Adhesion formation from release of dermoid contents in the peritoneal cavity and effect of copious lavage: a prospective, randomized, blinded, controlled study in a rabbit model

Combined Pharmacological and surgical treatments for recurrent chemical peritonitis due to rupture of a bilateral mature cystic teratoma: a case report

BACKGROUND

Mature cystic teratomas, a common type of benign ovarian tumors, are associated with complications such as twisting and tumor rupture; Rupture can cause severe chemical peritonitis, and no management policy has been established for the intraoperative and postoperative periods. Although peritoneal lavage and reoperation have been reported, the optimal treatment approach remains undetermined.

CASE PRESENTATION

A 30-year-old woman (gravida 0, para 0, and no sexual history) presented with abdominal pain and fever. Blood examination revealed high levels of WBC 9200/µL and CRP 23.7 mg/dL, although hemoglobin was normal. Serum tumor marker levels were also elevated (CA125 58.5 U/mL, CA19-9 36117 U/mL). Abdominal computed tomography revealed bilateral ovarian tumors (92 and 68 mm in the right and left ovaries, respectively). Each tumor cavity had calcification with increased fatty tissue density. We performed laparoscopic surgery for suspected diagnosis of torsion or rupture of a mature cystic teratoma. Intraoperative findings showed spontaneous rupture followed by chemical peritonitis. Therefore, we performed removal of the bilateral adnexal tumors and peritoneal lavage with 3000 mL warm saline to remove fatty components from the abdominal cavity. We also inserted an intra-abdominal drain to remove the residual fatty components. Amoxicillin was also administered for 10 days after surgery. The inflammatory response decreased, and the fever diminished 1 day postoperatively. The patient was discharged on the 10th postoperative day. However, on the 20th postoperative day, the fever and abdominal pain recurred. WBC 16,700/µL, CRP 26.46 mg/dL and tumor marker (CA125 172.3 U/mL, CA19-9 225.2 U/mL) levels were high. Intravenous administration of Prophylactic antibiotics was initiated. As no bacteria were detected in the blood cultures, we started oral prednisolone (5 mg/day) to treat the recurrent chemical peritonitis-induced inflammation. The blood test results and symptoms gradually improved. The patient was discharged on the 37th postoperative day.

CONCLUSION

To date, no systematic review has focused on determining the treatment strategy for bilateral rupture of mature cystic teratomas and severe refractory chemical peritonitis. Treating the patient with laparoscopic surgery at the first occurrence and oral steroids for peritonitis recurrence can help avoid highly invasive treatments, such as reoperation or laparotomy.

Protracted Chemical Peritonitis Following Laparoscopy for Dermoid Cyst: A management dilemma

Dermoid cysts are common benign ovarian tumours arising from totipotent germ cells. We report a rare case of chemical peritonitis and prolonged fever following laparoscopic salpingo-oophorectomy for torsion of a large ovarian dermoid and discuss the management of this patient with prolonged hospital stay, antibiotics and anti-inflammatory use, repeated drainage of the collection as well as re-laparotomy. The occurrence of this rare condition can be extremely distressing for the patient and treating surgeon alike, as the recommendations for management are limited. The management of chemical peritonitis may require one or more surgical procedures along with prolonged anti-inflammatory therapy.

Acute post-traumatic dermoid peritonitis: A rare entity

Rupture of ovarian dermoid-cyst is rare case. We report the case of a woman admitted for acute post-traumatic abdominal pain due to ruptured ovarian cyst. The patient was operated and we found a very abundant peritoneal effusion with left ovarian cyst which was broken. we performed a left adnexectomy.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

Granulomatous peritonitis caused by iatrogenic spillage of ovarian dermoid cystectomy: a case report and literature review

A 39-year-old nulliparous woman experienced continuous mild fever and abdominal pain since undergoing laparoscopic ovarian dermoid cystectomy 3 months previously in a local hospital. Abdominal computed tomography revealed diffuse heterogeneous fat infiltrations with numerous micronodules in the greater and lesser omentum, combined with ascites with thickening of the parietal peritoneum. The patient underwent exploratory laparoscopy, which included partial pelvic peritonectomy, excision of granulomas, and adhesiolysis with massive irrigation. The patient was treated successfully with laparoscopic surgery and all reproductive structures were spared without operative complications. To avoid peritonitis, complete removal of cyst contents and massive irrigation should be performed during ovarian dermoid cystectomy. Conservative surgical treatment may be a good choice for treating granulomatous peritonitis induced by iatrogenic rupture.

