Lower Quadrant Research Articles

Acute epiploic appendagitis - a rare differential diagnosis of acute abdomen.

Acute epiploic appendagitis is a rare differential diagnosis of unclear or acute abdomen. To describe - by means of a scientific case report - the extraordinary diagnosis of acute epiploic appendagitis along with contained diverticulitis and incarcerated herniation of the greater omentum into the hernial sac of a former trocar site (medical history, significant for laparoscopic ovarian cyst removal) in a 29-year-old female based on experiences obtained in the successful clinical case management, and on selective references from medical scientific literature. Medical history: A 29-year-old female was admitted with abdominal pain in the lower left quadrant. She reported a laparoscopic ovarian cyst removal 3 years prior. Physical examination of the abdomen revealed tenderness in the lower left quadrant without a palpable mass.Leading diagnoses were found using transabdominal ultrasound and confirmed by an abdominal CT scan; namely, incarcerated trocar hernia, diverticulitis of sigmoid colon, and acute epiploic appendagitis. Therapeutic approach was comprised of an explorative laparoscopy (because of the incarcerated hernia), adhesiolysis, removal of a tip of the greater omentum out of the hernial sac, closure of the hernial orifice, and removal of an unclear, inflamed, and bloody fatty tissue from the wall of the descending colon (histopathological investigation confirmed acute epiploic appendagitis). This was flanked by conservative treatment of diverticulitis of the sigmoid colon.Further clinical course was uneventful, with discharge on the 3rd postoperative day with favorable long-term outcome, characterized by no further complaints for 15 months. Acute epiploic appendagitis is an inflammatory, usually self-limiting condition of the epiploic appendages of the colon. It typically manifests with abdominal pain in the lower left quadrant. Imaging is an important diagnostic tool to determine whether the patient has, in fact, acute epiploic appendagitis, so recognizing the characteristic oval lesions with the surrounding inflammation and central fat attenuation on CT, as well as the hyperechoic oval lesions with a hypoechoic peripheral band on ultrasound images is crucial. Nevertheless, it is often overlooked in patients and confused with other differential diagnoses, such as appendicitis or diverticulitis. Although the condition appears infrequently, it is essential to be proficient in the diagnostic evaluation, as a misdiagnosis may lead to unnecessary treatment and even surgical intervention. , the patient was initially diagnosed with an incarcerated abdominal hernia, and therefore subsequently underwent surgery. The inflamed epiploic appendage was discovered in laparoscopic exploration, removed, and confirmed through the histopathology report. This is an approach to be performed with great caution so as not to 1. : misinterpret an inflamed diverticula or covered perforation of it as well as not 2. : overlooking a peritoneal tumor lesion.

Epiploic appendagitis

Paediatric abdominal pain continues to pose a diagnostic challenge in the acute hospital care setting. We describe an eleven-year-old boy who presented to the emergency department with acute-onset, sharp abdominal pain localised to right lower quadrant. Abdominal imaging was diagnostic for epiploic appendagitis (EA), with pathognomonic 'ring sign' and 'central dot' visualised on the axial computed tomography images. He responded well to conservative treatment, including a short course of non-steroidal anti-inflammatory drugs. EA is a lesser-known paediatric entity mimicking surgical conditions. However, steady but sharp and non-migratory characteristic of the pain in either of the lower abdominal quadrants should raise suspicion for EA. Early accurate diagnosis can prevent unnecessary surgical exploration in these patients.

