During an open appendectomy, the person with suspected appendicitis is placed under general  anesthesia  to keep the muscles completely relaxed and to keep the person unconscious. The incision is two to three inches (76 mm) long, and it is made in the right lower abdomen, several inches above the  hip bone . Once the incision opens the abdomen cavity, and the appendix is identified, the  surgeon  removes the infected tissue and cuts the appendix from the surrounding tissue. After careful and close inspection of the infected area, and ensuring there are no signs that surrounding tissues are damaged or infected.  In case of complicated appendicitis managed by an emergency open appendectomy, abdominal drainage (a temporary tube from the abdomen to the outside to avoid abscess formation) may be inserted, but this may increase the hospital stay. [ 92 ] [ needs update ]  The surgeon will start closing the incision. This means sewing the muscles and using  surgical staples  or  stitches  to close the skin up. To prevent infections, the incision is covered with a  sterile bandage  or surgical adhesive.


Laparoscopic appendectomy was introduced in 1983 and has become an increasingly prevalent intervention for acute appendicitis. [ 93 ]  This surgical procedure consists of making three to four incisions in the abdomen, each 0.25 to 0.5 inches (6.4 to 12.7 mm) long. This type of appendectomy is made by inserting a special surgical tool called a laparoscope into one of the incisions. The laparoscope is connected to a monitor outside the person's body, and it is designed to help the surgeon inspect the infected area in the abdomen. The other two incisions are made for the specific removal of the appendix by using  surgical instruments . Laparoscopic surgery requires  general anesthesia , and it can last up to two hours. Laparoscopic appendectomy has several advantages over open appendectomy, including a shorter post-operative recovery, less post-operative pain, and a lower superficial surgical site infection rate. However, the occurrence of an intra-abdominal abscess is almost three times more prevalent in laparoscopic appendectomy than open appendectomy. [ 94 ]


In pediatric patients, the high mobility of the cecum allows externalization of the appendix through the umbilicus, and the entire procedure can be performed with a single incision. Laparoscopic-assisted transumbilical appendectomy is a relatively recent technique but with a long published series and very good surgical and aesthetic results. [ 95 ]


The treatment begins by  keeping the person who will be having surgery from eating or drinking  for a given period, usually overnight. An  intravenous drip  is used to hydrate the person who will be having surgery.  Antibiotics  given intravenously such as  cefuroxime  and  metronidazole  may be administered early to help kill bacteria and thus reduce the spread of infection in the abdomen and postoperative complications in the abdomen or wound. Equivocal cases may become more difficult to assess with antibiotic treatment and benefit from serial examinations. If the stomach is empty (no food in the past six hours), general anaesthesia is usually used. Otherwise,  spinal anaesthesia  may be used.


Once the decision to perform an  appendectomy  has been made, the preparation procedure takes approximately one to two hours. Meanwhile, the surgeon will explain the surgery procedure and will present the risks that must be considered when performing an appendectomy. (With all surgeries there are risks that must be evaluated before performing the procedures.) The risks are different depending on the state of the appendix. If the appendix has not ruptured, the complication rate is only about 3% but if the appendix has ruptured, the complication rate rises to almost 59%. [ 96 ]  The most usual complications that can occur are pneumonia,  hernia  of the incision,  thrombophlebitis , bleeding and  adhesions . Evidence indicates that a delay in obtaining surgery after admission results in no measurable difference in outcomes to the person with appendicitis. [ 97 ] [ 98 ]


The surgeon will explain how long the recovery process should take. Abdomen hair is usually removed to avoid complications that may appear regarding the incision.


In most cases, patients going in for surgery experience nausea or vomiting that require medication before surgery. Antibiotics, along with pain medication, may be administered before appendectomies.


Hospital lengths of stay typically range from a few hours to a few days but can be a few weeks if complications occur. The recovery process may vary depending on the severity of the condition: if the appendix had ruptured or not before surgery. Appendix surgery recovery is generally much faster if the appendix does not rupture. [ 99 ]  It is important that people undergoing surgery respect their doctor's advice and limit their physical activity so the tissues can heal. Recovery after an appendectomy may not require diet changes or a lifestyle change.


The length of hospital stays for appendicitis varies on the severity of the condition. A study from the United States found that in 2010, the average appendicitis hospital stay was 1.8 days. For stays where the person's appendix had ruptured, the average length of stay was 5.2 days. [ 14 ]


After surgery, the patient will be transferred to a  postanesthesia care unit , so their vital signs can be closely monitored to detect anesthesia- or surgery-related complications. Pain medication may be administered if necessary. After patients are completely awake, they are moved to a hospital room to recover. Most individuals will be offered clear liquids the day after the surgery, then progress to a regular diet when the intestines start to function correctly. Patients are recommended to sit on the edge of the bed and walk short distances several times a day. Moving is mandatory, and pain medication may be given if necessary. Full recovery from appendectomies takes about four to six weeks but can be prolonged to up to eight weeks if the appendix has ruptured.


