DOUBLE J STENTING IN A DELAYED URETER INJURY DUE TO THERMAL NECROSIS FOLLOWING LAPAROSCOPIC-ASSISTED VAGINAL HYSTERECTOMY

The presenting symptom to a gynecologist for postoperative vaginal discharge, which may or may not be related to the gynecologic diagnosis. A 40-year-old woman with abnormal uterine bleeding came to ObGyn Opd. The diagnosis was simple endometrial hyperplasia for which laparoscopic assisted vaginal hysterectomy with bilateral salphingo oophorectomy was done. Post-Operative Day 18 patient developed vaginal discharge suggestive of urinary leakage. The postoperative delayed ureter injury is an unusual association with laparoscopic assisted vaginal hysterectomy. The management was ureter stent insertion. This case report could be guidance to surgeons about the postoperative management of ureter injury. Gynecologists should consider the presenting symptom of vaginal discharge in formulating their differential diagnosis.

A comparative study of laparoscopic assisted vaginal hysterectomy versus total abdominal hysterectomy in benign gynaecological conditions

Background: Laparoscopic assisted vaginal hysterectomy (LAVH) has become an alternative to Total Abdominal Hysterectomy (TAH) in cases difficult to manage via vaginal route. To compare the TAH and LAVH for benign uterine pathology.Methods: This prospective study conducted with the outcomes of Laparoscopic assisted vaginal hysterectomy with Total abdominal hysterectomy over a period of 2 years in 100 patients who are undergoing hysterectomies for benign uterine pathology. 50 underwent TAH and 50 underwent Laparoscopic Assisted Vaginal hysterectomy.Results: The average duration of surgery in TAH group is 50 minutes and it is 75 minutes in LAVH group (P<0.05). In TAH group, blood loss was more (250-500ml) in 28% of patients, where as it was <250 ml in 92% of patients in LAVH group. Mean blood loss is 238 ml and 130 ml in TAH and LAVH group (P<0.01). Only 3 (6%) patients in LAVH group required blood transfusion (P>0.05). Recovery and return to work after discharge from hospital was early with LAVH group as early. Recovery and return to work after discharge from hospital was early with LAVH group as early as 2 weeks in 46% of patients. In TAH group, it was late by 4 weeks in 52% of patients and by 6 weeks in 10% of patients.Conclusions: Thus, it can be concluded that LAVH is safe with less blood loss, shorter duration of hospital stay, early recovery to work, and other intra-operative and post-operative complications.

Unwarranted hysterectomy in a case of oro-vaginal-vulvar lichen planus in a young woman: a case report

Background Lichen planus is a rare autoimmune disease primarily affecting the skin and mucous membranes of the oral mucosa, vulva, and vagina. Diagnosis is difficult and often delayed as the clinicians do not associate the oral symptoms with the genital symptoms. This has a negative impact on the out-of-pocket expenditure and quality of life of the patients. We report this case, as only anecdotal cases have been reported so far from a developing country such as India. We highlight the unindicated hysterectomy that the patient had undergone because of lack of awareness regarding this condition. Our case report also highlights the importance of the multidisciplinary team approach to optimize outcomes and avoid unnecessary morbidity to such patients. Case presentation We report a North-Indian patient with oro-vaginal-vulvar lichen planus who presented to us with complaints of recurrent vulvovaginal symptoms for the last 5 years. She had been previously treated with multiple courses of antibiotics, antifungals, and topical steroids over the course of 3 years and finally offered laparoscopic-assisted vaginal hysterectomy (LAVH) by a private practitioner but got no relief. She also had complained of oral symptoms in the form of a burning sensation after eating spicy food, but did not seek any treatment for this. After multidisciplinary team discussion, a final diagnosis of oro-vaginal-vulvar lichen planus was made at our institute based on the clinical and histopathological findings. The patient was immediately started on oral prednisolone to which she responded with improvement in her symptoms. Conclusion Lichen planus is a chronic painful condition with significant impact on the quality of life. Women often suffer for several years before an accurate diagnosis is made. Treatment is challenging and needs to be individualized with a multidisciplinary approach to prevent progressive anatomical distortion and associated morbidity.