A Novel Method for Evaluating Postoperative Adhesions in Rats

Purpose/Aim: Postoperative adhesions remain an undesirable and commonly symptomatic side effect of abdominopelvic surgeries. Animal models of postoperative adhesions typically yield heterogeneous adhesions throughout the abdominal cavity and are not easily quantified. Here we present a novel method of postoperative adhesion assessment and report its reliability and measurement error.

MATERIALS AND METHODS

A model of cecal abrasion with partial sidewall attachment was performed on female rats. After 1, 2, 4, or 7 days of recovery, the rats were euthanized and their abdominopelvic cavities were systematically evaluated for postoperative adhesions. The necropsy was recorded through the surgical microscope. Four raters were trained to use a ballot to capture key factors of the adhesions as they viewed the recordings. Their ratings were compared for measurement error and reliability (using Bland-Altman plots and intraclass correlation coefficients, respectively) and for the ability to discriminate differences in experimental groups. A subset of the data was analyzed to determine practical utility.

RESULTS

The rating system was shown to have low measurement error and high inter-rater reliability for all parameters measured. Applied practically, the system was able to discriminate groups in a manner that was expected.

CONCLUSIONS

We have developed and validated a rating system for postoperative adhesions and shown that it can detect group differences. This method can be used to quantify postoperative adhesions in rodent models.

Pelvic pedicled omental flaps and autologous free omental grafts in a rabbit model

BACKGROUND

There is a need to identify an inexpensive, effective method to prevent postoperative adhesion formation. The objective of this study was to create a novel model for studying omentum as a pelvic adhesion barrier. Randomized, prospective, controlled surgical intervention with serial follow-up in 16 female rabbits at a University-based Center for Comparative Medicine. Interventions included bilateral hysterotomy incision and repair. The left hysterotomy was randomized into coverage with an omental flap or graft; the right hysterotomy remained uncovered. Adhesions were scored via laparoscopy on postoperative days 2, 4, 8, and 12; postmortem evaluation and scoring took place on postoperative day 16. Statistical tests consisted of Kappa tests of agreement between adhesion scorers and Kruskal-Wallis nonparametric tests for the comparison of adhesion scores by intervention arm and by uterine horn.

RESULTS

All omental flaps and grafts survived. The only significant difference in mean adhesion scores was seen in non-hysterotomy-associated adhesions, where grafts had a lower score than flaps (p = 0.03).

CONCLUSIONS

Survival of all omental flaps and grafts demonstrates that this is a practical model for studying omentum as a pelvic adhesion barrier. Determining the efficacy of omentum as a pelvic adhesion barrier will require further investigation.

Ovarian preservation in children for adenexal pathology, current trends in laparoscopic management and our experience

Aims:

Primary cysts and tumors of the ovary alongwith torsion are often regarded as an indication for open oophorectomy because of the fear of leaving an ischemic organ inside and chances of recurrence. We wish to report our experience of both modalities of management where we initially removed adenexal torsion by either laparoscopic salpingo-oophorectomy or oophorectomy, but later followed a more conservative approach of adenexal lesion removal with ovarian preservation.

Materials and Methods:

Retrospective review of clinical records of patients with ovarian pathology who were managed laparoscopically.

