Infected urocolpos and generalized peritonitis secondary to labia minora adhesions

Introduction

Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty.

Case report

A 9-year-old girl presented with a 2-day history of abdominal pain and fever. Urinary continence had never been obtained, with diurnal leaks. Physical examination showed signs of peritoneal irritation and a subtotal vulvar obstruction due to LMA. At surgery, after LMA lysis, a large amount of cloudy urine-like fluid emptied under pressure from the vagina. Laparoscopy showed generalized peritonitis without any intraabdominal cause. The same Escherichia coli was identified in the infected urocolpos and the abdominal fluid. Postoperative course was uneventful.Because of recurrent LMA, the patient underwent several courses of local estrogen therapy. Labia minora hypertrophy with LMA developed 2 years after peritonitis, requiring surgical reduction labioplasty. We used a new technique with interposition of skin flaps. The girl is now well, without LMA or infection, 4 years after labioplasty.

Conclusion

Although rare, subtotal vulvar obstruction because of LMA may lead to infected hydrocolpos and peritonitis. Recurrent LMA may necessitate surgical labioplasty.     

Two experimental models for generating abdominal adhesions

PURPOSE: To develop dependable rat models for generating abdominal adhesions that allow for objective evaluation and quantification. METHODS: Two adhesion models were devised and compared with conventional side-wall models involving cecal abrasion and peritoneal excision or abrasion. model T (tissue): removal of a 2.5 by 2.5 cm segment of full-thickness abdominal wall with overlying skin closure, exposing the viscera to subcutaneous tissue; model M (mesh): removal of an identical segment, replacing the defect with a 2.5 by 2.5 cm polypropylene mesh sewn to the cut edges. This exposed the viscera directly to the mesh surface. Seven days after operation, the character and extent of the adhesions were assessed at autopsy. Results were expressed as the percent area of subcutaneous tissue involved (T) or of mesh surface involved (M). For model T the percent involvement of the circumference of the defect edge was also recorded. The extent of omental and intestinal adhesions were evaluated individually. RESULTS: The classical side-wall models showed inconsistent patterns of adhesion formation and were difficult to evaluate. Every animal from both models M and T developed extensive adhesions. The mean coverage of mesh surface (M) was 93% and subcutaneous surface (T) 82%. In model T the mean involvement of the defect cut edge was 80% of the circumference. All model T animals had both intestinal and omental adhesions whereas there were no intestinal attachments in model M. Tenacity of adhesions did not differ significantly between animals or models. CONCLUSIONS: Adhesion models M and T are consistent, predictable, and dependable. They each yield extensive adhesion coverage to a defined site, which allow for standardized measurement.     

生化调经汤结合水囊分离宫腔粘连及上节育环治疗人流术后闭经的临床研究

目的研究生化调经汤结合水囊分离宫腔粘连、上节育环治疗人流术后闭经的疗效。方法选择2007年3月至2012年3月在本院就诊的人流术后月经停止六个月以上或三个周期以上不来月经的患者为研究对象,随机分成实验组及对照组各40例,两组均予子宫输卵管造影,确诊为宫腔粘连所致闭经。结果实验组治愈34例,无效6例,治愈率85%,对照组治愈23例,无效17例,治愈率57.5%。结论生化调经汤结合水囊分离宫腔粘连、上节育环治疗人流术后闭经疗效显著,值得临床推广应用。     

Laparoscopic adhesiolysis: consensus conference guidelines

Aim Laparoscopic adhesiolysis has been demonstrated to be technically feasible in small bowel obstruction and carries advantages in terms of post‐surgical course. The increasing dissemination of laparoscopic surgery in the emergency setting and the lack of concrete evidence in the literature have called for a consensus conference to draw recommendations for clinical practice. Methods A literature search was used to outline the evidence, and a consensus conference was held between experts in the field. A survey of international experts added expertise to the debate. A public jury of surgeons discussed and validated the statements, and the entire process was reviewed by three external experts. Results Recommendations concern the diagnostic evaluation, the timing of the operation, the selection of patients, the induction of the pneumoperitoneum, the removal of the cause of obstructions, the criteria for conversion, the use of adhesion‐preventing agents, the need for high‐technology dissection instruments and behaviour in the case of misdiagnosed hernia or the need for bowel resection. Conclusion Evidence of this kind of surgery is scanty because of the absence of randomized controlled trials. Nevertheless laparoscopic skills in emergency are widespread. The recommendations given with the consensus process might be a useful tool in the hands of surgeons.     

Flexor tenolysis

Tenolysis is a valuable tool in the management of flexor adhesions after injury to the hand. The indications for this surgical procedure, the technique with technical tip, and postoperative management are discussed. Careful preoperative selection of appropriate surgical candidates, prudent planning for potential complications, and a patient compliant with their postoperative therapy are requirements for a successful outcome.     

