Yetkin Karasu

Large bowel injuries during gynecological laparoscopy.

Laparoscopy is one of the most frequently preferred surgical options in gynecological surgery and has advantages over laparotomy, including smaller surgical scars, faster recovery, less pain and earlier return of bowel functions. Generally, it is also accepted as safe and effective and patients tolerate it well. However, it is still an intra-abdominal procedure and has the similar potential risks of laparotomy, including injury of a vital structure, bleeding and infection. Besides the well-known risks of open surgery, laparoscopy also has its own unique risks related to abdominal access methods, pneumoperitoneum created to provide adequate operative space and the energy modalities used during the procedures. Bowel, bladder or major blood vessel injuries and passage of gas into the intravascular space may result from laparoscopic surgical technique. In addition, the risks of aspiration, respiratory dysfunction and cardiovascular dysfunction increase during laparoscopy. Large bowel injuries during laparoscopy are serious complications because 50% of bowel injuries and 60% of visceral injuries are undiagnosed at the time of primary surgery. A missed or delayed diagnosis increases the risk of bowel perforation and consequently sepsis and even death. In this paper, we aim to focus on large bowel injuries that happen during gynecological laparoscopy and review their diagnostic and management options.

Anomalies of major retroperitoneal vascular structure.

Objective: To identify anomalies of major retroperitoneal vascular structure (AMRVS) during oncological retroperitoneal surgery and to investigate the effects of these anomalies in surgical procedures. Materials and Methods: Two hundred twenty-nine patients who underwent systematic para-aortic and bilateral pelvic lymph node dissection up to the renal vein between September 2006 and December 2008 were included. Normal architecture and structural anomalies of inferior vena cava, abdominal aorta, renal arteries and veins, and common iliac artery and vein were studied. Results: The mean age of the patients was 54.2 years. Anomalies of major retroperitoneal vascular structure were present in 39 patients (17%). Anomalies of renal vessels were identified in 31 patients. Supernumerary renal arteries and veins observed in 11 patients (17%) were the most common renal vessel anomaly. Great vessel injury was present in 19 patients (8.3%). Vascular complication rate was 20.5% in patients with AMRVS. However, in 4 of 8 patients with vascular complication and AMRVS, the complication was not related with anomalous vascular structures. None of the complications was serious and were corrected surgically. There was no difference between patients with AMRVS and those without AMRVS regarding age, body mass index, the extent of upper abdominal dissemination of malignancy and presence of comorbidity for intraoperative bleeding. There was no difference in intraoperative hemorrhage and amount of transfused red blood cell units between the groups. Conclusion: Great vessel anomalies, discovered in 1 of 6 patients, were together with increased risk of vascular complications. The probability of presence of vascular anomalies should be taken into account during lymph node dissection.

Lidocaine for pain control during intrauterine device insertion

The aim of this study was to compare the effects of topical lidocaine spray, cream and injection on pain perception during intrauterine device (IUD) insertion.

The effect of luteal-phase support with vaginal progesterone on pregnancy rates in gonadotropin and clomiphene citrate/intra-uterine insemination cycles in unexplained infertility: A prospective randomised study

The purpose of this study is to analyse the effect of luteal-phase support on pregnancy rates in gonadotropin + intra-uterine insemination (Gn/IUI) and clomiphene citrate (CC) +IUI (CC/IUI) cycles in patients with unexplained infertility. Equal numbers of patients were recruited in two treatment arms (CC/IUI and Gn/IUI) (n = 100, n = 100, respectively). In each group, 50 patients received vaginal progesterone for 14 days (Crinone 8% vaginal gel, 90 mg per day) for luteal-phase support from the day after IUI and continued until menstruation or the 10th week of gestation if pregnant. There were 29 clinical pregnancies among 200 patients. Pregnancy rates were 12% in CC/IUI cycles, 10% in luteal-phase-supported CC/IUI cycles 16% in Gn/IUI cycles and 20% in luteal-phase-supported Gn/IUI cycles. Although pregnancy rates were higher in Gn/IUI cycles compared to CC/IUI cycles, luteal-phase support did not significantly affect the pregnancy rates in both groups. This study implies that luteal-phase support with progesterone has no pronounced beneficial effect on pregnancy rates in either CC/IUI or Gn/IUI cycles in patients with unexplained infertility.

