Re: Opinions on laparoscopy (long)
From: Andrew Folley (agfolley@hotmail.com)
Tue Sep 27 19:49:43 2005
Its not the bladder. It is the ureter and probably the distal portion 2-4
cm from the right ureteral vesical junction. IVP will demonstate
extavasation. Get urology involved. They may be able to reimplant with
ureteroneocystotomy. Good luck. andy
>From: "Richard Chudacoff, MD" <rchudacoff@mylinuxisp.com>
>Reply-To: ob-gyn-l@obgyn.net
>To: Multiple recipients of list OB-GYN-L <ob-gyn-l@dns.obgyn.net>
>Subject: RE: Opinions on laparoscopy (long)
>Date: Tue, 27 Sep 2005 15:00:34 -0500
>
>Agree with the idea that there may have been a bladder injury, although
>with
>almost a liter of fluid when the Foley was placed makes me think it was a
>small laceration. Other option would be a cysto-intestinal fistula. IVP?
>
>Richard Chudacoff, MD
>
>This message is confidential, intended only for the named recipient(s) and
>may contain information that is privileged or exempt from disclosure under
>applicable law. If you are not the intended recipient(s), you are notified
>that the dissemination, distribution or copying of the messages is strictly
>prohibited. If you receive this message in error, or are not the named
>recipient(s), please notify the sender at either the e-mail address or
>telephone number above and delete this e-mail from your computer.
>
> _____
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Larry
>Glazerman
>Sent: Tuesday, September 27, 2005 1:40 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: RE: Opinions on laparoscopy (long)
>
>I hada similar case once, and it was a bladder laceration with urinary
>ascites. As that gets absorbed, it will bump up the BUN and creatinine. Was
>CT done with IV contrast? Consider cysto/retrograde.
>
>Larry R. Glazerman, MD
>
>Ob-Gyn at Trexlertown, PC
>
>larry.glazerman@lvh.com
>
> _____
>
>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 12:16 PM
>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.
>
><< image001.jpg >>
|
|