Diagnosis of mixed dementia by double dichotomy

AbstractBackgroundProper classification of patients with dementia is critical in clinical trials. Dual Alzheimer’s disease (AD) and vascular pathology (mixed dementia‐MX) is the most common form of dementia estimated to be as high as 70% in pathological series. However, separation clinically is difficult, which has led to use of biomarkers. A biological definition of AD based on biomarkers has been proposed for research studies with identification of amyloid and tau in CSF or PET. Including in the ATN formula, biomarkers for vascular disease (V), obtained from MRI, separates MX subjects, improving diagnosis of AD and vascular cognitive impairment (VCI).MethodsWe used vascular disease biomarkers from MRI and AD biomarkers from CSF with a double dichotomy statistical approach to more precisely define four major groups of patients in the UNM and Alzheimers's Disease Neuroimaging Initiative (ADNI) cohorts. We compared the UNM dataset (N=80) with subjects from ADNI (N=538). Diffusion tensor imaging (DTI) biomarkers (mean free water and PSMD) were combined with CSF amyloid (A) and tau (T) to identify MX patients. We formed a composite vascular disease score (cVDS) with DTI, and a composite AD score (cADS) with CSF amyloid and phosphoTau181.ResultsPlotting cVDS on the x‐axis and cADS on the y‐axis placed subjects in one of four biologically defined quadrants: bAD (biological AD) in the upper left, bSIVD (biological subcortical ischemic vascular disease) in the lower right, bMX (biological mixed dementia) in the upper right, and bCN (biological controls) in the lower left quadrant (Figure). We identified MX, using a double dichotomy statistical method. The UNM cohort had 25% MX, while in ADNI there were 11.5% (Table). The ADNI group had a higher percentage of bCN (43%) and bAD (35%) than the UNM cohort; this was because UNM was one of 7 sites in the MarkVCID consortium with enriched VCI subjects and ADNI excluded vascular disease subjects.ConclusionsOur results show that adding a vascular factor (V) to the ATN formula creates a MX group, improving classification of patients by creating a more homogeneous AD group, which permits AD clinical trials with fewer subjects

Symptomatic isolated right common iliac artery aneurysm in the setting of renal ectopia.

An 80-year-old man presented with right lower abdominal pain for 1 day. Physical examination revealed tenderness and a pulsatile abdominal mass in the right lower quadrant. Computed tomography angiography showed an isolated right common iliac artery aneurysm with a maximum diameter of 69.2 mm and a right pelvic kidney (A/Cover). Two right renal arteries arising from the aorta supplied the pelvic kidney (B). A retrograde pyelogram is displayed in (C). The anatomy was not suitable for endovascular devices.

S101 Colosplenic Fistula in Inflammatory Bowel Disease: A Scoping Review

Background: A colosplenic fistula is an extremely rare complication of Crohn’s disease (CD) first described in a 1985 case report that remains relatively poorly understood due to its infrequent incidence. With only a few colosplenic fistulas reported worldwide, the diagnosis and management of patients with colosplenic fistula is vague. Hence, we described a review of patients with colosplenic fistula due to inflammatory bowel disease (IBD) to summarize colosplenic fistula etiology, clinical features, diagnosis, management, and prognosis to help clinicians gain a better understanding of this unusual complication and provide an aid if it were to be encountered. Methods: We conducted a systematic search of articles published from 1946 to June 2022 in Ovid MEDLINE, Ovid EMBASE, Scopus, Web of Science, and Wiley Cochrane Library to identify patients with colosplenic fistulas. Studies with etiology of IBD were included. Results: The search strategy retrieved 141 references and a total of 4 studies reporting 4 patients with colosplenic fistula in the setting of IBD were analyzed. Most patients (75%) were male, with a median age of 33 years. All 4 (100%) patients had prior diagnosis of CD, with a median time of 12.5 years since diagnosis. Two patients had extraintestinal manifestations of IBD (uveitis, erythema nodosum, ankylosing spondylitis). Three patients were on long-term sulfasalazine and 2 (50%) were on corticosteroids. Etiology: Our review revealed that patients with CD formed a fistula tract from their colon to the adjacent spleen due to chronic, transmural inflammation and ulceration. Active inflammation was observed in the adjacent colon on pathology or endoscopy. Clinical features: Most patients presented with complaints of recurring fever, leukocytosis, and left upper quadrant pain or discomfort. Diagnosis: The most widely-used and effective diagnostic imaging was the computed tomography (CT) scan. CT with intravenous (IV) contrast helped identify splenic lesions and colonic thickening, while enteral contrast was useful to identify fistula tract. Chest X-rays, plain abdominal films, and colonoscopy were not essential in diagnosing a colosplenic fistula. Use of magnetic resonance imaging (MRI) was not reported in any case. Management: Most patients were promptly treated with IV fluid and broad-spectrum antibiotics. Only one patient was started on IV steroids. Most patients underwent surgical intervention of colosplenic fistulas with splenectomy and segmental resection of the affected col1on. One case offered temporary diverting loop ileostomy with plans for future splenectomy and colectomy. Prognosis: Symptoms resolved with surgical intervention. No postoperative complications or mortalities were reported. Conclusion(s): Our review revealed that patients with Crohn’s disease can form a fistula tract from their diseased colon to the adjacent spleen due to transmural inflammation. Diagnosis can be achieved with a CT scan with enteral and/or intravenous contrast. Most colosplenic fistulas can be successfully treated with laparotomy, splenectomy, and resection of the affected colon with low rate of postoperative complications. Our pooled analysis of available colosplenic fistula cases may serve as an aid for diagnosis and management of this rare entity.

