Re: Opinions on laparoscopy (long)
From: Andrew Folley (agfolley@hotmail.com)
Tue Sep 27 12:41:27 2005
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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