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The experience of performing a conseceutive series of 1092 tubal sterilizations, using a local anesthesia, at a free standing outpatient clinic in the US between 1976-81 is reported. The clinic's experience demonstrated that low cost sterilizations could be performed safely in a facility lacking a general anesthesiologist, a blood bank, and a laporatomy set-up. Initially, unipolar forceps and closed laporscope tocar insertion was used, but in 1977 clinic personnel began using Kleppinger bipolar forceps to reduce the risk of ectopic burns and Hasson's open laparoscopy method to reduce the risk of extraperitoneal gas insufflation and vascular injury. Patient were initially screened over the telephone for cardiopulmonary disorders and other contraindications. 72 hours before the operation, they were counseled and informed of the risks. Preliminary laboratory examinations included blood counts, urinalyses, Papanicolaou smears, and gonorrhea cultures. In performing the sterilizations the local anesthestic, Xylocaine, was used. Surgical procedures included 1) administering a tranquilizing agent and an analgesic intravenously, 2) performing a paracervical block using a local anesthestic; 3) achieving uterine elevation; 4) infiltrating the subumbilical layers of the anterior abdominal wall with local anesthestic; 5) making a 1.5 cm incision; 6) inserting a 10 mm operating laparoscope; 6) creating pneumoperitoneum with nitrous oxide; 7) spraying and infiltrating the isthmic portion of the fallopian tubes with the local anesthestic; 8) cauterizing the tubes at 3 sites; and 9) releasing the pneumoperitoneum and closing up. Operating time is 15 minutes. The patient is observed for an hour and then discharged. The 1092 patient treated at the clinic had a median age of 31.7, a mean gravidity of 2.9, and a mean parity of 2.0. 17% had never delivered, 12.1% had never married, and 36% used no previous method of contraception. At the time of sterilization, 87 of the patients had IUDs removed, and 100 had abortions performed. Between 1976-81, complications associated with the sterilizations included 1) 2 cases of pelvic infection; 2) 7 cases of abdominal pain; 3) 6 cases each of incision bleeding, incision hematoma, and dysmenorrhea; and 4) 1 case each of vaginocervical laceration, vaginal bleeding, and paralytic ileus. 4 pregnancies were reported following sterilization, and 2 of these were ectopic pregnancies. 3 of the pregnancies occurred during the 1st 2 years of clinic operation, and only 1 during the last 3 years.
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PMID:Laparoscopic sterilization in a free-standing clinic: a report of 1,092 cases. 624 61

100 women ranging in age from 26-34 years were followed up for 4-21 months after undergoing sterilization by tubal occlusion using intraluminal threads and silver clips. The number of children/woman ranged from 1-5 with 80% having 2. 31 women underwent sterilization postmenstrually, 11 midmenstrually, 28 premenstrually, 12 after abortion, and 8 during lactation. The timing was unknown in 8 cases. The silver clips used were hook eye "db" shaped, 3 mm wide, .5 mm thick, and 70, 100, or 150 mg in weight. Local anesthesia, suprapubic small abdominal incision, and oviduct delivery were the usual procedures. The clips were placed where the tube is relatively straight and avascular, often near the isthmus or ampulla. No. 4 nylon thread was drawn through the tube and a silver clip was put on each tube and tightened until the threads could no longer be moved. The extra thread was snipped off about 3 mm from the clip. There were no pregnancies among 95 patients followed up. 18 patients had varying degrees of lumbago or leg pain and 1 complained of serious lower abdominal pain, especially after coitus. Pelvic examination in 74 patients showed 1 case of slight thickening in the right appendix region but no pelvic masses. Hysterosalpingography in 22 patients showed 1 case with incomplete occlusion on 1 side. The method is believed to be safe and suitable for use in smaller hospitals and outpatients. Reversibility has been demonstrated in rabbits.
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PMID:Oviduct occlusion by intraluminal thread and silver clips. 641 60

The patient with diabetes represents to the surgeon a particular challenge in the management of acute abdominal problems. In addition to their ongoing and potential metabolic problems, diabetics have specific difficulty in their ability to handle infections and heal wounds. The present report reviews the general principles in the peri-operative management of diabetics and discusses the implications in the diabetic of several specific clinical problems. In view of the known accelerated atherosclerosis associated with diabetes, the risks of anesthesia and surgery must be assessed in the context of the coronary, cerebral, visceral, and peripheral vascular status. Infections in diabetics (potential or established) must be treated aggressively and promptly. Acidosis in the diabetic with abdominal pain must be considered both a metabolic problem and a possible secondary manifestation of an intra-abdominal process. In view of these challenges, the need for careful, anticipatory management of the diabetic patient facing major abdominal surgery is clear.
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PMID:Diabetes and abdominal surgery: the mutual risks. 642 50