Most people with appendicitis recover quickly after surgical treatment, but complications can occur if treatment is delayed or if  peritonitis  occurs. Recovery time depends on age, condition, complications, and other circumstances, including the amount of alcohol consumption, but usually is between 10 and 28 days. For young children (around ten years old), the recovery takes three weeks.


The possibility of peritonitis is the reason why acute appendicitis warrants rapid evaluation and treatment. People with suspected appendicitis may have to undergo a  medical evacuation . Appendectomies have occasionally been performed in emergency conditions (i.e., not in a proper hospital) when a timely medical evacuation was impossible.


Typical acute appendicitis responds quickly to appendectomy and occasionally will resolve spontaneously. If appendicitis resolves spontaneously, it remains controversial whether an elective interval appendectomy should be performed to prevent a recurrent episode of appendicitis. Atypical appendicitis (associated with suppurative appendicitis) is more challenging to diagnose and is more apt to be complicated even when operated early. In either condition, prompt diagnosis and appendectomy yield the best results with full recovery in two to four weeks usually. Mortality and severe complications are unusual but do occur, especially if peritonitis persists and is untreated.


Another entity known as the appendicular lump is talked about. It happens when the appendix is not removed early during infection, and the omentum and intestine adhere to it, forming a palpable lump. During this period, surgery is risky unless there is pus formation evident by fever and toxicity or by ultrasound. Medical management treats the condition.


An unusual complication of an appendectomy is "stump appendicitis": inflammation occurs in the remnant appendiceal stump left after a prior incomplete appendectomy. [ 100 ]  Stump appendicitis can occur months to years after initial appendectomy and can be identified with imaging modalities such as ultrasound. [ 101 ]


The history of appendicitis traces back to ancient medical texts, though its clear clinical understanding emerged in the 19th century. Berengario da Carpi provided the first recorded description of the appendix in the 16th century, followed by  Andreas Vesalius  and  Gabriele Falloppio . Clinical understanding progressed in the 18th and 19th centuries, marked by Lorenz Heister's autopsy findings, Claudius Aymand's surgical intervention, and J. Mestivier's operation for appendicitis. Prior to the use of the term  appendicitis , it was described with terms including  perityphlitis ,  typhlitis ,  paratyphlitis , and  extra-peritoneal abscess of the right iliac fossa . [ 102 ]  The term "appendicitis" was coined by the American physician  Reginald Heber Fitz  in 1886, leading to standardized diagnosis and treatment, including Charles McBurney's identification of McBurney's point. Modern appendectomy techniques evolved in the early 20th century, coinciding with advancements in pathology, notably demonstrated by Ludwig Aschoff in 1908. [ 103 ] [ 104 ]


Appendicitis is most common between the ages of 5 and 40. [ 106 ]  In 2013, it resulted in 72,000 deaths globally, down from 88,000 in 1990. [ 107 ]


In the United States, there were nearly 293,000 hospitalizations involving appendicitis in 2010. [ 14 ]  Appendicitis is one of the most frequent diagnoses for emergency department visits resulting in hospitalization among children ages 5–17 years in the United States. [ 108 ]


Adults presenting to the emergency department with a known family history of appendicitis are more likely to have this disease than those without. [ 109 ]


Bowel obstruction , also known as  intestinal obstruction , is a mechanical or  functional obstruction  of the  intestines  which prevents the normal movement of the products of  digestion . [ 2 ] [ 5 ]  Either the  small bowel  or  large bowel  may be affected. [ 1 ]  Signs and symptoms include  abdominal pain ,  vomiting ,  bloating  and not passing  gas . [ 1 ]  Mechanical obstruction is the cause of about 5 to 15% of cases of  severe abdominal pain of sudden onset  requiring admission to hospital. [ 1 ] [ 2 ]


Causes of bowel obstruction include  adhesions ,  hernias ,  volvulus ,  endometriosis ,  inflammatory bowel disease ,  appendicitis ,  tumors ,  diverticulitis ,  ischemic bowel ,  tuberculosis  and  intussusception . [ 1 ] [ 2 ]  Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and volvulus. [ 1 ] [ 2 ]  The diagnosis may be made on plain  X-rays ; however,  CT scan  is more accurate. [ 1 ]   Ultrasound  or  MRI  may help in the diagnosis of children or  pregnant  women. [ 1 ]


The condition may be treated conservatively or with  surgery . [ 2 ]  Typically  intravenous fluids  are given, a  nasogastric (NG) tube is placed through the nose into the stomach  to decompress the intestines, and  pain medications  are given. [ 2 ]   Antibiotics  are often given. [ 2 ]  In small bowel obstruction about 25% require surgery. [ 6 ]  Complications may include  sepsis , bowel  ischemia  and  bowel perforation . [ 1 ]


