COMPARISON OF "MISGAV LADACH" AND PFANNENSTIEL SURGICAL TECHNIQUE OF CESAREAN SECTION

A prospective randomized trial of 111 women undergoing caesarean section was carried out in the Pula General Hospital. 49 operations were performed by the Pfannenstiel method of caesarean section, 55 by the “Misgav Ladach” method and 7 by lower midline laparotomy. It was proved that the cases where the “Misgav Ladach” method was implemented, compared to the Pfannenstiel method, showed a significantly shorter delivery/extraction and operative time (p=0.0009), the incision pain in the second postoperative day was significantly lower (0.021), we recorded a quicker stand up and walking (p=0.013), significantly less analgesic injections and a shorter duration of analgesia were required (p=0.0009) and the bowel function was sooner recovered (p=0.001). The “Misgav Ladach” method of caesarean section has advantages over the Pfannenstiel method by being significantly quicker to perform, with diminished postoperative pain and less use of postoperative analgesics. The recovery of physiologic functions is faster. No differences were found in intraoperative bleeding, mother morbidity, scar appearance, uterus postoperative involution and the assessment of the inflammation response to the operative technique

Morbidity and chronic pain following different techniques of Caesarean Section: a comparative study

Broj porođaja dovršenih carskim rezom u stalnom je porastu i jedna je od najčešćih operacija širom svijeta. Posljednjih desetak godina broj porođaja dovršenih carskim rezom povećao se više od dvostruko, dok u nekim zemljama čak polovica žena rodi incizijom trbušne stijenke. Danas je, više nego u prošlosti, nužno ocijeniti dugoročno cjelokupno fizičko zdravlje žene nakon carskog reza te razviti najučinkovitiju i sigurnu operativnu tehniku s ciljem boljih kratkoročnih i dugoročnih postoperativnih rezultata. Standardni postupak u većini zemalja zapadne Europe poprečni je rez koji je krajem prošlog stoljeća uveo Pfannenstiel. U posljednjem desetljeću u mnogim je zemljama započeta primjena tehnike carskog reza Misgav Ladach. Tehnika pristupa razlikuje se od onih klasičnih po načelu reza i otvaranja abdomena, ali i u drugim operativnim detaljima šivanja maternice i zatvaranja abdomena. Operativne pojedinosti usvojene u tehnici Misgav Ladach pokazale su u randomiziranim kontroliranim studijama značajne prednosti za kratkoročne postoperativne rezultate. Ovi povoljni rezultati dokazani su u ovome istraživanju i u dugoročnom razdoblju. Zaključak ovoga istraživanja je da su u pacijentica operiranih tehnikom Misgav Ladach, za razliku od tehnike Pfannenstiel, bolji dugoročni postoperativni rezultati nakon pet i više godina od učinjenog carskog reza. Rezultati su statistički bolji u jačini boli, pojavi kronične i neuropatske boli, razini zadovoljstva postoperatvnim ožiljkom i općim stanjem, kao i bržim začećem. Razlika u usporedbi tih dviju skupina u kvaliteti pražnjenja crijeva, mokrenja te u seksualnim funkcijama nije bilo.Research examining long-term outcomes after childbirth performed with different techniques of Caesarean section have been limited and don't provide information on morbidity and neuropathic pain. The study compares two groups of patients submitted to the traditional method using Pfannenstiel incision and patients submitted to the Misgav Ladach method five and more years after the operation. We find better long term postoperative results in the patients that were treated with Misgav Ladach in comparison to the Traditional Method. The results were statistically better regarding the intensity of pain, presence of neuropathic and chronic pain, level of satisfaction about cosmetic apparence of the scar, overall physical health and mean time to get pregnant. No differences were found in bowel function, voiding and sexual function

OVARIAL AND EXTRAOVARIAL CARCINOMA (diagnosis and treatment)

