Bleeding abdominal scar endometriosis-a case report

Presence of functional endometrial tissue anywhere outside the uterine mucosa is called endometriosis. It is hormone dependent and almost exclusively it affects the women of reproductive age. Abdominal scar endometriosis is a rare condition and it is due to deposition of endometriotic tissue in the wound site during various obstetric or gynecological operative procedures. Scar endometriosis followed by lower segment caesarean section (LSCS) is very rare and presents with co-menstrual pain and bleeding. Our case presented with active bleeding from abdominal LSCS scar during menstruation which is extremely a rare presentation. Wide excision and histo-pathological examination confirm the diagnosis. A 28-year-old lady with previous history of LSCS 2 years back presented with complaining of swelling and bleeding from the previous LSCS scar during menstruation, persisting for 4-5 days, repeatedly in every menstrual cycle for last 6 months. On examination a swelling with active bleeding from it was noted over the previous LSCS scar. Routine investigation and coagulation profile was with in normal limit and on ultrasonography a firm mass was noted. After wide excision and histo-pathological Examination, the diagnosis was confirmed. Co-menstrual swelling, pain and bleeding from the previous LSCS scar should not be neglected and may be due to scar endometriosis.

EVALUATION OF MIDLINE INCISION VERSUS PARAMEDIAN INCISION FOR EMERGENCY LAPAROTOMIES

Prospective randomized controlled study was conducted between October,2015 and September,2017 evaluating midline incision and paramedian incision in case of emergency laparotomies. A total of 60 cases were randomized into two groups of 30 each. Time taken for midline incision opening and closing was less 9.86 min as compared to paramedian incision is 19.08 min. This is due to opening and closure of abdomen in layered manner in paramedian incision. Three cases of burst abdomen were reported in midline incision as compared to one case in paramedian incision. Cases having previous abdominal scar were excluded from the present study. 4 cases of incisional hernia were reported in case of midline incision as compared to one case in paramedian incision.

Quality Assurance of the Gallbladder and Relationship Between Gallstones and Abdominal Panniculus Thickness in Adult Hospital Autopsies

Objectives Inconsistency in the autopsy report can be a liability issue. We studied the discordance between the presence of the gallbladder and a corresponding abdominal scar and suggest how to improve this error. To our knowledge, the relationship between abdominal panniculus thickness in adult hospital autopsies and the presence of gallstones has not been reported in the literature. We report the correlation between age, sex, average panniculus thickness, and gallstones. Methods The laboratory information system was searched for autopsies performed between 1/1/09 and 12/21/18. Patients <18 years old and partial, nonabdominal autopsies were excluded. Autopsy reports were reviewed, and the following data were recorded: age, sex, presence or absence of gallbladder, abdominal scars, abdominal panniculus thickness, and gallbladder pathology. Results Out of 385 autopsies reviewed, 48 (12.5%) had cholecystectomies. Of these 48 patients, 6 (12.5%) abdominal scars were not documented. The presence of the gallbladder was not mentioned in 6 (1.6%) reports. The most common pathology was gallstones, 78 (20.3%); cholesterolosis, 9 (2.3%); and cholecystitis, 6 (1.6%). The average age of females and males with gallstones was 68.9 and 66.4 years, respectively. The average abdominal panniculus thickness in males with and without gallstones and in females without gallstones was 3.3 cm. In contrast, the average abdominal panniculus thickness in females with gallstones was 4.0 cm. Conclusion Our study demonstrated that 12.5% of our autopsy reports failed to document the presence of abdominal scars in patients who surgically lacked a gallbladder. There is a need to improve documentation of abdominal scars and the presence or absence of the gallbladder. This can be achieved by creating mandatory fields (eg, gallbladder present/surgically absent) in the autopsy report template. Also, our study found that females with gallstones have a thicker abdominal panniculus than females without gallstones and males with or without gallstones.