About 3.2 million cases of bowel obstruction occurred in 2015 which resulted in 264,000 deaths. [ 3 ] [ 7 ]  Both sexes are equally affected and the condition can occur at any age. [ 6 ]  Bowel obstruction has been documented throughout history, with cases detailed in the  Ebers Papyrus  of 1550 BC and by  Hippocrates . [ 8 ]


Depending on the level of obstruction, bowel obstruction can present with  abdominal pain ,  abdominal distension , and  constipation . Bowel obstruction may be complicated by  dehydration  and  electrolyte abnormalities  due to vomiting; respiratory compromise from pressure on the  diaphragm  by a distended abdomen, or  aspiration  of vomitus; bowel  ischemia  or  perforation  from prolonged distension or pressure from a foreign body and subsequently  sepsis  due to  bowel flora . [ 9 ]


In small bowel obstruction, the  pain  tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation. [ 10 ]  Common physical exam findings may include signs of  dehydration , abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds. [ 11 ]


In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation. [ 12 ]  Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction. [ 13 ]  Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of  volvulus  and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable  hernia , abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass. [ 6 ]


The main diagnostic tools are  blood tests ,  X-rays  of the abdomen, CT scanning, and  ultrasound . If a mass is identified,  biopsy  may determine the nature of the mass. [ citation needed ]


Radiological  signs of bowel obstruction include bowel distension (small bowel loops dilated >3 cm) and the presence of multiple (more than 2) air-fluid levels on supine and erect abdominal  radiographs . [ 16 ]  Ultrasounds may be as useful as CT scanning to make the diagnosis. [ 17 ]


Contrast enema  or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with  sensitivity  of 97% and  specificity  of 96%. [ 18 ]


Colonoscopy , small bowel investigation with ingested camera or push  endoscopy , and  laparoscopy  are other diagnostic options.


Differential diagnoses  of bowel obstruction include:


Causes of  small bowel  obstruction include: [ 2 ]


After abdominal surgery, the incidence of small bowel obstruction from any cause is 9%. In those where the cause of the obstruction was clear, adhesions are the single most common cause (more than half). [ 22 ]


Causes of large bowel obstruction include: [ 23 ]


Outlet obstruction is a sub-type of large bowel obstruction and refers to conditions affecting the anorectal region that obstruct  defecation , specifically conditions of the pelvic floor and anal sphincters. Outlet obstruction can be classified into four groups. [ 24 ]


Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management. [ 25 ] [ 26 ]  Patients are monitored by the surgical team for signs of improvement and resolution of the obstruction on imaging; if the obstruction does not clear then surgical management for the treatment of the causative lesion is required. [ 27 ]  In malignant large bowel obstruction, endoscopically placed self-expanding metal  stents  may be used to temporarily relieve the obstruction as a bridge to surgery, [ 28 ]  or as  palliation . [ 29 ]  Diagnosis of the type of bowel obstruction is normally conducted through initial plain  radiograph  of the abdomen, luminal contrast studies,  computed tomography scan , or  ultrasonography  prior to determining the best type of treatment. [ 30 ]


Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer. [ 31 ]


In the management of small bowel obstructions, a commonly quoted surgical aphorism is: "never let the sun rise or set on small-bowel obstruction" [ 32 ]  because about 5.5% [ 32 ]  of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies ( volvulus , closed-loop obstructions,  ischemic bowel , incarcerated  hernias , etc.). [ 2 ]  Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of  peritonitis  such as rebound tenderness,  elevated heart rate , fever, and elevated inflammatory markers on lab work, such as  lactic acid . [ 33 ] [ 34 ]


A small flexible tube ( nasogastric tube ) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting.  Intravenous therapy  is utilized and the urine output may be monitored with a  catheter  in the  bladder . [ 35 ] [ 36 ]


Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and  X-ray images  are made to ensure he or she is not getting clinically worse. [ 37 ]


Conservative treatment involves insertion of a  nasogastric tube , correction of dehydration and  electrolyte  abnormalities.  Opioid  pain relievers may be used for patients with severe pain but alternate pain relievers are preferred as opioids can decrease bowel motility. [ 38 ] Antiemetics  may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required.


Most patients improve with conservative care in 2–5 days. When the obstruction is cancer, surgery is the only treatment. Those with  bowel resection  or  lysis  of adhesions usually stay in the hospital a few more days until they can eat and walk. [ 39 ]


Small bowel obstruction caused by  Crohn's disease , peritoneal  carcinomatosis , sclerosing  peritonitis ,  radiation enteritis , and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery.


The prognosis for non-ischemic cases of SBO is good with mortality rates of 3–5%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%. [ 40 ]


Cases of SBO related to cancer are more complicated and require additional intervention to address the  malignancy , recurrence, and  metastasis , and thus are associated with a more poor prognosis. [ 41 ]  Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction. [ 42 ]


All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery. [ 43 ]  More than 90% of patients also form adhesions after major abdominal surgery. [ 44 ]
Common consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility. [ 44 ]


Endoscopic stenting  is a medical procedure by which a  stent , a hollow device designed to prevent constriction or collapse of a tubular organ, is inserted by  endoscopy . They are usually inserted when a disease process has led to narrowing or obstruction of the organ in question, such as the  esophagus  or the  colon .


