Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China (all authors).

ABSTRACT

Introduction: The occurrence of pregnancy with Cushing syndrome (CS) is rare but with high risks, posing a great challenge to the clinical diagnosis and treatment of the disease.

Case Description: From Aug 2016 to Aug 2019, we admitted two pregnant women with CS caused by adrenal tumors. After multidisciplinary consultation, they underwent emergency Cesarean section because of heart failure and severe hypoxemia, and finally delivered a living baby after adjuvant therapy. Both patients underwent retroperitoneal laparoscopic adrenectomy (RLA) 2.6 and 1.5 months postpartum to have the adrenal tumors removed successfully. The post- operative pathology confirmed the adrenal tumor as adrenocortical adenoma. Partial hormone replacement therapy was initiated postoperatively and withdrawn uneventfully 1 year after RLA in both patients, and both patients have recovered well.

Conclusion: It is difficult to find CS in early pregnancy, and when it is detected in late pregnancy, it often poses a great risk because it is necessary to consider the safety of both mother and fetus, which requires multidisciplinary coordination and cooperation to positively adjust the cardiopulmonary function and internal environment after Cesarean section, knowing that timely RLA to remove the adrenocortical adenoma can effectively cure CS.

Key Words: Pregnancy, Cushing syndrome, Adrenal tumor, Heart failure, Hypertension.

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Department of Surgery, University of Miyazaki Faculty of Medicine, Kiyotake, Miyazaki City, Miyazaki, Japan (Drs Kai, Ikeda, Ichihara, Hamada, Nagatomo, and Nanashima).
Department of Obstetrics and Gynecology, University of Miyazaki Faculty of Medicine, Kiyotake, Miyazaki City, Miyazaki, Japan (Drs Matsuzawa, Ushijima, Furukawa, and Sameshima).

ABSTRACT

Introduction: Acute appendicitis is the most common general surgical problem during pregnancy. Laparoscopic appendectomy has been gaining widespread popularity and has been accepted as a minimally invasive surgery based on evidence for its use in appendicitis in pregnant patients. However, the gravid uterus in the third trimester and the frequent suction required for abscess drainage make the working space intractable.

Case Description: We report a case in which an AirSeal intelligent flow system (ASIFS) (CONMED Corporation, Utica, NY, USA) was useful for laparoscopic appendectomy and abscess drainage for perforated appendicitis in a 31-wk pregnant patient. ASIFS allowed successful maintenance of a working space, thus making it possible to excise the appendix at its base with double ligation and effectively drain the abscess with no maternal and fetal complications. To our knowledge, there have been no reports of the use of ASIFS in a pregnant patient. A past study reported that ASIFS could induce hypothermia compared with a conventional CO2 supply tube in patients. Although intraoperative hypo- thermia did not occur in our patient, it would be prudent to carefully avoid frequent suctioning in the short term and to warm the patient intraoperatively because maternal and fetal bodies are susceptible to change in hemodynamics.

Conclusion: Surgeons should consider the use of ASIFS before deciding to convert from laparoscopic appendectomy to an open procedure in pregnant patients.

Key Words: laparoscopic appendectomy, perforated appendectomy, third trimester, AirSeal intelligent flow system.

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Desert Women’s Care, Scottsdale, Arizona USA (Dr. Demir)
(Student), Arizona State University, Tempe, Arizona USA (Ms. Yousif)

ABSTRACT

Introduction: Although the conventional method of total laparoscopic hysterectomy has been multi-port access, advances in equipment have permitted fewer and smaller incisions.

Case Description: We present the first known case of single incision, 8.5-mm total laparoscopic hysterectomy employing 3-mm instruments. Three separate trocars were inserted through a single skin incision in a triangular array and hysterectomy was performed in the usual manner.

Conclusions: With advancements in laparoscopic instrumentation fewer and smaller incisions can be used to accomplish hysterectomy. This case represents the continued convergence back toward total vaginal hysterectomy as the “gold standard” minimally invasive hysterectomy.

Key Words: Total laparoscopic hysterectomy, Single incision, Multiple incision.

