Low Transverse Incision Research Articles

Dehiscence in Caesarean Scars

Ultrasound assessment of the uterus pre Assisted Fertility is routine. Using transvaginal sonography, caesarean scars can be evaluated and the integrity of the scar assessed, pre conception. Caesarean section is a controversial topic in modern obstetrics. There is no disputing it is necessary in many cases to save the life of the baby or the mother. There are 'non-medical' situations, however, where women and their doctor choose this form of birth for convenience, fear of pain during vaginal delivery or concerns about lawsuits. The increase in the number of C-sections gives rise to the increase in complications in successive pregnancies and future fertility. A “low transverse uterine incision” requires a transverse cut through the isthmic portion of the uterus. This is safer than the “classic” C-section, where the cut is vertical, and has a very small chance of breaking open during later pregnancies. 'Rupture' may occur in an intact uterus or involve the majority of a previous cesarean scar. 'Dehiscence' is a separation that involves only a portion of the uterine scar. 'Windows' are a partial rather than complete separation of the uterine layers. Saline infusion can be used to confirm any areas of dehiscence within the Caesarean scar in the non pregnant-state. For women having difficulties with conception and in pre fertility program management evaluation of the C-scar is an important part of uterine evaluation.

Laparoscopic retrieval of retained intraperitoneal drains in the immediate postoperative period

Retained intraperitoneal Penrose drain secondary to fracture and adhesions in the immediate postoperative period happens on occasion. Most are unreported because of the fear of medico-legal problems. Previous management of such iatrogenic complications requires repeated laparotomy or wound exploration. Two patients who underwent appendectomy for ruptured appendicitis, with retained intraabdominal drains in the immediate postoperative period, managed eventually by laparoscopic retrieval are presented. Both patients had right low transverse incisions and intraabdominal drains exiting through a separate right lateral abdomen skin opening. Patient 1 had a stuck intraabdominal drain unable to be removed up to the second week. Patient 2’s drain retracted intraperitoneally after its mobilization on the sixth post-op day. Both were managed by laparoscopy under general anesthesia with successful removal of both drains. Patient 1 underwent the procedure 3 weeks after the appendectomy, whereas Patient 2 had the procedure on her sixth post-op day. An additional new 1-cm wound in the periumbilical area was done for the introduction of pneumoperitoneum and 10-mm port for which the laparoscope was inserted. The second 5-mm port was inserted through the old drain site wound with peritoneal entry opening separate from the previous peritoneal defect viewed from laparoscope. Both drains had some marked adhesions from ingrowth of omentum to the side holes of the drain, causing it to get stuck in the pelvic cavity. This laparoscopic approach in the management of such iatrogenic complication, besides being cosmetically acceptable, contributes to early recovery and discharge of the patient, and helps to lessen the friction in the recently worsening doctor-patient relationship in Taiwan.

Elevation of Serum CA-125 in Mucinous Cystadenoma of the Ovary with Torsion: A Rare Occurrence and Review of the Literature

Aim: Benign neoplasms of the ovary originating from epithelial tissue are common tumors in adult women. They are, however, rarely seen in children or adolescent girls with elevation of serum carbohydrate antigen- 125 (CA-125). The present report describes a rare case of premenarchal women with a giant mucinous cystadenoma (MCA) of the ovary with torsion complicated with elevation of serum CA-125. Case: A 15-year-old, premenarchal, previously healthy girl was referred to our hospital with a 2-week history of left lower abdominal pain. Physical examinations showed a firm and mobile mass with tenderness in the left lower quadrant. Tumor markers showed CA-125 at 124.1 U/ml. An enhanced computed tomography scan showed a multiloculated tumor that was partly solid, compressing the small intestine, uterus, and urinary bladder, but no signs of organ invasion, lymph node swelling, or ascitis. Via a lower transverse incision, the right Fallopian tube was observed to have twisted 1620。 counterclockwise, and a tense cyst measuring 22.0 × 12.0 × 10.5 cm and weighing 1.78 kg was found in the right ovary. Release from torsion and unilateral salpingo-oophorectomy with tumor removal was performed because blood flow to the right Fallopian tube did not improve after torsion release. The histopathological findings showed an MCA of the ovary without cell dysplasia. The patient did not receive adjuvant chemotherapy following surgery. There was no evidence of recurrence at 2 years. Disucussion: We need to consider MCA of the ovary when there is elevation of the serum CA-125 and an ovarian mass.

