Cases reported "Adnexal Diseases"

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1/33. Adnexal torsion and pulmonary embolism: case report and review of the literature.

    The classical teaching was that twisted adnexa should be resected and not untwisted, so as not to increase the risk of pulmonary embolism (PE). A patient recently was seen who developed PE after adnexal resection. Because this complication followed the conventional management of salpingo-oophorectomy, the literature was examined for cases of adnexal torsion and PE to see if the operative management (untwisting vs. excision without untwisting) could be implicated as a contributing factor. Three hundred nine cases of adnexal torsion managed by untwisting and 672 cases treated by adnexectomy without detorsion (untwisting) were found. The incidence of PE after adnexal torsion was 0.2 percent, and this incidence was not increased when the adnexa were untwisted. Therefore, we conclude that detorsion of twisted adnexa does not increase the risk of PE, compared with excision without untwisting. PE does occur in cases in which adnexal resection is performed without untwisting. Thus, detorsion of twisted adnexa should be considered at laparoscopy or laparotomy without fear of increasing the incidence of PE.
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2/33. Gasless laparoscopy under epidural anesthesia for adnexal cysts during pregnancy.

    OBJECTIVE: To evaluate laparoscopic adnexal cystectomy during pregnancy using an open technique with a whole abdominal wall-lift method under epidural anesthesia. STUDY DESIGN: Seven cases of adnexal cysts during pregnancy were resected using a gasless laparoscopic (extracorporeal) method with a whole abdominal wall-lift. We performed this procedure without using general anesthesia or CO2 pneumoperitoneum. RESULTS: All operations were performed successfully without complications. All patients resumed normal activity within one week. The subsequent antenatal courses of the patients were uneventful. There were no severe complications during the operations or postoperative courses. Six patients had vaginal deliveries of normal infants at term. No abnormal findings were found in the antenatal course of patient 7 until 30 weeks of gestation. CONCLUSION: Based on our limited experience, this procedure may be safe.
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keywords = operative
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3/33. Treatment strategy for pelvic actinomycosis: case report and review of the literature.

    BACKGROUND: Pelvic actinomycosis is a chronic granulomatous suppurative disease caused by an anaerobic Gram positive organism actinomyces israelii usually associated with intra-uterine devices. Pelvic actinomycosis can mimick pelvic or intra-abdominal malignancy leading to mutilating surgical exeresis. RESULTS: We present a pelvic actinomycosis secondary to long-standing intra-uterine device use in a 50-year old European woman treated by intravenous antibiotic therapy, and then by a total abdominal hysterectomy and bilateral salpingoophorectomy to free the pelvis from abscess. We point out the difficulty in diagnosis, and the importance of high-dose intravenous antibiotic therapy to reduce the very high risk for nearby pelvic structure injuries, reported in the literature, leading to post-operative morbidity.
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keywords = operative
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4/33. Small bowel incarceration in a broad ligament defect.

    We report the case of a 33-year-old woman whose medical history included three normal pregnancies without previous abdominal or pelvic surgery. She presented with small bowel obstruction. An abdominal computed tomography (CT) scan study revealed air fluid levels in the pelvis. Laparoscopic exploration revealed a viable ileal loop incarcerated through the mesoligamentum teres. The intestinal loop was reduced and the broad ligament defect was closed with a laparoscopic absorbable clip. Among internal hernias, hernias through a defect in the broad ligament represent only 4-7%. Defects within the broad ligament can be either congenital (ruptured cystic structures reminiscent of the mesonephric or mullerian ducts) or secondary to operative trauma, pregnancy and birth trauma, or prior pelvic inflammatory disease. CT scan may be diagnostic by showing incarceration of a dilated intestinal loop in the Douglas pouch with air fluid levels. This is the first reputed case of a totally laparoscopic repair of a bowel incarceration through a broad ligament defect.
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keywords = operative
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5/33. Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion.

    BACKGROUND/PURPOSE: Adnexal torsion is a serious condition that frequently may result in ovarian removal, and there always is a risk of castration if the contralateral ovary undergo torsion as well. In this study, the authors present their experience with adnexal torsion in 15 children and describe a catastrophic event, asynchronous bilateral adnexal torsion, with review of the literature. methods: Between November 1993 and November 2000, 15 children under 15 years of age who had undergone operation because of torsion of uterine adnexal structures were evaluated. Two illustrative cases with asynchronous bilateral adnexal torsion are presented. RESULTS: Fourteen cases were associated with additional adnexal pathology, whereas in 1 case the torsion was of normal uterine adnexa. Sonographic studies improved the preoperative diagnosis. Hemorrhagic necrosis of the adnexa secondary to the torsion was found in all cases except 3 and necessitated adnexal resection. In only 3 cases preservation of the adnexa was possible. Asynchronous adnexal torsion occurred in 2 patients in the time course. Both were treated by laparotomy and adnexal untwisting and fixation by permanent multiple interrupted sutures. In their final evaluation at 40 and 8 months after the operation, they were found to have good ovarian function. CONCLUSION: Considering the risk of subsequent contralateral torsion and its impact on future fertility, the authors believe that conservative management (untwisting the ovary and pexing, both retained detorsed and contralateral, ovaries) should be considered in cases of ovarian torsion in children.
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ranking = 1
keywords = operative
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6/33. Papillary cystadenocarcinoma arising in a paratubal mesothelial cyst of the mesosalpinx--a case report.