There are various types of endoscopic stents: plastic stents, uncovered self-expandable metallic stents, partially covered self-expandable metallic stents, and fully covered self-expandable metallic stents. [ 1 ]   Self-expandable metallic stents  "play an important role in the management of malignant obstructing lesions in the gastrointestinal tract." [ 2 ]


A stent may be inserted into the  common bile duct  during an  endoscopic retrograde cholangiopancreatography , especially if  gallstone  removal is deemed too risky. [ 3 ]


Some complications of metallic stents are: stent migration (occurring in 20 to 40% of the cases). Stents with anchoring flaps or flared ends can reduce the risk of migration. Cholecystitis can be a complication for stenting of malignant biliary stricture. Stent occlusion may occur from tumor or tissue overgrowth, or due to sludge deposits, causing the development of cholangitis. [ 1 ]


An  epidural abscess  refers to a collection of pus and infectious material located in the  epidural space  superficial to the  dura mater  which surrounds the  central nervous system . Due to its location adjacent to brain or spinal cord, epidural abscesses have the potential to cause weakness, pain, and paralysis.


A  spinal epidural abscess  (SEA) is a collection of pus or inflammatory granulation between the  dura mater  and the  vertebral column . [ 1 ]   Currently the annual incidence rate of SEAs is estimated to be 2.5–3 per 10,000 hospital admissions.  Incidence of SEA is on the rise, due to factors such as an aging population, increase in use of invasive spinal instrumentation, growing number of patients with risk factors such as diabetes and intravenous drug use. [ 1 ]   SEAs are more common in posterior than anterior areas, [ 2 ]  and the most common location is the  thoracolumbar  area, where  epidural space  is larger and contains more fat tissue. [ 3 ]
SEAs are more common in males, and can occur in all ages, although highest prevalence is during the fifth and seventh decades of life. [ 1 ]


Combined treatment of emergency surgery and antibiotics is the preferred treatment for the spinal epidural abscess, removing existing pus (which is tested for microorganisms to select the most appropriate antibiotic) and removing pressure from the spinal cord and nerve roots. Antibiotic therapy should start after obtaining pus for microbiological investigation. [ citation needed ]


A  cranial epidural abscess  involves pus and granulation tissue accumulation in between the dura mater and cranial bone. These typically arise (along with  osteomyelitis  of a cranial bone) from infections of the ear or paranasal sinuses. They rarely can be caused by distant infection or an infected  cerebral venous sinus thrombosis .  Staphylococcus aureus  is the most common pathogen. Symptoms include pain at the forehead or ear, pus draining from the ear or sinuses, tenderness overlying the infectious site, fever, neck stiffness, and in rare cases focal seizures.  Treatment requires a combination of antibiotics and surgical removal of infected bone. [ 4 ]


article/232570  at  eMedicine


A  gastrojejunocolic fistula  is a disorder of the human  gastrointestinal tract . It may form between the transverse colon and the upper  jejunum  after a  Billroth II  surgical procedure.  (The Billroth procedure attaches the jejunum to the remainder of the stomach.) Fecal matter thereby passes improperly from the colon to the stomach, and causes  halitosis . [ citation needed ]


Patients may present with  diarrhea , [ 1 ]   weight loss  and  halitosis  as a result of fecal matter passing through the  fistula  from the colon into the stomach.


A  glomectomy  is an excision of a  glomus body  or a  glomus cell , usually in the case of a  glomus tumor . This operation was formerly performed for the treatment of severe, chronic  asthma , [ 1 ]  but has since been abandoned for this purpose due to its lack of efficacy. [ 2 ] [ 3 ]


In  human anatomy , the  greater sac , also known as the  general cavity (of the abdomen)  or  peritoneum of the  peritoneal cavity  proper , is the cavity in the  abdomen  that is inside the peritoneum but outside the  lesser sac .


It is connected with the lesser sac via the  omental foramen , also known as the  foramen of Winslow  or  epiploic foramen , which is anteriorly bounded by the portal triad –  portal vein ,  hepatic artery , and  common bile duct .


The  ileojejunal bypass  is an  experimental   surgery  designed as a remedy for  morbid obesity . [ 1 ] [ 2 ]


It was first performed on a series of patients at White Memorial Hospital,  Los Angeles, California , in the mid-to-late 1970s. It has since been discarded, as the complications from the surgery, including malnutrition, vitamin deficiencies, protein and albumin deficiency, liver and renal failure, and kidney stones, highly outweighed the benefits. Many patients who received this surgery consequently underwent reversal surgery.