Results:

46 cases of pediatric ovarian pathology were managed between March 2006 and March 2013 in two centers by a team of surgeons. The age ranged from 1 days to 18 years (average 14.3 years) and the pathology varied from 30 cases of a simple ovarian cyst with torsion, 3 cases of ovarian torsion without any cyst, 7 cases of a dermoid cyst with torsion in all, 1 case of secreting ovarian tumor and 5 cases of a paraovarian cyst with torsion. All patients had a normal tumor marker except 1 girl with a functional ovarian tumor who had elevated LDH and estrogen levels alongwith suppressed LH and FSH. In the initial period of our study we did 1 salpingo-oophorectomy for a suspected complex lesion and two oophorectomies for torsion with a simple cyst. In the later part of our study we performed laparoscopic cystectomy and ovarian preservation in 40 cases, including 7 cases of dermoid, where we performed laparoscopic detorsion with dermoid cystectomy and ovarian preservation in the same sitting. In three cases of chronic torsion who presented to us late, we could not preserve the ovary and had to resort to salpingo-ophorectomy. Histology showed a simple corpus luteal and follicular ovarian cyst in 31 cases, a paraovarian cyst in 5 cases with mature teratoma in 7 cases. Twenty-five patients with ovarian preservation following detorsion were subjected to follow-up ultrasound, who were found to have normal shape, size and blood flow compared to the contra lateral side.

Conclusion:

We outline our experience from the management of 46 cases of various ovarian pathologies with and without ischemia and found that ovarian torsion with a benign pathology and ischemia is not a contraindication for ovarian preservation, as pointed out in the current literature.

"Tie over ring" sutureless compression based gastrointestinal anastomotic method: experimental rat model

INTRODUCTION

Giving the ever-rising trend of pediatric minimally invasive surgery besides early neonatal surgical interventions, intestinal anastomosis turns out to be a time consuming stage due to several anatomical as well as technical difficulties. A perfect bowel anastomosis method should be easy, rapid, safe and reliable in creation of bowel continuity with minimal tissue damage. In this light, sutureless anastomotic methods have been introduced, using compression based anastomosis with biofragmentable rings or powerful magnets. Accordingly, this experimental animal model study has evaluated the result of an easy, rapid intestinal sutureless anastomotic technique via simple tying over an intraluminal ring, in comparison with conventional handsewn bowel anastomosis.

METHODOLOGY

Thirty Wistar-Albino male rats were enrolled and small bowel was transected via a midline laparotomy. A grooved plastic ring was inserted into the ileal lumen and both intestinal cutting ends were fixed over the ring with a simple tie in the first group. On the other hand, enteroenterostomy was performed by the conventional method of handsewn anastomosis in the second group. After 14 days, rats were sacrificed to evaluate for intraperitoneal adhesion and abscess formation in addition to other evidences of anastomotic leakage. Furthermore, the anastomotic site integrity, tensile strength and healing stage were assessed microscopically.

RESULTS

The mean operative time and intraoperative bleeding in the tie over ring group were significantly less than those in the handsewn anastomosis group. Anastomotic stricture was more common in the conventional anastomosis group while the anastomotic tensile strength was significantly higher in the tie over ring group. Histopathological healing parameters and final healing score were almost similar in both groups but mean inflammatory cell infiltration in handsewn anastomosis was significantly higher.

CONCLUSION

"Tie over ring" is a simple method of anastomosis that is feasible, fast, safe and functionally effective for bowel reconstruction in animal models that could be reconsidered in human bowel anastomosis.

Laparoscopic resection of benign ovarian tumours in children with gonadal preservation

PURPOSE

Ovarian tumours are often regarded as an indication for open oophorectomy, especially following torsion. We wish to report our results of laparoscopic ovarian cystectomy with ovarian preservation.

METHODS

Retrospective review of clinical records of patients who where managed with laparoscopic ovarian cystectomy with ovarian preservation.

