Acinic Cell Carcinoma with Extensive Neuroendocrine Differentiation: A Diagnostic Challenge

Primary salivary gland carcinoma with neuroendocrine differentiation is of rare occurrence, especially so in the parotid gland. Amongst the various reported primary tumors with neuroendocrine differentiation, acinic cell carcinoma (ACC) one such tumor. A 48 year old lady presented with a gradually increasing right infra-auricular swelling for a period of 1 year which enlarged suddenly in a short period. Contrast Enhanced Computed Tomography (CECT) suggested diagnosis of Pleomorphic Adenoma. Fine Needle Aspiration Cytology (FANC) yielded a cystic fluid suggesting a possibility of Warthin’s tumor or Oncocytic lesion. Intraoperative findings were suggestive of a Warthin’s tumor. Initial histopathological examination of the tumor was suggestive of neuroendocrine carcinoma. However, extensive sectioning revealed peripheral islands of ACC. Immunoexpression of S-100, Neuron specific Enolase (NSE), Chromogranin A and Synaptophysin confirmed the diagnosis. The possibility of neuroendocrine differentiation in a primary salivary gland tumor should be kept in mind whenever a salivary gland tumor shows only neuroendocrine histology

A Vagino-Laparoscopic Strategy for Hysterectomy of Large Uteri to Ease Surgical Challenges

Ramkrishna Purohit, Jay Gopal Sharma, Devajani Meher Purohit General Hospital, Bargarh, Odisha, IndiaCorrespondence: Ramkrishna Purohit, Purohit General Hospital, Bargarh, Odisha, 768028, India, Email [email protected]: To develop a vagino-laparoscopic strategy for hysterectomy (VLH) to treat uteri with large fibroids at ≥ 16 weeks of gestation to ease surgical challenges.Patients and Methods: This was an observational study conducted in our private general hospital on 64 consecutive cases involving uteri with large and benign fibroids at ≥ 16 weeks of gestation. We excluded cases with an associated ventro-fixed uterus and large cervical fibroids.Interventions: The VLH strategy involves vaginal separation of the uterosacral with the uterine arteries followed by laparoscopic separation of the remaining upper pedicles. The uterus was then removed vaginally.Results: The largest uteri receiving treatment was at 26 weeks of gestation and the mean uterus weight was 869.60 ± 275.10 g (range: 500– 1900 g). The VLH strategy was successful in 63 (98.43%) cases irrespective of the configuration of the uterus. One case (1.56%) required mini-laparotomy conversion due to the need for adhesiolysis; this case exhibited extensive adhesion of the rectum to the posterior wall of the uterus due to a history of previous myomectomy of the posterior wall. There were no conversions due to failed laparoscopic exposure of the adnexal or uterine vascular pedicles, or due to uncontrolled intraoperative bleeding. There were no cases of urinary tract injury or other major complications. The vaginal detachment of uterosacral ligaments before the laparoscopic phase of the VLH strategy increased upwards mobility and dislodged the cervico-isthmic level of large uteri from the narrow lower aspect of the pelvis to the upper wider part of the pelvis; this eased the surgical challenges associated with such cases and avoided complications during laparoscopy.Conclusion: We developed a vagino-laparoscopic strategy for hysterectomy that can ease the technical challenges associated with the majority of large uteri.Keywords: surgical challenges during laparoscopic hysterectomy, large fibroid uterus, laparoscopic hysterectomy, thick uterovesical scar, displaced adnexal and uterine vessel

Vagino-Laparoscopic Conservative Strategy of Hysterectomy in Indicated Cases of Severe Pelvic Endometriosis Followed by 24 Months of Depot-Medroxyprogesterone Acetate Therapy— A Symptom-Solving Treatment Model to Ease Surgical Challenges