Abdominal surgical incisions and perioperative morbidity among morbidly obese women undergoing cesarean delivery

Objective To test the hypothesis that there is no difference in perioperative morbidity and the type of uterine incisions between vertical skin incisions (VSI) and low transverse skin incisions (LTSI) at the time of cesarean delivery in morbidly obese women. Study design Retrospective cohort study of morbidly obese women (BMI > 35 kg/m 2) who underwent cesarean delivery between June 2004 and December 2006. Results During the study, 424 morbidly obese women underwent cesarean section. Patients with VSI were older (31.0 ± 6.2 years vs. 26.7 ± 5.8 years), heavier (48.2 ± 9.1 kg/m 2 vs. 41.7 ± 6.7 kg/m 2), and more likely to have a classical than a low transverse uterine incision (65.9% vs. 7.3%), p < 0.001. After controlling for confounders, women with VSI did not have an increase in perioperative morbidity, but underwent more vertical uterine incisions (adjusted odds ratio = 18.49, 95% CI: 6.44, 53.07). Conclusion VSI and LTSI are safe in morbidly obese patients undergoing cesarean section, but there is a tendency for increased vertical uterine incisions in those who underwent VSI.

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision. From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups. There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Maternal and Neonatal Outcomes of Repeat Cesarean Delivery in Women with a Prior Classical versus Low Transverse Uterine Incision

We compared maternal and neonatal outcomes following repeat cesarean delivery (CD) of women with a prior classical CD with those with a prior low transverse CD. The Maternal Fetal Medicine Units Network Cesarean Delivery Registry was used to identify women with one previous CD who underwent an elective repeat CD prior to the onset of labor at ≥36 weeks. Outcomes were compared between women with a previous classical CD and those with a prior low transverse CD. Of the 7936 women who met study criteria, 122 had a prior classical CD. Women with a prior classical CD had a higher rate of classical uterine incision at repeat CD (12.73% versus 0.59%; P < 0.001), had longer total operative time and hospital stay, and had higher intensive care unit admission. Uterine dehiscence was more frequent in women with a prior classical CD (2.46% versus 0.27%, odds ratio 9.35, 95% confidence interval 1.76 to 31.93). After adjusting for confounding factors, there were no statistical differences in major maternal or neonatal morbidities between groups. Uterine dehiscence was present at repeat CD in 2.46% of women with a prior classical CD. However, major maternal morbidities were similar to those with a prior low transverse CD.

Modified port placement and pedicle first approach for laparoscopic concomitant cholecystectomy and splenectomy in children

Aim:Laparoscopy is becoming the preferred modality for concomitant cholecystectomy and splenectomy (CAS). Usually, six to seven ports are employed for CAS, and spleen is removed by classical lateral approach or anterior approach. We report here our modified five-port and pedicle first approach for CAS in children to minimize the intraoperative bleeding and maximize the access.Materials and Methods:Twenty-one children underwent laparoscopic CAS with this new approach and their data were recorded prospectively. Following cholecystectomy (with ports 1–4), left side was elevated by 30°. The spleen was lifted by a grasper/fan retractor through port no. 5. The pedicle was dissected and splenic vessels were divided by ligasure (vessels < 8 mm), and for bulkier pedicle, vascular endo-GIA stapler was used. Short gastric and gastrosplenic ligament, lower pole and phrenico-colic attachments and upper pole attachments were dissected by ligasure in that sequence. Spleen was placed in endosac and delivered by digital fracture technique. Occasionally, lower transverse incision was made to deliver a massive spleen.Results:There were 12 males and 9 females with an average age of 8 years. Fourteen had sickle cell disease (SCD) and 7 had SCD and beta thalassemia. All CAS were completed successfully without any complication. Total duration was 160 minutes. Cholecystectomy took an average of 35 minutes. Average blood loss was 140 ml. The mean splenic weight was 900 g and mean length was 20 cm. Duration of hospitalization was 3–4 days.Conclusion:CAS can be successfully performed by five ports. The pedicle first approach is extremely helpful in moderate to massive spleens as it reduces splenic size, vascularity and bleeding from capsular adhesions or inadvertant lacerations.