Comparative study of non-descent vaginal hysterectomy and laparoscopy assisted vaginal hysterectomy

Background: We aimed to assess and compare intra operative and post-operative parameters and complications associated with non-descent vaginal hysterectomy group (NDVH) and laparoscopic assisted vaginal hysterectomy group (LAVH).Methods: In this observational study 100 patients with uterine size not exceeding 12 weeks of gravid uterus, adequate uterine mobility, fibroid uterus, dysfunctional uterine bleeding, chronic cervicitis, adenomyosis and post-menopausal bleeding were divided into two groups to undergo either NDVH and LAVH. Their intra-operative and post-operative parameters were compared.Results: The mean operating time was significantly less in NDVH group as compared to LAVH group cases (65.44 vs 83.12 mins; p<0.01). Blood loss (210.22 vs 261.58 ml; p-0.03) during the procedure and drop in haemoglobin (1.22 vs 1.62 gm%; p-0.08) was also lower with NDVH group as compared to LAVH group respectively. Requirement of blood transfusion, adnexotomy and incidence of anaesthesia related complications were similar between the two study groups. Median VAS score was significantly less in NDVH group as compared to LAVH group at immediate post-op period and at day 1 respectively (p<0.01). We observed a comparable mean hospital stay for the patients in the two study groups (5.52±1.33 vs 6.01±1.39 days, p value=0.71).Conclusions: Based on the results of the present study, we conclude that NDVH is safe and should be offered as the first surgical choice in women with uterine enlargement due to benign pathology and non-prolapsed uterus.

Is lymph node dissection mandatory among early stage endometrial cancer patients? A retrospective study

Background Whether routine lymph node dissection for early endometrial cancer is beneficial to survival is still controversial. However, surgeons usually perform lymph node dissection on all patients with early endometrial cancer. This study aimed to prove that the risk of lymph node metastasis, as defined by our standard, is very low in such patients and may change the current surgical practice. Methods 36 consecutive patients who had staged surgery for endometrial cancer were collected. All eligible patients meet the following very low risk criteria for lymph node metastasis, including: (1) preoperative diagnosis of endometrial cancer (preoperative pathological diagnosis), (2) tumors confined to the uterine cavity and not beyond the uterine body, (3) PET-MRI lymph node metastasis test is negative. PET-MRI and pathological examination were used to assess the extent and size of the tumor, the degree of muscular invasion, and lymph node metastasis. Results The median age at diagnosis was 52 years (range 35–72 years). The median tumor size on PET-MRI was 2.82 cm (range 0.66–6.37 cm). Six patients underwent robotic surgery, 20 underwent laparoscopic surgery, 8 underwent Laparoscopic-assisted vaginal hysterectomy, and 2 underwent vaginal hysterectomy. 23% (63.9%) patients had high-grade (i.e. 2 and 3) tumors. Among the 36 patients who underwent lymph node sampling, the median number of lymph nodes retrieved was 32 (range 9–57 nodules). No patient (0%) was diagnosed with lymph node metastasis. According to the policy of each institution, 8 patients (22.2%) received adjuvant therapy, and half of them also received chemotherapy (4 patients; 50%). Conclusions None of the patients who met the criteria had a pathological assessment of lymph node metastasis. Omitting lymph node dissection may be reasonable for patients who meet our criteria.

Laparoscopic assisted vaginal hysterectomy: an experience at a Fortis Escorts hospital

Background: The objective of this study was to evaluate the laparoscopic assisted vaginal hysterectomy (LAVH) in terms of demographic data of patients, indications, uterine size, intraoperative and postoperative complications, amount of blood loss, operative time and duration of hospital stay.Methods: A retrospective study was conducted on 160 cases, who underwent laparoscopic assisted vaginal hysterectomy in the period between October 2018 to November 2019 at the Fortis Escorts Hospital, Faridabad, Haryana, India.Results: Majority of patients (58.75%) belongs to age group between 40-50 year. Only 30.62% cases had a history of one previous abdomino-pelvic surgery. Majority of cases (52.5%) in the study group had uterine size between 6-12 weeks. Most common indication of hysterectomy in this study was fibroid uterus which account for 49.37% of cases followed by dysfunctional uterine bleeding (16.87%) cases. Mean time of surgery in this study was 114.4±0.59 min and average blood loss was 135.62±47.63 ml. The mean weight of uterus was 243.75±82.94 gm. 5% cases had major intraoperative complications while minor postoperative complications were seen in 16.87% cases. Bladder injury was seen in 1.25%. Major haemorrhage occur in 1.25%. In this study conversion to laparotomy rate was 1.25%. Only one case of ureteric injury and one case of bowel injury was noted. Among minor complications fever (6.25%) and urinary tract infection (5.62%) were mainly seen. Mean duration of hospital stay was 2.82±1.17 days.Conclusions: LAVH enables the surgeon to convert most of the abdominal hysterectomies into vaginal ones and hence decreases postoperative pain, decreases complications, lesser duration of hospital stay and rapid return to normal activity.

