Laparoscopic repair of femoral hernia involving the bladder with coexisting indirect inguinal hernia in a young man: a case report

Background Bladder hernias are rare conditions that are difficult to diagnose preoperatively; many cases are diagnosed intraoperatively or postoperatively due to bladder injury. Most bladder hernias are direct inguinal hernias that involve the bladder in obese men older than 50 years old. We describe a rare case of a left femoral hernia involving the bladder in a young man. Case presentation A 32-year-old man with a bulge in the left inguinal region underwent laparoscopic transabdominal preperitoneal repair. Laparoscopy revealed a left indirect inguinal hernia. When the preperitoneal space was dissected toward the Retzius space along the vesicohypogastric fascia, the bladder was found to be protruding into the femoral ring and adhere to the hernial orifice severely. The bladder was reduced carefully without causing injury. After dissection, we repaired the left myopectineal orifice with a mesh. The patient was discharged on postoperative day 1 without complications. No recurrences or symptoms were noted at the 12-month follow-up. Conclusions A femoral hernia involving the bladder in a young man is rare. This case demonstrated that dissection along anatomical landmarks is important for preventing injuries to the bladder because even young men may have bladder hernias.

Duration of Exposure to General Endotracheal Anesthesia during Cesarean Deliveries at Term and Perinatal Complications

Objective To examine whether the duration of time from initiation of general endotracheal anesthesia (GETA) to delivery for cesarean deliveries (CDs) performed is related to perinatal outcomes. Study Design This is a retrospective study of patients with singleton nonanomalous gestations undergoing CD ≥37 weeks of gestation under GETA with reassuring fetal status at a single tertiary care center from 2000 to 2016. Duration from GETA initiation until delivery was calculated as the time interval from GETA induction to delivery (I-D), categorized into tertiles. Outcomes for those in the tertile with the shortest I-D were compared with those in the other two tertiles. The primary perinatal outcome was a composite of complications (continuous positive airway pressure or high-flow nasal cannula for ≥2 consecutive hours, inspired oxygen ≥30% for ≥4 consecutive hours, mechanical ventilation, stillbirth, or neonatal death ≤72 hours after birth). Secondary outcomes were 5-minute Apgar score <7 and a composite of maternal morbidity (bladder injury, bowel injury, and extension of hysterotomy). Bivariable and multivariable analyses were used to compare outcomes. Results Two hundred eighteen maternal–perinatal dyads were analyzed. They were dichotomized based on I-D ≤4 minutes (those in the tertile with the shortest duration) or >4 minutes. Women with I-D >4 minutes were more likely to have prior abdominal surgery and less likely to have labored prior to CD. I-D >4 minutes was associated with significantly increased frequency of the primary perinatal outcome. This persisted after multivariable adjustment. In bivariable analysis, 5-minute Apgar <7 was more common in the group with I-D >4 minutes, but this did not persist in multivariable analysis. Frequency of maternal morbidity did not differ. Conclusion When CD is performed at term using GETA without evidence of nonreassuring fetal status prior to delivery, I-D interval >4 minutes is associated with increased frequency of perinatal complications. Key Points

Maternal outcome in accreta cases. Conservative surgery and hysterectomy in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from January 2017 to January 2018

HIGHLIGHT1. As the incidence of placenta accreta is increasing which seems to parallel the increasing cesarean delivery rate, advance planning should be made for the management of delivery. 2. Maternal outcome of placenta accreta cases in a national hospital was reported based on the surgical technique performed.3. No significant results of maternal outcome undergoing conservative surgery and conventional hysterectomy in managing accreta cases in the national hospital.ABSTRACTObjectives: To report maternal outcome based on surgical technique on the management of accreta. The study was conducted in Cipto Mangunkusumo Hospital, Jakarta, Indonesia from January 2017 to January 2018.Case Report: There were 1609 cases of pregnant women delivered during the study period. From these, the prevalence of previous caesarean section was 73 cases, including 20 cases of accreta. Total maternal mortality for 1 year in Cipto Mangunkusumo Hospital, Jakarta, Indonesia, was 11, and accreta contributed 3 cases. We reported 20 cases of accreta in pregnancy The maternal outcomes, including bladder injury, duration of operation, intraoperative bleeding, length of hospitalization, and mortality, were evaluated. From 20 cases, 8 patients had one previous caesarean history, 11 had second previous caesarean section, while 2 patient had third previous caesarean section history. Of women with placenta accreta, about 7 patients (35%) had delivery in fullterm pregnancies, while 13 (65%) had delivery in preterm pregnancy. Surgical technique in accreta management mostly was hysterectomy to override bleeding complication along the delivery. From 20 cases, 16 caesarean sections were followed-up with hysterectomy. Four cases were with conservative management. From all the hysterectomy performed, four were complicated with bladder injury. The mean intraoperative bleeding was 600 - 5500 cc of blood, while the mean of post-operative transfusion was 1000 -3000 cc. There were 2 maternal deaths in this study. Thirteen patients were admitted to the ICU after the procedure.Conclusion: Accreta increases morbidity due to massive bleeding. It is important to have algorithm for managing abnormal implantation of the placenta. Our cases revealed no significant results of maternal outcome between conservative surgery and conventional hysterectomy in managing accreta cases in Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Osr1 Is Required for Mesenchymal Derivatives That Produce Collagen in the Bladder