Surgical Management of Adnexal Masses in Pregnancy

Background and Aim: The incidence of suspicious adnexal masses is on the rise during pregnancy due to advancement of ultrasonography in the modern era. The prevalence of adnexal masses varied from 6% to 25% in gestational age of <20 weeks during pregnancy. However, due to a paucity of large randomized studies, little is known regarding their treatment during pregnancy. The present study aimed to assess the surgical management of suspected adnexal masses during pregnancy. Material and Methods: This retrospective study was carried out on 28 suspected adnexal masses pregnant women in the Department of Gynecology, Saidu Group of Teaching Hospital Swat during the period from March 2022 to August 2022. Patients with definite indications were assessed through surgical intervention, tumor markers, MRI (Magnetic Resonance Imaging), and as per International Ovarian Tumour Analysis (IOTA) ultrasound rules. Pregnant women who had a laparoscopy or laparotomy before 20 weeks of pregnancy to treat an adnexal mass were enrolled. SPSS version 28 was used for data analysis. Results: The overall mean age was 28.4 ± 1.9 years with an age range from 18 years to 35 years. The mean gestational age was 16.4± 1.7 weeks. Of the total 28 suspected adnexal masses, the prevalence of benign and malignant cases were 22 (78.6%) and 6 (21.4%) respectively. Out of 28 cases, about 18 (64.3%) had laparoscopic surgery and 10 (35.7%) had laparotomy. The left upper quadrant entry technique was used in 17 (60.7%) cases. Due to extensive pelvic adhesion, 3 (10.7%) required conversion from laparoscopic to laparotomy surgery. The laparoscopic group lost considerably less blood (66.7 ±52.4 vs 148.9 ±178.0 mL, P.051) and had hospitalization for short duration (2.6 ±0.9 vs 3.7 ±1.2 days, P.005) than the laparotomy group. One woman miscarried shortly after undergoing surgery. Obstetric outcomes did not differ significantly between the laparoscopy and laparotomy groups. Conclusion: The present study concluded that surgical treatment of adnexal masses appears to benefit both the mother and the fetus during pregnancy. Thorough clinical examination, individualized imaging, and prompt action assist in the identification and management of suspected adnexal masses during pregnancy. Keywords: Surgical management, Adnexal masses, Pregnancy, Laparoscopy, Laparotomy

A rare cause of abdominal pain: Acute pancreatitis due to intragastric balloon

The intragastric balloon is one of the interventional treatments used to treat obesity. This case report presents a 28-year-old woman undergoing intragastric balloon insertion to treat obesity. Thirty-five days later, she was admitted to the emergency department with acute abdominal pain, nausea, and vomiting. During the physical examination, she had pain on deep palpation in the right lower quadrant. The laboratory showed only high serum amylase levels of 563 IU/L (range 28-100 IU/L). The abdominal ultrasound did not detect gallstones or enlarged intra or extrahepatic ducts. A computed tomography scan was performed, and intragastric balloon and distal pancreatic oedema without mass and peri-pancreatic fluid collection were detected. Intravenous hydration and anti-biotherapy were started. On the second day of hospitalization, the patient's amylase value returned to the normal range (40 IU/L). The patient who tolerated oral intake was discharged on the 3rd day of hospitalization. Diagnosis of pancreatitis is made by a history of intragastric balloon insertion, a pancreatitis-like clinical picture, and biochemical and radiological confirmation of the clinical diagnosis. In such cases, conservative therapy should be applied first; the intragastric balloon should be removed only in patients resistant to treatment or with a long-term intragastric balloon.

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

Exophytic interstitial ectopic pregnancy removal: novel use of Endoloop for uterine cavity preservation

The Rate of Appendicular Neoplasm in Patients Who Underwent Appendectomy for Acute Appendicitis at King Abdulaziz Medical City, Riyadh