Maternal and Neonatal Outcomes of Repeat Cesarean Delivery in Women with a Prior Classical versus Low Transverse Uterine Incision

Maternal and Neonatal Outcomes of Repeat Cesarean Delivery in Women with a Prior Classical versus Low Transverse Uterine Incision

Anterior abdominal wall nerve and vessel anatomy: clinical implications for gynecologic surgery

We sought to describe relationships of clinically relevant nerves and vessels of the anterior abdominal wall. The ilioinguinal and iliohypogastric nerves and inferior epigastric vessels were dissected in 11 unembalmed female cadavers. Distances from surface landmarks and common incision sites were recorded. Additional surface measurements were taken in 7 other specimens with and without insufflation. The ilioinguinal nerve emerged through the internal oblique: mean (range), 2.5 (1.1-5.1) cm medial and 2.4 (0-5.3) cm inferior to the anterior superior iliac spine (ASIS). The iliohypogastric emerged 2.5 (0-4.6) cm medial and 2.0 (0-4.6) cm inferior. Inferior epigastric vessels were 3.7 (2.6-5.5) cm from midline at the level of the ASIS and always lateral to the rectus muscles at a level 2 cm superior to the pubic symphysis. Risk of anterior abdominal wall nerve and vessel injury is minimized when lateral trocars are placed superior to the ASISs and >6 cm from midline and low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscles.

Primary small intestinal lymphoma presenting as a groin abscess

Sir, Small bowel cancers are rare; primary small intestinal lymphoma accounts for 15–20% of these tumours. Patients with small intestinal lymphoma frequently present with abdominal emergencies to the surgeon.[1] A 50-year-old man presented with a 6-month history of a right groin swelling. On further questioning, the patient reported weight loss and reduced appetite. He reported no abdominal pain and changes in bowel habits. Physical examination revealed a large right groin swelling measuring approximately 15 cm in diameter. The swelling had the features of an abscess (red, hot, tender, and fluctuant) extending downwards into the right thigh and upwards into the right lower quadrant of the abdomen. Laboratory tests showed a mild leucocytosis of 12.3 × 109/L, a haemoglobin concentration of 11.4 g/100 mL and a C-reactive protein of 311 mg/L. A computed tomography (CT) scan revealed a soft tissue mass measuring 12 cm × 12 cm × 23 cm occupying the right hemipelvis and extending into the right inguinal region [Figure 1]. There was no thoracic or abdominal lymphadenopathy. Figure 1 CT image showing mass extending into the right side of the pelvis The patient underwent incision and drainage of this abscess. There was a large amount of faeculant material filling the entire abscess cavity; this appeared to be extending upwards medial to the femoral vessels, along the femoral canal. Laparotomy through a right lower transverse incision was made. Surprisingly, there was no intraperitoneal faecal contamination. Exploration revealed a full thickness retroperitoneal perforation of the terminal ileum with fecal contamination of the retroperitoneal space of the right iliac fossa. It was evident that part of the circumference of the terminal ileum was incarcerated in the femoral ring resulting in a femoral hernia and consequent perforation. An ileocaecal resection was performed. Histopathological examination confirmed diffuse large B-cell lymphoma. Two months later, a repeat CT scan showed a reduction of the right pelvic mass to 7.5 cm × 12 cm, with no evidence of lymph node involvement elsewhere. The patient has currently fully recovered from surgery and is receiving chemotherapy. The gastrointestinal tract is the most common site of extranodal non-Hodgkin lymphoma.[1] In 20–30% of cases, the small intestine, particularly the ileum, is affected.[2] Small intestinal lymphomas most commonly cause abdominal pain (82%).[3,4] Other presenting symptoms include changes in bowel habits (16%), a palpable abdominal mass (16%), and blood in the stool (15%).[2] In approximately 30–50% of patients, however, the initial presentation of small bowel lymphoma is an abdominal emergency,[1,5] with perforation present in up to 37% of cases.[5] A review of literature in English revealed no cases of small intestinal lymphoma presenting as a groin abscess. What was unique about this patient was that despite having a small bowel perforation, he did not present with an abdominal emergency. As the perforation was extraperitoneal, the presentation was that of a chronic right groin swelling, which was diagnosed clinically as an abscess. The duration of the symptoms before seeking medical advice was also unusually long (6 months). This perhaps reflected the patients own beliefs and character. This is believed to be the first documented case of primary small intestinal lymphoma causing a groin abscess as a result of intestinal perforation. This case highlights the variable and somewhat unusual presentation of these tumours.