The extracellular matrix of the bladder consists mostly of type I and III collagen, which are required during loading. During bladder injury, there is an accumulation of collagen that impairs bladder function. Little is known about the genes that regulate production of collagens in the bladder. We demonstrate that the transcription factor Odd-skipped related 1 (Osr1) is expressed in the bladder mesenchyme and epithelium at the onset of development. As development proceeds, Osr1 is mainly expressed in mesenchymal progenitors and their derivatives. We hypothesized that Osr1 regulates mesenchymal cell differentiation and production of collagens in the bladder. To test this hypothesis, we examined newborn and adult mice heterozygous for Osr1, Osr1+/−. The bladders of newborn Osr1+/− mice had a decrease in collagen I by western blot analysis and a global decrease in collagens using Sirius red staining. There was also a decrease in the cellularity of the lamina propria, where most collagen is synthesized. This was not due to decreased proliferation or increased apoptosis in this cell population. Surprisingly, the bladders of adult Osr1+/− mice had an increase in collagen that was associated with abnormal bladder function; they also had a decrease in bladder capacity and voided more frequently. The results suggest that Osr1 is important for the differentiation of mesenchymal cells that give rise to collagen-producing cells.

STRATEGIES FOR ANESTHESIA MANAGEMENT OF CESAREAN DELIVERIES WITH ABNORMAL PLACENTAL PLACEMENT–ANESTHETIST’S PERSPECTIVE

Objective: To discuss problems faced in the management of emergency and elective cesarean sections with known or unknown abnormal placental placement and their management. Study Design: Retrospective observational study. Place and Duration of Study: Different Hospitals for the last 7 years from 2013 to 2020. Methodology: This retrospective observational study of 120 cases was selected for data collections that underwent anesthesia. Variables under study were age, weight, type of abnormal placenta, fluid, blood/blood products given during surgery, hysterectomy done, general surgeon help required, anesthesia type, and redo of operations. Results: A total of 120 patients were operated having abnormal placentation. The frequency of placenta previa 90 (75%), and accreta was 30 (25%). Primigravida patients were 19 (15.8%) and multigravida patients were 101 (84.1%). hysterectomy was done in 28 (23.3%) patients. Spinal anesthesia was given in 50 (41%) patients while 70 (58.3%) patients have general anesthesia. The spinal anesthesia was later on converted to general anesthesia in 32 (26.6%) patients out of 50 (41%). Only 12 (10%) patients were reopened for uncontrolled bleeding and 4 (3.3%) patients were sent to tertiary care hospital for further management. The general surgeon was called for help in 24 (20%) of patients and bladder injury occurred in 25 (20.8%) patients. No mortality was found during this period. Conclusion: Abnormal placental placement is a threat to mother life as well fetus and team of dedicated doctor is required to deal with this emergency. Use of inotropes can help to save the precious lives.

Intraoperative surgical difficulties encountered during repeat caesarean section in a tertiary care centre in Northeast India

Background: Caesarean section is the commonest obstetric operative procedure worldwide. The potential perioperative problems in repeat caesarean section include adhesions, increased blood loss, prolonged operative time, injuries to adjacent structures, hysterectomy etc. These increase with increase in caesarean section number.Methods: Hospital based observational study, conducted at Dept. of Obstetrics and Gynaecology, Assam Medical College, from July 2019 to June 2020 with the aim to study intraoperative difficulties encountered during repeat caesarean section. Cases were grouped into two main groups based on number of prior caesarean sections. A detailed history, clinical and intraoperative findings of all pregnant women undergoing repeat caesarean section were noted. Results were tabulated and analysed.Results: Out of 400 women with prior caesarean section who underwent repeat caesarean. 321 had 1 prior caesarean and rest had 2. Among the cases cephalopelvic disproportion was the commonest (43.25%) indication and obstructed labour was the least common (0.25%). Common complications were adhesions (38.25%), thinned lower uterine segment (27%), advance bladder (19.50%), uterine dehiscence (14.75%), excess blood loss (12.75%), extension of uterine incision (8.25%), uterine rupture (1%), placenta accrete (0.75%), and bladder injury (0.5%). Intraoperative complications like adhesions, uterine dehiscence, delivery and operating time were significantly higher in women with 2 prior caesarean section compared to 1 prior caesarean section (p<0.001).Conclusions: Women with caesarean scar are at high risk in subsequent pregnancies particularly in a country like India where antenatal care is often neglected. Best technique to reduce multiple potential complications of repeat caesarean section is to reduce the rates of primary and repeat caesarean sections whenever possible.