Intra-abdominal infection  ( IAI , also spelled  intraabdominal ) is a group of  infections  that occur within the  abdominal cavity . They vary from  appendicitis  to  fecal peritonitis . [ 1 ]  Risk of death despite treatment is often high. [ 1 ]


IAIs can be classified into uncomplicated and complicated infections. Uncomplicated infections often involved the infection of single organ and can be controlled by surgical removal of the source of infection, and antibiotics is not required after the surgery to control the infection. In complicated infections, the infection spread to a part or to the whole of the  peritoneum , causing  peritonitis . Meanwhile, peritonitis can be classified into primary, secondary, and tertiary peritonitis. Primary peritonitis is the diffuse bacterial infection of the peritoneum while the integrity of the gastrointestinal tract is preserved (in cases of  ascites ); secondary peritonitis is the infection of peritoneum where the integrity of gastrointestinal tract is compromised; tertiary peritonitis is reinfection of peritoneum 48 hours after apparently good surgical control of secondary peritonitis. [ 2 ]


Those with suspected with IAIs usually have acute onset of abdominal pain with signs of local or generalised  inflammations  such as pain,  tenderness  (pain on touching), fever,  tachycardia  (increased heart rate), or  tachypnea  (increased breathing rate). In more severe cases, such as organ failure, signs such as  hypotension  (low blood pressure),  oliguria  (reduced urine output), sudden onset of  altered level of consciousness , and  lactic acidosis  will appear. [ 2 ]


In case of  appendicitis , signs such as fever, positive  psoas sign , migration of pain from umbilicus to the  right iliac fossa  increases the likelihood of the disease; while signs such as vomiting before the pain reduces its likelihood to occur. [ 2 ]


CT scan and ultrasound has been used routinely to complete the assessment of IAIs. CT scan has higher sensitivity and specificity than ultrasound to access the condition. However, CT scan poses radiation risk to the subject. [ 2 ]  MRI scan is less readily available than CT scan or ultrasound in hospitals to diagnose IAIs. However, it has been proposed to be used in those who are pregnant and have inconclusive findings on ultrasound. The sensitivity and specificity of MRI in diagnosing acute appendicitis are 94% and 96% respectively. [ 2 ]


Laparoscopic surgery has also been used to diagnose the cause of IAIs when imaging is unhelpful. Besides, the laparoscopic surgery can also initiate treatment in the same setting. The accuracy is very high, in the range of 86 to 100%. [ 2 ]


The  lesser sac , also known as the  omental bursa , is a part of the  peritoneal cavity  that is formed by the  lesser  and  greater omentum .  Usually found in mammals, it is connected with the  greater sac  via the  omental foramen  or  Foramen of Winslow . In mammals, it is common for the lesser sac to contain considerable amounts of fat.


If any of the marginal structures rupture their contents could leak into the lesser sac. If the stomach were to rupture on its anterior side though the leak would collect in the  greater sac . [ citation needed ]


The lesser sac is formed during  embryogenesis  from an infolding of the greater omentum. The open end of the infolding, known as the  omental foramen  is usually close to the stomach. [ citation needed ]


A  Meckel's diverticulum , a true  congenital   diverticulum , is a slight bulge in the  small intestine  present at birth and a  vestigial  remnant of the  vitelline duct . It is the most common malformation of the  gastrointestinal tract  and is present in approximately 2% of the population, [ 1 ]  with males more frequently experiencing symptoms.


Meckel's diverticulum was first explained by  Fabricius Hildanus  in the sixteenth century and later named after  Johann Friedrich Meckel , who described the embryological origin of this type of diverticulum in 1809. [ 2 ] [ 3 ]


The majority of people with a Meckel's diverticulum are  asymptomatic . An asymptomatic Meckel's diverticulum is called a  silent  Meckel's diverticulum. [ 4 ]  If symptoms do occur, they typically appear before the age of two years. [ 5 ]  The most common presenting symptom is painless  rectal bleeding  such as  melaena -like black offensive stools, followed by  intestinal obstruction ,  volvulus  and  intussusception . Occasionally, Meckel's diverticulitis may present with all the features of  acute appendicitis . [ 6 ]  Also, severe pain in the  epigastric region  is experienced by the person along with bloating in the epigastric and umbilical regions. At times, the symptoms are so painful that they may cause sleepless nights with acute pain felt in the foregut region, specifically in the  epigastric  and  umbilical  regions. [ citation needed ]  In some cases, bleeding occurs without warning and may stop spontaneously. The symptoms can be extremely painful, often mistaken as just stomach pain resulting from not eating or constipation. [ citation needed ]  Rarely, a Meckel's diverticulum containing ectopic pancreatic tissue can present with abdominal pain and increased serum amylase levels, mimicking acute pancreatitis. [ 7 ]


The lifetime risk for a person with Meckel's diverticulum to develop certain  complications  is about 4–6%. Gastrointestinal bleeding,  peritonitis  or  intestinal obstruction  may occur in 15–30% of symptomatic people (Table 1). On rare occasions the diverticulum can herniate through the abdominal wall also known as a  Littre hernia.  Only 6.4% of all complications require surgical treatment, and untreated Meckel's diverticulum has a  mortality rate  of 2.5–15%. [ 8 ]