P0133INCREASED INTRA-ABDOMINAL PRESSURE DURING LAPARASCOPIC PNEUMOPERITONEUM ENHANCES ALBUMINURIA VIA RENAL VENOUS CONGESTION, ILLUSTRATING PATHOPHYSIOLOGICAL ASPECTS OF HIGH OUTPUT PREECLAMPSIA

Background and Aims Intra-abdominal hypertension (IAH) causes severe organ dysfunction. Our aim is to evaluate the effect of increased intra-abdominal pressure (IAP) on renal function, hypothesizing that venous congestion may increase proteinuria and fluid retention without endothelial dysfunction. Method Three urine samples were collected from 32 non-pregnant women undergoing laparoscopic assisted vaginal hysterectomy (LAVH) and from 10 controls placed in Trendelenburg position for 60 minutes. Urine sampling was done before (PRE), during or immediately after (PER), and two hours after (POST) the procedure. Urinary albumin, protein and creatinine concentrations were measured in each sample, ratios were calculated and compared within and between groups. Results During LAVH, the albumin/creatinine ratio (ACR) increased and persisted POST-procedure, which was not observed in controls. A positive correlation existed between the LAVH duration and the relative change in both ACR and protein/creatinine ratio (PCR) PER- and POST-procedure. Conclusion Iatrogenic IAH increases urinary ACR and PCR in non-pregnant women via a process of venous congestion. This mechanism might explain the presentation of one specific subtype of late-onset preeclampsia, where no drop of maternal cardiac output is observed.

Increased Intra-Abdominal Pressure During Laparoscopic Pneumoperitoneum Enhances Albuminuria via Renal Venous Congestion, Illustrating Pathophysiological Aspects of High Output Preeclampsia

Intra-abdominal hypertension (IAH) causes severe organ dysfunction. Our aim is to evaluate the effect of increased intra-abdominal pressure (IAP) on renal function, hypothesizing that venous congestion may increase proteinuria and fluid retention without endothelial dysfunction. Three urine samples were collected from 32 non-pregnant women undergoing laparoscopic-assisted vaginal hysterectomy (LAVH) and from 10 controls placed in Trendelenburg position for 60 min. Urine sampling was done before (PRE), during or immediately after (PER), and two hours after (POST) the procedure. Urinary albumin, protein and creatinine concentrations were measured in each sample, and ratios were calculated and compared within and between groups. During LAVH, the albumin/creatinine ratio (ACR) increased and persisted POST-procedure, which was not observed in controls. A positive correlation existed between the LAVH duration and the relative change in both ACR and protein/creatinine ratio (PCR) PER- and POST-procedure. Iatrogenic IAH increases urinary ACR and PCR in non-pregnant women via a process of venous congestion. This mechanism might explain the presentation of one specific subtype of late-onset preeclampsia, where no drop of maternal cardiac output is observed.

An experience of gynaecological laparoscopic surgeries at low resource setting.

Introduction: Evolution of laparoscopy has revolutionised the field of gynaecological surgery for more than 40 years.Owing to the long learning curve, added expenses and lack of awareness among patients and surgeons, its introduction and development in Nepal is not upto the timeline. Gynaecologic laparoscopy (GL) seems to be introduced at BP Koirala institute of Health Sciences, Dharan,Nepal (BPKIHS) since 2002. It remained in latency because of widespread lack of equipment and skilled personnel. Some laparoscopic procedures like diagnostic laparoscopy, laparoscopic tubal ligation and very few laparoscopic assisted vaginal hysterectomy (LAVH) were done from 2002 - 2012 (10 years). Since then more gynecologists have been trained in GL which has contributed to expansion of GL. Objective: The objective of this study is to study and share trends of gynaecological laparoscopic surgeries performed at BPKIHS. Methodology: All the patients undergoing GL surgeries have been analyzed for the indication, type of procedure, conversion and its complications. We took data from operation theatre register and patient case sheet from July 2004 to May 2018. We divided this period into two phase viz Phase 1: July 2004-June 2013 and Phase 2: July 2013- till May 2018. Results: Total number of GL done in this period was 427. Out of which 102 cases were from phase one and rest of the cases were done in five years of phase II. Number of operative laparoscopy has increased in phase 2 compared to phase 1. In last five years there was155 (47.6%) cases of adnexal surgery, 77 (23.6%) cases of diagnostic laparoscopy.Total laparoscopic hysterectomy was done in 25 (7.6%) cases. Conversion to laparotomy was done in4.6% (n=15) cases. Overall 12(3.7%) patient had major complications. Oral diet started at 4-6th hour post-operatively, and mobilization started after 24 hours. Seventy percent of patient had a hospital stay of 2days and rest stayed for 3 days. Conclusions: There is rising trend in operative GL at BPKIHS. We are facing less complication with expanding experience. There has been good learning from each case. GL has well demonstrated its advantages of reducing postoperative pain and morbidity, short hospital stay, and less postoperative recovery time. We have plans to get new gadgets and expand services in GL.