Ioannis Tsimpanakos

Are we underutilizing Palmer's point entry in gynecologic laparoscopy?

OBJECTIVE To report our experience using Palmers point entry in women undergoing gynecologic laparoscopic surgery. DESIGN Retrospective observational study. SETTING University teaching hospital, London, United Kingdom. PATIENT(S) We reviewed all patients who underwent laparoscopic gynecologic surgery under the care of the senior author between January 1, 2005, and December 31, 2008. INTERVENTION(S) Gynecologic laparoscopic surgery. MAIN OUTCOME MEASURE(S) Indications, incidence, success, and complications of using Palmers entry. RESULT(S) Three hundred eighty-five patients underwent laparoscopic surgery. We used umbilical entry in 249 (64.6%) and Palmers entry in 136 (35.4%). In almost three fourths of cases, the indications for using Palmers point were previous laparotomy or the presence of large uterine fibroids. The next most common reasons for choosing Palmers point were known documentation of intra-abdominal adhesions from prior laparoscopies, large ovarian cysts, and hernias or hernia repairs. Entry via Palmers point was successful in all but two cases (98.5%), and there were no entry-related complications. CONCLUSION(S) Our experience shows that laparoscopic entry using the left upper quadrant is safe with a low failure rate. Because the vast majority of gynecologic laparoscopies are done using subumbilical entry, it seems that Palmers entry is underused by many gynecologists, despite it being safer in patients at risk of underlying adhesions and more appropriate in the presence of a large pelvic mass or a nearby hernia.

Techniques to reduce blood loss during open myomectomy: a qualitative review of literature.

Open myomectomy is the most adopted surgical strategy in the conservative treatment of uterine fibroids. According to several studies, the likelihood that a woman could develop uterine myomas is estimated around 75% by the age of 50. Open myomectomy is nonetheless a complicated surgery in terms of blood loss and need for transfusion. Many strategies have been published with the aim of limiting intra and post-operative bleeding complications. The scope of this review is to describe in detail the different techniques reported in literature focusing on their validity and safety.

Two cases of myomectomy complicated by intravascular hemolysis and renal failure: disseminated intravascular coagulation or hemolytic uremic syndrome?

OBJECTIVE To present two cases of myomectomy complicated by intravascular hemolysis leading to acute renal failure and discuss the differential diagnosis and possible mechanism. DESIGN Case report. SETTING Minimally Invasive Therapy Unit, University Department of Obstetrics and Gynecology. PATIENT(S) Two premenopausal patients with uterine fibroids. INTERVENTION(S) Both patients underwent otherwise uncomplicated myomectomies, one by laparotomy and one by laparoscopy, with tourniquets around the uterine and ovarian vessels being used to control intraoperative bleeding. MAIN OUTCOME MEASURE(S) Renal function in the postoperative period. RESULT(S) Both patients developed a very rare complication after surgery of severe thrombocytopenia with microangiopathic hemolytic anemia leading to acute renal failure. One patient made a full recovery within weeks but the other still has reduced renal function almost 2 years after the surgery. The differential diagnosis consisted of disseminated intravascular coagulation or hemolytic uremic syndrome. CONCLUSION(S) The etiology of thrombotic microangiopathy in these patients was unclear, but disruption and manipulation of fibroids during surgery may have led to the dissemination of pro-coagulant tissue factor containing particles leading to disseminated intravascular coagulation or hemolytic uremic syndrome, perhaps aggravated by utero-ovarian ischemia caused by the tourniquets.

Intrauterine adhesions after open myomectomy: an audit.

