A COMPARATIVE STUDY BETWEEN CLOSURE VERSUS NON-CLOSURE OF PERITONEUM DURING CAESAREAN SECTION

AIMS : To assess the short term outcome of closure versus non-closure of both visceral and parietal peritoneum during caesarean section on basis of Duration of surgery (to compare operative time in both groups),Post-operative pain,Use of analgesics,Return of bowel movements and Postoperative febrile episodes STUDY SETTING: This study was conducted in Department of Obstetrics and Gynecology , Guru Gobind Singh Medical College and Hospital, Faridkot. STUDY DESIGN: This was a randomized controlled trial of over 300 patients consisting of 2 groups. Group 1 undergoing closure of peritoneum (control group) and Group 2 with non-closure of peritoneum (study group). The study was approved by the Institutional Ethics Committee. Methods and Material: Atotal of 300 cases undergoing emergency or elective lower segment caesarean section were recruited for the study . The study was approved by the Institutional Ethics Committee. After a detailed history, general physical examination, obstetric examination and routine investigations, informed consent was taken from each patient for participation in the study. Group allocation was done using Microsoft excel where randomization was done using serial number of patients prior to commencement of the study and the women were randomly allocated to one of the two groups (closure or non-closure group 150 in each) . Results: In the present study, mean age of the patients of the closure group and non-closure group was 29.2 years and 28.1 years respectively. Mean duration of procedure among patients of the closure group and non-closure group was 39.69 minutes and 32.26 minutes respectively.Among the patients of the closure group, mean VAS(Visual Analogue Scale) at immediate postoperative period, at postoperative 6 hours, postoperative 12 hours and postoperative 24 hours was found to be 4.8, 6.33, 4.61 and 3.86 respectively. In the present study, 8 percent of the patients of the nonclosure group while 10.4 percent of the patients of the closure group had incidence of postoperative febrile episode . Mean time for returning of bowel movements for the patients of the closure group and non-closure group was 1.72 days and 1.49 days respectively. Mean duration of hospital stay among the patients of the closure group and non-closure group was 2.3 days and 2.06 days respectively . Postoperative wound infection was present in 1.6 percent of the patients of the closure group and 1.6 percent of the patients of the non-closure group. Postoperative wound dehiscence was present in 0.8 percent of the patients of 55 the closure group and 0.8 percent of the patients of the non-closure group . Conclusions: Avoiding the closure of visceral and parietal peritoneum at caesarean delivery is associated with lesser operating time, decreased incidence of febrile morbidity and lesser need for postoperative analgesics. Hence , routine closure of peritoneum at caesarean section can be avoided.

Cyst of canal of Nuck-a rare clinical entity: case series and review of literature

A small evagination of parietal peritoneum forms the canal of Nuck. By the first year of life this extension condenses into a fibrous cord. Cyst of canal of Nuck is a rare developmental anomaly. The inguinal canal is traversed by the spermatic cord in male and the round ligament of uterus in female. The processus vaginalis accompanies the round ligament through the inguinal canal through into the labium majus. This evagination of parietal peritoneum forms the canal of Nuck in the female. These cases are rarely seen in surgical practice. In this case series we described three clinical scenario of canal of Nuck and their management.

