Cl Lee

Extraumbilical insertion of the operative laparoscope in patients with extensive intraabdominal adhesions.

In 12 patients who had known or suspected intraabdominal adhesions, we evaluated the benefit of using Palmers point for inserting the Veress needle and primary cannula during laparoscopic adhesiolysis to prevent direct intestinal injury. After inserting the laparoscope through this point, four women were found to have extreme intestinal adhesions around the umbilical area, and intestinal or severe omental injury might occur if the cannulas were inserted directly through the umbilical fossa. The other eight patients had omentum, partial to severe, adherent to the anterior abdominal wall. No complication occurred during insertion of the Veress needle and primary cannula through Palmers point. Nine patients had successful laparoscopic adhesiolysis and were discharged within 2 days. In the other three women the procedure was converted to laparotomy because of extensive intestinal adhesions (2 patients) and small bowel injury during laparoscopic adhesiolysis (1). Palmers point can be considered a safe and good alternative site for inserting the Veress needle and primary cannula to lyse dense intestinal and extensive omental adhesions. This technique should provide the surgeon with wider visual angel and surgical field, thus making adhesiolysis much easier to perform.

Use of Palmer's point for insertion of the operative laparoscope in patients with severe pelvic adhesions: Experience of seventeen cases

Seventeen patients who had known or suspected intra-abdominal adhesions underwent laparoscopic surgery with the use of Palmers Point for insertion of the operative laparoscope. Five of them were found to have extensive periumbilical adhesions. Intestinal or omental injury can occur if the trocar is inserted directly through the umbilical fossa. Though the incidence of direct trauma is reportedly low, there were still mild to moderate omental adhesions to the anterior abdominal wall, as we expected, in the remaining 12 patients. Possible inadequate aspiration and irrigation during laparoscopic removal of a dermoid cyst in one woman had resulted in severe postsurgical intraabdominal adhesions. More than two 10 mm incisions were used in our patients for insertion of the laparoscope interchangeablely to facilitate the procedure of laparoscopic adhesiolysis. The operative field can be expanded greatly. Fourteen patients completed the laparoscopic surgery, and the other 3 had alternative procedures eventually. No complications occurred during the laparoscopic procedure. The postoperative courses were uneventful in all 17 patients. Our experience suggests that Palmers Point is a good alternative for insertion of the Veress needle and laparoscope in patients with previous laparotomies and suspected severe pelvic adhesions.

Extra-umbilical incisional hernias after operative laparoscopy: prevention and management

defined by the American College of Obstetricians and Gynecologists (ACOG) criteria [3]. Statistical analysis was performed using the X2-test and a P value of < 0.05 was considered significant. Among 26 266 pregnant women, 1121 (4.3%) were diagnosed with pre-eclampsia at our institution. The fetal gender ratio (male/female) between pregnant women with and without pre-eclampsia were not significantly different (1.02 vs. 1.04, P > 0.05, Table 1). When the pre-eclamptic pregnancies were further segregated into mild and severe preeclamptic groups, 565 (50.4%) were classified as mild and 556 (49.6%) were classified as severe. We found no significant difference in fetal gender ratio between normotensive pregnant women and mild pre-eclamptics (1.04 vs. 1.01, P > 0.05) or severe pre-eclamptics (1.04 vs. 1.04, P > 0.05). After adjusting for the potential confounding factors of race and parity, the fetal gender ratio between norLetters IO the Editor I61

Hysteroscopic extraction of a vaginal foreign body in a child

A 3.5-year-old girl had a persistent, foul-smelling, blood-tinged vaginal discharge. She was initially treated for recurrent and persistent vulvovaginitis, which resulted in no improvement. Vaginoscopy revealed an intravaginal foreign body, which was removed successfully by hysteroscopy. We believe hysteroscopy is safe, convenient, effective, and easy to perform, even in a child.

Bowel injury by the suction-irrigator during operative laparoscopy

Bowel injury is common during operative laparoscopy, yet injury by the suction-irrigator has never been reported to our knowledge. Any injury to the sigmoid colon by suction-irrigator occurred during intestinal retraction. Primary repair was performed through minilaparotomy incision. In addition to the potentially damaging effect of the instrument, a firm, distended, and unprepared bowel was a leading factor in this injury. We recommend that all patients have bowel preparation before operative laparoscopy, and that great care be taken for all surgical manipulations, even when employing traditionally atraumatic instruments.

Laparoscopic repair of bowel herniation through previous cannula insertion sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Laparoscopic Repair of Bowel Herniation Through Previous Cannula Insertion Sites

Operative laparoscopy frequently requires large cannulas below or above the umbilicus, which may result in unusual complications such as small bowel herniation through these insertion sites. Three women experienced small bowel herniation through cannula incision sites, either extraumbilically or paraumbilically, after major laparoscopic surgery. Two patients who had undergone laparoscopic myomectomy developed small bowel herniation through the 12-mm extraumbilical cannula site on postoperative days 7 and 8, respectively. In the first woman, the nontender, palpable, and reducible herniation healed spontaneously, with no episode of herniation during follow-up. The second patient required laparoscopic reduction of the herniated loop and repair of the fascial defect. The last woman had undergone laparoscopic-assisted vaginal hysterectomy and developed small bowel herniation through an unrecognized fascial defect paraumbilically 3 days postoperatively. Intended repair by laparoscopy was changed to laparotomy due to extensive and incarcerated bowel herniation.

Laparoscopic removal of a large leiomyoma using airlift gasless laparoscopy

Some discrepancies still exist with regard to the efficacy of laparoscopic removal of large symptomatic leiomyomas. In our experience, when performing myomectomy, airlift gasless laparoscopy has several advantages. First, a small incision can be made, through which conventional surgical instruments (endoscopic equipment is not required) are inserted and the myomectomy is efficiently performed. Second, the large excised leiomyoma can be cut into strips easily with a conventional long knife and removed through a small abdominal incision. Third, sutures can be placed easily, and the surgeon can place fingers through a small surgical wound to palpate the organ and tie the knot directly. Fourth, high-pressure irrigation and large-volume suction devices can be used without fear of decompressing the pneumoperitoneum. Finally, the potential risks of metabolic and hemodynamic instability due to carbon dioxide insufflation to establish pneumoperitoneum are avoided.