Table 1 – Complications of Meckel's Diverticulum: [ 9 ]


Bleeding of the diverticulum is most common in young children, especially in males who are less than 2 years of age. [ 10 ]  Symptoms may include bright red blood in stools ( hematochezia ), weakness, abdominal tenderness or pain, and even  anaemia  in some cases. [ 11 ]


Bleeding may be caused by:


The appearance of stools may indicate the nature of the bleeding:


Inflammation of the diverticulum can mimic symptoms of appendicitis, i.e., periumbilical tenderness and intermittent crampy abdominal pain. Perforation of the inflamed diverticulum can result in peritonitis. Diverticulitis can also cause  adhesions , leading to intestinal obstruction. [ 14 ]


Diverticulitis may result from:


Symptoms:  Vomiting, abdominal pain and severe or complete  constipation . [ 18 ]


Anomalies between the diverticulum and umbilicus may include the presence of a fibrous cord,  cyst , fistula, or sinus, leading to: [ 14 ]


Neoplasms  (tumors) in Meckel's diverticulum may cause bleeding, acute abdominal pain, gastrointestinal obstruction, perforation or intussusception. They may be  benign  or  malignant . [ 14 ]


The omphalomesenteric duct (omphaloenteric duct, vitelline duct, or yolk stalk) normally connects the embryonic midgut to the yolk sac ventrally, providing nutrients to the midgut during embryonic development. The vitelline duct narrows progressively and disappears between the 5th and 8th weeks of gestation. [ citation needed ]


In Meckel's diverticulum, the proximal part of vitelline duct fails to regress and involute, which remains as a remnant of variable length and location. [ 16 ]  The solitary diverticulum lies on the antimesenteric border of the ileum (opposite to the  mesenteric attachment ) and extends into the umbilical cord of the embryo. [ 8 ]  The left and right vitelline arteries originate from the primitive  dorsal aorta , and travel with the vitelline duct. The right becomes the  superior mesenteric artery  that supplies a terminal branch to the diverticulum, while the left involutes. [ 17 ]  Having its own blood supply, Meckel's diverticulum is susceptible to obstruction or infection.


Meckel's diverticulum is located in the  distal   ileum , usually within 60–100 cm (2 feet) of the  ileocecal valve . This  blind segment  or small pouch is about 3–6 cm (2 inch) long and may have a greater  lumen  diameter than that of the  ileum . [ 20 ]  It runs antimesenterically and has its own blood supply. It is a remnant of the connection from the  yolk sac  to the small intestine present during  embryonic development . It is a  true diverticulum , consisting of all three layers of the  bowel  wall:  mucosa ,  submucosa  and  muscularis propria . [ 17 ]


As the vitelline duct is made up of  pluripotent  cell lining, Meckel's diverticulum may harbor abnormal tissues, containing embryonic remnants of other tissue types.  Jejunal ,  duodenal  mucosa or  Brunner's tissue  were each found in 2% of  ectopic  cases.  Heterotopic  rests of  gastric  mucosa and  pancreatic  tissue are seen in 60% and 6% of cases respectively. Heterotopic means the displacement of an organ from its normal anatomic location. [ 21 ]  Inflammation of this Meckel's diverticulum may mimic appendicitis. Therefore, during appendectomy, ileum should be checked for the presence of Meckel's diverticulum, if it is found to be present it should be removed along with appendix. [ citation needed ]


A  memory aid  is the rule of 2s: [ 22 ]


However, the exact values for the above criteria range from 0.2–5 (for example, prevalence is probably 0.2–4%). [ citation needed ]


It can also be present as an indirect  hernia , typically on the right side, where it is known as a " Hernia of  Littré ". A case report of strangulated  umbilical hernia  with Meckel's diverticulum has also been published in the literature. [ 23 ]  Furthermore, it can be attached to the umbilical region by the vitelline ligament, with the possibility of vitelline cysts, or even a patent vitelline canal forming a vitelline  fistula  when the umbilical cord is cut. Torsions of intestine around the intestinal stalk may also occur, leading to obstruction,  ischemia , and  necrosis .


