Severe Intra-abdominal Adhesions Research Articles

Preoperative sonographic prediction of intra-abdominal adhesions using sliding sign at repeat caesarean section at the University of Maiduguri Teaching Hospital, Nigeria: a prospective observational study

ObjectiveTo determine if the presence or absence of sonographic sliding sign preoperatively is a good predictor of the presence and type of intra-abdominal adhesions; and to determine the time taken...

Indocyanine green fluorescence-guided laparoscopic colorectal cancer surgery with prophylactic retrograde transileal conduit ureteral catheter placement after previous total cystectomy: a case report

BackgroundIatrogenic ureteral injury (UI) is a potentially serious complication of colorectal cancer surgery. Performing perioperative placement of ureteral stents or intraoperative fluorescence navigation surgery for the ureter using indocyanine green (ICG) has been employed as a method of preventing UI. However, transileal conduit stent placement has been considered challenging because it is difficult to identify the ureteral orifice due to the anatomical changes caused by a previous surgery. We report a case in which laparoscopic colectomy was safely performed using a combination of prophylactic transileal conduit ureteral catheter placement and intraoperative ICG fluorescence navigation surgery.Case presentationA 75-year-old man presented to our hospital complaining of vomiting and abdominal distension. He had a history of open total cystectomy and ileal conduit urinary diversion 11 years prior to admission. Computed tomography confirmed colon dilation with fecal impaction from the ascending colon to the sigmoid colon and wall thickening in the sigmoid colon. Colonoscopy during the transanal ileus tube insertion revealed a Borrmann type II tumor with circumferential stenosis 10 cm distal to the junction between the descending colon and the sigmoid colon. The patient was diagnosed with colorectal ileus due to obstructive sigmoid colon cancer and underwent transanal ileus tube insertion. Severe intra-abdominal adhesions were expected due to the previous total cystectomy, and the left ureter was near the sigmoid colon tumor; therefore, prophylactic retrograde transileal conduit ureteral catheter placement was performed one day before the elective surgery.During the operation, 20 ml (5.0 × 10–2 mg/ml) ICG was administered from the transileal conduit ureteral catheter, and ICG fluorescence of the ureter was observed in the retroperitoneum. Laparoscopic Hartmann's operation was successfully performed, confirming ureter fluorescence. The operation time was 231 min, with 5 mL of intraoperative bleeding. The ureteral catheter was removed 3 days after the operation. The patient’s postoperative course was good with no complications, and he was discharged on postoperative day 7.ConclusionsProphylactic transileal conduit ureteral catheter placement and ICG fluorescence navigation surgery were effective in performing laparoscopic colorectal surgery with severe adhesions after urinary diversion.

Role of single-incision laparoscopic surgery in the management of small bowel obstruction.

Small bowel obstruction (SBO) arises on various backgrounds, and the surgical procedure is often modified intraoperatively as needed. Single-incision laparoscopic surgery (SILS) is less invasive than conventional multiport laparoscopic surgery (MPS) and reported to be equally safe and efficient. We have been applying SILS to SBO requiring surgical treatment, and we conducted a retrospective study to clarify the role of SILS in the management of SBO. Thirty-four consecutive patients were identified for inclusion in the study through a review of hospital records of patients having undergone surgery for SBO between May 2013 and June 2018. Patients with tumor- or hernia-related SBO were excluded. We also identified, for comparison, a group of patients who had undergone open surgery for SBO during the preceeding 5-year period. The primary study endpoint was the SILS completion rate, and analyses were performed to identify risk factors for conversion to open surgery and perioperative complications. The SILS completion rate was 70.6% (24/34 patients), with conversion open surgery required for the remaining 10 (29.4%) patients. Conversion was necessitated by limited working space in 5 (50%) patients, discovery of massive necrosis in 3 (30%), and non-detection of the responsible lesion in 2 (20%). Univariable analysis showed an American Society of Anesthesiologists Physical Status score (p = 0.020) and severe intra-abdominal adhesions (p = 0.007) to be risk factors for conversion. Conversion to open surgery (vs complete SILS) was significantly associated with increased operation time (p = 0.018), blood loss (p = 0.021), postoperative stay (p = 0.010), and postoperative complications (p = 0.004). Open surgery was significantly associated with increased postoperative stay (p = 0.026) and postoperative complications (p = 0.011). SILS appears to be a reasonable surgical treatment option for selected patients with SBO.