RESULTS

Twelve records were identified over a 3-year period. The average age was 11.8 years (9-15). Presentation was of a mass in nine patients and torsion in three patients. Average size of the mass was 8.2 cm (5-18). Two patients had bilateral lesions. All patients were noted to have normal tumour markers. Successful cystectomy with ovarian preservation was accomplished in all cases using 3-port laparoscopy. The bilateral lesions were addressed at the same surgery with no increased length of stay or morbidity. In the three patients with acute torsion, an initial laparoscopic detorsion was performed with delayed laparoscopic cystectomy and ovarian preservation 7-10 days later. There was one complication of a minor umbilical port site infection. Histology was of a mature teratoma in ten cases and simple cyst in two. Six patients underwent routine ultrasonographic follow-up at 2-5 months at which time the involved ovary assumed a size and shape and blood flow comparable to the contra-lateral ovary in five patients. In one patient the affected side was smaller, 8.6 ml compared to 10 ml on the contra-lateral ovary. The remaining patients have been followed up clinically and remain asymptomatic.

CONCLUSION

Laparoscopic cystectomy with ovarian preservation can be successfully applied to benign ovarian tumours. Acute ovarian torsion is not a contraindication to this technique where a two stage procedure still enables us to offer ovarian preservation.

Comparison between powdered gloves, powder-free gloves and hyaluronate/carboxymethylcellulose membrane on adhesion formation in a rat caecal serosal abrasion model

OBJECTIVE

Intraabdominal adhesion formation and prevention is one of the major conflicts of modern surgery. We aimed to determine the effects of powdered gloves versus powder-free gloves and hyaluronate/carboxymethylcellulose membrane (H/CMCm) in a rat caecal serosal abrasion model.

METHODS

Sixty wistar albino rats were subjected to a standardized lesion by caecal abrasion model. In group 1, the procedure was performed with sterile powdered gloves. In group 2, the procedure was performed with powder-free sterile gloves. The H/CMCm was applied directly to the abraded caecum in group 3. Formation of adhesions were determined on one half of the animals from each group on the 7th postoperative day, and on the other half on the 15th postoperative day.

RESULTS

There was a statistically significant difference between the adhesion scores on day 7 and 15 in groups 1 and 2 (p = 0.005, p = 0.007). There was no significant difference in adhesion scores on day 7 and 15 in group 3 (p = 0.145). The mean adhesion score was significantly higher in group 1 (powdered glove group) than group 2 (powder-free glove group) and group 3 (powder-free glove plus H/CMCm) on postoperative day 7 (p = 0.001). However, no significant difference was found between groups regarding adhesion scores on postoperative day 15 (p = 0.607). The comparisons of group 2 versus group 3, both on postoperative day 7 (p = 0.051) was not statistically significant, whereas a significant difference was detected between group 1 versus group 2 and group 3 on postoperative day 7 (p = 0.013, p = 0.001).

CONCLUSION

Our experiment shows that the use of powder-free gloves may be as beneficial as Seprafilm in preventing postoperative adhesion formation.

[Ovarian dermoid cyst complicated by chemical peritonitis. Case report]

Dermoid cyst is the most frequent benign ovarian tumor. Its spontaneous or more frequently iatrogenic intraperitoneal rupture may lead to a chemical peritonitis. This is a rare complication but with a potentially dangerous issue. We report a case of a patient who developed chemical peritonitis after laparoscopic management of ovarian dermoid cysts. Three further interventions, associated with systemic anti-inflammatory treatment, were necessary to resolve symptoms completely. On the basis of this case, we aim to re-access the characteristics of dermoid cysts and highlight in particular the potential complication of chemical peritonitis and the following attitude to avoid this.

Effect of endometrioma cyst fluid exposure on peritoneal adhesion formation in a rabbit model

OBJECTIVE

To determine whether copious lavage and suction of human endometrioma fluid placed in the peritoneal cavity of rabbits reduces adhesion formation compared to no lavage.

DESIGN

Prospective, randomized, blinded study.

SETTING

Academic research environment.

ANIMAL(S)

Twenty-four female New Zealand white rabbits.

INTERVENTION(S)

Rabbits randomized into three groups: [1] laparoscopy with instillation of human endometrioma material, no lavage; [2] laparoscopy with instillation of human endometrioma material, followed by clearance of all visible endometrioma fluid by saline lavage and suction; [3] laparoscopy alone.

MAIN OUTCOME MEASURE(S)

Six weeks after laparoscopy, adhesions scored by laparotomy using standard visual assessment scoring system and histologic microscopic evaluation. Data evaluated using Kruskal-Wallis and median nonparametric tests.

