Here's Malcolm's case:
Saw this girl this morning ( 11.30 our time ). Admitted overnight Wednes/Thursday.
22yo three previous term deliveries.
Last delivery 9w ago.
Early in last pregnancy ( 8w ) presents to our unit with abdo pain, +ve preg test, amenorrhoea, etc. Vag.U/S done by resident showed intra- uterine gestation, and nothing else. At 20 weeks anomaly scan showed normal fetus, but left adnexal echoes ? cyst ( sorry I don't have report ), follow up is planned, but she moves and has baby elsewhere without any action about "cyst".
Late Wednesday she presents to ER with intermnittent lower abdo pain. Before she is seen by ob/gyn intern ER intern does tests including plain abdo X-ray ( ~ your KUB [see I'm learning the lingo ! ] ). This shows three small areas of calcification just left of midline in pelvis. Interns queried renal calculi. Decided to manage conservatively and await my opinion and radiologists report.
Radiologist reports as classical features of left sided ovarian Dermoid.
I see her confirm history as above. She looks sick.
What would you do now ?
What did I do now ?
What did my registrar/resident think I should do ?
REPLIES
What would you do now ?
Scope. No US.
What did I do now ?
Scope. No US.
What did my registrar/resident think I should do ?
TVUS ----> Cut her.
Zach Newton
Z. B. Newton, III, M.D.
Atlanta/Gyn
What would you do now ?
Laparoscopy. Treat as indicated by laparoscopic findings. (My partner would have the "Step" trocar ready to insert through the vagina so he could idilate it, inflate the impermeable bag, drop the cyst into the cul-de-sac, and extract it through the vagina. I would have to hold him off until the anesthesia kicked in)!
What did I do now ?
You 'scoped her. You British dudes are too macho to let a little adnexal mass get in the way of a good scope case.
What did my registrar/resident think I should do ?
Laparotomy with salpingooophorectomy.
D. Ashley Hill, M.D. Orlando, FL
Well how conservative do you want to be? I diagnosis a dermoid cyst with intermitent torson. #1 laparascope, un twist, watch for viability if ok, ovarian cystectomy with suturing of the ovary to prevent re torsion untill the pedical shrinks, thus conserving the ovary. #2 same scenario but no viability laparascopic SO #3 do the case open, no guts no glory
Myer S. Bornstein, M.D.,F.A.C.O.G.
Chairman Department of Obstetrics and Gynecology
Morton Hospital and Medical Center
Taunton, MA
If after conservative assessment she was in fact sick, would proceed to Laparoscopy. If the mass is torted, one could Un-tort a la Bruhat's studies. If it is in fact a cyst, could proceed to adnexal surgery as indicated. If this is a ruptured dermoid however, one must remnember the cases of peritonitis that have been reported both at laparotomy and laparotomy. At 8 weeks would do the entire procedure laparoscopically.
Jay Kulkin, MD
Malcom, I will guess that you took her to surgery for a suspected torsion of the ovary. I prefer to do these by laparoscope and preserve the ovary if possible. Unfortunately, the last few I have had were too far gone to allow conservative therapy.
Miles E Mahan, Major, MD
Dept. OB/GYN Darnall ACH Ft. Hood, Tx
Currently assigned as Bn
Surgeon 1st CAV Task Force Charger ( Kuwait bound)
Laparoscopic cystectomy
What did I do now ?
Wait for our answers :-) and same as above
What did my registrar/resident think I should do ?
Ask on the net and let them operate on!
Bernard Cristalli MD CNGOF
Paris - France
Remove it... However it's customary in your area.
Joe Pastorek, MD
Louisianian, USA
What would you do now ?
EXAMINE THE PATIENT! so that I would get a feel for it.
What did I do now ?
EXAMINED THE PATIENT.
What did my registrar/resident think I should do ?
OPERATE.
With the presentation made here, I would guess that this is a twisting (I don't think torsing is a word) serious cystadenoma with large psammoma bodies. How's that for going out on a limb??
Dan Braun, MD
Indiana, USA
MALCOLM THEN WROTE BACK WITH THE FOLOWING UPDATE ON THE SITUATION:
What would you do now ?
Mostly you said scope her and aim to remove cyst laparoscopically. My concern about this is that Dermoids don't always have a nice tissue plane, and if you rupture it at laparoscopy it will make one hell of a mess. Next I'd be worried about how to get it out. Looking at the teeth on X-ray and imagining how big ther cyst would be I anticipated something like 10-12cm. I tend to think one quick Mini-lapartomy is much better than a long and difficult laparoscopy with three or more puncture sites.
In fact a transvaginal ultrasound scan had been done. Unusually without any attempt at abdo scan first. It showed little, it not being possible to properly visualise either ovary. Certainly no left sided cyst was see.
What did I do now ?
I took her to theatre and when she was on the table anaesthetised I could see what I had failed to palpate by not having examined her ! Large abdomino-pelvic mass extended more than 2/3 from symphysis to umbilicus. WHOOPS ! I had accepted the residents findings from the previous evening !
I therefore continued with my original plan of mini-laparotomy, but rather less mini !
What did my registrar/resident think I should do ?
He thought I should deal with it laparoscopically. In fact due to another commitment he wasn't in theatre with me.
Malcolm Griffiths, MD
United Kingdom
WHICH ELICITED THE FOLLOWING REPLIES:
Agree with your basic principle. Extended OR time and difficult manipulation, particularly when object is potential source of noxious contamination, is circus-surgery. Some dermoids are readily managed laparoscopically. When in doubt of anatomical configuration, as in Part I, preliminary scoping provides the means of determining which surgical approach is more appropriate.
Given the findings at EUA (exam under anesthesia), going straight to laparotomy was a clear path.
In the above context, pre-op ultrasound would change nothing.
In fact a transvaginal ultrasound scan had been done. Unusually without any attemopt at abdo scan first. It showed little, it not being possible to properly visualise either ovary. Certainly no left sided cyst was see.
Important negative information that was derived from TVUS was the apparent absence of the right ovary in the pelvis. Something was of sufficient mass to cause both ovaries to be elevated abdominally.
I took her to theatre and when she was on the table anaesthetised I could see what I had failed to palpate by not having examined her ! Large abdomino-pelvic mass extended more than 2/3 from symphysis to umbilicus. WHOOPS ! I had accepted the residents findings from the previous evening !
I therefore continued with my original plan of mini-laparotomy, but rather less mini !
What did my registrar/resident think I should do ?
He thought I should deal with it laparoscopically. In fact due to another commitment he wasn't in theatre with me.
Registrar did not have knowledge of EUA.
OK. Second part of the quiz is - once I had opened her up what did I find ?
Bilateral dermoids, at least one with torsion.
Zach Newton, MD
Atlanta GA, USA
Ok, so it sounds like you were having a bad day. I will gamble and bet that the calcifications weren't associated with a dermoid. I hope that you didn't end up finding a serous cystadenocarcinoma (psammoma bodies are often calcified and noted on roentologic examination). If so, you probably ended up doing one of two things. 1. You opened her up and noted the ascites along with a mass that was very suspicious for cancer, in which case washings were done and because she was not properly consented you closed her up and sent her to an oncologist. Or 2. you proceeded (because she was well counselled), sent a frozen and treated her based on the findings by pathology.
Maj Miles Mahan, MD
AND THE WINNER IS........................
ZACH NEWTON, MD had the closest call!OBGYN.net will be sending Zach a prize once we figure out what it is. Zach already has an OBGYN.net tee shirt. Malcolm on the other hand owes him dinner in Lutton. Definately worth the trip. ;-)