Role of Laparoscopic Adhesiolysis in Adhesive Intestinal Obstruction

Background: Adhesive Intestinal obstruction is an inevitable complication of abdominal surgeries with significant morbidity associated with poor quality of life and predispose to repeated hospitalization. Laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction. However, laparoscopic adhesiolysis has not gained wide acceptance because of concerns regarding iatrogenic injury to the bowel and limited visualization secondary to distended bowel.Subjects and method: Between the period of November 2017 and June 2019in the General Surgery Department of Zagazig university Hospitals 12 patient included 6 males (50.0%) and 6 females (50.0%) with mean age (38.4±7.1) complaining of adhesive intestinal obstruction all of them were operated laparoscopically for lysis of adhesions. Results: laparoscopic adhesiolysis was done in (58.3%) of the study group followed by laparoscopic adhesiolysis with intraoperative enterotomy (25.0%) and lastly Conversion to open procedure for lysis of adhesions due to excessive adhesions was done in (16.7%) of the study group.Conclusions: Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. Patients who require an emergent operation are good candidates for laparoscopic adhesiolysis. Patients who have a chronic or recurrent partial obstruction documented on a contrast study are also good candidates for laparoscopic adhesiolysis.

2570 What's the Limit of Total Laparoscopic Myomectomy?∼In Terms of Intraoperative Conversion∼

Video Objective To assess what limit to complete surgical procedure of laparoscopic myomectomy (LM), I review surgical outcomes of cases performed LM, laparoscopy-assisted myomectomy (LAM) and abdominal myomectomy (AM), and present the cases converted from LM to LAM. Design Retrospective cohort study. Setting Urban general hospital in Japan. Patients All women who were underwent myomectomy, between 2014 to 2018. Interventions Medical records were reviewed for baseline characteristics and perioperative outcomes. Measurements and Main Results First, I present our operative procedure of LM. We have modified diamond trocar placement.After the vasopressin injection into the myometrium of fibroid surface,we make incisions with ultrasonic or electric scalpel and enucleate fibroids. After the suturing of myometrium, we make posterior colpotomy and carry out them transvaginally. If fibroids are too large to be carried out, we perform intracorporal or intravaginal manual morcellation. Second, A total of 1123 patients were undergone myomectomy in our hospital between 2014 to 2018. The mean ±SD specimen weight of LM, LAM, AM was 180.5±153, 597.0±389.1, 972.9±738.9g, dominant myoma diameter was 6.7±2.4, 10.3±3.6, 12.8±5.8cm. 4 out of 1029 (0.39༅) LM cases were shifted to LAM during surgery, one case due to numerous myoma and three cases due to severe intraabdominal adhesion. No difference in perioperative complications was found for LM group with other procedures. All cases were performed blood test and imaging test by ultrasonography or magnetic resonance imaging (MRI) preoperatively. When a malignancy is suspected, the specimen is extracted using a protection bag. In 1123 cases performed uterus-preserving surgery, only 1 case (0.09%) was revealed as malignant postoperatively. Conclusion LM is feasible and safe surgical procedure with appropriate selection of patients.

Pharmacological Mobilization and Recruitment of Stem Cells in Rats Stops Abdominal Adhesions After Laparotomy

Adhesions are a very common complication in the abdominal surgery. Animal studies and human trials have evaluated strategies designed to reduce and prevent postsurgical adhesions but few have an evidence base that justifies routine use. A strategy to prevent adhesions effectively remains an urgent need. We studied a reproducible model of intra-peritoneal adhesion formation in rats using laparotomy with several peritoneal sutures to produce the adhesions. Here we show that entraining endogenous stem cells into injury sites using the combined effect of AMD3100 and low-dose FK-506 (AF) can reduce the adhesion score significantly and abolish peritoneal adhesions in 45% of animals in a rat model of severe postsurgical intra-abdominal adhesions, compared with saline controls. Searching for mechanisms, we found AF treatment dramatically increased SDF-1 expressing cells, HGF expressing Ym1+ M2 macrophages and CD133+ stem cells in the injury sites of peritoneal surface at day 5 post-operation. Our results demonstrate that medically induced recruitment of autologous stem cells using AF significantly reduced postsurgical intra-abdominal adhesions. These findings suggest a novel effective therapeutic approach to preventing adhesions in patients.