Blunt Expansion of the Low Transverse Uterine Incision at Cesarean Delivery

The surgical approach to low transverse cesarean delivery has been modified since it was first described in 1926, but the main steps are largely the same. Transversal expansion-the conventional procedure used to extend the surgical incision-involves separation of the surgeon’s index fingers in a transverse direction (medial to lateral and slightly cephalad at the same time). The investigators hypothesized that expansion of uterine incision by separation of the surgeon’s forefingers in a cephalad-caudad direction along the midline might avoid greater lateral extension of the distal incision and could minimize tissue trauma. This prospective randomized study compared cephalad-caudad and transversal expansion in a total of 811 women who were scheduled for low-segment transverse cesarean delivery after 30 weeks’ gestation; 406 women were assigned to the transversal expansion group, and 405 to the cephalad-caudad expansion group. Baseline obstetric and demographic characteristics were similar in the 2 groups. An extension was defined as any lateral or vertical uterine wall defect that required additional surgery to repair. Excessive bleeding during the procedure was defined as estimated blood loss of >1500 mL. The primary outcome measure was the incidence of unintended extension. There was no significant difference between the groups in the estimated blood loss or the need for transfusions. Univariate analysis showed that the occurrence of unintended extension was significantly higher in the transverse group than in the cephalad-caudad group (7.4% vs. 3.7%; P = 0.03). As a result, more women in the transverse group required additional sutures. The incidence of blood loss of >1500 mL was also higher in the transverse group compared with the cephalad-caudad group (2.0% vs. 0.2%; P = 0.04). Multivariate logistic regression analysis showed that transversal expansion was an independent risk factor for unintended expansion and blood loss of >1500 mL. These data show that there is less risk with the cephalad-caudad technique for unintended extension and blood loss of >1500 mL compared with transversal expansion. The investigators conclude from these findings that the cephalad-caudad technique is preferred when lower segment cesarean delivery is performed.

Minilaparotomy Approach Employing a Küstner Incision for Rectal Cancer Resection: Report of Three Cases

A minilaparotomy approach ( 7 cm) for colorectal cancer resection is feasible and safe. Such minilaparotomy generally employs a small vertical incision. A low transverse abdominal incision (a Kustner incision) has been shown to be associated with cosmetic advantage, less postoperative pain, and fewer wound-complications than the midline incision. We report three cases (75-year-old female, 64-year-old male, and 74year-old female) who underwent anterior resection of rectal cancer via a minilaparotomy approach employing the Kustner incision. No handport or laparoscope was used. The median body mass index was 18.9 (range, 18.3-19.3) kg/m 2 . The rectal tumors were located in the rectosigmoid and the upper rectum. There were no intraoperative complications. The median operating time and operative blood loss were 160 (range, 159-162) min and 80 (range, 30-90) ml, respectively. All tumors were curatively resected. The patients quickly returned to normal function without morbidity or mortality. No patients developed wound-related complications. During a median follow-up period of 27.4 (range, 26.829.0) months, all patients are alive without tumor recurrence. In addition, neither incisional hernia nor nerve damage developed. We conclude that the minilaparotomy approach employing a Kustner incision is a less invasive and an attractive method with a cosmetic advantage for rectal cancer resection in selected patients. ACTA MEDICA NAGASAKIENSIA 53: 51－54, 2008

Surgical Management of Inguinal Neuralgia After a Low Transverse Pfannenstiel Incision