单线Kessler并连续周边缝合法修复趾深屈肌腱的实验研究

目的探讨应用单线Kessler并连续周边缝合法修复鸡的趾深屈趾肌腱的应用价值。方法选用70只来亨鸡，右侧A组为实验组，左侧B组为对照组，每组70侧。选第三趾为手术趾，暴露Ⅱ区屈肌腱，横行切断趾深屈肌腱后采用9-0无创伤缝合线。A组采用单线Kessler并连续周边缝合法；B组采用单线Kessler缝合法，两组均缝合腱鞘。术后6周手术显微镜视下观察肌腱粘连性状，术后2、4、6周在B超及光镜下观察肌腱愈合情况，术后6周扫描电镜下观察肌腱周边愈合情况，术后即刻和4周测量肌腱缝合口2mm间隙形成负荷及最大抗拉强度。结果1．粘连性状：术后6周A组肌腱粘连少于B组。2．B超：A组强回声及条状强回声出现的时间、数量较B组分别提前、增多。3．光镜：术后4周A组胶原纤维产生数量比B组明显增多。4．扫描电镜：术后6周，A组65％肌腱胶原纤维与周围组织之间较疏松为3级粘连，15％为4级粘连；B组10％为3级粘连，80％为4级粘连。5．A组抗间隙生成能力及最大抗张能力较B组大，差异有统计学意义（P〈0．01）。结论单线Kessler并连续周边缝合法是一种简单、实用、省事、效果较佳的肌腱缝合方法。     

The role of laparoscopic adhesiolysis in the treatment of patients with chronic abdominal pain or recurrent bowel obstruction.

BACKGROUND: Major abdominal operations result in random and unpredictable scar tissue formation. Intraabdominal scar tissue may contribute to recurrent episodes of bowel obstruction, chronic abdominal pain, or both. Laparoscopic adhesiolysis may provide relief of symptoms in patients with prior abdominal surgery with chronic abdominal pain or recurrent bowel obstruction. METHODS: Between September 1996 and April 1999, 35 patients underwent laparoscopic adhesiolysis. Fifteen of the patients had adhesiolysis in conjunction with other major laparoscopic procedures and were excluded from the study. Twenty of the patients who underwent adhesiolysis only were retrospectively assessed for symptomatic relief as well as peri-operative morbidity and mortality. RESULTS: Two of 20 patients were not available for long-term follow-up. In the 18 remaining patients, laparoscopic adhesiolysis was performed on 13 patients with abdominal pain and 5 patients with recurrent bowel obstruction. The follow-up period ranged from 1 to 32 (mean 11) months. Sixteen of the 18 (88.9%) operations were completed laparoscopically. Two operations were converted to open for partial enterectomy. An additional enterotomy was repaired laparoscopically. All 3 operative complications were encountered in patients operated on during hospitalization for active bowel obstruction. No mortalities or blood transfusions occurred. One patient required rehospitalization for nonoperative management of an intraabdominal hematoma. Fourteen of the 18 (77.8%) had subjective improvement in their quality of life after operation. Only 1 patient has required repeat adhesiolysis. CONCLUSIONS: Laparoscopic adhesiolysis is a safe and effective management option for patients with prior abdominal surgery with chronic abdominal pain or recurrent bowel obstruction not attributed to other intraabdominal pathology. Laparoscopic intervention in patients with active bowel obstruction may increase the risk of operative complications.     

A case of cow's milk allergy in the neonatal period-evidence for intrauterine sensitization?

Clinical manifestations of cow's milk allergy rarely occur in the first days after birth. We report on a newborn presenting with hemorrhagic mecon-ium in the first hour of life followed by bloody diarrhea in the next few days. At day 14, an elevaled total IgE, specific IgE to cow's milk and an eosinophilia in peripheral blood were found. Symptoms disappeared when the milk feed was changed to an extensively hydrolyzed casein formula. Two challenges with cow's milk formula (on day 30 and at 7 months of age) were followed by recurrence of vomiting, watery diarrhea and failure to thrive. At the age of 17 months cow's milk was tolerated well. Although other pathogenetic mechanisms cannot completely be ruled out, there is strong evidence that cow's milk allergy— induced by intrauterine sensiti-zation—explains the symptoms in our patient. In conclusion, cow's milk allergy can occur even in the first days of life, and our clinical observation supports the concept of intra-uterine sensitization to allergens.     

Robotic urological surgery in patients with prior abdominal operations is not associated with increased complications

BACKGROUND: The da Vinci Surgical Robotic System is being increasingly used to perform complex urological operations by minimally invasive techniques. Prior abdominal surgery associated with intra-abdominal adhesions may complicate robotic surgery. METHODS: We used a cohort of consecutive 49 patients undergoing a variety of robotic urological procedures at our institution to study the impact of prior abdominal operations on early perioperative complications. RESULTS: A total of 21/49 (43%) patients (Group A) had no history of prior abdominal surgery and the rest 28/49 (57%; Group B) had undergone prior abdominal surgery. The incidence of peritoneal adhesions was significantly higher in patients with prior abdominal surgery compared to the rest of the cohort, 54% versus 10% (P=0.002). The median operative time, estimated blood loss, postoperative drop in hemoglobin, time to hospital discharge, postoperative narcotic analgesic use and postoperative complication rate between group A and group B were not statistically different. The overall perioperative complication rate for the entire cohort was 14.3%, with 6-8% of complications occurring in each of the two groups (P=1.0). Comparative subset analysis of 28 patients in Group B, 15 (54%) and 13 (46%) with or without intra-abdominal adhesions did not reveal a significant difference in perioperative complication rates either. However, operative time was longer in patients with intra-abdominal adhesions compared to patients without, median of 590 (281-922) and 434 (153-723) min respectively, although not statistically significant (P=0.059). CONCLUSION: Our study demonstrates that robotic urological surgery can be performed in patients with prior abdominal surgery without increased perioperative complications.