Postoperative outcome was compared for 235 patients who were sterilized by unipolar tubal electrocoagulation and for 269 patients who were sterilized by the application of Hulka Clemens spring-loaded tubal clips. Clip application patients had fewer complications but experienced more postoperative discomfort than electrocautry patients. All the sterilizations were performed by the same physician at the Aberdeen Royal Infirmary from 1976-1978. All the patients received general anesthesia, administered by the same anesthetist. Operating time for the tubal electrocautery technique was 7.5 minutes and 5.5 minutes for the tubal clip procedure. 14 of the electrocautery patients and 6 of the clip application patients experienced complications. For the electrocautery patients 1) 11 experienced tubal bleeding and laporotomy to stop bleeding was required for 2 of the patients; 2) 1 patient received bowel damage; and 3) 2 patients had uterine perforations. For the 6 tubal clip patients 1) 2 had uterine perforation; 2) 1 had pelvic sepsis; and 3) in 3 of the patients clips were lost and not retrieved. Only 1 pregnancy was reported, and in that patient adhesions had obstructed the tube during the operation. Immediately following surgery the majority of the patients experienced mild abdominal pain. 9.4% of the clip patients and 1.3% of the electrocautery patients experienced severe pain. 48.5% of the electrocautery patients and 36.0% of the clip patients experienced shoulder pain. Laparoscopic clip sterilization was recommended as a safer technique than electrocoagulation.
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PMID:Outpatient laparoscopic sterilisation: Comparison between electrocautery and clip application. 644 41

2 case reports, thought to be the first of their kind, describe an uncommon complication of hysterectomy, prolapsed fallopian tubes, and an even more unusual surgical remedy for the condition, laparoscopy. Case 1 was a 26-year-old female, gravida 3, para 2, who presented with extreme abdominal pain and dyspareunia lasting for several months. 4 years previously she had a complicated therapeutic abortion and sterilization, which led to a total hysterectomy. 8 months postoperatively she complained of abdominal pain, and biospy revealed fimbriated fallopian tube. 1 year after that, the patient returned with similar symptoms, and a histologic report of the vaginal apex was fallopian tube. 2 years later, on physical examination, a 2-cm bright red polypoid mass was visualized at the right side of th vaginal apex, and it was extremely tender. The patient was admitted to the hospital, and a diagnostic laparoscopy under general anesthesia was performed. The prolapsed fallopian tube was seen, and it was excised from the vaginal vault and returned to the peritoneal cavity during the diagnostic procedure. The operation took 40 minutes with minimal blood loss. Postoperatively the patient reports relief of abdominal pain and absence of dyspareunia. Case 2, a 44-year-old woman, complained of lower abdominal pain 4 weeks after a hysterectomy. Again, visual examination showed a bright red polypoid mass which was tender to touch. Because of the success of Case 1, a diagnositic laparoscopy was done, and, using the same techniques as Case 1, the patient had her prolapsed tube returned to the peritoneal cavity. 3 months postoperatively, Case 2 has no complaints.
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PMID:Laparoscopic repair of the prolapsed fallopian tube. 644 94

This study reports our experience of laparoscopy under local anaesthesia in 250 patients; the procedure was safe, quick and easy to perform with minimal inconvenience to the patient. We advocate the early use of laparoscopy in patients with ascites and when there is difficulty in the diagnosis of patients with jaundice and hepatomegaly, an accurate histological diagnosis being obtained in the majority. In patients with intra-abdominal malignancy, in whom surgery is planned, laparoscopy can detect disseminated disease and so avoid an unnecessary laparotomy. Laparoscopy may also provide a diagnosis in patients presenting with a variety of vague symptoms such as abdominal pain, weight loss, lethargy etc. We have found laparoscopy an excellent investigation if positive but, as if only allows the surface inspection of viscera, when negative, we recommend caution in its interpretation.
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PMID:The value of laparoscopy under local anaesthesia in 250 medical and surgical patients. 644 48

Information from 2 recent books on the most common abortion techniques is presented. Menstrual aspiration can be performed up to 14 days after a missed period. A flexible plastic cannula 4-5 mm in diameter is passed through the cervix to the uterus, and the contents are evacuated using a syringe. Little dilatation is required and the procedure is done under local anesthesia. Aspiration through the 12th week is usually done under general anesthesia using a cannula and mechanical aspiration. A curette is used to assure that the abortion is complete. Local anesthesia is used in some places. From 12-16 weeks a combination of scraping and aspiration is used with general anesthesia and sometimes forceps. The uterine cervix requires greater dilatation. After 16 weeks the amniotic fluid is removed and a solution of salt and water is injected into the woman under local anesthesia. Contractions begin about 24 hours later. Labor may also be induced by oxytocin or prostaglandins which result in 8-15 hours of labor. This method of abortion probably causes the greatest amount of anxiety in the patient. Uterine scraping is described in the 2nd book as a procedure in which the cervix is progressively dilated with metal instruments of different sizes until it is sufficiently dilated to permit passage of the curette. Laminaria tents were previously placed in the cervix 24 hours prior to the abortion to achieve slow and progressive dilatation. General anesthesia is required because cervical dilatation is painful. In uterine aspiration the contents of the uterus are removed using tubes called Karmen cannulas. It is sometimes possible to avoid cervical dilatation by using thin cannulas, in which case general anesthesia may be avoided. After the aspiration the uterus may be scraped to assure the complete removal of the uterine contents. Prostaglandins may be used to initiate uterine contractions leading to expulsion of the uterine contents during the 2nd trimester of pregnancy. The procedure may cause significant side effects. Other procedures consist of injecting various substances into the uterine cavity during the 2nd trimester of pregnancy. Hysterotomy involves surgical opening of the abdomen and is analogous to cesarean section. Possible complications of an induced abortion include uterine perforation, bleeding, infection, and in extreme cases maternal death through sepsis. Medical attention should be sought in cases of hemorrhage, abdominal pain, fever, or general malaise after an induced abortion.
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PMID:[Literary but technical abortion]. 655 11

