOMY

Abstract The usefulness of laparoscopic surgery in esophageal cancer surgery has been reported in the MIRO trial, but there are few reports of laparoscopic surgery in esophageal subtotal resection, which is the standard surgical procedure in Japan. Furthermore, chest procedures are often performed by thoracoscopic surgery, making it difficult to evaluate laparoscopic operations. This time, we retrospectively examined the usefulness of laparoscopic procedure in right thoracotomy surgery. From 2007 to 2019, 135 patients with esophageal cancer who underwent thoracotomy and subtotal esophagectomy and were reconstructed by gastric tube (post-sternal route, cervical anastomosis) were included. In the laparoscopic group (Lap group), gastric mobilization and perigastric lymph node dissection were performed under 5-port. The stomach was pulled out of the abdominal cavity with a small laparotomy of 4-5 cm to prepare a gastric tube. In the case of open surgery (Open group), epigastric midline incision (15-20 cm) was performed up to the navel. There were 67 cases in the Lap group and 68 cases in the Open group. There was no difference in thoracotomy time between the two groups. In the Lap group, the amount of bleeding was significantly less than in the Open group (289g vs 376g), and the operation time was longer. Lung complications of Clavien-Dindo classification Grade 2 or higher were significantly less in the Lap group (10% vs 24%). There was no difference between the two groups in anastomotic insufficiency and recurrent laryngeal nerve palsy. The number of dissected lymph nodes was significantly higher in the Lap group. Laparoscopic abdominal manipulation in open esophageal cancer surgery was useful in reducing pulmonary complications.

Diastasis recti is associated with incisional hernia after midline abdominal surgery.

Incisional hernia occurs in up to 20% of patients after abdominal surgery and is most common after vertical midline incisions. Diastasis recti may contribute to incisional hernia but has not been explored as a risk factor or included in hernia risk models. We examined the association between diastasis recti and incisional hernia after midline incisions. In this single-center study, all patients undergoing elective gastrointestinal surgery with a midline open incision or extraction site in a prospective surgical quality collaborative database between 2016 and 2020 were included. Eligible patients had axial imaging within 6months prior to surgery and no less than 6months after surgery to determine the presence of diastasis recti and incisional hernia, respectively. Radiographic hernia-free survival was assessed with log-rank tests and multivariable Cox regression, comparing patients with and without diastasis width > 25mm. Of 156 patients, forty-four (28.2%) developed radiographic hernia > 1cm. 36 of 85 patients (42.4%) with DR width > 25mm developed IH, compared to 9 of 71 (12.7%) without DR (p < 0.001). Hernia-free survival differed by DR width on bivariate and multivariable Cox regression, adjusted hazard ratio: 3.87, 95% confidence interval: 1.84-8.14. Diastasis recti is a significant risk factor for incisional hernia after midline abdominal surgery. When present, surgeons can include these data when discussing surgical risks and should consider a lower risk, off-midline approach when feasible. Incorporating diastasis into larger studies may improve comprehensive models of incisional hernia risk.

Penile Girth Enhancement Using Amniotic Membrane in a Rabbit Model: A stereological study.

This study aimed to evaluate the efficacy of penile girth enhancement (PGE) using amniotic membrane (AM) as a graft in a rabbit model. Additionally, quantitative histological data of the structure of the penis were obtained by stereological studies. This study was conducted at the Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. In this study, 20 adult male rabbits of similar age and weight were allocated to two groups: sham surgery and surgery+AM. Both groups underwent surgery in which a longitudinal I-shaped midline incision was made in the tunica albuginea on the dorsal surface of the penis. The surgery+AM group underwent PGE using AM as a graft. The penile length and mid circumference were measured using a vernier caliper before and two months after the surgery. The mean total volume and diameter of the penis significantly increased in the surgery+AM group (P <0.03 and P <0.04, respectively). On stereological evaluation, a significant increase in the mean volumes of the tunica albuginea and corpora cavernosa was observed in the surgery+AM group compared to the sham group (P <0.01 and P <0.03, respectively). Additionally, the mean volume densities of the collagen bundles, muscle fibres, cavernous sinuses, and the total number of fibroblasts and smooth muscle cells increased in the surgery+AM group compared to the sham group (P <0.05 each). No infections, bleeding or other complications were observed. The use of AM as a graft is a method that shows promising results for material use in penile enhancement. Thus, it may be considered for PGE in the future.

The Optimal Cesarean Skin Incision in Patients with Super Obesity.