A  technetium-99m  ( 99mTc )  pertechnetate  scan, also called Meckel scan or nuclear scintigraphy scan, is the investigation of choice to diagnose Meckel's diverticula in children. This scan detects  gastric mucosa ; since approximately 50% of symptomatic Meckel's diverticula have ectopic gastric or pancreatic cells contained within them, [ 24 ]  this is displayed as a spot on the scan distant from the stomach itself. In children, this scan is highly accurate and  noninvasive , with 95% specificity and 85% sensitivity; [ 17 ]  however, in adults the test is only 9% specific and 62% sensitive. [ 25 ]  This scan is more accurate in children because gastric mucosa is found in 90% of bleeding diverticula; which is the most common symptom in children, not adults.  [ 26 ]


Patients with these misplaced gastric cells may experience  peptic ulcers  as a consequence. Therefore, other tests such as  colonoscopy  and screenings for  bleeding disorders  should be performed, and  angiography  can assist in determining the location and severity of bleeding. Colonoscopy might be helpful to rule out other sources of bleeding but it is not used as an identification tool. [ citation needed ]


Angiography  might identify brisk bleeding in patients with Meckel's diverticulum. [ 17 ]


Ultrasonography  could demonstrate omphaloenteric duct remnants or cysts. [ 27 ]   Computed tomography  (CT scan) might be a useful tool to demonstrate a blind ended and inflamed structure in the mid-abdominal cavity, which is not an appendix. [ 17 ]


In asymptomatic patients, Meckel's diverticulum is often diagnosed as an incidental finding during  laparoscopy  or  laparotomy . [ citation needed ]


Treatment is surgical, potentially with a laparoscopic  resection . [ 17 ]  In patients with bleeding, strangulation of bowel, bowel perforation or  bowel obstruction , treatment involves surgical resection of both the Meckel's diverticulum itself along with the adjacent bowel segment, and this procedure is called a "small bowel resection". [ 17 ]  In patients without any of the aforementioned complications, treatment involves surgical resection of the Meckel's diverticulum only, and this procedure is called a simple  diverticulectomy . [ 17 ]


With regards to asymptomatic Meckel's diverticulum, some recommend that a search for Meckel's diverticulum should be conducted in every case of  appendectomy /laparotomy done for  acute abdomen , and if found, Meckel's diverticulectomy or resection should be performed to avoid secondary complications arising from it. [ 28 ]


Meckel's diverticulum occurs in about 2% of the population. [ 21 ]  Prevalence in males is 3–5 times higher than in females. [ 20 ]  Only 2% of cases are symptomatic, which usually presents among children at the age of 2. [ 8 ]


Most cases of Meckel's diverticulum are diagnosed when complications manifest or incidentally in unrelated conditions such as laparotomy, laparoscopy or contrast study of the small intestine. Classic presentation in adults includes intestinal obstruction and inflammation of the diverticulum (diverticulitis). Painless rectal bleeding most commonly occurs in toddlers. [ 5 ]


Inflammation in the ileal diverticulum has symptoms that mimic appendicitis, therefore its diagnosis is of clinical importance. Detailed knowledge of the pathophysiological properties is essential in dealing with the life-threatening complications of Meckel's diverticulum. [ 17 ]


In  human anatomy , the  omental foramen  ( epiploic foramen ,  foramen of Winslow  after the anatomist  Jacob B. Winslow , or uncommonly  aditus ;  Latin :  Foramen epiploicum ) is the passage of communication, or foramen, between the  greater sac , and the  lesser sac  of the  peritoneal cavity .


It has the following borders:


As the portal vein is the most posterior structure in the hepatoduodenal ligament, and the inferior vena cava lies under the posterior wall, the epiploic foramen can be remembered as lying between the two great veins of the abdomen.


This article incorporates text in the  public domain  from  page 1156  of the 20th edition of   Gray's Anatomy   (1918)


A  Paget's abscess , named by eminent British surgeon and pathologist Sir  James Paget , is an  abscess  that recurs at the site of a former abscess which had resolved. [ 1 ] [ 2 ]


Pelvic abscess  is a  collection of pus  in the  pelvis , typically occurring following lower abdominal  surgical procedures , or as a complication of  pelvic inflammatory disease  (PID),  appendicitis , or lower genital tract infections. [ 1 ]  Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  It can lead to sepsis and death. [ 1 ]


Blood tests typically show a  raised white cell count . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Ultrasound ,  CT-scan  or  MRI  may be used to locate the abscess and assess its dimensions. [ 1 ]  Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT . [ 3 ]  Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]


Signs and symptoms include a high  fever , pelvic mass, vaginal bleeding or discharge, and lower  abdominal pain . [ 1 ]  There may be urinary frequency,  diarrhoea , or persistent  feeling of needing to pass stool . [ 4 ]  Other symptoms may include fatigue, nausea, and vomiting. [ 2 ]  Clinical features might not be apparent until the pelvic abscess has grown in size. [ 2 ]  The lower abdomen is generally tender; one or both sides. [ 2 ]  A bulging of the front wall of the rectum might be felt on digital examination via the rectum or vagina. [ 2 ]


Complications include sepsis and  peritonitis . [ 1 ]  In the longterm, a  fistula  may develop. [ 2 ]