The authors assessed the long-term pain relief after local nerve blocks or neurectomy in patients suffering from chronic pain because of Pfannenstiel-induced nerve entrapment. The low transverse Pfannenstiel incision has been associated with chronic lower abdominal pain because of nerve entrapment (2%-4%). Treatment options include peripheral nerve blocks or a neurectomy of neighboring nerves. Knowledge on adequate (surgical) management is scarce. Patients treated for iliohypogastric and/or ilioinguinal neuralgia after a Pfannenstiel incision received a questionnaire assessing current pain intensity (by 5-point verbal rating scale), complications, and overall satisfaction. Twenty-seven women with Pfannenstiel-related neuralgia were identified between 2000 and 2007. A single diagnostic nerve block provided long-term pain relief in 5 patients. Satisfaction in women undergoing neurectomy (n = 22) was good to excellent in 73%, moderate in 14%, and poor in 13% (median follow-up, 2 years). Complications were rare. Successful treatment improved intercourse-related pain in most patients. Comorbidities (endometriosis, lumbosacral radicular syndrome) and earlier pain treatment were identified as risk factors for surgical failure. Peripheral nerve blocking provides long-term pain reduction in some individuals. An iliohypogastric or ilioinguinal nerve neurectomy is a safe and effective procedure in most remaining patients.

The Maylard incision: a low transverse incision variant seen in DIEP flap breast reconstruction

A low transverse abdominal incision, most commonly the Pfannenstiel incision, is often used in obstetric and gynecologic surgery. The Maylard low transverse abdominal incision is a rare variant in which the deep inferior epigastric vessels are ligated. This is clinically important and has significant implications for preoperative planning of reconstructive surgery based on these vessels. Four candidates for deep inferior epigastric perforator (DIEP) flap breast reconstruction were identified with a suspected Maylard incision prior to surgery. Preoperative imaging with Duplex ultrasound was important in select cases for identification of vessel patency and direction of flow. Identification of 'high-risk patients allows for appropriate patient counselling and surgical planning.

Blunt expansion of the low transverse uterine incision at cesarean delivery: a randomized comparison of 2 techniques

The purpose of this study was to compare 2 methods of expansion of the uterine incision at the time of cesarean delivery. Women who underwent a low-segment transverse cesarean delivery were assigned randomly to have the blunt expansion of the uterine incision by the physician separating the fingers either in a transversal direction or in a cephalad-caudad direction. The primary outcome measure was the incidence of unintended extensions. The transversal (n = 406) and cephalad-caudad (n = 405) expansion groups were similar with regard to patient characteristics, indication to surgery, type of anesthesia, and proportion of emergency procedures. No difference in the need for transfusions (0.7% vs 0.7%; P = 1.0) or estimated blood loss (440 +/- 341 vs 398 +/- 242 mL; P = .09) was noted. The incidence of unintended extension (7.4% vs 3.7%; P = .03) and blood loss of >1500 mL (2.0% vs 0.2%; P = .04) was significantly higher in the transversal expansion group, compared with the cephalad-caudad group. Transversal expansion was an independent contributor to unintended extension and blood loss of >1500 mL. Because it is associated with less risk of unintended extension and excessive blood loss, expansion of the uterine incision with a cephalad-caudad traction should be preferred to transversal expansion when a cesarean delivery is performed.

Comparison of Three Hysterectomy Methods in a Set of Female to Male Transsexuals

Purpose: The aim of our study was to compare three widely used surgical techniques of hysterectomy in the well defined sub-population of patients undergoing hysterectomy - FtM transsexuals. Material and methods of investigation: Hysterectomy with bilateral adnexectomy was performed in 61 FtM transsexuals; patients were randomized into three categories: abdominal hysterectomy through a lower midline laparotomy (AHL), abdominal hysterectomy through a low transverse incision (AH), and total laparoscopic hysterectomy (TLH). Methods of assessing the results: The criteria studied were duration of surgery, blood loss and the length of post-operative hospitalization. The incidence of complications was also recorded. Results: Mean blood loss (136 ml) in the TLH patients was significantly lower than in either the AH (217 ml) or the AHL (226 ml) patients. Similarly, the length of post-operative hospitalization was significantly shorter for TLH (4.7 days) than for AH (6.4 days) and AHL (6.7 days). However, the duration of the surgery was significantly longer in TLH group (110 minutes) than with either the AH (55 minutes) or AHL (54 minutes). Differences between the AH and AHL procedures were not significant in any of the three studied criteria. Discussion, conclusions: In our set of patients TLH was associated with lower blood loss and shorter hospital stay compared to the laparotomic procedures and we found no post-operative complications in TLH patients. The only significant disadvantage was longer duration of TLH procedure compared to the open procedures. Based on our experience, we regard TLH as the method of choice in the surgical management of the FtM transsexuals.