Feasibility of single-incision laparoscopy for ruptured ectopic pregnancies with hemoperitoneum

Abstract Background: The aim of this study was to compare single-incision laparoscopic surgery (SILS) and conventional laparoscopy in ectopic pregnancies accompanied by severe hemoperitoneum. Material and methods: The main outcome measures were duration of surgery, intraoperative bleeding quantity, complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay. Results: A total of 53 women, 28 in the conventional laparoscopy group and 25 in the SILS group, participated in the study. There were no differences in demographic characteristics between the two groups. There were no differences in terms of variables including gestational week, beta human chorionic gonadotropin (βhCG) levels, and operation time. No intraoperative complications were observed in either group. The groups exhibited no significant differences regarding additional analgesic requirements or postoperative pain scores. However, pain at the sixth postoperative hour was lower in the SILS group. This effect was not observed at 12 and 24 hours. Conclusion: SILS appears to be effective and safe for the treatment of ruptured ectopic pregnancies accompanied by hemoperitoneum.

Comparison of single-incision and conventional laparoscopic surgery for benign adnexal masses.

Abstract Background: Our aim was to compare single incision and conventional laparoscopic surgeries performed for benign adnexal masses with regard to their intraoperative characteristics and postoperative pain levels. Material and methods: The main outcome measures were laparoscopic entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay. Results: A total of 71 women, 39 in the conventional laparoscopy group and 32 in the SILS group, participated in the study. Demographic findings did not differ between the two groups. Similarly, rates of intraoperative complications, rates of conversion to laparotomy, pre- and postoperative hematocrit levels were not significantly different between the groups. Laparoscopic entry time was shorter in the SILS group (10.4 ± 5.9 min. vs. 5.28 ± 1.7 min.). However, total operation time was similar in the two groups. The groups did not show significant differences regarding additional analgesic requirements, or postoperative pain scores after 24 h. However, pain scores in the recovery room and after six and 12 h were lower in the SILS group. Conclusion: SILS seems to be effective and safe for the treatment of benign adnexal masses. SILS appears to be advantageous regarding postoperative pain especially in the early period.

Comparison of Single Incision and Conventional Laparoscopic Surgery for Surgical Sterilization

Objective: To compare the intraoperative characteristics and postoperative pain levels of single incision and conventional laparoscopic surgeries performed for surgical sterilization. Study Design: A single center prospective observational study was conducted to compare the conventional and single incision laparoscopic (SIL) partial salpingectomies performed for surgical tubal sterilization. In total of 110 women, 62 in the conventional laparoscopy and 48 in the SILS group participated in the study. The main outcome measures were peritoneal entry time, total operation time, amount of bleeding, intraoperative complications, post-operative pain scores, additional analgesic requirements, and length of hospital stay. Statistical analysis was accomplished using the chi-square test or Mann Whitney U test, where appropriate. Results: Demographical findings did not differ between the two groups (p>0.05). Similarly, total operation time, rates of intraoperative complications, conversion to laparotomy, length of hospital stay, pre and postoperative hematocrit levels were not significantly different between the groups. Peritoneal entry time was shorter in the SIL group (7.1 min. vs. 4.8 min., p 0.05). Conclusion: SILS seems a safe and feasible alternative to conventional laparoscopy for surgical tubal sterilization. Keywords: Partial salpingectomy, Tubal ligation, Contraception, Surgical sterilization, Single Incision Laparoscopy

Severe ovarian hyperstimulation syndrome in spontaneous pregnancy treated successfully with cabergoline

Ovarian hyperstimulation syndrome (OHSS) is a relatively common complication in infertile patients treated with exogenous gonadotropins. Ovarian hyperstimulation in spontaneous pregnancies is a rare but possible. The pathogenesis of spontaneous OHSS is not well known. Risk factors for OHSS are young age, polycystic ovaries, low body mass index, high gonadotropin dose, increased estradiol and human chorionic gonadotropin levels, multiple pregnancy, OHSS history, molar pregnancy and hypothyroidism. In this report we present a case of severe spontaneous OHSS with a brief summary of the literature. She was hospitalized and treated in the clinic with the diagnosis of severe OHSS accompanying spontaneous pregnancy.

Meckel Gruber Syndrome diagnosed in two consecutive pregnancies

Meckel Gruber syndrome is a lethal, autosomal recessive, multisystemic disorder that is associated with a mutation affecting ciliogenesis. In this report, we present two consecutive pregnancies of a woman complicated with MKS. In the first pregnancy with MKS, the amniotic fluid index was under 1 cm with bilateral polycystic fetal kidneys. Postabortion macroscopic examination of the first fetus revealed multiple congenital anomalies including occipital encephalocele, axial polydactyly and pes equinovarus. Ultrasound examination during the second gestation revealed a singleton pregnancy complicated by MKS. There were multiple congenital anomalies including an occipital encephalocele, polycystic and horseshoe shaped kidneys, axial polydactyly, cleft lip and palate.

Prenatal diagnosis of fetal acrania using two and three dimensional ultrasound

Malformations of the central nervous system are one of the most common congenital anomalies of the fetus. In this report we aimed to summarize a case of fetal acrania diagnosed in the first trimester and the use of two and threedimensional ultrasound in early diagnosis of the disease.