RESULT(S)

For groups 1, 2, and 3, respectively, mean total clinical adhesion scores were 0.67 (95% confidence interval [CI] -0.87, 2.2), 3.67 (95% CI 1.27, 6.07), and 0 (95% CI 0, 0). Group 2 had statistically significantly higher mean adhesion scores compared to group 1. Histologic adhesion scores followed the trend of clinical adhesion scores.

CONCLUSION(S)

In this rabbit model, human endometrioma fluid exposure in the peritoneal cavity is not associated with adhesion formation. Instillation of endometrioma fluid followed by copious saline lavage is strongly associated with adhesion formation.

Role of peritoneal lavage in adhesion formation and survival rate in rats: an experimental study

Following laparotomy, almost 95% of patients develop adhesions. To prevent adhesion formation, peritoneal lavage has been investigated and many different lavage solutions have been proposed. In this study, different peritoneal lavage solutions were evaluated, testing their ability to prevent adhesion formation. Three consecutive steps were followed: (1) The lethal dose of Eschericia coli injected in the rat peritoneal cavity was determined, (2) the morbidity and mortality rates of different solutions for peritoneal lavage (i.e., saline, twice-distilled water, antiseptics, and antibiotics solutions) was investigated, and (3) the capability of the different lavage solutions to prevent adhesion formation was tested. Two hundred and ninety-eight rats were employed in this study. After intraperitoneal injection of E. coli, infection (clinical signs and animal vitality), adhesion formation (explorative laparoscopy, peritoneumgraphy and Zühlke scale grading), and animal performance status were investigated. All differences were evaluated by chi-square and analysis of variance (ANOVA) tests. Saline solution showed a low morbidity rate with no deaths. Twice-distilled water was associated with 100% mortality rate, as opposed to 45-75% for antiseptics, and 0-3% mortality for antibiotics. Antibiotics determined higher adhesion formation by Zühlke score as compared to saline solution (p < .001), while no difference was observed between antiseptics and saline (p = NS). Peritoneal lavage with 37 degrees C saline solution was associated with low adhesion formation and high survival rate as compared to twice-distilled water and antiseptics. Antibiotics solutions had high survival rate and high adhesion formation. Twice-distilled water and antisepsis should be avoided when based on the data obtained in this work.

Short-Term Morbidity and Long-TermRecurrence Rate of Ovarian Dermoid CystsTreated by Laparoscopy Versus Laparotomy

OBJECTIVE

To compare the short-term morbidity and the long-term recurrence rate of ovarian dermoid cysts in women treated conservatively by laparoscopy with the outcomes in women treated by laparotomy.

METHODS

This retrospective multicentre cohort study compared the outcomes of removal of dermoid cysts by laparoscopy with removal by laparotomy. All specimens were confirmed histologically as dermoid cysts. We reviewed all medical records and identified all surgical interventions for dermoid cysts over a 10-year period (1993-2003) in two academic centres in Quebec City. Of the 299 women treated for ovarian dermoid cysts, 167 were treated by laparotomy and 132 were treated by laparoscopy. To compare short-term morbidity, we excluded those who had undergone ophorectomy or any concomitant surgery, and we consequently reviewed the records of 98 patients in the laparotomy group and 100 patients in the laparoscopy group. To compare long-term recurrence rates we excluded only those patients who had had oophorectomy. In total, 245 women with available follow-up were identified as having ovarian cystectomy (95 in the laparoscopy group and 150 in the laparotomy group). Two-tailed Fisher exact test was used for analysis of categorical variables, and Student t test or Wilcoxon rank test were used for analysis of continuous variables comparing the two groups. Life table analysis using the Kaplan-Meier method was performed to assess the risk of long-term recurrence.

