Re: Opinions on laparoscopy (long)
From: art fougner, md (evsono@pipeline.com)
Tue Sep 27 13:22:43 2005
Is the ascites persisting? or resolving?
Art
At Tue, 27 Sep 2005, Andrew Folley wrote:
>
>Glen
>Tough to mak out what is going on. Some thoughts would be possibility of
>ureteral injury due to dissection and cautery. We are use to obstructions
>but more likely is that she has a uretero-peritoneal fisutla. Could the
>ascites be urine? Injury could explain the ecoli in the urine and some many
>of symptoms. Check IVP look for extravasation. A bowel injury is unlikely
>as it would have given her peritonitis. She had no peritonitis. Good luck,
>andy
>
>>From: "Elrod Darryl G MAJ 48 MDOS/SGOBO" <Darryl.elrod@LAKENHEATH.AF.MIL>
>>Reply-To: ob-gyn-l@obgyn.net
>>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>>Subject: Opinions on laparoscopy (long)
>>Date: Tue, 27 Sep 2005 11:15:45 -0500
>>
>>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
>>
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--
art fougner, md
"If you don't know where you are going, you will wind up somewhere else."
Lawrence Peter Berra
