Faculty Bibliography

We report 2 unusual cases of partial bowel obstruction resulting from adherence to a barbed suture presenting 3 to 4 weeks after robotic-assisted sacrocolpopexy for uterovaginal prolapse. Both patients underwent an uncomplicated robotic-assisted supracervical hysterectomy and sacrocolpopexy. Immediate postoperative recovery was uncomplicated. Three to four weeks after surgery, both patients presented with symptoms of nausea, vomiting, and abdominal pain and were found to have small bowel obstructions requiring a return to the operating room. Upon surgical exploration, a loop of small bowel was found to be adhered to a segment of the barbed suture at the sacral promontory, which had been used to close the peritoneum over the mesh. Subsequent to release, both patients had an uneventful recovery.

BACKGROUND AND OBJECTIVES/OBJECTIVE:To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period. METHODS:Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS:There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30). CONCLUSION/CONCLUSIONS:Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.

This is the case of a 45-year-old woman with a history of asthma and smoking who developed complete left lung and right upper lobe collapse secondary to mucus plugs that developed immediately postoperatively after an uncomplicated reconstructive pelvic surgery. This rare intraoperative complication was successfully treated in the recovery room with bedside fiber-optic bronchoscopy. This resulted in complete resolution of her pulmonary findings within 24 hours of bronchoscopy.

OBJECTIVE:This study evaluated the efficacy of intraoperative extrinsic manual compression on the bladder, or Crede maneuver (CM) for tape adjustment during transobturator tape (TOT) sling procedure versus the traditional method where tension-free tape is adjusted the same for all patients. METHODS:All patients undergoing TOT sling procedure for stress urinary incontinence (SUI) between May 2008 and June 2011 by the first author were assessed. Tape adjustment was either performed in a traditional manner, leaving a tonsil clamp-size space between the sling and posterior urethra, or by using CM after filling the bladder to 300 ml capacity. Patients were considered cured at postoperative visits if they had no SUI symptoms and negative Cough Stress Test (CST) result, improved if they had some SUI symptoms and negative CST result, and failed if symptomatic and had positive CST result. The Fisher exact test and the Wilcoxon rank sum test were used to evaluate the baseline differences between the 2 groups, along with multiple logistic regression to evaluate independent predictors of cure. RESULTS:The continence rate was 77.67% in the traditional group (87/112) and 79.65% (137/172) in the CM group (P = 0.76). Older patients and smokers were less likely to be continent (odds ratio, 0.95; P = 0.015; and odds ratio, 0.22; P = 0.003, respectively). Five (4.5%) of the 112 patients in the traditional group and 12 (6.9%) of the 172 patients in the CM group had adverse outcomes including transient urinary retention, mesh erosion, or dysuria (P = 0.45). CONCLUSION/CONCLUSIONS:Using CM for intraoperative tape adjustment does not improve continence rates compared to the traditional method of TOT sling placement.

BACKGROUND:Labial adhesions are most commonly described in prepubertal girls. Only a few cases have been reported in postmenopausal women presenting with incomplete voiding. CASE/METHODS:This report describes a case of a 51-year-old postmenopausal woman who presented with incomplete voiding and urinary incontinence. On examination, she had complete labial fusion and intraoperative findings of distal vaginal stenosis due to a constriction band. The patient was surgically treated with lysis of the labial fusion, posterior vaginal advancement flap with complete resolution of her urinary symptoms. CONCLUSION/CONCLUSIONS:In this report, we present a case of a postmenopausal patient with complete labial fusion, distal vaginal stenosis, and incomplete voiding who underwent successful surgical management with good anatomical results and complete resolution of urinary symptoms.

