Combined Medical and Minimally Invasive Robotic Surgical Approach to the Treatment and Repair of Cesarean Scar Pregnancies [Case Report]
Background and Objectives/UNASSIGNED:The rise in cesarean deliveries, has led to increase in maternal complications in subsequent pregnancies such as abnormal placental implantation, uterine rupture, hemorrhage and, less commonly, cesarean scar pregnancies (CSP). Our objective was to describe patient characteristics following a combined medical and surgical treatment approach to first trimester cesarean scar pregnancies. Methods/UNASSIGNED:This was a case series approved by the Institutional Review Board of cesarean scar pregnancies over a two-year period at a single academic institution. The study included five patients with diagnosed cesarean scar pregnancies opting for pregnancy termination with the desire for fertility preservation. Medical treatment involved intra-gestational sac injection of lidocaine followed by systemic injection of methotrexate. At a minimum of two months later, surgical resection of cesarean scar pregnancy and repair of the uterus was performed. Results/UNASSIGNED:Median patient age was 36 (range 34â€‰-â€‰42) years, with 4 (3â€‰-â€‰10) prior pregnancies and 2 (1â€‰-â€‰3) prior cesarean deliveries. 40% (2/5) were Hispanic, 20% (1/5) Caucasian, 20% (1/5) African-American, and 20% (1/5) South Asian. After medical intervention, patients waited on average 4.6â€‰Â±â€‰2.3 months before surgery. No post-intervention complications or recurrences occurred. Two patients had a subsequent pregnancy. Conclusion/UNASSIGNED:This case series demonstrates an ideal management of cesarean scar pregnancy using combined medical and surgical approach in treating current ectopic pregnancy and repairing the uterine defect successfully without recurrence.
Robotic Repair of Complicated Vesico-[utero]/Cervicovaginal Fistula after Cesarean Section
STUDY OBJECTIVE/OBJECTIVE:To demonstrate intra- and postoperative steps in a successful management of a complicated vesico-[utero]/cervicovaginal fistula. DESIGN/METHODS:Stepwise demonstration of the technique with narrated video footage. SETTING/METHODS:A urogenital fistula in developed countries mostly occurs after gynecologic surgeries but rarely from obstetric complications. The main treatment of a urogenital fistula is either transvaginal or transabdominal surgical repair. We present a case of a 36-year-old woman, gravida 3 para 3-0-0-3, who developed a complicated large vesico-[utero]/cervicovaginal fistula after an emergent repeat cesarean section. Robotic repair was performed 2 months after the injury using the modified O'Connor method. Blood loss was minimal, and the patient was discharged from the hospital 1 day postoperatively. Follow-up showed complete healing of the fistula with no urine leakage, frequency of urination, or dyspareunia. The patient resumed normal bladder function and menstrual period up to 4 months after the repair procedure. INTERVENTIONS/METHODS:The basic surgical principle of urogenital fistula repair is demonstrated: (1) development of vesicovaginal spaces by dissection of the bladder from the uterus and the vagina, (2) meticulous hemostasis, (3) adequate freshened of the fistula edges, (4) tension-free and watertight closure of the bladder. We also demonstrate some other techniques that have developed though our own practice: (1) facilitating bladder distention by temporarily blocking the fistula, (2) placement of a ureteral catheter to protect the ureters, (3) interposition with omental flap, (4) single layer through and through closure of a cystotomy with 2-0 V-Loc suture (Covidien, Irvington, NJ). CONCLUSION/CONCLUSIONS:Complicated urogenital fistulas may be repaired successfully using minimally invasive surgery using robotic assistance, enabling less blood loss, faster recovery, shorter hospital stay, and fewer complications, etc.
Use of laparoscopy for resolution of intussusception in the third trimester of pregnancy: a case report [Case Report]
BACKGROUND:Laparoscopy has been used for the resolution of acute abdominal surgical conditions in the second trimester of pregnancy for years. There are few case reports, however, regarding its use in rare presentations of the acute abdomen later in pregnancy. CASE/METHODS:We report a case of the use of laparoscopy in the resolution of an intussusception in the 34th week, creating a smaller incision and providing the benefits of minimally invasive surgery. CONCLUSION/CONCLUSIONS:We suggest that laparoscopy be considered for further utilization as a safe and minimally invasive alternative for surgical procedures in the third trimester of pregnancy.