FC 102PD INDUCED ARTERIOLAR AND PERITONEAL PATHOMECHANISMS ARE PARTIALLY REVERSED AFTER KIDNEY TRANSPLANTATION

Background and Aims Due to the unphysiological composition of PD fluids, chronic peritoneal dialysis (PD) induces progressive peritoneal fibrosis, hypervascularization, and vasculopathy. The evolution of the PD membrane and vasculopathy following kidney transplantation (KTx) is largely unknown. Method Arteriolar and peritoneal tissues were obtained from 107 children with chronic kidney disease (CKD5), 72 children on PD (treated with neutral pH PD fluids, with low glucose degradation product content, GDP) and 21 children, who underwent KTx 4-5 weeks after a median 21 months of PD. Specimen underwent standardized digital quantitative histomorphometry. Molecular mechanisms were studied in omental arterioles microdissected from surrounding fat by multi-omics followed by Gene Set Enrichment Analysis (GSEA); key findings were validated in parietal tissues of independent, matched cohorts by quantitative immunohistochemistry (n=15/group). Results Arteriolar transcriptome and proteome GSEA revealed suppression of leucocyte migration and T-cell activation / secretory pathways regulation, of sprouting angiogenesis biological processes and of epithelial proliferation and cell cycle after KTx as compared to PD. Lipid / fatty acid metabolism, autophagy and ATP synthesis pathways were activated. Transcriptome analysis including KTx, PD and CKD5 specifically attributed regulation of arteriolar lipid and fatty acid metabolism to transplantation and comprised 140 transcripts; their regulation was confirmed on the proteome level. Hub gene fatty acid synthase was identified by protein interaction analysis (string-db.org). 15 arteriolar genes activated by PD were inactivated after KTx and included glucose metabolisms and cytoskeleton related transcripts. 24 transcripts and 10 corresponding proteins induced by PD were still active after KTx and associated with biological processes related to TGF-ß signaling, fibrosis and mineral absorption. In line with arteriolar multi-omics findings, peritoneal hypervascularization induced by chronic PD was reversed after Tx to CKD5 level. CD45 positive tissue infiltrating leucocytes count was reduced by 40% and was independently associated with microvessel density in multivariable analysis including PD vintage, daily GDP exposure and recent KTx. Peritoneal lymphatic vessel density, submesothelial thickness, activated fibroblast, fibrin deposit, macrophage and EMT cell counts remained unchanged after KTx compared to PD. Arteriolar lumen to vessel ratios (a marker of vasculopathy) were similar in both groups. Vessel-homeostasis-related proteins in independent, matched cohorts demonstrated increased caspase-3 abundance in peritoneal arterioles after KTx. Arteriolar VEGF-A, thrombospondin, angiopoietin1/2, and hypoxia-inducible factor-1 (HIF-1a) were unchanged, while submesothelial HIF-1a and angiopoietin1/2 were decreased after Tx, favoring vessel maturation. The abundance of the key driver of fibrosis, TGF-ß-effector pSMAD2/3, was unchanged in the peritoneum and arterioles after Tx. Conclusion Our multi-omics analyses of fat covered omental arterioles, not directly exposed to PD fluids, demonstrate inhibition of PD induced immune response and angiogenesis pathways, of glucose metabolism and cytoskeleton regulation to levels similar as seen in children with CKD5. Arteriolar lipid and fatty acid metabolism is selectively altered after KTx. Reversal of low GDP PD induced hypervascularization and inflammation of the parietal peritoneum after KTx, mirror molecular changes in omental arterioles, while profibrotic activity persists after KTx in omental arterioles and in the parietal peritoneum.

Effect of Closure of Anterior Abdominal Wall Layers on Early Postoperative Findings at Cesarean Section: A Prospective Cross-sectional Study

Objective To investigate the effect of closure types of the anterior abdominal wall layers in cesarean section (CS) surgery on early postoperative findings. Methods The present study was designed as a prospective cross-sectional study and was conducted at a university hospital between October 2018 and February 2019. A total of 180 patients who underwent CS for various reasons were enrolled in the study. Each patient was randomly assigned to one of three groups: Both parietal peritoneum and rectus abdominis muscle left open (group 1), parietal peritoneum closure only (group 2), and closure of the parietal peritoneum and reapproximation of rectus muscle (group 3). All patients were compared in terms of postoperative pain scores (while lying down and during mobilization), analgesia requirement, and return of bowel motility. Results The postoperative pain scores were similar at the 2nd, 6th, 12th, and 18th hours while lying down. During mobilization, the postoperative pain scores at 6 and 12 hours were significantly higher in group 2 than in group 3. Diclofenac use was significantly higher in patients in group 1 than in those in group 2. Meperidine requirements were similar among the groups. There was no difference between the groups' first flatus and stool passage times. Conclusion In the group with only parietal peritoneum closure, the pain scores at the 6th and 12th hours were higher. Rectus abdominis muscle reapproximations were found not to increase the pain score. The closure of the anterior abdominal wall had no effect on the return of bowel motility.

Hydroceles of the Canal of Nuck in Adults—Diagnostic, Treatment and Results of a Rare Condition in Females

Nuck’s hydroceles, which develop in a protruding part of the parietal peritoneum into the female inguinal canal, are rare abnormalities and a cause of inguinal swelling, mostly resulting in pain. They appear when this evagination of the parietal peritoneum into the inguinal canal fails to obliterate. Our review of the literature on this topic included several case reports and two case series that presented cases of Nuck hydroceles which underwent surgical therapy. We present six consecutive cases of symptomatic hydroceles of Nuck’s canal from September 2016 to January 2020 at the Department of Surgery of Charité Berlin. Several of these patients had a long history of pain and consecutive consultations to outpatient clinics without diagnosis. These patients underwent laparoscopic or conventional excision and if needed simultaneous hernioplasty in our institution. Ultrasonography and/or Magnetic Resonance Imaging were used to display the cystic lesion in the inguinal area, providing the diagnosis of Nuck’s hydrocele. This finding was confirmed intraoperatively and by histopathological review. Ultrasound and magnetic resonance imaging (MRI) captures, intraoperative pictures and video of minimal invasive treatment are provided. Nuck’s hydroceles should be included in the differential diagnosis of an inguinal swelling. We recommend an open approach to external Type 1 Nuck´s hydroceles and a laparoscopic approach to intra-abdominal Type 2 Nuck hydroceles. Complex hydroceles like Type 3 have to be evaluated individually, as they are challenging and the surgical outcome is dependent on the surgeon’s skills. If inguinal channel has been widened by the presence of a Nuck’s hydrocele, a mesh plasty, as performed in hernia surgery, should be considered.