Ovarian cancer is one of the most malignant tumors in women, and its mortality rate is higher than in all other gynecological malignancies, both in our country and throughout the world. Ovarian cancer is one of the five most recurrent cancers in women in developed countries. The highest rate in Europe is found in the northern European countries and the lowest in the countries of East and South Europe. According to data from the year 1995, Lithuania had the highest ovarian cancer rate in Europe (23/100.000 women), and Macedonia the lowest (7,8/100.000 women). The mean rate for entire Europe was 13,4/100.000. The ovarian cancer rates vary significantly from country to country, and they reflect trends in fertility and the use of oral contraceptives

BRACHIAL PLEXUS PALSY AND HOARSENESS OF THE VOICE DURING LUMBAR EPIDURAL ANALGESIA FOR LABOR AND DELIVERY: A CAUTIONARY TALE

The lumbar epidural analgesia is one of better ways of controlling pain during labor but it still can be followed with complications and unintentional side effects. Neurologic complications of epidural analgesia are rare. We present two cases of healthy women where epidural analgesia was induced during active labor. Repeated intermittent epidural doses of local anesthetics and the left lateral decubitus position of the patients induced the cephalic spread of the anesthetic drug along the epidural space with the appearance of unilateral brachial plexus palsy and hoarseness of the voice. These side effects disappeared spontaneously but caused anxiety in the patients and in all medical staff. Elevated control by anesthetists is necessary in case of epidural analgesia during active labor to avoid risky complications like the high sympathetic block

Comparison of a re-analyzed vaginal hysterectomy to a classical one

Objective. To evaluate advantages of a re-analyzed vaginal hysterectomy (the ten-step vaginal hysterectomy – TSVH) as compared to a traditional technique of vaginal hysterectomy. Patients and methods. A prospective randomized study involving 66 patients with pelvic organ prolapse; 46 operations were performed using the classical technique of vaginal hysterectomy (modifi ed Heaney method) and 20 using the TSVH. Results. TSVH results in shorter operating time, shorter hospital stay, and signifi cantly less need for analgesia compared to the Heaney method. There is no difference in blood loss, pain intensity and degree of patient satisfaction 7 days after surgery. Conclusion. The ten-step vaginal hysterectomy which is a structured method based on the analysis of several possible surgical steps seems to be simple to perform, teach and learn. Because of its didactic presentation, this method can successfully promote vaginal hysterectomy when teaching new generations of gynecological surgeons, and should be adopted for routine clinical use

Comparison of a re-analyzed vaginal hysterectomy to a classical one

Objective. To evaluate advantages of a re-analyzed vaginal hysterectomy (the ten-step vaginal hysterectomy – TSVH) as compared to a traditional technique of vaginal hysterectomy. Patients and methods. A prospective randomized study involving 66 patients with pelvic organ prolapse; 46 operations were performed using the classical technique of vaginal hysterectomy (modifi ed Heaney method) and 20 using the TSVH. Results. TSVH results in shorter operating time, shorter hospital stay, and signifi cantly less need for analgesia compared to the Heaney method. There is no difference in blood loss, pain intensity and degree of patient satisfaction 7 days after surgery. Conclusion. The ten-step vaginal hysterectomy which is a structured method based on the analysis of several possible surgical steps seems to be simple to perform, teach and learn. Because of its didactic presentation, this method can successfully promote vaginal hysterectomy when teaching new generations of gynecological surgeons, and should be adopted for routine clinical use

KARCINOM JAJNIKA: MOŽEMO LI GA RANIJE OTKRITI?