Background Appendicitis is a common reason for hospitalization. Rarely do people with acute appendicitis have an appendiceal mass called an abscesses or inflamed phlegmon. The goal of this study was to determine the prevalence of different appendiceal tumors including neuroendocrine tumors, adenocarcinoma, carcinoid, and mucinous and evaluate patient demographic data (e.g., age and gender) at a major tertiary care center in Riyadh, Saudi Arabia. Materials and methods We conducted a cross-sectional analytical review of patient records of 1513 patients who received an appendectomy and were diagnosed with acute appendicitis from 2015 to 2020 at King Abdulaziz Medical City, Riyadh, Saudi Arabia. We used nonprobability sampling to collect the sample. The study included patients older than 14 years. We also recorded patient demographic information, including age, gender, history, and final pathology. Results The mean age of our study population was 27.9 years (standard deviation [SD], 12.3 years). Our study had 958 male patients and 555 female patients. One thousand four hundred fifty-eight patients (96.3%) had right lower quadrant (RLQ) tenderness, and 228 patients had fever (15.0%). One thousand one hundred thirteen patients (73.5%) had rebound tenderness, 1,178 had nausea (77.8%), and 1,100 had high white blood cell (WBC) counts (72.7%). One thousand four hundred eighty-six patients received laparoscopic surgery (98.2%). Most patients (95.3%; n=1,443) had no postoperative complications. Appendicitis pathology was present in 1,381 patients (91.3%). Only 15 patients (1%) had tumor-related pathology, and these patients were significantly older than patients with nontumor-related pathology (p<.001) and had less RLQ pain, rebound tenderness, and pain migration but higher WBC counts. Pain migration was significantly inversely correlated with age: as age increased, pain migration was reported less often (odds ratio, 0.99, 95% confidence interval, 0.98 to 0.99; p=0.001). Conclusion This study aimed to determine the prevalence and types of appendiceal tumors in cases of acute appendicitis and the corresponding patient demographic data at a major tertiary care center in Riyadh, Saudi Arabia. According to our results, patients with appendicitis present with fever, rebound tenderness, nausea, and high WBC count. Appendiceal masses mainly occur in a later age group with less migration of pain and high WBC count. However, migration of pain is inversely related to age. Physicians treating patients with acute appendicitis should bear these data in mind and consider the presence of appendiceal tumors in appropriate patients.

The Diagnostic Accuracy of Pure-Tone Audiometry Screening Protocols for Vestibular Schwannoma in Patients with Asymmetrical Hearing Loss-A Systematic Review and Meta-Analysis.

(1) Background: Magnetic resonance imaging (MRI) is the gold standard investigation for all patients who present with asymmetrical hearing loss (AHL) and a high index of suspicion for vestibular schwannoma (VS). However, pure-tone audiometry (PTA) is an investigation that can be used for the screening of these patients in order to reduce the costs. The aim of this systematic review and meta-analysis was to evaluate the diagnostic accuracy of different PTA protocols for VS in patients with ASHL, when compared with MRI; (2) Methods: Medline, Embase, and Cochrane databases were used to find relevant studies. All prospective and retrospective observational studies that evaluated the accuracy of PTA protocols for the screening of VS were assessed, according to the international guidelines; (3) Results: We analyzed seven studies (4369 patients) of poor-to-moderate quality. Their pooled sensitivity was good (0.73-0.93), but their specificity was low (0.31-0.60). All protocols were located in the right lower quadrant on the likelihood scattergram, and the post-test probabilities for positive and negative diagnosis of these protocols were extremely low; (4) Conclusions: PTA protocols cannot be used for a proper screening or diagnosis of vestibular schwannoma despite their good sensibility, and MRI remains the gold standard for this purpose.

Cistadenoma mucinoso del apéndice cecal en paciente con cuadro clínico de apendicitis aguda operado de apendicetomía por laparoscopia

Mucoceles of the appendix are rare, predominate in women and usually present as a palpable mass in the right lower quadrant. Most patients are asymptomatic. The mucocele is defined as a cystic dilatation of the appendicular lumen caused by mucin accumulation. We present the case of a male patient in his seventh decade with clinical symptoms of acute abdomen with suspicion of acute appendicitis, laparoscopic hemicolectomy surgery was performed after finding findings of tumor dependent on ascending colon (blind region), indurated 80 × 100 mm approximately, performing right hemicolectomy plus ileocolonic lateroterminal anastomosis with adequate postoperative evolution. Keywords: Mucocele; appendix; appendicitis.

