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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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