Ovarian cancer is the fourth most common gynecological malignancy in Croatia. Reasons for high fatality rates are the rapid growth of cancer and the late presentation of nonspecific symptoms in its advanced stage. Survival rates are significantly improved if cancer is detected early, while still in its localized stage. Screening the general population with the Ca-125 tumor marker and transvaginal ultrasound is not recommended at this time. Although there are no routine diagnostic techniques, early detection of ovarian carcinoma can be significantly improved with early recognition and objectivisation of nonspecific symptoms, analysis of potential biomarkers, as well as the use of multimodal tests

FOLLOW-UP OF EPITHELIAL OVARIAN CANCER PATIENT AFTER PRIMARY TREATMENT (Controversies and actual guidelines)

SAŽETAK. Objavljene smjernice vezane za follow-up pacijentica primarno liječenih od karcinoma jajnika, ali i drugih ginekoloških malignoma, temelje se na podacima samo nekoliko studija koje nisu randomizirane i koje ne prikazuju učinkovitost i utrošak/dobrobit pretraga što su korištene za dijagnozu recidiva bolesti. Te studije/preporuke nisu usuglašene po vrsti pretraga i vremenskoga intervala pregleda. Uz to kod detekcije recidiva u pacijentica primarno liječenih od karcinoma jajnika, ostaje još terapijska dilema s obzirom na to da će gotovo svaka pacijentica s recidivom bolesti umrijeti. Follow-up asimptomatskih pacijentica najčešće obuhvaća uvid u povijest bolesti, serumski CA 125, ginekološki fizikalni pregled i često ultrazvučni pregled, a koriste se i druge radiološke pretrage kada simptomi i znakovi ukazuju na mogući recidiv bolesti. U literaturi nalazimo dvije oprečne tendencije. Prva koja vodi minimalističkome praćenju i druga koja, na osnovi novih procedura, lijekova i tehnologija, potiče kliničara da se koristi skupim pretragama koje još nisu znanstveno opravdane. Potrebna su velika prospektivna randominizirana ispitivanja koja uspoređuju minimalistički follow-up s intenzivnim skupim pristupom pretraga. Studije moraju voditi računa o ciljevima liječnika (dobri i učinkoviti rezultati koji jamče najbolju kliničku praksu), potrebama pacijentica (percepcija da je liječenje vođeno na odgovarajući način) i realnim mogućnostima zdravstvenoga sustava. Te studije trebale bi jasnije usporediti objektivni klinički ishod (sveukupno preživljenje, vremenski interval bez bolesti i komplikacije) te subjektivni ishod (kvalitetu života i očekivanja pacijentica).All the guidelines published regarding the follow up of patient primary treated for ovarian cancer and other gynecological cancer, are the results only of few studies not randomised and in absence of evidence of effectiveness and cost/benefit of the procedure used for diagnosis of recurrent disease. Few formal guidelines exist regarding the surveillance of these patients, and there is no agreement in the literature about the type and timing of examinations to perform. Moreover, the objective of follow-up is unclear as recurrent epithelial ovarian cancer continues to be a therapeutic dilemma and quite all the relapsed patients will eventually die of their ¬disease. The follow-up of asymptomatic patients generally include complete clinical history, serum cancer antigen (CA 125) assay, physical examination, and often ultrasound examination, whereas additional radiologic imaging techniques are usually performed when symptoms or signs appear. Currently, there exist two opposite tendencies suggesting different follow-up modalities. On one side »minimalistic« follow-up and on the other side, the introduction of new drugs and new technologies induce the physician to prescribe expensive examinations without proved utility. Prospective randomised clinical trials have to be planned in order to ¬compare minimalistic and intensive follow-up policies. These trials have to evaluate the relationship between the gynecological oncologist’s needs (good quality scentific data available, which leads the best clinical practice), patient’s need (according to the satisfaction degree they feel about the treatments and follow-up) and possibility of health care system. New clinical trials also are needed in order to evaluate the relationship between the objective clinical outcome (overall survival, disease-free interval, and complications) and the subjective outcome (quality of life and expentacies of the patient)

An different approach to CSE-EVE for reducing hypothension during Caesarean section under spinal anaesthesia

