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Background: Mesh erosion is a well-known complication after use of mesh for pelvic organ prolapse repair. The most common site of mesh erosion is the vagina. Nonvaginal mesh erosions into ...

BACKGROUND: Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS. PURPOSE OF THE STUDY: To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH. METHODS: A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul’s Hospital. RESULTS: The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m(2), and median parity was 2 (range 0–7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up. CONCLUSIONS: OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

Background: Myomectomy scar pregnancy is a rare form of intramural pregnancy in which the gestational sac is implanted within the myometrium, separate from the endometrial cavity and fallo...

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

A 24-year-old unmarried woman had undergone laparoscopic myomectomy for single degenerated myoma of size 15 cm. Uncontained morcellation of the myoma was done with an electromechanical morcellator. Two years later, she presented with abdominal pain, and laparoscopy revealed enlarged uterus (20 weeks) with multiple degenerated myomas. There were multiple parasitic myomas measuring 1-3 cm in the pelvis and anterior abdominal wall which were removed laparoscopically. Histopathology of all the myomas including parasitic myomas confirmed the diagnosis of leiomyoma. The formation of parasitic myomas was assumed to be due to the myomatous fragments which were left behind during morcellation at the time of initial myomectomy. Methods to prevent this complication are colpotomy, mini-laparotomy, or in-bag morcellation.

The occurrence of symptomatic maternal arrhythmias during pregnancy is a cause of concern for the well-being of both the mother and the fetus. In women of reproductive age, the commonest arrhythmia is paroxysmal supraventricular tachycardia (SVT). SVT in pregnancy is defined as any tachyarrhythmia with a heart rate greater than 120 beats/min [1]. There are no reliable data on the incidence of paroxysmal SVT in pregnant women. The incidence in the general population is 35 per 1,00,000 person-years [2]. Over half of these patients are asymptomatic. The main mechanism for the development of SVT is via reentry (atrioventricular nodal reentrant tachycardia in 60 % of cases and atrioventricular reentrant tachycardia in 30 % cases) [3]. Episodes of SVT occur with increased frequency during pregnancy particulary in third trimester. Proposed mechanisms include the hyperdynamic circulation, the altered hormonal milieu, increased circulating levels of catecholamines, increased adrenergic receptor sensitivity and increased maternal effective circulating volume causing atrial stretch [4, 5]. Potential risk factor for SVT in pregnancy is underlying congenital or structural heart disease [6]. In most cases, there is no history of heart disease. Physical treatment like sinus carotid massage or Valsalva maneuvers followed by drug therapy is tried in hemodynamically stable patients. In cases of failure of above measure or when there is hemodynamic compromise, electrical cardioversion or invasive method like radiofrequency ablation is justified, which may jeopardize the mother and her fetus. No large-scale studies or randomized control trials regarding safety of ECV in pregnancy and agents for successful cardioversion are available [7]. The recommendations published by American College of Cardiology/American Heart Association Task Force on Practice Guidelines/European Society of Cardiology Committee for Practice Guidelines are solely based on expert consensus [8]. We present a case of maternal SVT with hemodynamic instability which failed to respond to physical and drug therapy.

Ectopic pregnancy is still an important cause of maternal mortality. The incidence of ectopic pregnancies is reported to be rising. Spontaneous bilateral tubal ectopic pregnancy in the absence of preceding induction of ovulation is extremely unusual occurrence and is the rarest form of ectopic pregnancy. The estimated incidence is 1 in 725 to 1580 of all ectopic corresponding to one per 200000 live births. The preoperative diagnosis of bilateral ectopic pregnancy remains a challenge. Serum β-hCG, TVS, color Doppler help making diagnosis of ectopic pregnancy but laparoscopy is gold standard diagnostic modality. The diagnosis of bilateral tubal pregnancy is usually made intra-operatively. This underscores the importance of identifying and closely examining both tubes at the time of surgery, even in the presence of significant adhesive disease. Salpingostomy, salpingotomy, salpingectomy, segmental resection, fimbrial expression are the operative modalities described for management of ectopic pregnancy.

Study Objective To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. Design A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). Setting In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. Interventions A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. Conclusion Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.

A 45-year-old woman was brought into the emergency ward of a tertiary care hospital. The patient gave a history of excess bleeding and passage of clots per vaginum since the past 15 days. The patient had a history of severe headaches, body ache, giddiness and vomiting. She was diagnosed with idiopathic thrombocytopenic purpura (ITP) and severe anemia six months before this incidence. The authors performed a diagnostic pelvic and transvaginal ultrasound and reported the presence of uterine fibroids. They determined that these fibroids had aggravated the bleeding which was caused by ITP. The diagnosis of ITP coupled with severe anemia prevented the authors from using the traditional approach of a hysterectomy in such a case. She was administered tranexamic acid, testosterone enanthate, blood, intravenous immunoglobulins, steroids and platelets transfusion. Uterine artery embolization (UAE) was tried for arresting menorrhagia, but was unsuccessful. Finally, a Bakri® balloon, normally used for management of post-partum hemorrhage (PPH), was inserted and retained for 48 hrs.. The bleeding gradually ceased and significant improvements in hematocrit and platelet count were observed. However, the patient then suffered from a deep vein thrombosis (DVT) in the lower extremity, which was treated with low molecular weight heparin (LMWH), a thrombectomy and an Inferior vena cava Filter. Patient was advised a hysterectomy to curb her symptoms, however, she was too exhausted of surgical procedures and refused. Therefore, the authors decided to employ the use of Selective Estrogen Receptor Molecule Therapy (SERM). 3-months post-intervention, patient is thriving and stable.