A Rare Case of Non-Gestational Ovarian Mixed Intermediate Trophoblastic Tumor Associated with a Mature Cystic Teratoma

Abstract Introduction/Objective Ovarian non-gestational trophoblastic tumors are rare with only a few documented cases. We report a case of a 22-year-old non-sexually active woman who presented to the emergency department with ongoing left lower quadrant abdominal pain. Workup showed elevated Beta-human chorionic gonadotropin levels (152 mIU/mL) and a left ovarian mass. This was initially thought to be an ectopic pregnancy, however patient was non- sexually active. Patient underwent a left oophorectomy and the specimen was sent to pathology. Methods/Case Report Microscopic examination of the ovary revealed a mature cystic teratoma with intimately associated foci of loosely cohesive pleomorphic atypical cells. The atypical cells also replaced some of the blood vessel walls and infiltrated the residual ovarian parenchyma. Mitoses were present at (2/10hpf). No necrosis or chorionic villi were identified. Immunohistochemical stains were performed, and the atypical cells were positive for GATA3, inhibin, and human placental lactogen. These cells also showed an elevated ki67 proliferative index (15%). All these findings supported a diagnosis of a placental site trophoblastic tumor. Focally, well-defined cystic structures composed of large epithelioid cells were also noted. These epithelioid cells were positive for GATA3, inhibin, and p63. These cells were negative for human placental lactogen and showed an elevated ki67 proliferative index (12%), findings consistent with an epithelioid trophoblastic tumor component. Ovarian intermediate trophoblastic tumors are rare and could be of gestational or non-gestational origin. To confirm a non-gestational origin, DNA genotyping was performed. Results showed identical genetic profiles in the teratoma, the intermediate trophoblastic tumor, and in the patient’s benign ovarian tissue. This finding confirmed the diagnosis of a non-gestational mixed intermediate trophoblastic tumor associated with a mature cystic teratoma. This tumor is exceedingly rare with only a few reported cases in literature. Results (if a Case Study enter NA) NA Conclusion The diagnosis of a non-gestational mixed intermediate trophoblastic tumor is exceedingly rare with only a few reported cases in literature. The combination of immunohistochemistry and dna genotyping confirmed our suspicion and yielded the correct diagnosis.

A Common Diagnosis Delayed by Three "Wrong Footing" Anchoring Errors - it is Difficult to Remember What You Have Forgotten.

If a patient has unexplained lower left abdominal pain, it is advisable to deploy a "searchlight" strategy.When a hydroureter was found to have no apparent source obstruction, a vertical tracing strategy should have been undertaken to detect its root cause.To avoid the wrong diagnosis through anchoring bias, pivot and cluster strategy - deploying differential diagnosis specific to the initial diagnosis (constipation in this case) - should be adopted at the start, considering the important differential diagnosis and thus preventing a missed diagnosis.

7600 Identifying Risk Factors for Adhesion Formation in the Left Upper Quadrant - Preliminary Findings of a Prospective Study

<h3>Study Objective</h3> To identify risk factors for development of adhesions in the left upper quadrant (LUQ). <h3>Design</h3> Multi-site, prospective study approved by each institution's local institutional review board. <h3>Setting</h3> Two large academic tertiary referral centers. <h3>Patients or Participants</h3> All laparoscopic cases performed by study staff on adult patients were eligible. Cases were performed per standard protocol with entry approach and location per surgeon preference. Intraoperative photo documentation of four abdominal quadrants was obtained at the onset of each case, and additional areas as indicated. A data collection form was completed after each case to capture data on adhesiogenic events (such as prior surgeries, infections, endometriosis, radiation), time spent for adhesiolysis, route of entry, location and grade of adhesions, if present. <h3>Interventions</h3> No interventions were included in this study. The primary outcome of this study is the presence and severity of adhesions identified in the LUQ at the time of laparoscopy for benign gynecologic disease. <h3>Measurements and Main Results</h3> We present interval findings from study onset in 2019 until February 2022. A total of 520 laparoscopic cases have been collected, with an overall adhesion incidence of 59.4%. The overall incidence of adhesions present in the LUQ was 1.9%. Among patients with a history of gastric banding, sleeve gastrectomy, and Roux-en-Y bypass (n=24), there were 2 cases with adhesions in the LUQ (8.3%); one with filmy adhesions and one with dense cohesive adhesions between bowel and the anterior abdominal wall. These two patients had prior open gastric bypass and open gastric bypass revision with colectomy. No visceral or vascular injuries were noted when LUQ entry was performed. <h3>Conclusion</h3> Our early data suggests that the overall rate of adhesions in the LUQ is low, especially with prior laparoscopic gastric procedures. While a history of gastric surgery should not preclude abdominal entry in the LUQ, vigilance is important to avoid inadvertent injury to underlying structures.