Background and Objectives: Spinal anaesthesia is the most preferred anaesthetic technique for elective as well as for unplanned Caesarean section.Spinal-induced hypotension remains the most important side effect with a reported incidence between 20% and 100%. It can cause maternal discomfort (nausea and vomiting) and impaired utero-placental perfusion. The present study was designed to examine the influence of epidural volume effect on the spread and duration of low dose hyperbaric levobupivacaine. The aim of this study was to evaluate the influence of epidural restriction (injection of saline) on the distribution of anaesthesia as well as the incidence of hypotension during the spinal anaesthesia. Methods: After the approval by Ethics Committee, 60 full term parturient women (ASA I or II) with uncomplicated pregnancies were prospectively randomized into two groups: SA group (single shot spinal anaesthesia) included 37 patients and CSE-EVR (combined spinal-epidural anaesthesia) included 39 patients were we induced the restriction of the spinal space by epidural volume compression. The blocks were performed at L2/3 or L3/4 level in sitting position, in CSE-EVR group using the needle through-needle technique. The initial dose for CSE-EVR was exactly half of the SA dose (0,5 mg per 10 cm height of hyperbaric levobupivacaine and 20microg fentanyl). After spinal injection, an epidural catheter was located in the CSE-EVR and injected a volume of 20 ml saline solution. After injection women, were turned supine with a left uterine displacement. Surgery was allowed when a sensory block at or above T8 dermatome was established.We evaluated the height of the block by the pinprick method and the motor block by Bromage scale, 10 minutes after spinal injection, during the operation time and at the end of surgery. Hemodynamic monitoring (NIBP, HR) was assessed every 2 minutes until the childbirth, then every 5 minutes during operative time. Anaesthetic efficacy was evaluated for breakthrough pain by visual analogue pain score (VAPS), Apgar score at birth, umbilical artery-pH, and epinephrine consumption. Results: The level of anaesthesia 10 minutes after the induction was significantly higher in spinal group (SA) than in CSE-EVR T5 (T4-T7) vs.T7(T6-T8).The SA group experienced complete motor block during the time of anaesthesia, while the CSE-EVR group demonstrated significantly faster motor recovery. The incidence of hypotension and ephedrine supplementation was significantly lower in the CSE-EVR group (19 patients vs.35) than in the SA group (p<0.05).The neonatal outcome and umbilical artery-pH was higher in the CSE-EVR group. Both groups were comparable in demographic data, VAS scores, preloading and infusion volume, atropine or ephedrine use, and adverse effects as nausea or skin pruritus. Conclusions: We demonstrated a possible restriction of the spread of spinal anaesthesia by using epidural volume restriction with 20 ml saline as part of a combined spinal epidural technique. The study shows that CSE with EVR with only 50% of the levobupivacaine dose provided adequate anaesthesia for elective caesarean delivery, as well as better maternal hemodynamic stability

Placenta praevia percreta with initial bladder and parametrial invasion: a cause of life threatening hemorrhage after repeated cesarean section

Placenta percreta is a rare, but potentially life-threatening condition associated with high maternal mortality and morbidity rates, and caused by severe obstetric hemorrhage. Due to rising cesarean section rates, an increased incidence of different forms of adherent placentas (accreta, increta and percreta) has been observed. Although unsuspected during the antenatal period, diagnosis at the time of labor is usually secondary to the inability to define a cleavage plane. The associated hemorrhage can be substantial, and hysterectomy is frequently required. Definitive surgical management is the traditional treatment strategy; however, several authors have recently reported their experiences with conservative management, and some of them had success with this approach. We describe a case of massive, post-cesarean vaginal hemorrhage that occurred in the third postpartum period as the result of a misunderstood placenta percreta invading the parametria and bladder. Post-cesarean hysterectomy, bladder wall repair, and unilateral internal iliac artery ligation were performed to control massive intraoperative hemorrhage. There should be high rate of suspicion for placenta percreta with bladder and parametrium invasion in the evaluation of pregnant women with a history of Cesarean delivery and placenta previa at Cesarean section