Perforation of the esophagus due to thermal injury after laparoscopic radiofrequency ablation for hepatocellular carcinoma: a case for caution

BackgroundSeveral reported complications associated with radiofrequency ablation for liver tumors are due to thermal damage of neighboring organs. We herein report a first case of esophageal perforation due to thermal injury of laparoscopic radiofrequency ablation (RFA).Case presentationA 75-year-old woman was treated repeatedly with RFA (percutaneous and laparoscopic) and transcatheter arterial chemoembolization for hepatocellular carcinoma. One week after laparoscopic RFA for recurrent HCC located in segment 2 of the liver, dysphagia and thoracic pain occurred. Upper gastrointestinal endoscopy revealed a perforated esophageal ulcer at the esophago-gastric junction. Inflammation was localized because of severe intra-abdominal adhesion due to repeat surgery, so we decided to treat the patient conservatively. The perforation of the esophagus gradually scarred, and exacerbation did not occur after restarting oral intake.ConclusionsWhen patients with a history of abdominal surgery or intra-abdominal inflammation undergo thermal ablation therapy, caution is required, as there is a possibility of thermal injury of unexpected organs.

The occurrence and severity of intra-abdominal adhesions in cases of pregnancies complicated by placenta accreta: A case control study

ObjectiveTo examine the occurrence of intra-abdominal adhesions (IAA) among women with placenta accreta (PA). Study designCase control study conducted at a single teaching hospital on data from January 2004 to December 2016. The cases included women who underwent a cesarean hysterectomy due to PA and had a pathological confirmation of accretion. The controls were matched for delivery date and number of cesarean deliveries (CDs) at a ratio of 1:4. IAA were categorized as “none”, “filmy”, or “dense”. The outcome measures were rate of IAA. In order to detect a 25% difference in overall IAA between the groups, with alpha of 0.05 and 80% power, a sample size of 165 women was needed. ResultsOverall, 165 women (33 and 132 in the case and control groups, respectively) were included. Except for maternal age, there were no statistically significant differences between the groups in demographic and obstetric variables. Overall IAA rate was 30.3% and 47.7% in the case and control groups, respectively (RR: 0.64; 95% CI: 0.37–1.10, p = 0.04). Rate of dense adhesions was 15.2% and 32.6% in the case and control groups, respectively (RR: 0.47, 95% CI: 0.20–1.08; p = 0.03). After adjustment for maternal age, there was a significantly lower rate of overall IAA (RR = 0.39; 95% CI: 0.17-0.93; p = 0.02) and dense adhesions (RR = 0.30; 95% CI: 0.11-0.87; p = 0.02) among the cases. ConclusionThe incidence and severity of IAA following CDs are low, among women who develop PA.

Sliding Sign for Intra-abdominal Adhesion Prediction Before Repeat Cesarean Delivery.

The sliding sign (the relative motion between the abdominal and uterine wall as assessed by ultrasonography) may help identify severe intra-abdominal adhesions before repeat cesarean delivery. We conducted a prospective observational study of scheduled repeat cesarean deliveries. Using transabdominal ultrasonography, while the parturient breathed deeply, the ultrasonographer recorded a video clip in a sagittal plane lateral to the umbilicus. These clips were assessed for the presence (sliding-positive) or absence (sliding-negative) of relative movement between the maternal abdominal and uterine wall. Surgeons blinded to ultrasonography results graded the severity of intraperitoneal adhesions intraoperatively. Study outcomes were the accuracy of the preoperative sliding sign for prediction of severe adhesions and its association with surgical times and bleeding. We recruited 370 women. A negative sliding sign was associated with severe adhesions (sensitivity 56%, 95% CI 35-76; specificity 95%, 95% CI 93-97). A similar accuracy (sensitivity 64%, 95% CI 43-82; specificity 94%, 95% CI 92-97) was achieved by combining the sliding sign with a history of adhesions in the previous surgery. In multivariable models, a negative sliding sign was significantly correlated with a longer interval from skin incision to delivery and increased risk for bleeding. A negative sliding sign predicts severe intra-abdominal adhesions encountered during repeat cesarean delivery, longer time to delivery, and a higher chance of bleeding.