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Department of Obstetrics and Gynecology, Bagcilar Research and Education Hospital, University of Health Sciences, Istanbul, Turkey (Dr. Tolga)
Department of Obstetrics and Gynecology, Sisli Research and Education Hospital, University of Health Sciences, Istanbul, Turkey (Dr. Karatas)

ABSTRACT

Introduction: Ovarian endometrioma, the clinical phenotype of endometriosis, is found in 17% to 44% of patients with endometriosis and is related to the severe form of the condition. The observation of endometrioma and dermoid tumor in the same ovary can be evaluated as atypical endometrioma or ovarian cancer in ultrasound findings.

Case Description: The objective of this report is to present two cases in which an endometrioma and a dermoid tumor are present in the same ovary and to review the subject together with the results of 10 previously reported cases in the literature.

Discussion: The ultrasound findings in atypical endometriomas and endometriomas that mimic ovarian tumors are combinations of papillary projections, hyperechoic irregular walls, a distinct solid mass, and calcifications. Magnetic resonance imaging is the second option for patients who are ultrasonographically identified as having an indeter- minate adnexal mass, and it can provide additional information in distinguishing between the two pathologies within the same ovary. Due to suspected malignancy, unnecessary tests and gynecologic oncology consultations are recommended in cases of atypical endometrioma. This may lead to an increase in the frequency of unnecessary midline laparotomy.

Key Words: Endometrioma; Dermoid cyst; Ultrasonography.

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Department of Gynecology, Helios Mariahilf Hospital Hamburg, Germany (Dr Favero).
Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg Altona, Germany and University of Cologne, Medical Faculty, Department of Gynecology (Dr Kohler).
Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg Altona, Germany (Drs Jacob and Molgg).
Department of Gynecology, Helios Mariahilf Hospital Hamburg, Germany (Dr Pfiffer).

ABSTRACT

Introduction: This case report demonstrates a rare complication that can be associated with power morcellation at the time of laparoscopic fibroid removal (myomectomy) in a patient previously treated by uterine artery embolization (UAE) that led to a relevant clinical misdiagnosis. UAE is an approved treatment option for symptomatic uterine fibroids. However, very little is known about possible migration of embolization particles into non-target organs.

Case Description: A 47-year-old woman was previously submitted to bilatera UAE due to large, symptomatic fibroids. Despite initial proven regression, she underwent endoscopic myomectomy one year later with unprotected morcellation. Approximately five years after endoscopic surgery a suspicious pelvic tumor with radiological signs of peritoneal carcinomatosis was found. The patient underwent total laparoscopic hysterectomy along with complete resection of the pelvic parietal peritoneum, where multiple peritoneal abnormalities were found. Intraoperative frozen section revealed inclusions of embolization particles within peritoneal leasions. Final pathology confirmed a uterine STUMP (smooth muscle tumor with uncertain malignant potential), a chronic inflammatory reaction of the peritoneum and the presence of multiple microspheres.

Conclusion: The current report is the first to describe the presence of embolization particles in the peritoneum, mimicking peritoneal carcinomatosis.

Key Words: Uterine artery embolization, Tris-acryl gelatin microspheres, Laparoscopic myomectomy, Power morcellation, Peritoneal carcinomatosis.

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ABSTRACT

Background: Because of inaccuracies in classification of Mullerian duct anomalies (MDAs), subsequent diagnostic and treatment errors have occurred. We present a case of a woman with an MDA that was misclassified.

Case: A woman with a recent spontaneous abortion and chronic dyspareunia was diagnosed with a complete didelphys by magnetic resonance imaging. Her initial treatment plan was based on an incorrect diagnosis. With reevaluation of the magnetic resonance imaging scan, both the appropriate diagnosis was obtained and the appropriate treatment performed.

Conclusion: MDAs have been incorrectly diagnosed because of outdated and incorrect classification systems. Because of outdated and incorrect theories about the embryogenesis of the female genital tract, many women are being incorrectly diagnosed and treated with these abnormalities.

Teaching Points: We will focus of the evidence-based diagnosis and treatment of MDAs with a focus on cooperation between the radiologists who assist in diagnosis and the physicians who care for the patients.

Key Words: Mullerian Duct Anomalies, Diagnosis, Treatment.

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Division of Minimally Invasive Gynecologic Surgery (Drs Kliethermes, Blazek, Rezai, and Dr Guan) and Division of Maternal Fetal Medicine (Dr Fox), Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA. Guangzhou Medical University, Guangzhou Shi, China (Mr Guan, Dr Guan).

