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Ectopic pregnancy: laparoendoscopic single-sitesurgery—laparoscopic surgery through a singlecutaneous incision Ricardo Francalacci Savaris, M.Dand Leandro Totti Cavazzola, M.D.
a Departamento de Ginecologia e Obstetrıcia e Programa de Pos-Graduacx~ao em Medicina, Ci^encias Cirurgicas da UniversidadeFederal do Rio Grande do Sul; and b Servic xo de Cirurgia Geral do Hospital de Clınicas de Porto Alegre, Porto Alegre, Brazil Objective: To report the use of laparoendoscopic single-site surgery for the management of ectopic pregnancy.
Design: Case report.
Setting: University hospital.
Patient(s): A 25-year-old woman with a 7-week ectopic pregnancy and pelvic inflammatory disease.
Intervention(s): Laparoendoscopic single-site surgery and broad-spectrum antibiotics.
Main Outcome Measure(s): Complete resolution of the ectopic pregnancy and pelvic inflammatory disease.
Result(s): A detailed description of the technique of a single-site surgery for management of ectopic pregnancy.
Conclusion(s): Our case presents the first report of single-site surgery for treating ectopic pregnancy. (FertilSterilÒ 2009;-:-–-. Ó2009 by American Society for Reproductive Medicine.) Key Words: Laparoscopy, ectopic pregnancy, surgery Over the last several decades, laparoscopy has been used in- avoiding other ports. We present a case of ectopic pregnancy creasingly in the management of ectopic pregnancy. New in which LESS for salpingectomy was performed with use of techniques and instruments have been used to optimize the a single umbilical cutaneous incision.
benefits of these surgeries. Among the main benefits fromlaparoscopic surgery are the reduced length of hospital stayand the size of the incisions to access the abdominal cavity.
A 25-year-old patient was seen in the emergency department Natural orifice transluminal endoscopic surgery (NOTES) complaining of recent onset of intense pain in the pelvic typifies the ultimate scar reduction in laparoscopic surgery.
region. Ultrasound image revealed an adnexal mass on the The initial concept behind NOTES was scarless surgery.
left side of the uterus and free fluid in the cul-de-sac. She This technique perforates the lumen of a healthy hollow had a positive urinary pregnancy test. A presumptive diagno- viscera, such as the stomach or colon, to access the peritoneal sis of ectopic pregnancy was made, and the patient was taken cavity, indeed eliminating scars. However, NOTES has been associated with a series of issues, such as problems withclosure of the gastric incision and avoidance of infections Surgery was performed with the patient under general en- Alternative surgical techniques have been developed, dotracheal anesthesia and in lithotomy position and a uterine and special attention has been given to laparoendoscopic manipulator in place. A 2.5-cm arciform incision was made at the base of the umbilicus, using the natural skin crease withinthe umbilicus. Subcutaneous dissection with umbilical de- The LESS technique was first introduced in general sur- tachment was performed. This approach increased the space gery for cholecystectomy and in urology for prostatec- for trocar placement, yielding better trocar triangulation.
tomy with use of a single port through the umbilicusand the bladder, respectively. As currently described, LESS The operative surgeon and the camera assistant stood on surgery requires the insertion of multiple low-profile ports the patient’s right and left side, respectively. The second through a single incision usually placed at the umbilicus assistant was used to move the uterine manipulator to pro-vide adequate exposure of the organs. Pneumoperitoneum A technique that resembles LESS was presented by Ghezzi was established with a Veress needle and use of the follow- et al. , who report laparoscopic salpingectomy for tubal ing parameters: intra-abdominal pressure 14 mm Hg, airflow pregnancy using one trocar with the ‘‘marionette-like’’ tech- 2.5 L/min. After lifting the aponeurosis with Kocher clamps, nique, which uses external sutures to provide retraction, thus a 10-mm trocar was placed for the camera attached to Received March 21, 2009; revised June 5, 2009; accepted June 8, 2009.
a 30-degree scope. Two auxiliary 5-mm trocars were placed R.F.S. has nothing to disclose. L.T.C. has nothing to disclose.
on each side of the 10-mm portal, as far apart as the skin Reprint requests: Ricardo Francalacci Savaris, M.D., Hospital de Clınicas incision allowed (The rigid scissors were inserted xo de Ginecologia e Obstetrıcia, Rua Ramiro through the left trocar. The rigid grasper was inserted Barcelos 2350/1125, Porto Alegre, RS, Brazil 90035-903 (FAX:55-51-21018117; E-mail: through the one on the right. Of note, the laparoscopic Fertility and Sterilityâ Vol. -, No. -, - 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
Savaris. Ectopic pregnancy managed with LESS technique. Fertil Steril 2009.
Savaris. Ectopic pregnancy managed with LESS technique. Fertil Steril 2009.
handle of the instruments sometimes was used in the upside- down position, to give more amplitude for the movement of Minimally invasive surgery was first advocated in the latter half of the 20th century. Its major principle is to be less inva-sive, leading to less physiologic stress, faster recovery, and The uterus was lifted by the uterine manipulator and moved to the side opposite the ectopic pregnancy. Adhesionswere identified, cauterized, and cut. Once the fallopian tube Natural orifice transluminal endoscopic surgery and single- with the ectopic pregnancy was exposed, the mesosalpinx port surgery use special instruments. In the case of NOTES, was accessible. The salpingectomy was performed as usual, a flexible endoscope is necessary. In the same manner, sin- with use of a monopolar electrodesiccation, followed by cut- gle-port surgery uses special ports, such as the TriPort or Quad- ting with scissors. After complete removal of the fallopian Port (Advanced Surgical Concepts, Bray, Ireland). On the tube, a 5-mm 30-degree optic (usually used for hysteroscopy) other hand, the LESS technique uses common laparoscopic in- with camera attached was put in the 5-mm trocar. A latex bag struments making it more feasible for general usage.
