Re: Opinions on laparoscopy (long)
From: Elrod Darryl G MAJ 48 MDOS/SGOBO (Darryl.elrod@LAKENHEATH.AF.MIL)
Wed Sep 28 17:17:23 2005
Good news. Her IVP was normal. No extravasations from the bladder or
ureter. Both ureters clearly seen from kidney to bladder as well.
I'm sure they could have told me as much from the CT I did a couple days
ago, but there is something satisfying about seeing a full IVP films to
show that all is well.
So far, she has been afebrile and tolerating po for the last 24 hrs.
We may never really know what caused any of this. Makes me wonder how
her pelvic pain will be now!
Glen
-----Original Message-----
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Garry
E. Siegel, M.D.
Sent: Wednesday, September 28, 2005 10:22 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: Opinions on laparoscopy (long)
I've done that, too. You may THINK you were no where near the
bladder/bowel etc., but one never knows. . . .
FWIW, when a patient has "trouble" like this after a laparoscopy, doing
a CT with oral and IV contrast to assess the integrity of the urinary
system and the intestine is paramount. I can't remember being mad that
I ordered one whenever I've been suspicious.
Garry
At Wed, 28 Sep 2005, Larry Glazerman wrote:
>
>Could you have punctured the bladder through and through with your
auxiliary
>trocar? That's what happened to me in my case.
>
>--
>Larry R. Glazerman, MD
>Ob-Gyn at Trexlertown, PC
>610-402-0161
>l.glazerman@rcn.com
>
> _____
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Elrod
>Darryl G MAJ 48 MDOS/SGOBO
>Sent: Wednesday, September 28, 2005 4:13 AM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: Opinions on laparoscopy (long)
>
>WBC was initially around 11-12 now fairly constant at 7. Bladder
injury
>would have nearly been impossible since there wasn't any obvious
disease in
>the anterior culdesac and I stayed well away from the bladder.
>
>New this morning is her C diff is positive.
>
>I can't wait to dictate this discharge summary.
>
>Glen
>
> _____
>
>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Jay
Kulkin
>Sent: Tuesday, September 27, 2005 6:16 PM
>To: Multiple recipients of list OB-GYN-L
>Subject: Re: Opinions on laparoscopy (long)
>
>We used to leave 1L of fluid or more in the pelvis for "floatation
effect"
>to avoid adhesion formation so i don't think leaving her a bit wet was
an
>issue. Clearly, some type of physiologic/ anatomic issue here. If she
>started to diurese, her fluid was somewhere to be mobilized back to the
>intravascular space so I'm doubting the ascites is urine---unless we
have a
>bladder injury with resultant illeus which may be associated with
ascites.
>Would like to know why this healthy, young women would third space at
all?
>Would have expected her to be febrile with abowel injury -yousaid her
h/h
>was stable. What about her white count?
>
>Jay
>
>Jay M. Kulkin, MD MBA FACOG
>Women's Institute For Health PC
>975 Johnson Ferry Road
>Suite 460
>Atlanta, Georgia 30342
>Ph: 404.832.0300
>Fax: 404-832-0070
>http://www.wifh.com
>
>>>----- Original Message -----
>From: Lynn D. <mailto:apgar10@montanadsl.net> Montgomery, M.D.
>To: Multiple <mailto:ob-gyn-l@dns.obgyn.net> recipients of list
OB-GYN-L
>Sent: Tuesday, September 27, 2005 12:53 PM
>Subject: Re: Opinions on laparoscopy (long)
>
>Should be able to perform electrolytes on the aspirated fluid to
determine
>if indeed it is urine.
>Sounds like a urinoma. I believe your ascites is urine. Was the CT
with
>kidney contrast? And was the radiologist thinking urine in abd. I
have
>seen this picture that radiologists (good ones) missed. All you see
is a
>cloudy abd pix. If no contrast given, you may want to redo the study.
>
> _____
>
>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
>
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--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