549: Placenta accreta and Intra-abdominal adhesions; the bright side

There is a well-known association between repeated cesarean deliveries (CDs) and the development of placenta accreta (PA). Defective scar decidualization leading to trophoblast invasion is believed to be the culprit for the developmental of accretion. Additionally, repeated CDs may lead to the developmental of severe intra-abdominal adhesions (IAA). Scar decidualization and IAA are both considered tissue healing processes. We aimed to examine the occurrence of IAA among women with PA. Case control study conducted at a single teaching hospital on data from January 2004 to December 2016. The study group included women who underwent a cesarean hysterectomy due to PA and had a pathological confirmation of accretion. The control group was matched for year of birth and number of CDs at a ratio of 1:4. IAA were categorized as “none,” “filmy,” or “dense”. The outcome measures were rate and severity of IAA. We hypothesized that the IAA rate would be lower in cases of defective healing, i.e., in cases of PA. In order to detect a decrease from 50% to 25% in any IAA among the control and the study groups respectively, with alpha (one sided) of 0.05 and 80% power, a sample size of 165 women was needed. Overall, 165 women (33 and 132 in the study and control groups respectively) were included. Except for maternal age, there were no statistically significant differences between the groups in demographic and obstetric variables including maternal diseases, prior abdominal surgeries, and the number of previous CDs. IAA rate was 33.3% and 47.7% in the study and control groups respectively (p=0.04). Rate of dense IAA was 15.2% and 32.6% in the study and control groups respectively (p=0.03). After adjustment for maternal age, there was a significantly lower rate of any IAA (RR=0.39; 95% CI: 0.17-0.93; p=0.02) and dense IAA (RR=0.30; 95% CI: 0.11-0.87; p=0.02) among the study group. The incidence and severity of IAA following CDs are lower among women who develop PA. Decreased wound healing may, at least partly, account for the reduced co-occurrence.

Laparoscopy of hepatocellular carcinoma is helpful in minimizing intra-abdominal adhesion during salvage transplantation.

PurposeThis study analyzes the impact of laparoscopic liver resection on intra-abdominal adhesion.MethodsPatients who underwent salvage liver transplantation after liver resection for hepatocellular carcinoma from January 2012 to October 2017 at our institution were included. Information about the severity of intra-abdominal adhesions was collected from a prospectively maintained database. Intra-abdominal adhesions were graded after the agreement of 2 surgeons who participated in the salvage liver transplantation based on predetermined criteria. Adhesion severity and demographic, operative, and postoperative data were compared between the laparoscopic group and the open group. Multivariate logistic regression was performed to consider potential factors related to severe adhesion during salvage transplantation.ResultsSixty-two patients who underwent salvage liver transplantation after liver resection were included in this study. Among them, 52 patients underwent open surgery, and 10 patients underwent laparoscopy. Adhesion was significantly more severe in the open group than in the laparoscopy group (P = 0.029). A multivariate logistic regression model including potential factors related to severe adhesion showed that laparoscopy (odds ratio, 0.168; 95% confidence interval, 0.029–0.970; P = 0.048) was the only significant factor.ConclusionLaparoscopic liver resection for hepatocellular carcinoma can minimize intra-abdominal adhesion during salvage liver transplantation.

Roux-En-Y Fistulojejunostomy: a New Therapeutic Option for Complicated Post-Sleeve Gastric Fistulas, Video-Report.

Laparoscopic sleeve gastrectomy (LSG) has become during the last few years the most frequent procedure in bariatric surgery. However, complications related to the gastric staple line can be even more serious. The incidence of gastric fistula after LSG varies from 1 to 7%. Its management can be very challenging and long. In case of chronic fistula and failure of the previous treatment, total gastrectomy or Roux-en-Y fistulo-jejunostomy (RYFJ) might be considered. RYFJ has been described very rarely as a salvage procedure of gastric leaks after LSG. Between January 2015 and December 2015, we have performed a RYFJ in two patients, with chronic and persisting gastric fistulas, one after LSG and one after duodenal switch, respectively. In the two patients, the RYFJ procedure was attempted laparoscopically but in one case (patient after duodenal switch), conversion into laparotomy was necessary because of severe intra-abdominal inflammatory adhesions. In our video, we are presenting the case of this particular patient treated laparoscopically with a late and persisting leak 1 year after LSG. In this multimedia high-definition video, we described the steps of our technique of laparoscopic RYFJ. There was neither mortality nor severe postoperative complications. The fistula control after a minimum of 6 months follow-up was 100% for both of patients. RYFJ in our particular case was efficient. However, larger series and longer follow-up are needed to confirm the efficiency of the RYFJ as a salvage procedure.