To facilitate postoperative flatus, Prostaglandin F2 alpha (PGF2 alpha) was given intravenously to 23 patients who underwent urological operations. The patients were 14 males and 6 females aged from 20 to 77 years old. Patients with hypertension or cardiovascular disease were not included. Twelve operations were performed under general anesthesia, and 8 under epidural anesthesia. Thirteen operations were performed for the upper urinary tract or adrenal gland, and 5 were for the lower urinary tract. In 2 cases, the peritoneal cavity was opened and operations were performed on the intestines. PGF2 alpha 2000 micrograms was added to the postoperative drip infusion and administered in 2 to 3 hours. Until the first flatus was recognized, PGF2 alpha was given once a day in the same manner. Twenty-six patients, 10 of whom were given either vagostigmine or pantothen postoperatively, served as the control group. PGF2 alpha accelerated the postoperative flatus by 8.7 hours (mean) compared with the control group, but it was not significant. The onset of flatus was significantly promoted under epidural anesthesia. Gastrointestinal movement tended to be facilitated in the PGF2 alpha group after lower urinary tract surgery and in the patients over 50 years old. Three patients complained of severe abdominal pain as a side effect; and, injection of PGF2 alpha was stopped. In 7 patients, mild stomachache , vascular pain, nausea, vomiting or elevation of blood pressure were observed.
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PMID:[The effect of prostaglandin F2 alpha on the gastrointestinal movement after urological surgery]. 658 61

An unusual case of pelvic abscess characterized by a relatively mild clinical course and unusual localization occurred in a previously healthy, married, 26-year old woman with 2 children and 1 previous abortion. The woman was admitted to the hospital for lower abdominal pain of 1 week's duration. A Lippes Loop C inserted 5 years earlier, 4 months after a term delivery, had caused no complications. The last menstrual period was 2 weeks before admission. 1 week before admission lower abdominal cramps and dysuria had started, and nitrofurantoin 400 mg daily was prescribed for suspected urinary tract infection. The patient was hospitalized when the pain worsened. The patient appeared well on admission. Abdominal examination disclosed a very tender suprapubic mass the size of a 14-week pregnancy. Vaginal examination revealed an anterior, normal-sized uterus adherent to the mass. An examination under general anesthesia revealed a 12 cm mass adherent to a normal sized uterus. Multiple adhesions prevented visualization of the pelvic organs during laparoscopy. The IUD was removed and sent for bacteriologic examination. Laparotomy revealed a mass with a diameter of 10 cm located between the bladder and the uterus and adherent to them and to the anterior abdominal wall. The tubes were hyperemic and edematous, and pus was noted in both fimbriae. Both ovaries appeared normal. The mass was excised and a frozen section examination established the diagnosis of an abscess, which was later confirmed by histopathologic examination. A course of intravenous gentamycin, ampicillin, and clindamycin was started. Polymicrobial infection with Streptococcus viridans, Staphylococcus, coagulase negative, and diptheroids was subsequently established. The postoperative course was uneventful, and physical examination a month later was normal. No explanation of the unusual location of the abscess in the visicouterine space or of the absence of most of the symptoms of an abscess was found.
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PMID:Pelvic abscess associated with a Lippes loop. An unusual case. 663 39

A review was made of 139 fiberoptic colonoscopies performed between 1975 and 1982 on 113 patients aged 1 month to 20 years. General anesthesia was used in four procedures. All others were done under sedation with meperidine (mean dose 2.9 mg/kg) and diazepam (mean dose 0.5 mg/kg). Indications were rectal bleeding in 52 patients; assessment and surveillance of known inflammatory bowel disease in 33 patients; and diagnostic evaluation of abdominal pain, diarrhea, and/or fever in 28 patients. The cecum was reached in 84% of diagnostic examinations. Comparison of findings on colonoscopy with barium enema in 75 patients showed agreement in 46, colonoscopic superiority in 25, and barium enema superiority in four. Bleeding sufficient to cause anemia was seen in 10/26 patients with polyps. Five minor complications and no major complications occurred. Flexible fiberoptic colonoscopy and polypectomy may be done usefully in childhood by physicians well versed and experienced with these procedures. Colonoscopy and biopsy changed the radiographic diagnosis from ulcerative colitis to Crohn's disease in several cases and indicated greater extent of colonic disease in several cases of ulcerative colitis and Crohn's disease. Colonoscopy is usually the most sensitive and accurate diagnostic tool for the evaluation of colonic disease, but barium enema and colonoscopy are complementary tests and barium enema should usually precede colonoscopy, with certain exceptions.
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PMID:Colonoscopy in childhood. 671 14


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