BACKGROUND:Ureteral injuries are known complications of urogynecologic surgery. Until now, ureteral reimplantation with laparotomy has been used in cases in which ureteral stenting of distal obstruction was unsuccessful. CASE/METHODS:We report a case of a 74-year-old woman with a recognized right ureteral injury after vaginal reconstructive surgery that failed ureteral stenting to relieve the obstruction and who presented with ureteral stricture and mild hydronephrosis 6 weeks postoperatively. Ureteroscopy with endoscopic balloon dilation reduced the stricture successfully. The patient remains asymptomatic, with normal renal sonogram, 6 months after the procedure. CONCLUSION/CONCLUSIONS:Endoscopic balloon dilation is an effective technique that can be used for the management of ureteral strictures after urogynecologic surgery and avoids further surgical intervention.

Although endometriosis is not infrequent, the occurrence of perineal endometriomata is relatively rare and is generally attributed to seeding of endometrial cells to the perineal body during obstetrical trauma. A 45-year-old female with a history of a colpoperineorrhaphy during menses and a remote history of obstetric perineal trauma presented with an enlarging perineal mass. Excision of the mass led to a clinical and histopathologic diagnosis of perineal endometriosis. Elective surgery disrupting the vaginoperineal epithelium performed during menses may facilitate the seeding of endometrial cells to the perineal body and formation of perineal endometriomata.

A 66-year-old female presented with symptoms suggestive of pelvic organ prolapse, history of fibroid uterus, and rectal pressure. Pelvic examination revealed a large pelvic mass filling the posterior cul-de-sac, occupying the rectovaginal septum, and compressing the rectum. There was a stage II pelvic organ prolapse of the posterior vaginal wall with distal vaginal wall extending to the hymen during valsalva. A CT scan confirmed the large pelvic mass distinct from the uterus measuring 9.4 × 9.8 × 6.2 cm. Colorectal workup revealed adenocarcinoma of colon on screening colonoscopy with biopsies. Patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy, colon resection, and abdominal resection of the pelvic mass in the rectovaginal septum and inferior to the uterus. The patient did not require any concomitant pelvic reconstruction and the posterior vaginal wall prolapse resolved after resecting the pelvic mass.

OBJECTIVES/OBJECTIVE:To compare the potential for postoperative laparoscopic adhesion formation utilizing either monopolar cautery or ultrasonic energy and to determine whether there is added benefit with the addition of a suspension of hyaluronate/carboxymethylcellulose in saline versus saline alone. METHODS:Injuries were induced in rabbits by using monopolar cautery on 1 uterine horn and adjacent sidewall and ultrasonic energy on the opposite. Hyaluronate/carboxymethylcellulose or saline was added to every other animal. Autopsies were performed after 3 weeks. Clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS:A very significant difference occurred in pathologic adhesion scores favoring the ultrasonic scalpel when the animals were treated with saline. However, a borderline significant difference was found in pathologic scores favoring the ultrasonic scalpel compared to the monopolar cautery. There was no significant difference in clinical adhesion scores between the 2 modalities. No significant difference in either score was found with the addition of hyaluronate/carboxymethylcellulose or saline with either instrument. CONCLUSION/CONCLUSIONS:No benefit was found for adhesion prevention with hyaluronate/carboxymethylcellulose. Although no reduction was achieved in clinical adhesions, the ultrasonic scalpel resulted in fewer histologic signs of tissue inflammation in the early postoperative period, suggesting that further clinical adhesions might develop over time with cautery.

BACKGROUND:Laceration of the iliac veins and their branches is a feared complication in abdominal sacral colpopexy. Hemorrhages can be extensive and difficult to control. CASE/METHODS:We report a case of a patient who, while undergoing abdominal sacral colpopexy, was found to have confluence of the iliac veins at the level of the second sacral vertebra instead of the expected fourth lumbar to first sacral vertebral bodies. The intraoperative course had to be revised because of the increased risk of bleeding. The patient tolerated the procedure well and without any complications. CONCLUSION/CONCLUSIONS:With pelvic reconstructive surgery becoming more commonplace, knowledge of possible anomalous vessels is important because modification of planned surgical approach may be necessary to avoid short-term and long-term complications.