was introduced through the 10-mm trocar. The 5-mm and The LESS procedure was first described for cholecystec- 10-mm trocars were used to insert two 5-mm forceps, which tomy by Curcillo (Podolsky et al. ). The approach to the were used to place the fallopian tube in the bag. The bag con- pelvic anatomy is familiar to the gynecologist, which may taining the specimen was removed through the 10-mm portal permit faster widespread use and acceptance. In addition, ). The aponeurotic incisions were closed with the skills required for performing the LESS technique are interrupted absorbable suture. The deep surface of the skinof the umbilical site was sutured to the fascial repair withabsorbable suture. The skin was closed with interrupted Final cosmetic aspect of the incision.
The operative time was 50 minutes, and there were no intra-operative complications. After surgery, the patient had signif-icant lower abdominal pain unrelieved by opioids. After fullevaluation with ultrasound, no pathologic abdominal fluidwas detected. On the third postoperative day, morphine waswithheld, after reviewing the patient’s story. The diagnosisof pelvic inflammatory disease was considered. Broad-spec-trum antibiotics (gentamicin and clindamycin) were initiated.
In 24 hours, the patient reported significant improvement ofthe pain. She was discharged from the hospital on postoper-ative day 5, with instructions to take doxycycline and metro-nidazole for an additional 11 days. On postoperative day 15,she returned for evaluation and suture removal. She was in Savaris. Ectopic pregnancy managed with LESS technique. Fertil Steril 2009.
Ectopic pregnancy managed with LESS technique quite similar to the traditional multiport laparoscopic tech- 2. Hazey JW, Narula VK, Renton DB, Reavis KM, Paul CM, Hinshaw KE, nique. In fact, the only difference is the position of trocars.
et al. Natural-orifice transgastric endoscopic peritoneoscopy in humans:initial clinical trial. Surg Endosc 2008;22:16–20.
It seems that the single-site technique allows better range 3. Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice of movements (better triangulation) than single-port systems, Translumenal Endoscopic Surgery. October 2005. Surg Endosc 2006;20: because even with a single incision at the skin, there is a greater distance between the ports at the level of the fascia, 4. Cuesta MA, Berends F, Veenhof AA. The ‘‘invisible cholecystectomy’’: compared with the manufactured port.
a transumbilical laparoscopic operation without a scar. Surg Endosc2008;22:1211–3.
To our knowledge, this is the first report of LESS for ec- 5. Desai MM, Aron M, Canes D, Fareed K, Carmona O, Haber GP, et al.
topic pregnancy. A similar technique was described by Single-port transvesical simple prostatectomy: initial clinical report.
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Ghezzi et al. but they used the marionette technique 6. Teixeira J, McGill K, Binenbaum S, Forrester G. Laparoscopic single- and a special urologic scope and trocar.
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Recently there are some (although scant) published data 7. Ghezzi F, Cromi A, Fasola M, Bolis P. One-trocar salpingectomy for the about clinically applied LESS, for cholecystectomy , ap- treatment of tubal pregnancy: a ‘marionette-like’ technique. Br J Obstet pendectomy and adrenalectomy . These publica- tions agree that the technique is feasible and can be 8. Gettman MT, Box G, Averch T, Cadeddu JA, Cherullo E, Clayman RV, achieved with instruments that are already available, which et al. Consensus statement on natural orifice transluminal endoscopicsurgery and single-incision laparoscopic surgery: heralding a new era makes the learning curve faster. In conclusion, this technique in urology? Eur Urol 2008;53:1117–20.
still needs to be evaluated in further clinical trials, preferably 9. Podolsky ER, Rottman SJ, Poblete H, King SA, Curcillo PG. Single port compared with standard laparoscopy, so that efficacy, safety, access (SPA) cholecystectomy: a completely transumbilical approach.
and potential benefits can be evaluated.
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10. Hodgett SE, Hernandez JM, Morton CA, Ross SB, Albrink M, Rosemurgy AS. Laparoendoscopic single site (LESS) cholecystectomy.
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11. Visnjic S. Transumbilical laparoscopically assisted appendectomy in children: high-tech low-budget surgery. Surg Endosc 2008;22:1667–71.
1. Delgado S, Ibarzabal A, Fernandez-Esparrach G. Natural orifice translu- 12. Castellucci SA, Curcillo PG, Ginsberg PC, Saba SC, Jaffe JS, minal endoscopic surgery: current situation. Gastroenterol Hepatol Harmon JD. Single port access adrenalectomy. J Endourol 2008;22:


Prothrombotic changes in users of combined oral contraceptives containing drospirenone and cyproterone acetate

develop thromboembolic complications [8] and/or recurrentin congenital factor XII deficiency—a study on 74 subjects from 14Swiss families. Thromb Haemost 1991; 65: 117–21. 6 Dyerberg J, Stoffersen E. Recurrent thrombosis in a patient with factorOne other woman with FXII deficiency had a very lowXII deficiency. Acta Haematol 1980; 63: 278–82. PAI-1 (plasminogen activator inhibitor)

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