8605 Gynecologic Laparoscopy in the Bariatric Patient: A Retrospective Review of Abdominal Access and Associated Complications

<h3>Study Objective</h3> To provide clinical direction on laparoscopic abdominal entry techniques in women with known history of laparoscopic Roux-en-Y Gastric Bypass (RYGB) undergoing gynecologic surgery and to identify any associated complications. <h3>Design</h3> Retrospective Chart Review and Case Series. <h3>Setting</h3> Community-based tertiary care medical center. <h3>Patients or Participants</h3> All patients who underwent RYGB between 2013 and 2020 and had a subsequent gynecologic procedure. <h3>Interventions</h3> Abdominal access. <h3>Measurements and Main Results</h3> Thirty-one patients were identified, of which 18 had an adnexal surgery and 13 a hysterectomy. At time of surgery, the mean age was 44 years and body mass index was 32 kg/m². The average interval time from RYGB to gynecologic surgery was 29 months. The majority of women (71%) had additional abdominal surgeries, among them 82% had prior laparotomies. Three entry sites were identified at the initial attempt to access the abdominal cavity; umbilical (71%), left upper quadrant (LUQ, 26%) and left lower quadrant (LLQ, 3%). Closed entry technique using the Veress needle was the most commonly used entry technique (68% versus 29% for optical trocar entry and 3% for open entry). There were no injuries resulting from abdominal access irrespective of the entry site or technique chosen. However, access was unsuccessful in 25% (2 out of 8) of the cases when attempted in the LUQ, resulting in conversion to alternative entry sites. <h3>Conclusion</h3> Successful and safe abdominal access in the bariatric patient can sometimes be challenging and preoperative surgical planning is essential. While no injuries during entry were reported regardless of site chosen, closed entry at the umbilicus using the Veress needle was the technique the most practiced and was associated with fewer attempts and conversions to alternative sites as compared to LUQ entry.

Vasopressin Injection Purse-String Ectopic Resection (VIPER) Technique for Laparoscopic Management of Cornual Ectopic

<h3>Study Objective</h3> To describe the VIPER technique for the laparoscopic management of cornual ectopic pregnancy; a technique that minimizes blood loss and mitigates risk of conversion to laparotomy. <h3>Design</h3> Case series. <h3>Setting</h3> High-volume, academic and academic-affiliated medical centers. <h3>Patients or Participants</h3> All patients presenting with cornual ectopic pregnancy managed surgically. <h3>Interventions</h3> Laparoscopic cornual resection by five Minimally Invasive Gynecologic Surgeons. The VIPER technique utilizes four ports (umbilical, left lower quadrant, and ipsilateral right sided) and a 30-degree laparoscope. After obtaining visualization, dilute vasopressin is injected into the myometrium adjacent to the pregnancy. The affected fallopian tube is disconnected distally. A purse-string stitch with uni-directional barbed suture is placed circumferentially around the pregnancy and cinched. This stitch achieves hemostasis regardless of rupture status. The needle is left attached, and a wedge resection of the cornua is performed with an ultrasonic device. The myometrial defect is repaired with the remaining suture. <h3>Measurements and Main Results</h3> 17 patients underwent laparoscopic cornuectomy between 2012 to 2022, with 7 found to be ruptured. The mean patient age was 30 years (range 20-41), mean body mass index was 31.4kg/m² (range 22-52), and mean gestational age was 8 weeks 6 days (range 5 weeks 6 days to 11 weeks 1 day). Patient risk factors included history of prior sexually transmitted infection (3 patients), in vitro fertilization (1 patient), and prior ectopic pregnancy (1 patient). The other twelve patients had no risk factors. The mean operative time was 107 minutes (range 50-229), with mean estimated blood loss of 41mL for non-ruptured and 412mL for ruptured ectopic pregnancies. The mean hemoperitoneum identified was 1117mL, (range 50mL to 3325mL). There were no conversions to laparotomy. 70.6% of patients were discharged on the day of surgery. <h3>Conclusion</h3> The VIPER technique is feasible and effective for the management of both non-ruptured and ruptured cornual ectopic pregnancy.