RESULTS

The mean diameter of the cyst in women who had a laparotomy was significantly larger than in women who had laparoscopy (8.27 cm vs. 5.94 cm), and significantly more women in the laparotomy group had bilateral cysts (16% vs. 5% in the laparoscopy group). In women who had laparoscopy, operating time was greater (P = 0.0363), but blood loss was less (P < 0.0001) and duration of hospital stay (P < 0.0001) was shorter. Spillage of the cyst's contents occurred in 18% of cases in the laparoscopy group and in 1% in the laparotomy group. Conversions of laparoscopy to laparotomy occurred in 11% of cases, mainly because of cyst size. Postoperative complication rates were similar in the two groups. Reintervention rate was 4.2% in the laparoscopy group and 0% in the laparotomy group (P = 0.0217). Using life table analysis, the probability of recurrence at two years was 7.6% (95% confidence intervals 2.9, 19.2) in the laparoscopy group and 0% in the laparotomy group.

CONCLUSION

Ovarian cystectomy performed by laparoscopy is associated with a higher incidence of intra-abdominal spillage than laparotomy, but this not associated with any increase in morbidity. Laparoscopic treatment results in a shorter hospital stay and less intraoperative blood loss than laparotomy, but it is associated with a significantly higher risk of recurrence.

Laparoscopic Treatment of Ovarian Dermoid Cysts: Eleven Years' Experience

STUDY OBJECTIVE

To compare laparoscopic and open approaches in the management of benign ovarian teratomas (dermoid cysts) with regard to operative outcome, complications, and postoperative follow-up. Factors that predispose to rupture of dermoid cysts during laparoscopic removal and rates of adhesion formation in women with and without cyst rupture during laparoscopic surgery also were considered.

DESIGN

Review of cases of women with dermoid cysts who underwent cystectomy either by laparoscopy or laparotomy in our department from 1992 through 2002 (Canadian Task Force classification III).

SETTING

The Infertility and Operative Laparoscopy units of the First Department of Obstetrics and Gynecology of the University of Athens, Alexandra Maternity Hospital, Athens, Greece.

PATIENTS

Two hundred twenty-two women with an ovarian mass requiring surgical management. Of these, 187 women with benign cystic teratomas underwent laparoscopic cystectomy, and 35 underwent cystectomy by laparotomy.

INTERVENTIONS

Cystectomy either by laparoscopy or laparotomy.

MEASUREMENTS AND MAIN RESULTS

Potential benefits of operative laparoscopy include reduced blood loss, less postoperative pain, shorter hospital stay, fast recovery, and an excellent cosmetic result.

CONCLUSION

Laparoscopy should be considered the method of choice for the removal of benign ovarian cystic teratomas as it offers the advantages of fewer postoperative adhesions, reduced pain, shorter hospital stay, and better cosmetic result. It should be performed by surgeons with considerable experience in advanced laparoscopic surgery.

Effects of laparoscopic lavage on adhesion formation and peritoneum in an animal model of pelvic inflammatory disease

STUDY OBJECTIVES

To develop an animal model of pelvic inflammatory disease (PID) that simulates intraluminal tubal damage and adhesion formation seen in human PID, and to evaluate peritoneal effects of laparoscopic lavage with 1% povidone-iodine, 0.5% povidone-iodine, and 0.05% chlorhexidine gluconate solutions.

DESIGN

Prospective, randomized, controlled study (Canadian Task Force classification I).

SETTING

Animal research operating room facility.

SUBJECTS

Forty-five 1-year-old Pasteurella-free New Zealand white rabbits.

INTERVENTION

Laparoscopy with instillation of one of five lavage solutions after bacterial inoculation with Neisseria gonorrhoeae, Bacteroides fragilis, Escherichia coli, and Peptococcus niger.

MEASUREMENTS AND MAIN RESULTS

Histologic evaluation revealed significantly more peritoneal inflammation after lavage with all three solutions than after no lavage or lavage with normal saline. Gross adhesion formation was visible in only one rabbit after lavage with normal saline. One animal having lavage with 1% povidone-iodine died immediately after injection for sedation before laparoscopic lavage, and was not included in the final results.