Can We Predict the Presence and Severity of Intra-Abdominal Adhesions before Cesarean Delivery

Aims: The study aimed to investigate whether we can predict the presence and severity of intra-abdominal adhesions before cesarean delivery using patient history, symptoms, and abdominal skin scar characteristics. Methods: In this prospective study, 143 pregnant women with history of previous abdominal surgery were included and they delivered by cesarean. Preoperative abdominal scar characteristics and symptoms as well as intraoperative abdominal adhesions were evaluated using the Manchester Scar Scale, a symptomatology questionnaire and the More Comprehensive Adhesion Scoring Method, respectively. Results: Patients with adhesions (n = 98) and without adhesions (n = 45) had similar baseline characteristics. In the adhesion group, abdominal scar scoring parameters were significantly increased. However, there was no significant correlation among total scar score, adhesion score, and symptom score. Conclusion: Despite the availability of many proposed methods, accurate prediction of the severity of surgery-related adhesions is beyond our current abilities. Therefore, as healthcare providers, obstetricians should avoid unnecessary use of the cesarean approach. This approach is more effective, beneficial, realizable, and reasonable than the prediction of surgery-related adhesions.

Laparoscopic modified Sugarbaker parastomal hernia repair with 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh technique.

The ideal mesh and mesh fixation technique for laparoscopic Sugarbaker (SB) parastomal hernia repair have not yet been identified. Sixteen patients with parastomal hernia who underwent laparoscopic modified SB repair (LSB) between June 2012 and October 2015 were retrospectively analyzed. LSB was performed using a developed standardized 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh (PCO-PM) technique. Out of 16 cases, 14 were primary and 2 recurrent hernias; 13 were para-end colostomy and 3 were para-ileal conduit (PIC) hernias. The median longitudinal and transverse diameters of the hernia orifice were 5cm (2.5-7cm) and 4.2cm (2-6cm), respectively. Five cases had a concomitant midline incisional hernia, which was simultaneously repaired. In all cases, the mesh was placed without deflection. The median operation time was 193 (75-386)min. Perioperative complications occurred in two cases (13%) with PIC, one intra-operatively and the other postoperatively. The intra-operative complication was enterotomy close to the ureteroenteric anastomosis of the ileal conduit; it was repaired through a mini-laparotomy. LSB was accomplished without any subsequent postoperative complications. The postoperative complication was ureteral obstruction that required creation of nephrostomy. Mini-laparotomy was necessary in those two cases (13%) because of intra-operative enterotomy and severe intra-abdominal adhesions. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed with a median follow-up of 14.5 (2-41) months. Our LSB using standardized mesh fixation technique is safe and feasible, and the PCO-PM seems to be the most optimal prosthesis.

Safety and Efficacy of Sodium Hyaluronate Gel and Chitosan in Preventing Postoperative Peristomal Adhesions After Defunctioning Enterostomy: A Prospective Randomized Controlled Trials.

Peristomal adhesions complicate closure of defunctioning enterostomy. The efficacy and safety of sodium hyaluronate gel and chitosan in preventing postoperative adhesion have not been extensively studied. This study aims to evaluate the safety and efficacy of sodium hyaluronate gel and chitosan in the prevention of postoperative peristomal adhesions.This was a prospective randomized controlled study. One hundred and fourteen patients undergoing defunctioning enterostomy were enrolled. Patients were randomly assigned to receive sodium hyaluronate gel (SHG group) or chitosan (CH group) or no antiadhesion treatment (CON group) during defunctioning enterostomy. The safety outcomes included toxicities, stoma-related complications, and short-term and long-term postoperative complications. Eighty-seven (76.3%) of the 114 patients received closure of enterostomy, during which occurrence and severity of intra-abdominal adhesions were visually assessed by a blinded assessor.Incidence of adhesion appears to be lower in patients received sodium hyaluronate gel or chitosan but differences did not reach a significant level (SHG group vs CH group vs CON group: 62.1% vs 62.1% vs 82.8%, P = 0.15). Compared with the CON group, severity of postoperative adhesion was significantly decreased in the SHG and CH group (SHG group vs CH group vs CON group: 31.0% vs 27.6% vs 62.1%; P = 0.01). There was no significant difference in the occurrence of postoperative complications and other safety outcomes among the 3 groups.Sodium hyaluronate gel or chitosan smeared around the limbs of a defunctioning enterostomy was safe and effective in the prevention of postoperative peristomal adhesions.