Ramkrishna Purohit,1 Jay Gopal Sharma,1 Devajani Meher,1 Mohammed Mahmoud Samy2 1Department of Obstetrics & Gynaecology, Purohit General Hospital, Bargarh, India; 2Department of Obstetrics & Gynaecology, Ainshams University, Cairo, EgyptCorrespondence: Ramkrishna Purohit, Department of Obstetrics & Gynaecology, Purohit General Hospital, Shakti Nagar, Bargarh, Odisha, 768028, India, Tel + 91-6646-234403, 234468 ; +91-94370 54403, Fax +91-6646-231597, Email [email protected]: To demonstrate the long-term outcome of a symptom-solving treatment model (SSTM).Patients and Methods: An observational study was carried out between June 2016 and December 2022 in our private setup on consecutive candidates of hysterectomy for severe pelvic endometriosis. Candidates were treated by the SSTM, which constitutes a systematic vagino-laparoscopic conservative strategy of hysterectomy with preservation of the ovary or ovaries followed by 24 months of postoperative depot-medroxyprogesterone acetate (DMPA) therapy. Cases were followed up to December 2022, 2.5 years beyond the last hysterectomy in May 2020.Main Outcome Measures: Relief of endometriosis-associated symptoms and prevention of recurrence in the long term.Results: Symptomatic relief of endometriosis-related pain, such as cyclical dysmenorrhoea, pelvic pain, dyschezia, and vaginal pain, occurred in all 68 (100%) cases from the next expected date of menstruation. None of the cases showed a recurrence of endometriosis-related pelvic pain; overall, 37 (54.41%) cases crossed 4– 6 years, and 31 (45.58%) cases crossed 2.5– 4.0 years following the hysterectomy operation. Four (5.88%) cases had non-endometriotic pelvic pain. None of the cases required repeat surgery or had any major side effects or complications due to DMPA. No major perioperative complications were observed. The results were achieved without the requirement of challenging extensive retroperitoneal laparoscopic dissection, ureterolysis, and rectum surgeries.Conclusion: This SSTM can be an option in indicated cases of severe pelvic endometriosis to provide symptom relief and prevent the recurrence of endometriosis-associated pelvic pain in the long term.Keywords: severe pelvic endometriosis, vagino-laparoscopic hysterectomy, relief of endometriosis-associated pelvic pain, recurrence of endometriosis-associated pelvic pain, DMPA therapy following hysterectomy, hysterectomy with ovarian conservation, symptom-solving treatment mode

A laparovaginal strategy to avoid bladder injury during laparoscopic-assisted vaginal hysterectomy in cases with ventrofixed uterus following previous cesarean section

Ramkrishna Purohit, Jay Gopal Sharma, Devajani Meher, Sanjay Raosaheb Rakh, Minal Choudhary Department of Obstetrics and Gynecology, Purohit General Hospital, Bargarh, Orissa, India Background: Laparoscopic hysterectomy for benign indications in cases with ventrofixed uterus following previous cesarean section (CS) increases the surgeon’s concern of bladder injury. The present study describes a laparovaginal strategy to avoid bladder injury during laparoscopic-assisted vaginal hysterectomy (LAVH) in cases with ventrofixed uterus following previous CS.Methods: In a retrospective study conducted in our private general hospital, we included consecutive cases of laparoscopically confirmed ventrofixed uterus associated with previous CS. These were from the cases who underwent LAVH for benign indications. Cases with uterus size >16 weeks of gestation were excluded. Patients’ clinical, intraoperative and postoperative characteristics were studied to evaluate the feasibility of the described laparovaginal strategy to prevent bladder injury during LAVH in cases with ventrofixed uterus.Results: A total of 35 cases with ventrofixed uterus underwent LAVH during the study. Six (17.14%) cases had a history of one CS, while 29 (82.86%) cases had a history of previous two or more CSs. A supravesical loose fatty tissue plane (supravesical space) indicating reach to the bladder wall during laparoscopic lysis of the uterus from the anterior abdominal wall was successfully demonstrated in all the cases. The bladder flap preparation was avoided. Uterovesical adhesions were dissected by posteroanterior approach during vaginal phase of LAVH in all the cases. LAVH was successfully performed in all the cases. None of the cases had bladder injury, laparotomic conversion or other major complications. Mean operating time for LAVH was 149.71±38.36 minutes (70–200 minutes). Mean uterine specimen weight was 162.85±92.57 g (60–500 g). Mean postoperative hospital stay was 2.42±0.73 days (2–5 days).Conclusion: In spite of severe adhesions in cases with a ventrofixed uterus following previous CS, bladder injury can be avoided during LAVH by the described laparovaginal approach in the present study.Short synopsis: The described laparovaginal approach may avoid bladder injury during laparoscopic-assisted vaginal hysterectomy in cases with a ventrofixed uterus following previous cesarean section. Keywords: laparoscopic-assisted vaginal hysterectomy, ventrofixed uterus, previous cesarean section, supravesical plane, bladder injur