A case report of Urinary bladder injury post laparoscopic appendectomy: A rare complication

Urinary bladder injury is a rare complication of laparoscopic abdominal surgery. The incidence is low and usually goes unidentified with confusing presentation. We report a case of such injury during laparoscopic appendectomy that was identified on 3rd post-operative day and a small 1 cm tear was found at posterior wall of bladder which and was repaired. There was also a collection anterior to bladder which was drained separately under radiological guidance later as on table cystogram did not show any leak anterior to bladder. Patient also had covid pneumonia during stay and patients stay and recovery was prolonged. Attention must be paid to port insertion under vision especially low insertion of supra pubic port should be avoided with pre op catheterization and key to diagnosis of injury is awareness of this rare entity. Keyword: Laparoscopic Appendectomy; Bladder Injury; Uroperitonium

EP.FRI.792 Laparoscopic port positioning in paediatric appendicectomy - a closed loop audit

Aims Laparoscopic appendicectomy is the most common laparoscopic procedure performed in children, typically with a suprapubic (SP) left-hand port position. This has been associated with bladder injury. Pre-operative bladder emptying can reduce the risk of this complication. The aim of this study was to evaluate compliance with local policy mandating left iliac fossa port placement (LIFPP) rather than SP. We assessed the rate of LIFPP before and after an educational intervention, and also audited if voiding status was included as part of the paediatric WHO checklist. Methods Retrospective data was collected before and after implementation of education, for 50 consecutive patients aged &lt;16 years undergoing laparoscopic appendicectomy. The education programme targeted operating department practitioners, paediatric nurses and surgeons, and included seminars and regular dissemination of the local protocol. Data analysis was performed using GraphPad Prism. Results Patients were evenly distributed by gender with 94% above the age of 10. Mean age was 13.8 years. There was a statistically significant improvement in compliance with LIFPP, from 72% to 100% (p &lt; 0.0001) after introduction of improved education, as well as significantly improved documentation of pre-operative voiding status from 12% to 40% (p = 0.0026). The rate of catheterisation intra-operatively was reduced from 20% to 8% (p = 0.1478). Conclusions Improved education has led to a significantly increased compliance with local port placement policy. Documentation of pre-operative voiding status has been included in the paediatric WHO checklist ‘SIGN IN’ section locally.

Minimally invasive management versus open surgery in the treatment of penetrating bladder injuries: a retrospective cohort study

Background While blunt extra-peritoneal bladder injury is typically treated non-operatively or with minimally invasive management, the treatment for penetrating bladder injury is generally open surgery. We identify a group of patients with penetrating bladder injury who were treated with minimally invasive management and compare the results with those who underwent traditional open surgical treatment. Methods This retrospective cohort study analyzes penetrating bladder injuries from a single trauma center from 2012 through 2019, and from the National Trauma Data Bank for 2016 and 2017. Mortality, complications, and length of stay were compared for minimally invasive management versus open surgery. We used Chi square to test significance for categorical variables, Mann–Whitney U test for ordinal variables, and T-test for continuous variables. Multivariate analysis was performed with multiple logistic, ordinal, and linear regression. Results Local: 117 (0.63%) had a bladder injury; 30 (25.6%) were penetrating. 6 (20.0%) were successfully treated with minimally invasive management with no complication versus 24 complications in 11 patients (45.8%) for open surgery (p = 0.047). Open surgical management was not a significant independent predictor of mortality or hospital length of stay. National Trauma Data Bank: 5330 (0.27%) had a bladder injury; 963 (19.5%) were penetrating. 97 (10.1%) were treated with minimally invasive management. The minimally invasive management group had 12 complications in 5 patients (4.9%) versus 280 complications in 169 patients (19.7%) for open surgery (p = < 0.001). Open surgery was a significant independent predictor of complications (OR 1.57, p = 0.003) and longer hospital length of stay (B = 5.31, p < 0.001). Conclusions Most penetrating bladder injury requires open surgery, however a small proportion can safely be managed with minimally invasive management. Minimally invasive management is associated with lower total complications and shorter hospital length of stay in select patients.

Complications of Ovarian Cancer Surgery in Dr. Cipto Mangunkusumo National Referral Hospital, Jakarta

Background: Ovarian cancer remains as one of the deadliest gynecologic problems globally. Often appears in advanced state, its surgery proves to be a challenge for clinicians. This study aim to present complications surrounding ovarian cancer surgery.Methods: This study was a cross-sectional study to analyze reports of intraoperative and postoperative complications in ovarian cancer patients undergoing laparotomy in Dr. Cipto Mangunkusumo National General Hospital, Jakarta from January 2018 to December 2019. Ovarian cancer patients undergoing laparotomy surgery were included in the study. Patients with a history of other cancers or having incomplete data were excluded from the study. Intraoperative complications included intestinal, ureter, bladder injury, and postoperative complications included paralytic ileus, surgical wound infection and sepsis were documented.Results: A total of 78 subjects were included in the study. The total proportion of complications was 19.2%. The most prevalent intraoperative complications were intestinal injury (12.8%), bladder injury (2.6%), and ureter injury (1.3%). Most prevalent postoperative complications reported were surgical wound infection (5.2%), sepsis (3.9%), while none of the patients had paralytic ileus.Conclusion: The proportion of intraoperative and postoperative complications in ovarian cancer surgery was still at alarming level (19.2%). Further steps are needed to ameliorate the rate of complications surrounding ovarian cancer surgery.