Clinical features, outcome and risk factors in cervical cancer patients after surgery for chronic radiation enteropathy

BackgroundRadical hysterectomy and radiotherapy have long been mainstays of cervical cancer treatment. Early stage cervical cancer (FIGO stage IB1–IIA) is traditionally treated using radical surgery combined with radiotherapy, while locally advanced cervical cancer is treated using radiotherapy alone or chemoradiotherapy. In this retrospective study, we describe and analyse the presenting clinical features and outcomes in our cohort and evaluate possible risk factors for postoperative morbidity in women who underwent surgery for chronic radiation enteropathy (CRE).MethodsOne hundred sixty-six eligible cervical cancer patients who underwent surgery for CRE were retrospectively identified between September 2003 and July 2014 in a prospectively maintained database. Among them, 46 patients received radical radiotherapy (RRT) and 120 received radical surgery plus radiotherapy (RS + RT). Clinical features, postoperative morbidity and mortality, and risk factors for postoperative morbidity were analysed.ResultsRS + RT group patients were more likely to present with RTOG/EORTC grade III late morbidity (76.1 % vs 92.5 %; p = 0.004), while RRT group patients tended to show RTOG/EORTC grade IV late morbidity (23.9 % vs 7.5 %; p = 0.004). One hundred forty patients (84.3 %) were treated with aggressive resection (anastomosis 57.8 % and stoma 26.5 %). Overall and major morbidity, mortality and incidence of reoperation in the RRT and RS + RT groups did not differ significantly (63 % vs 64.2 % [p = 1.000], 21.7 % vs 11.7 % [p = 0.137], 6.5 % vs 0.8 % [p = 0.065] and 6.5 % vs 3.3 % [p = 0.360], respectively). However, incidence of permanent stoma and mortality during follow-up was higher in the RRT group than in the RS + RT group (44.2 % vs 12.6 % [p = 0.000] and 16.3 % vs 3.4 % [p = 0.004], respectively). In multivariate analysis, preoperative anaemia was significantly associated with overall morbidity (p = 0.015), while severe intra-abdominal adhesion (p = 0.017), ASA grades III–V (P = 0.022), and RTOG grade IV morbidity (P = 0.018) were predicators of major morbidity.ConclusionsRadiation-induced late morbidity tended to be severe in the RRT group with more patients suffering RTOG/EORTC grade IV morbidity, while there were no significant differences in postoperative morbidity, mortality and reoperation. Aggressive resection was feasible with acceptable postoperative outcomes. Severe intra-abdominal adhesion, ASA grades III–V and RTOG/EORTC grade IV late morbidity contributed significantly to major postoperative morbidity.

Successful emergency resection of a massive intra-abdominal hemophilic pseudotumor

An intra-abdominal pseudotumor is a rare complication of hemophilia. Surgical treatment is associated with high morbidity and mortality rates and reported cases are scarce. We present a 66-year-old Caucasian male suffering from severe hemophilia type A treated for 10 years with Factor VIII. Major complications from the disease were chronic hepatitis B and C, cerebral hemorrhage and disabling arthropathy. Twenty-three years ago, retro-peritoneal bleeding led to the development of a large intra-abdominal pseudotumor, which was followed-up clinically due to the high surgical risk and the lack of clinical indication. The patient presented to the emergency department with severe sepsis and umbilical discharge that had appeared over the past two days. Abdominal computed tomography images were highly suggestive of a bowel fistula. The patient was taken to the operating room under continuous infusion of factor VIII. Surgical exploration revealed a large infected pseudotumor with severe intra-abdominal adhesions and a left colonic fistula. The pseudotumor was partially resected en bloc with the left colon leaving the posterior wall intact. The postoperative period was complicated by septic shock and a small bowel fistula that required reoperation. He was discharged on the 73(rd) hospital day and is well 8 mo after surgery. No bleeding complications were encountered and we consider surgery safe under factor VIII replacement therapy.