ABSTRACT

Introduction: Preterm labor and cervical insufficiency are significant health problems in obstetrics. They can lead to devastating outcomes for families and significant costs. Cervical and abdominal cerclages can improve outcomes in appropriately selected patients.

Case Report: This is a case of a 31-year-old woman (Gravida 8, Para 1-2-4-1) who presented at 11 weeks with a diamniotic–dichorionic twin gestation. A laparoscopic abdominal cerclage was placed and she successfully carried her pregnancy to 35 weeks, when she was delivered for obstetric indications.

Discussion: Despite convincing literature suggesting increased morbidity with cerclage placement in twin gestations, in properly selected patients, a cerclage may in fact be beneficial. Growing evidence has shown effectiveness of laparo- scopically placed cerclages, and should be considered an alternative to laparotomy. Laparoscopic abdominal cerclage can safely be performed for twin gestation. Multispecialty approach can improve outcomes and increase safety. Gentle tissue handling is important in all laparoscopic surgery, but especially during pregnancy.

Key Words: Abdominal cerclage, Laparoscopic cerclage, Twin pregnancy.

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Unit of Gynecologic Oncology (Drs Abbas, El Neemany, Pursell, and El Sahwi) and Department of Pathology (Dr Sun), Meridian Health, Neptune, New Jersey, USA.

ABSTRACT

Introduction: The incidence of STIC is increasing because of standardization of fallopian tube fimbria examination. We report a case of incidental STIC in a patient being treated for cervical dysplasia. A case report is presented with a review of the literature.

Case Description: This is a 46-year-old BRCA patient who had repeated cervical intraepithelial neoplasia (CIN) type III and underwent robot-assisted total laparoscopic hysterectomy and bilateral salpingectomy, after a subsequent incidental finding of STIC. Laparoscopic surgical staging was completed and 18-month surveillance had been achieved at this writing.

Discussion: Incidental STIC in patients without genetic susceptibility to hereditary breast and ovarian cancer (HBOC) syndrome has been reported. Patients found to have an incidental STIC lesion should be considered for completion of surgical staging and surveillance and should be referred for BRCA1 or -2 mutation testing. A good outcome is likely.

Key Words: Risk reducing salpingectomy, Serous tubal intraepithelial carcinoma.

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Department of Biliary Surgery, Shengjing Hospital of China Medical University, Shenyang City, People’s Republic of China (both authors).

ABSTRACT

Introduction: Symptomatic Meckel’s diverticulum during pregnancy and inverted Meckel’s (“ windsock ”) divertic- ulum are rare occurrences. Preoperative diagnosis is difficult, and inverted diverticulum can be misdiagnosed as lipoma.

Case Description: We report a case of Meckel’s diverticulum during pregnancy, causing a hernia of the small intestine, and a case of inverted Meckel’s diverticulum causing an ileocolic intussusception.

Discussion: When dealing with small-bowel obstruction of unknown origin, Meckel’s diverticulum is a cause that is easy to miss. Early laparoscopic exploration helps as an auxiliary diagnostic tool and can avoid small-bowl necrosis or intestinal perforation caused by long-standing small bowel obstruction.

Key Words: Bowel malformation, Laparoscopic surgery, Meckel’s diverticulum, Pregnancy.

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Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea (Dr. Yi).

ABSTRACT

Introduction: Cornual pregnancy on the same side as a previous salpingectomy is a very rare pathologic condition in cases of spontaneous pregnancy.

Case Description: A 31-year-old woman (gravida 2, para 0) was admitted with abdominal pain and vaginal hemorrhage. She had a history of laparoscopic left salpingectomy for tubal pregnancy 6 years ago at another hospital. Two-port laparoscopy with a multichannel port was performed and revealed a left cornual pregnancy with hemoperitoneum. Five months later, she visited our emergency department because of abdominal pain. We performed 2-port laparoscopy, using a multichannel port for a left cornual pregnancy with hemoperitoneum.

Discussion: Two-port laparoscopy with a multichannel port for recurrent cornual pregnancy was relative safe and easy, with the advantages of reduced surgical morbidity, less bleeding, and shorter operative time.

Key Words: Cornual pregnancy, Laparoscopy, Recurrence, Salpingectomy, Salpinx.

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