This study aimed to evaluate if supraumbilical midline vertical incision performed in patients with a hanging pannus (umbilicus at the level of the pubic bone) is a reasonable alternative to the Pfannenstiel in patients with body mass index (BMI) ≥ 50 kg/m2 undergoing cesarean delivery. Retrospective cohort study in patients with BMI ≥ 50 kg/m2 undergoing cesarean delivery at a single center from 2016 to 2020. Study groups were Pfannenstiel's versus supraumbilical vertical skin incision. If patients had a hanging pannus (umbilicus at the level of the pubic bone), vertical incisions were performed. Otherwise, Pfannenstiel's incision was performed. Decision for the incision was made prospectively. Primary outcome was a composite of need for blood transfusion, presence of immediate surgical complications, and presence of delayed surgical complications. Secondary outcomes included the individual components of the primary outcome, the median surgical blood loss, total operative time, time from skin incision to delivery of neonate, hysterotomy type, and neonatal outcomes. MedCalc 19.5.1 was used for analysis. A total of 103 patients with BMI ≥50 kg/m2 were included. Of those, 68 (66%) had Pfannenstiel's and 35 (34%) had supraumbilical vertical incisions. There was no statistically significant difference in the incidence of the primary outcome (12 vs. 11%, p = 0.96). There was neither significant difference in immediate or delayed postoperative complications nor in neonatal outcomes. However, patients in the vertical midline incision group were more likely to have a classical hysterotomy (52%) compared with the Pfannenstiel group (6%; p < 0.05), increased overall median surgical blood loss (1,000 vs. 835 mL, p < 0.05), and increased total surgical time by a median of 30 minutes (p < 0.05). In patients with super obesity and hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and implications in future pregnancies. · Patients with BMI >50 kg/m2 were allocated to different incision types based on subcutaneous fat distribution pattern. If umbilicus was at level of pubic bone, supraumbilical vertical skin incision was made. · There were no significant differences between Pfannenstiel's and supraumbilical vertical incisions in terms of the composite outcome and immediate or delayed postoperative complications and neonatal outcomes.. · In patients with a hanging pannus, performing a supraumbilical vertical midline incision offers a reasonable alternative to Pfannenstiel's incision, but patients should be counseled about the increased risk for classical hysterotomy and subsequent implications in future pregnancies..

Mechanical intestinal obstruction in underweight, elderly women due to an incarcerated obturator hernia.

Obturator hernia is an infrequent pelvic hernia observed in elderly, emaciated and multiparous women. It often presents with nonspecific clinical symptoms, making it difficult to diagnose. We conducted a retrospective descriptive study on 11 patients admitted to our hospital for obturator hernia from 2009 to 2020. All the patients were diagnosed with intestinal obstruction due to incarcerated obturator hernia preoperatively. Eight patients underwent laparotomy with low midline incision. Laparoscopic approach was tried on the other three patients with two patients converting to open surgery because of inadequate visualization, and only one patient received laparoscopic repair. Of the 10 patients receiving laparotomy, seven cases received obturator hernia repair with a match and three cases were subjected to bowel resection (two cases intestinal necrosis and one case intestinal perforation). Simple peritoneal closure was performed on the three contaminated cases. One patient died of septic shock and multiple organ failure. The emergent computed tomography allow for early and precise diagnosis of incarcerated obturator hernia. Laparotomy with low midline incision is commonly used to manage obturator hernia in an emergency, whereas laproscopic approach may only apply to some selected cases.

Intravenous leiomyomatosis of the uterus: still discovered on anatomopathological examination

Background: Leiomyomas beyond the uterus are defined by benign smooth muscle cell tumors outside of the uterus. Intravenous leiomyomatosis is a rare type of uterine leiomyoma and is characterized by the formation and growth of benign leiomyoma tissue within the vascular wall. Herein, we present a case of Intravenous leiomyomatosis successfully treated by surgical removal and a review of actual medical recommendations. Case presentation: A 49 - year-old woman, maghrébin, G3 P2, no family history of uterine myomas mentioned, having systemic arterial hypertension, presented to our department with hypogastric pain and abnormal uterine bleeding in the prior five months resulting in anemia which required iron supplementation. On physical examination the vital signs were normal. A palpable mass in the hypogastrium was noted. The rest of the exam was unremarkable. Pelvic ultrasound showed a huge uterus with multiple heterogeneous leiomyomas, including at least one intracavity. Computed tomography scans and magnetic resonance imaging were not done initially due to the unaffordability of the patient. The initial diagnosis was leiomyoma. The decision to perform a total abdominal hysterectomy and bilateral salpingo-oophorectomy was taken. The abdomen was opened by a midline vertical incision. During surgery, multiple subserosal, intramural and submucosal fibroids ranging from 2 cm × 3 cm to 10 cm × 10 cm were seen. On pathological examination, the uterus measured 19 cm in the largest diameter and weighed 1.3 kg. The cut section showed white nodular myometrial masses. Microscopically, intravascular growth of benign smooth muscle cells is found within venous channels lined by endothelium. The diagnosis of Intravenous leiomyomatosis of the uterus without malignant transformation was retained. The patient was monitored for 14 months and subsequent computed tomography did not reveal any evidence of tumor recurrence. The follow-up will be performed annually till the age of menopause. Conclusion: Intravenous leiomyomatosis is a benign, rare and potentially lethal pathology. It especially affects premenopausal women with a history of uterine myoma, whether operated on or not. They require close and prolonged follow-up because of the high risk of recurrence.