CONCLUSION

Bacterial inoculation using an intrauterine insemination catheter did not produce clinical adhesions in 43 of 44 rabbits. Histologic evaluation revealed significantly more peritoneal inflammation in the lavage with povidone-iodine and chlorhexidine gluconate compared with no lavage or lavage with normal saline.

Laparoscopic surgery of dermoid cysts--intraoperative spillage and complications

OBJECTIVE

To assess the risks of complications including intraoperative spillage following laparoscopic dermoid cyst enucleation.

STUDY DESIGN

A retrospective case series comparison of 390 patients who had surgery at our hospital from 1992 to 1998 for teratomas of the ovary.

RESULTS

43 patients were treated with laparotomy. Two malignant teratomas were observed in this group. In seven patients, the dermoid cysts were removed as part of a vaginal hysterectomy. Three hundred and forty patients had surgery via laparoscopy. Enucleation of the dermoid cyst in toto using a salvage bag for removal was only possible in few cases without contamination of the abdominal cavity by spillage of cyst contents. There were no serious complications in any patients including those with laparoscopic cystectomies and intraperitoneal spill.

CONCLUSION

The laparoscopic treatment of benign teratomas is a safe procedure. Primary laparotomy as well as adenectomy is also to be taken into consideration with young patients, if suspicion of malignancy, rapid growth, doubtful infiltration or large size of tumor is present.

Managing mature cystic teratomas of the ovary

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.

Adhesion formation in intubated rabbits increases with high insufflation pressure during endoscopic surgery

The aim of the study was to test the hypothesis that the increase in adhesion formation by CO(2) pneumoperitoneum is caused by mesothelial hypoxaemia. Therefore the effect of the intra-abdominal pressure together with the flow rate upon adhesion formation was evaluated in rabbits following laser and bipolar lesions during endoscopic surgery using humidified CO(2) at 35 +/- 1 degrees C. The intra-abdominal pressure and flow rate were 5 mmHg and 1 l/min in group 1 (n = 5), 5 mmHg and 10 l/min in group 2 (n = 4), 20 mmHg and 1 l/min in group 3 (n = 5) and 20 mmHg and 10 l/min in group 4 (n = 4) respectively. A rapid and reliable intubation method for rabbits was developed to permit high insufflation pressure. By two-way analysis of variance, total adhesion scores following a laser lesion increased with flow rate (P = 0.0003) and insufflation pressure (P = 0.002). Total adhesion scores of bipolar lesions increased with pressure (P = 0.02) but not with flow rate (P = 0.1). The total adhesion scores of laser and bipolar lesions together increased with flow rate (P = 0.005) and with insufflation pressure (P = 0.004). There was no statistical interaction between flow rate and insufflation pressure. In conclusion, the insufflation pressure in endoscopic surgery with CO(2) pneumoperitoneum is a co-factor in adhesion formation, together with desiccation.

Pelvic adhesion formation after intraperitoneal installation of gallstones in a rabbit model

OBJECTIVE

To investigate whether intraperitoneal gallstones increase the risk of pelvic adhesions in a rabbit model.

DESIGN

Prospective, randomized, blinded, sham and human antigen controlled trial.

SETTING

An academic research environment.

SUBJECT(S)

Twelve New Zealand white rabbits.

INTERVENTION(S)

Twelve rabbits were divided into three groups of four each; a sham operation group, a gallstone and bile group (study group), and a human serum albumin and bile group (antigenic control). Three weeks after the operation individual subjects were randomized, with groups concealed to observers, and a necropsy was performed on each rabbit.

MAIN OUTCOME MEASUREMENT(S)

Necropsy was performed on each rabbit, and the adhesions were scored for extent, type, tenacity, inflammation, and gallstone involvement.

RESULT(S)

There was a statistically and biologically significant increase in gallstone involvement in adhesions, especially pelvic adhesions, in the study group.

CONCLUSION(S)

This study, along with an increasing number of case reports, suggests that gallstones inadvertently left in the peritoneal cavity may increase the morbidity of laparoscopic cholecystectomy. In females of reproductive age these gallstones may induce pelvic adhesions that may interfere with fertility or be associated with pelvic pain.