Evaluation of preoperative predictive factors for difficult laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis. However, of all Laparoscopic cholecystectomies, 1-13% requires conversion to an open surgery. Thus, for surgeons it would be helpful to establish criteria that would predict difficult laparoscopic cholecystectomy and conversion preoperatively. The objective of the study was to assess preoperative parameters for predicting the difficult laparoscopic cholecystectomy and its conversion.Methods: Prospective study includes 100 patients having symptomatic cholelithiasis. All patients underwent elective LC in Department of General Surgery in Menoufia University Hospital and Tala General Hospital. The collected data of preoperative factors include sex, age, previous attack, history of ERCP, obstructive jaundice, obesity (BMI), lower abdominal scar, palpable gallbladder, wall thickness of, number of stones, size of stones and impacted stone. Difficulty levels according to intraoperative parameters were easy (0–5), difficult (6–10), and conversion from laparoscopic to open surgery.Results: In this study, previous history of attacks of cholecystitis (p=0.001) and wall thickness (p=0.007) were found to be statistically significant in predicting difficult LC in both univariate and multivariate analyses. Other factors such as age (p=0.002), BMI greater than 27.5 (p=0.02), palpable GB (p=0.003), impacted stone (p=0.01) were found to be statistically significant in predicting difficult LC. Factors such as sex, and abdominal scar were not statistically significant in predicting difficult LC.Conclusions: The difficult laparoscopic cholecystectomy and conversion to open surgery can be predicted preoperatively based on number of previous attacks of cholecystitis, WBC count, Gall bladder wall thickness and size of stones.

Use of Strict Patient Selection Criteria to Achieve Significant Surgical Outcomes from a Low DIEP Flap Breast Reconstruction

Background The low deep inferior epigastric perforator (DIEP) flap was first introduced in 2016 as it had aesthetic advantages over the conventional DIEP flap. With our experience of over 100 low DIEP flap procedures to date, we have conspicuously lowered complication rates and established more definitive criteria to select proper candidates. Methods We analyzed 103 patients who underwent breast reconstruction with the low DIEP flap at our hospital between May 2014 and June 2018. Demographics, patient selection criteria, flap specifics, surgical outcomes including postoperative complications, and the location of the abdominal scar and umbilicus were reviewed retrospectively. Results The mean patient age was 46.7 years, and the average body mass index was 23.7 kg/m2. A low DIEP with an average weight of 377 g was utilized within 6 hours 17 minutes in this cohort. There was no significant difference in the rate of venous congestion or fat necrosis compared with the conventional DIEP flap. The average distance from the pubic hairline to the abdominal scar was 0.6 cm and from the anterior superior iliac spine to the abdominal scar was −0.4 cm. The postoperative location of the umbilicus was 7.0 cm above the pubic hairline. Conclusion The low DIEP flap is not only a reliable option for a breast reconstruction but is an aesthetically superior approach with a lower abdominal scar and natural umbilicus. Patients may benefit from this technique if prudently selected by computed tomography (CT) angiography. A perforator that is larger than 1 mm in diameter and well enhanced on CT angiography from the division of the external iliac artery to the abdominal skin particularly in the intramuscular course should be selected.

Atypical Endometrial Hyperplasia Arising in a Cesarean Section Scar: A Mechanism of Malignant Transformation

The incidence of scar endometriosis in Cesarean sections varies between 0.03 and 0.4%. However, the recently increased rate of Cesarean sections worldwide may be causing an increase in occurrence of scar endometriosis. This report presents anatomopathological evidence of an early-stage malignant transformation in endometriotic tissue from a post-Cesarean scar and briefly reviews possible underlying mechanisms. A 40-year-old woman with a body mass index of 42.7 was referred to the gynecological department with recurrent pain and presence of a palpable mass in her Cesarean section scar. She had undergone this procedure 7 years earlier and began experiencing discomfort and pain at the incision site 6 months postoperatively. Surgical treatment was instituted with complete removal of the lesion. Anatomopathological examination revealed endometriotic tissue intertwined with atypical endometrial hyperplasia and fibrosis. At 2 years’ follow-up, she was asymptomatic, both clinically and based on ultrasound examination. Endometriotic foci inoculated within an abdominal scar may undergo malignant transformation. Long-lasting abdominal scar endometriosis, in morbidly obese women, requires special attention from the physician.