Les caractéristiques de la cicatrice pariétale de césarienne sont des facteurs prédictifs des adhérences pelviennes. Étude de cohorte prospective

To investigate whether abdominal scar characteristics could predict the incidence and severity of intra-abdominal adhesions found at repeat cesarean delivery.Prospective cohort study including 151pregnant women with at least one previous cesarean delivery and who delivered abdominally in the department of obstetrics and gynaecology of Farhat Hached teaching hospital-Sousse-Tunisia, during 6 months. Abdominal scar characteristics were studied. The main outcome measure(s) were the incidence and severity of intra-abdominal adhesions. Statistical analysis was performed using SPSS 18.0.Of 151 women enrolled into this trial, 111 (73.5%) had adhesions, 57 (37.8%) had dense adhesions. Of all the abdominal scar characteristics studied, a depressed scar was associated with an increased incidence of both dense and filmy intra-abdominal adhesions and frozen pelvis if compared of women who did not have a depressed scar (P<10(-4) ; RR=7.6; IC=2.98-19.45). A number of previous cesarean section equal or more than 2 was also correlated with an increased incidence of severe intra-abdominal adhesions and frozen pelvis if compared with women who had only one previous cesarean section (P=0.002; RR=2.53; IC=1.16-5.56).A depressed abdominal scar of a previous cesarean delivery and a number of previous cesarean sections are significantly correlated with the incidence and severity of intra-abdominal adhesions.

Abdominal scar characteristics: do they predict intra-abdominal adhesions with repeat cesarean deliveries?

The aim of this study was to evaluate the relation between abdominal scar characteristics and the severity of intra-abdominal adhesions with repeat cesarean deliveries. A total of 208 women with at least one previous cesarean delivery at or beyond 37 weeks of gestation who were admitted for repeat cesarean delivery were enrolled in this study. Scars were categorized as depressed, flat or elevated according to their appearance, and hyperpigmented or the same color as the surrounding skin according to their pigmentation status. Intraoperative adhesions were graded according to the modified Nair's classification and categorized as no adhesion, filmy or dense adhesions. No significant difference was found between women with or without adhesions regarding age, body mass index, gestational week at delivery, number of previous cesarean deliveries or the duration since the last cesarean delivery. Women with depressed scars had more intra-abdominal adhesions than women with flat or elevated abdominal scars (P = 0.013). There was no significant difference in the incidence of hyperpigmented and non-pigmented scars between women with or without adhesions (39.4% vs 41.3% and 60.6% vs 58.7%, respectively) (P > 0.05). Scar width was significantly larger in patients with intra-abdominal adhesions than in patients without adhesions (3.6 ± 1.1 vs 3.2 ± 0.9) (P = 0.003), whereas scar length did not differ significantly (15.2 ± 1.3 vs 15.1 ± 2.1) (P > 0.005). There is a relation between depressed abdominal scars and intra-abdominal adhesions, whereas pigmentation status does not differ between women with or without adhesions.

Impact of laparoscopy for diagnosis and treatment in patients with disorders of sex development

ObjectiveTo review laparoscopy in patients with disorders of sex development (DSD) in order to clarify its usefulness in diagnosis, devising subsequent therapeutic strategies and managing patients with various conditions. Patients and methodsBetween April 1992 and December 2012, 29 laparoscopic surgeries were performed in 25 DSD patients. Among them, ten were diagnostic laparoscopy including gonadal biopsy, and 19 were therapeutic laparoscopy. Surgical procedures and complications were evaluated. ResultsFor diagnostic laparoscopy, laparoscopic gonadal biopsy was performed in three patients. Inspection, with or without open gonadal biopsy, was performed on four out of seven patients with 46XY DSD or mixed gonadal dysgenesis (MGD). Additional surgery was planned and performed based on diagnostic laparoscopic findings in six out of seven patients. In the three patients with ovotesticular DSD, the gonadal pathology was diagnosed as: testis/ovary in one, testis/ovotestis in one and ovary/ovotestis in one – this was from the laparoscopic inspection and/or gonadal biopsy. However, the final diagnoses were bilateral ovotestis in two patients and ovary/ovotestis in one patient.For therapeutic laparoscopy, surgical procedures were: gonadectomy in 17 patients (bilateral in 13, unilateral in three, partial in two); hysterectomy in two patients; orchiopexy in one; and sigmoid vaginoplasty in one patient (included multiple procedures). There were no severe perioperative complications. In the four patients with a history of diagnostic laparoscopy, no severe intra-abdominal adhesions that would disturb therapeutic laparoscopic surgery were observed. ConclusionWhile diagnostic laparoscopy was helpful in devising a therapeutic surgical strategy in most of the patients with DSD who were suspected as having complex gonadal status or Müllerian duct derivatives, attention must be paid to precisely diagnosing the gonadal status in ovotesticular DSD. On the other hand, therapeutic laparoscopic surgeries were valuable procedures in treating DSD patients, even with a history of previous diagnostic laparoscopy.