    Primary carcinoma arising from a paratubal cyst in the mesosalpinx in uncommon. Serous tumors of low malignant potential outnumber invasive carcinomas, which are often of endometrioid type. Only five cases of serous papillary cystadenocarcinoma with capsular invasion have been documented. We report a case of invasive papillary cystadenocarcinoma arising in a large paratubal cyst of the mesosalpinx, in an infertile woman. Possible hormonal basis, its link to serous borderline and malignant tumors of the peritoneum, and value of pre/intra operative cyst fluid cytology are discussed. Lack of definitive management protocols, prognostic indicators and possible consequences are briefly reviewed.
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ranking = 1
keywords = operative
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7/33. Hemorrhagic corpus luteum cyst torsion in term pregnancy: a case report.

    hemoperitoneum during pregnancy resulting from spontaneous rupture of adnexal torsion is a rare cause of fetal and maternal death. Presenting symptoms include severe abdominal pain, followed rapidly by maternal shock and fetal distress. It is hard to localize the adnexae in advanced pregnancy. Here, we present a case of spontaneous rupture of hemorrhagic corpus luteum cyst torsion that had not been previously diagnosed by ultrasound during term pregnancy. The patient was sent to our emergency room for sudden onset of severe low abdominal pain. Treatment consists of maintenance of adequate circulating intravascular volume and rapid surgical intervention. Preoperative diagnosis of adnexal torsion during term pregnancy is very difficult, although it is always identified during surgery.
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ranking = 1
keywords = operative
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8/33. Laparoscopic management of adnexal masses in pregnancy: a case series.

    OBJECTIVE: To determine the feasibility, safety, limiting factors, and advantages of laparoscopic management of adnexal masses in pregnancy. STUDY DESIGN: During a 12-year period, 48 laparoscopic procedures were performed in 47 patients with adnexal masses in pregnancy. Laparoscopic surgery was done during the first trimester of pregnancy in 17 cases, the second trimester in 27 cases and the third trimester in four cases. All the procedures were performed with general anesthesia and curarization. The laparoscopic cystectomies were performed either with the intra-peritoneal or the trans-peritoneal technique. RESULTS: The indications were: persistant or sonographically abnormal ovarian cyst (36 cases), torsion or rupture of ovarian cyst (8 cases), and symptomatic pelvic mass (3 cases). Two borderline tumors were discovered. The laproscopic procedure could not be performed in two cases due to dense adhesions and difficulty of hemostasis. No patient encountered complications during the intra- and post-operative periods. The mean hospital stay was 3.8 days. The outcome of the pregnancy was normal in all cases except one fetal loss 4 days after the laparoscopy. CONCLUSION: Laparoscopic management of adnexal masses in pregnancy by an experienced team, is a safe and effective procedure that allows, compared to the traditional surgery, a shorter hospital stay, a reduced rate of post-operative complications and a decreased maternal and fetal morbidity.
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ranking = 2
keywords = operative
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9/33. Predictors of clinical outcomes in the laparoscopic management of adnexal masses.

    OBJECTIVE: laparoscopy has become an accepted approach in the management of adnexal masses. We evaluated clinical outcomes of laparoscopic management of adnexal masses thought to be benign preoperatively. methods: We performed a retrospective study of patients undergoing laparoscopic evaluation of adnexal masses over a 7-year period. Regression models evaluated predictors of blood loss, length of stay, complications, mass rupture, conversion to laparotomy, and operating time. Preoperative predictors of malignant and borderline disease were evaluated using a separate model. RESULTS: Complications occurred in 8% of 396 patients undergoing laparoscopic evaluation of adnexal masses and were associated with concurrent hysterectomy (P =.01) and smaller mass (P =.01). Conversion to laparotomy occurred in 25% and was associated with larger mass (P =.001), prior hysterectomy (P =.002), and younger age (P =.002). Mass rupture occurred in 25% and was associated with prior (P <.001) or concurrent (P =.003) hysterectomy and younger age (P =.001). blood loss greater than 500 mL was associated with concurrent hysterectomy (P <.001). length of stay was associated with concurrent (P <.001) and prior (P <.001) hysterectomy, larger mass (P =.01), prior abdominal surgery (P =.009), and medical comorbidities (P =.007). Malignancy occurred in 2%, and laparoscopic management was not associated with adverse outcomes. CONCLUSION: Adnexal masses thought to be benign preoperatively were successfully managed laparoscopically in three fourths of cases and clinical outcomes were acceptable. To a great extent, adverse events were attributable to concurrent hysterectomy rather than removal of the adnexal mass.
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ranking = 3
keywords = operative
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10/33. Four ovarian cancers diagnosed during laparoscopic management of 1011 women with adnexal masses.

    OBJECTIVES: This study was conducted to assess the value of laparoscopic management of adnexal masses. Two concerns we wish to address are the failure to diagnose early ovarian cancer at laparoscopy and worsening the prognosis of stage I cancer by spilling fluid during surgery. STUDY DESIGN: The setting is a predominantly referral-based, private subspecialty practice. All operations were preformed in the outpatient surgical suite of a large suburban hospital. After extensive patient screenings, which included history and physical examination, preoperative serum CA 125 levels (since 1988), and pelvic ultrasonography, 1209 adnexal masses were managed laparoscopically. RESULTS: Of 1011 patients with surgical management, ovarian cancer was discovered intraoperatively in four. CONCLUSIONS: Our findings indicate that with consistent use of frozen sections of all cyst walls and suspicious tissue, laparoscopic management did not alter the prognosis. Neither CA 125 level, pelvic ultrasonography, nor peritoneal cytologic testing had sufficient diagnostic specificity to predict malignancy. Experienced surgeons using intraoperative histologic sampling may safely evaluate adnexal mass laparoscopically.
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ranking = 3
keywords = operative
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