Factors that increase the risk of leakage during surgical removal of benign cystic teratomas

The contents of mature cystic teratomas can be a potent irritant resulting in chemical peritonitis. Using a retrospective cohort, we examined the various risk factors for leakage of benign cystic teratomas during laparoscopy and laparotomy. Cyst leakage of the benign cystic teratoma contents was the primary endpoint. In all, 158 women underwent surgery for a total of 178 ovarian benign cystic teratomas. Statistical analysis was performed using chi(2), Mann-Whitney U and multivariate logistic regression analysis. A total of 115 benign cystic teratomas was successfully removed without intra-operative leakage and 63 underwent intra-operative leakage either at laparoscopy or laparotomy. The likelihood of success of removing the benign cystic teratoma intact was unrelated to age, pre-operative size or surgical technique. There was no difference among cystectomies performed by laparotomy in surgeon experience or the presence of adhesions. However, surgeons with more laparoscopic experience (>35 laparoscopies/year) were less likely to have intra-operative leakage (relative risk: 0.5, 95% confidence interval: 0.2, 1.2) compared to surgeons with less experience (<20/year) at cystectomy (26.1 versus 51.2% respectively). Oophorectomy significantly reduced the frequency of intra-operative leakage at both laparoscopy and laparotomy (14.7%). These findings suggest that laparoscopic experience can reduce the risk of leakage at cystectomy. At laparotomy, lack of surgeon postgraduate years of experience was not a risk factor for leakage.

New directions in the prevention of adhesion in laparoscopic surgery

The aim of this review is to appraise critically the literature over the past year with respect to new developments in adhesion prevention strategies. The majority of the work continues to be focused on animal models, and interest continues into the usage of heterologous barriers, which are increasingly derived from or related to hyaluronic acid. The recent trend has been to develop barriers that are not only effective but also technically easy to use for the laparoscopic surgeon--hence the development of barrier gels. It is only through the development of these user-friendly barriers that many laparoscopic surgeons will be willing to incorporate these important preventative measures into their busy daily practice. Routine usage of adhesion prevention measures will ultimately reduce patient morbidity and mortality and relieve the burden on health service provision.

Ovarian dermoid cyst leakage--a cautionary tale

This case illustrates that when a dermoid cyst is punctured, an immediate operative laparoscopy or laparotomy should be performed, along with lavage, to avoid the problems associated with dermoid cyst contents spillage.

Effects of pirfenidone and dermoid cyst fluid on adhesion formation

OBJECTIVE

To evaluate the effects of pirfenidone and human dermoid cyst fluid on adhesion formation in a rat model.

DESIGN

A prospective, blinded, controlled study.

SETTING

Sprague-Dawley white rats in a conventional laboratory setting.

INTERVENTION(S)

Rats were divided into four groups according to the type of solution tested (dermoid fluid, 0.05 mg of pirfenidone, normal saline, and a combination of dermoid fluid and pirfenidone). In the first experiment, the solution (0.5 mL) was injected intraperitoneally. In the second experiment, the solution was instilled intraperitoneally after a standardized injury to the right uterine horn. The degree of adhesion formation was evaluated 2 weeks after the initial surgery.

RESULT(S)

Human dermoid cyst fluid caused adhesion in 4 of 10 intact rats and in 9 of 10 standardized injured rats. Pirfenidone did not decrease adhesion formation. No adhesion was found after injection of saline or pirfenidone in intact rats. The mean +/- SEM adhesion score in standardized injured rats was higher in the dermoid group (4.6 +/- 0.6) than in the pirfenidone group (2.8 +/- 0.7) or the saline group (3.8 +/- 0.5). The mean +/- SEM adhesion score in intact rats was 0.6 +/- 0.3 after dermoid fluid injection and after dermoid instillation in standardized injured rats was 4.6 +/- 0.6.

CONCLUSION(S)

Human dermoid fluid causes adhesion formation even in intact rats, and the adhesion is worse in the presence of serosal injury. Intraperitoneal pirfenidone does not decrease adhesion formation.