PSUN235 Dopamine-induced polyuria

Abstract Background Dopamine acts on dopamine-1 receptors in the renal vasculature at a low dose, resulting in natriuresis and diuresis. Polyuria is a rare condition found in patients who receive dopamine infusion. We report a young female hospitalized for ovarian torsion who underwent several surgical procedures had been infected with gram-negative bacteremia. She received a dopamine infusion for hypotension with relative bradycardia. Subsequently, she developed polyuria. Case presentation A 25-year-old female was referred to UMC hospital for acute diverticulitis with micro-perforation from the sigmoid colon. She presented to the outside hospital with abdominal pain, fever, nausea, and vomiting for four days. On arrival, she had a fever of 101.9F. Initial laboratory showed leukocytosis and lactic acidosis. CT abdomen at UMC revealed 16×11cm mass in the left lower quadrant, potentially originating from the left ovary. The patient was treated with IV Zosyn for acute diverticulitis. On day 5 of admission patient remained to have abdominal pain, fever, and worsening lactic acidosis. She was taken to OR for exploratory laparotomy with dissection of left salpingo-oophorectomy for torsion of adnexal mass resection. On day 91 of admission, the patient developed low-grade fever (100.7F) and hypotension (BP 63/30) with the MAP of 40. IV NS 1L was administered. CT abdomen revealed no intra-abdominal or pelvic abscess or fluid collection. For possible septic shock, the patient was started on empirical IV antibiotics. Despite IV fluid resuscitation, blood pressure remained low, vasopressin and norepinephrine were initiated. Day 92, she developed new-onset bradycardia, EKG showed third-degree AV block. IV dopamine infusion was started at the rate of 5mcg/kg/min. During dopamine infusion, the patient voided between 400-600mL/h. Over the 12-h period, the urine output was about 5L. Endocrinology was consulted for polyuria. Laboratory studies showed urine osmolality 384mOsm/kg, urine electrolytes were UNa 130mmol/L, UK 20.1mmol/L, UCl 115mmol/L, BUN/Cr 28/1.0. Approaching polyuria, the diuresis was associated with high urine osmolality and sodium, which exhibited characteristic features of solute diuresis with natriuresis. The diuretic phase of acute renal injury could not be implicated in this patient since she has stable renal function without azotemia. There was no evidence of urinary tract obstruction to suggest post obstruction diuresis. Central or peripheral diabetes insipidus was ruled out by the lack of characteristic water diuresis. It was suspected that the diuresis was related to the dopamine infusion. Thus, dopamine infusion was discontinued. The urine output dropped within a few hours. The patient's urine output stabilized to 0.8-1.0ml/min. The striking drop in urine output after discontinuity of dopamine is consistent with the role of dopamine in this patient's diuresis. Conclusion This is a rare case report of dopamine-induced polyuria in septic shock patient. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Laparoscopic Abdominal Cerclage after Prior Radical Trachelectomy

<h3>Study Objective</h3> To present a case and surgical video of laparoscopic abdominal cerclage placement after prior radical trachelectomy and demonstrate techniques in overcoming challenging dissections and an alternative surgical technique in placement of cerclage. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> In the operating room with a patient in dorsal lithotomy position with both arms tucked. A 10mm port was placed at the umbilicus and 3 additional 5mm ports were placed in the right and left lower quadrant and suprapubic region. A uterine manipulator, flexible laparoscopic, and bipolar sealing device were used. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> A 34yo P2 with prior surgical history of exploratory laparotomy, radical trachelectomy, sentinel lymph node mapping, pelvic lymphadenectomy for stage 1B1 cervical squamous cell cancer. She had been disease free for two years and she had erosion of her vaginal cerclage that had been placed at the time of her original surgery. She had two prior cesarean deliveries prior to her cervical cancer diagnosis and desired future fertility. She underwent a laparoscopic abdominal cerclage with cystoscopy and ureteral catheter placement. <h3>Measurements and Main Results</h3> Laparoscopic placement of abdominal cerclage was successful. Surgical techniques in navigating difficult dissections are reviewed in the video. In the absence of a cervicouterine junction, placement a 5mm Mersilene tape cerclage at the neo-cervical region was successful. There were no intra or post-operative complications. Patient had a good surgical recovery. <h3>Conclusion</h3> This video demonstrates challenges in placement of an abdominal cerclage following a radical trachelectomy due to distortion of anatomy and dense post-surgical adhesions. The video demonstrates that laparoscopic placement at the neo-cervical junction can be accomplished successfully and safely.