OBJECTIVE To estimate the incidence of intrauterine adhesions after open myomectomy. STUDY DESIGN A prospective audit descriptive study was conducted involving thirty-six women who had undergone open myomectomy for symptomatic fibroids at a large undergraduate teaching hospital. A follow-up out-patient hysteroscopy was performed three months after surgery. RESULTS At hysteroscopy, eighteen patients (50%) were found to have mild to moderate intrauterine adhesions. The number of fibroids removed was significantly higher in patient who developed adhesions (median value 22 versus 9.5, p<0.05). Pre-operative GnRHa therapy, uterine size, opening of the uterine cavity during surgery, specimen weight, estimated blood loss, post-operative bleeding or pyrexia were similar whether or not adhesions were found. CONCLUSION Open myomectomy represents an important but currently underappreciated aetiological factor in the formation of intrauterine adhesions.

An Unusual Case of Cervical Diverticulum Identified by Presence of 3 Cavities at Diagnostic Hysteroscopy

Herein is presented the case report of a patient who had severe dysmenorrhea since menarche, known right unicornuate uterus with a left rudimentary horn, and recurrent hematometra. Previous hysteroscopic drainage of the hematometra temporarily alleviated the symptoms. At subsequent hysteroscopy, 3 cavities were identified, 2 corresponding to the uterine horns and the other to a cervical diverticulum. Hysteroscopic metroplasty with drainage of the rudimentary horn hematometra provided long-term relief of the symptoms. The diagnosis was verified at diagnostic laparoscopy.

The case of the lost Mirena

This report discusses a case of a 46-year-old woman with a migrating Mirena levonorgestrel-releasing intrauterine device (LNG-IUD). It states that this is the first known report of a Mirena perforating the uterus and expelled spontaneously from the peritoneal cavity.

Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain

labelled as ‘a randomised controlled trial’ in the title. I would be grateful if the authors could explain the discrepancy between the title of the study and its description. In a commentary attached to the paper, Emeritus Professor of Medical Ethics, Raanan Gillon, speculated on whether the recruitment to the abandoned trial might have been more offputting (rather than encouraging) than ethically necessary. According to the Helsinki Declaration, ‘each potential subject must be adequately informed of... the anticipated benefits and potential risks of the study’. I would be grateful if the authors could summarise the anticipated benefits and potential risks related to each trial arm as they were presented in the patient information sheets, and comment on Professor Gillon’s suggestion. j

Re: Urinary tract injuries in laparoscopic gynaecological surgery; prevention, recognition and management

Key content Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery. Injury to either bladder or ureter results in significant morbidity for the patient and may lead to litigation. Knowledge of pelvic anatomy, training and meticulous technique are of paramount importance in reducing the incidence of urinary tract injury. Ideally an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may result in early recognition and intervention. Learning objectives To understand the common risk factors of urinary tract injury at laparoscopy. To learn strategies to prevent injury where possible. To learn strategies for intraoperative and postoperative recognition and repair of such injuries. To understand the significance of multi-disciplinary management of such injuries. Ethical issues Limited evidence shows that laparoscopic hysterectomy may carry a higher risk of urinary tract injury compared with abdominal hysterectomy. Should patients be counselled accordingly?

Myomectomy: Results and Complications

Uterine fibroids are common hormone sensitive benign tumours of the uterus, with a reported incidence of up to 30–40 % in women of reproductive age with variations depending on the age group and ethnic background. Although they are asymptomatic in many cases, the presence and persistence of clinical symptoms warrants medical or surgical intervention. Myomectomy is advisable for symptomatic women who want to preserve their uterus. Myomectomy can be performed trans-abdominally, laparoscopically, vaginally or hysteroscopically. The aim of this intervention is to alleviate any menstrual symptoms and improve fertility. Whatever the route of surgery, however, myomectomy is classified as a major operation which is associated with both short- and long-term complications which, in many respects, depend on the size, location and number of fibroids. Apart from risks such as infection, bruising, deep vein thrombosis, which apply to any major surgical procedure, complications range from major intra-operative blood loss, occasionally necessitating hysterectomy, to longer term problems of post-operative adhesions and fibroid recurrence. There are also route-specific potential complications related to the type of myomectomy.

A new technique to biopsy both horns in a septate or bicornuate uterus.

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