Improving Esthetics and Safety in Abdominoplasty With Broad Lateral Subcostal Perforator Preservation and Contouring With Liposuction

Suction-assisted lipectomy (SAL) in association with abdominoplasty has been regarded with trepidation, with ischemia of the apron flap, skin loss, and open wounds among the potential dire consequences. Leaving midabdominal and epigastric fatty excess, however, confers suboptimal contour and often a mediocre cosmetic result. In this study, a theoretical and technical approach that improves esthetics and safety in anterior and circumferential abdominoplasty with contouring using SAL is described and evaluated. Forty-two patients were treated with follow-up ranging from 5 to 40 months (mean follow-up 19 months). Through a low-transverse incision, the upper flap is elevated widely to the umbilical horizontal. The umbilicus is circumcised. The dissection then proceeds in a narrow column above the rectus sheaths to the xiphoid. Judicious subcostal undermining is performed, maintaining an intact bilateral subcostal "perforator zone" of 4 to 6 cm. Diastasis repair and anterior sheath plication are performed, and the umbilicus is anchored to the fascia. Excess skin and fat are excised from the inferior aspect of the flap, and the flap is inset. Wetting solution is instilled, and SAL of the entire flap, particularly in the midline and in the region of the neoumbilicus, is performed. Data were reviewed retrospectively. Twenty-seven anterior and 15 circumferential procedures were performed. There were 36 females and 6 males. There was one hematoma (3%) requiring re-exploration (male, circumferential), and 3 seromas (7%) treated with percutaneous aspiration. There was no infection, skin loss, or wound dehiscence. Contrary to classic abdominoplasty undermining to the costal margins, the maintenance of a broad subcostal blood supply allows for liberal flap contouring with suction. With this technique, liposuction can be safely used in abdominoplasty to maximize esthetic outcomes.

234: Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision

234: Maternal and neonatal outcomes of repeat cesarean delivery in women with a prior classical versus low transverse uterine incision

Subpectoral Breast Augmentation Through the Abdominoplasty Incision

Abdominoplasty and breast augmentation are often performed together, and subglandular augmentation through the abdominoplasty incision has been previously described. Nine cases of subpectoral breast augmentation and abdominoplasty performed through a single low transverse abdominal incision were performed between 2002 and 2005. The selection criteria included women who were healthy, nonsmokers, without true breast ptosis or breast deformity requiring additional shaping. The subpectoral space was accessed and the pectoralis major origins were mobilized under direct vision, and the implant pocket was shaped with the aid of a breast sizer and breast dissector. The mean follow-up was 22 months. The surgical goals were realized in all cases, with no asymmetry or implant-related complications. The standard abdominoplasty incision provides ample exposure for the creation of a subpectoral pocket and precise placement of implants. The procedure should be considered in patients who wish abdominal recontouring and breast augmentation and have minimal ptosis.

Influence of uterine exteriorization versus in situ repair on post-cesarean maternal pain: a randomized trial

This study was done to compare post-cesarean delivery pain associated with routine exteriorization of the uterus versus in situ uterine repair in the puerperium. This prospective study included 206 women who underwent cesarean delivery under general anesthesia and who were randomly assigned to two groups based on the site of uterine repair: exteriorized uterine repair (102 women) versus in situ uterine repair (104 women). Exclusion criteria were neuraxial blockade and patient refusal to participate. Visceral and incisional pain was assessed on the first and second postoperative nights using a visual analog score of 0-100 mm. There were no significant differences between the groups in maternal age, weight, gestational age, race, preoperative hemoglobin or gravidity. All subjects underwent general anesthesia and had a low transverse incision of the uterus. Exteriorization was associated with higher postoperative visceral pain scores: first night 66.7 vs. 43.5 (P<0.001); second night 44.6 vs. 23.9 (P<0.001). The incidence of postoperative fever and wound infection, postoperative hemoglobin and duration of hospital stay were similar between groups. Exteriorization of the uterus for repair of the uterine incision increases the first- and second-night postoperative pain significantly in women undergoing cesarean section.