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Re: Opinions on laparoscopy (long)From: ainsron (ainsron@sbcglobal.net)Tue Sep 27 11:31:28 2005
Sounds like she was third spacing fluid and got fluid overloaded. Ronald E. Ainsworth, MD, FACOG -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod Darryl G MAJ 48 MDOS/SGOBO Sent: Tuesday, September 27, 2005 9:16 AM To: Multiple recipients of list OB-GYN-L Subject: Opinions on laparoscopy (long) Last week I operated on a 23 yo G0, young healthy active duty woman. She had previously had laparoscopy for pelvic pain where they fulgurated endometriosis. By her op pictures, the implants were located in the posterior cul de sac across both uterosacral ligaments and between them over the upper vagina and rectum. There did not appear to be much in the anterior cul de sac. Prior to me seeing her, she had also gone through 6 months of Depo Lupron with add back. My approach was going to be excision of peritoneal implants rather than recauterizing implants. Surgery was fairly uneventful. I was able to use sharp dissection to peel away most of the peritoneum from the posterior culdesac and both ovarian fossas. Both ureters were seen before and after the dissection. I had a rectal probe in the rectum and a sponge stick in the vagina to be able to locate these. Blood loss was about 100ml. I tried not to burn much so I left it a bit 'oozy' but by no means actively bleeding. In PACU her pain wasn't well controlled and she couldn't void. She was then admitted. Serial H/H over the next 24hrs were stable. VS initially were stable as well. She was able to void 100-200ml at a time. Pain was still an issue so she stayed. On POD 2 now, she became hypoxic with desats to the 80s on RA. O2 was added and she came back up to normal. At the same time she became tachycardic with HR to 130s. EKG, CXR and KUB were orderd. EKG-sinus tach CXR-right pleural effusion KUB-dilated large bowel with all bowels apparently pushed to the midline, with presumptive diagnosis of ascites. Days begin to get fuzzy at this point, but over the next several days the following happen. Foley gets put in with 1000ml out, grossly infected and subsequently grows out E coli. Cipro started. BUN/Cr bump to 25/2.5 IVF changed and within a day renal function normalizes. Renal ultrasound normal. Ascites confirmed. Pt still is not passing flatus nor tolerating any clears. By POD 5-6 pt begins to diurese well, begins to have some liquid stool but still vomiting. Last night, NG tube placed with 950ml out. Today pt vomits NG out. CT scan today shows clearance of pleural effusions, large amount of ascites but no dilated bowels or signs of abscess. Labs show electrolyte disturbances (low K, low phosp, low magnesium) all being replaced. Pericentesis just done with clear fluid noted. Cell count, gram stain and culture all pending. Can anyone make sense of a plausible cause for this? As I've read some things on Endometriosis Zone on obgyn.net it seems all I've done previously with simple fulguration of endometriosis isn't really doing anything to treat the disease. So I tried to expand my thinking and skills and do a more aggressive excision. Now I'm stumped and not sure I did the right thing by this patient. I appreciate the help Glen //SIGNED// D. Glen Elrod, Maj., USAF, MC Obstetrician/Gynecologist Chief of Obstetrics 48 MDOS/SGOBO RAF Lakenheath, England Telephone DSN: 314-226-8130 Comm: +44 (0) 1638 52 8130 Notice of Confidentiality Under the Privacy Act of 1974, you must safeguard all information reflected on this e-mail and, if applicable, all attachments. Disclosure of information is IAW AFI 33-119, AFI 33-127, AFI 37-131, AFI 37-132, AFI 33-219, and PL 93-579" This e-mail message including any attachments is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message. Any questions pertaining to disclosure should be directed to the privacy officer.
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