ODP050 Oncocytic Adrenocortical Carcinoma Presenting with Hematuria

Abstract Introduction Adrenocortical carcinoma (ACC) is rare and aggressive endocrine tumor. It is commonly noticed due to symptoms of hormone excess, mass-effect, or incidentalomas. Different histological variants are noted, which include: oncocytic, myxoid, sarcomatoid, and the conventional subtype. The oncocytic variant is usually seen on the left side, and usually presents with symptoms of mass-effect. Only around 17% were noted to be functional. We present an interesting case of ACC (oncocytic type) which presented with hematuria. Case Presentation 70-year-old female with a history of morbid obesity, hypertension, anxiety, GERD, tubular adenoma, hyperlipidemia, and lumbar radiculopathy came in to see her primary care for hematuria and back pain. She has a long-standing history of back pain, for which she has had an EMG, which showed mild axonal polyneuropathy and bilateral L5 radiculopathy. Apart from hematuria, she denies any other urinary complaints. Additionally, she denied any fever, chills, nausea, abdominal pain, sweating, tremor, headache, palpitations, easy bruising, fractures, muscle weakness, hirsutism, or changes in her weight. She has a family history of pancreatic cancer and is currently retired, and denies alcohol, tobacco, or recreational drug use. A KUB X-ray was ordered which showed calcification in the left upper quadrant, concerning for a splenic artery aneurysm; this led to a CTA abdomen, which showed a large 7.2 cm heterogenous enhancing solid left adrenal mass, concerning for primary adrenal carcinoma, which was new compared to imaging 2 years ago. Also seen was a 0.7 cm enhancing right hepatic lobe lesion, along with a 1.5 cm splenic artery aneurysm. Following this, an abdomen MRI with contrast showed a 7×7×7 cm solid heterogeneously enhancing left upper quadrant mass beside the left adrenal gland and pancreas. Subsequently, a CT guided needle biopsy was done, which revealed scant adrenal tissue. PET scan showed a hypermetabolic mass, arising from the left adrenal, consistent with adrenal carcinoma. At this point, an endocrinology referral was placed, and other lab work including 24-hour urine free cortisol, DHEA-S, 24-hour urine metanephrine, and aldosterone/renin ratio was done. DHEA-S level was elevated at 264 mcg/dl (12-133). She was then transferred to a tertiary care facility, where she underwent a left adrenalectomy, para-aortic lymphadenectomy, nephrectomy, splenectomy, and distal pancreatectomy. Pathology confirmed adrenal cortical carcinoma (oncocytic type), with negative margins, Ki-67 labelling index of 25%, and no lymphovascular invasion, pT2pNO. She was then discharged home with visiting nurses. Conclusion Oncocytic ACC is an infrequent tumor, which presents with symptoms of mass effect, and definitive diagnosis requires histopathological assessment. The Lin–Weiss–Bisceglia (LWB) system and Helsinki score help establish malignant potential. Fortunately, it has a decreased tendency to metastasize and a better prognosis than other ACC subtypes. Further studies to understand oncocytic ACC are needed. Presentation: No date and time listed

8718 Novel Use of Viscera Retainer for Safer Resection of Posterior Fibroids during Laparoscopic Myomectomy

<h3>Study Objective</h3> To demonstrate a novel use of an abdominal viscera retainer for improving safe access to the posterior aspect of the uterus during laparoscopic myomectomy. <h3>Design</h3> Surgical film. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Patient with a large 7 × 7cm subserosal and intramural fibroid at the posterior aspect of the uterine body and fundus. <h3>Interventions</h3> A viscera retainer is a device widely used by surgeons to retain omentum and protect underlying bowel during fascial closure of laparotomy cases. The device has been used to improve speed of closure while significantly reducing the risk of unintended needle punctures. During this laparoscopic myomectomy case, we used an umbilical port for the camera, left and right lower quadrant ports, and a midline suprapubic mini-laparotomy incision using a mini GelPoint. We used a medium sized viscera retainer, measuring approximately 6 × 9 inches. The retainer is able to be easily rolled for placement in the pelvis through the mini GelPoint. Once in the abdomen, the retainer can be positioned into the posterior cul-de-sac overtop of any underlying bowel. The weighted center spine helps to keep the device in place and prevents bowel from inadvertently moving into the surgical field. <h3>Measurements and Main Results</h3> The viscera retainer was able to be used as an intra-abdominal retraction device and physical protective barrier for the bowel during laparoscopic myomectomy, specifically during enucleation of the fibroid and suturing of the hysterotomy. <h3>Conclusion</h3> This unique use of a device typically reserved for laparotomy improved surgeon's access to the posterior aspect of the uterus for dissection and enucleation of posterior fibroids during laparoscopic myomectomy.