Pelvic abscess typically occurs following  gynecological surgery  and  abdominal surgery ; hysterectomy, laparotomy, caesarian section, and induced abortion. [ 1 ]   It may occur as a complication of  pelvic inflammatory disease  (PID),  appendicitis ,  diverticulitis ,  inflammatory bowel disease  (IBD), trauma, pelvic organ cancer, or lower genital tract infections. [ 1 ] [ 3 ]  The abscess may be in the  pouch of Douglas ,  fallopian tube ,  ovary , or  parametrium . [ 1 ]  It begins as inflammation or a  collection of blood  in the pelvis. [ 1 ]  Other risk factors include immunodeficiency, pregnancy,  hydrosalpinx ,  endometrioma , poorly controlled  diabetes ,  kidney disease ,  obesity , and genital tract abnormalities. [ 1 ] [ 2 ]  Opening the rectum to resect a  rectal cancer  may lead to developing a pelvic abscess. [ 3 ]


PID in females may lead to a  tubo-ovarian abscess , where the abscess may be in the  fallopian tube  or  ovary . [ 1 ] [ 2 ]


In children, it is more frequently associated with IBD and appendicitis. [ 5 ]


Blood tests typically show a  raised white cell count , often with a high  ESR  and  C-reactive protein . [ 1 ]  Other tests generally include  urine pregnancy test ,  blood  and  exudate culture , and  vaginal wet mount . [ 1 ]   Medical imaging  to assess the dimensions and locate the abscess may include  ultrasound ,  CT-scan  or  MRI . [ 1 ]


Other conditions that appear similar include  ectopic pregnancy , PID, appendicitis,  kidney stone ,  bowel obstruction , and sepsis following  miscarriage  or  termination of pregnancy . [ 1 ]


Treatment is with  antibiotics  and drainage of the abscess; typically guided by  ultrasound  or  CT ,  through the skin ,  via the rectum , or  transvaginal  routes. [ 3 ]  Occasionally antibiotics may be used without surgery; if the abscess is at a very stage and small. [ 2 ]  Until sensitivities are received, a broad spectrum antibiotic is generally required. [ 2 ]  Sometimes, a laparotomy of laparoscopy is required. [ 2 ]


Endoscopic ultrasound (EUS) is a minimally invasive alternative method. [ 3 ]  Treatment also includes  adequate hydration . [ 1 ]


Further surgery such as is sometimes required to treat the underlying cause; such as salpingo-oophorectomy for tubo-ovarian abscess. [ 2 ]


Pelvic abscess responds well to antibiotics and hydration. [ 1 ]  The outcome is less successful in the presence of fistula. [ 2 ]


It is uncommon. [ 2 ]  The incidence of pelvic abscess is less than 1% in an individual undergoing obstetric and gynecological operative procedure. [ 3 ]


A  retrograde appendicectomy  is a form of  surgery  to remove an  appendix  that is retrocaecal and adherent [ 1 ]  or otherwise inaccessible, so that the  appendicectomy  is performed in a retrograde fashion. [ 2 ]  In cases of acute appendicitis, antegrade appendicectomy is the preferred option, but in cases where the base of the appendix is accessible but is difficult to identify or deliver its more distal portion, a retrograde appendicectomy becomes necessary. [ 3 ]


Firstly, the base is divided between artery forceps then the appendiceal vessels are then ligated, the stump ligated and invaginated, and gentle traction on the caecum will enable the surgeon to deliver the body of the appendix, which is then removed from base to tip. [ 4 ]


Subphrenic abscess  is a disease characterized by an accumulation of infected fluid between the  diaphragm ,  liver , and  spleen . [ 2 ]   This  abscess  develops after surgical operations like  splenectomy .
Presents with cough, increased respiratory rate with shallow respiration, diminished or absent breath sounds, hiccups, dullness in percussion, tenderness over the 8th–11th ribs, fever, chills, anorexia and shoulder tip pain on the affected side. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death.
Patients who develop peritonitis may get localized abscesses in the right or left subphrenic space. The right side is more common due to the high frequency of ruptured appendices and perforated duodenal ulcers.
Two common approaches to draining a subphrenic abscess are 1) incision inferior to or through the bed of the 12th rib (no need to create an opening in the pleura or peritoneum) 2) an anterior subphrenic abscess is often drained through a subcostal incision located inferior and parallel to the right costal margin.  [ 3 ]  It is also associated with  peritonitis . [ 4 ]


This article related to  pathology  is a  stub . You can help Wikipedia by  expanding it .


This article about a medical condition affecting the respiratory system is a  stub . You can help Wikipedia by  expanding it .


A  tracheo-esophageal puncture  (or  tracheoesophageal puncture ) is a surgically created hole between the  trachea  (windpipe) and the  esophagus  (food pipe) in a person who has had a total  laryngectomy , a surgery where the  larynx  (voice box) is removed. The purpose of the puncture is to restore a person’s ability to speak after the vocal cords have been removed. This involves creation of a  fistula  between the trachea and the esophagus, puncturing the short segment of tissue or “common wall” that typically separates these two structures.  A voice prosthesis is inserted into this puncture. The prosthesis keeps food out of the trachea but lets air into the esophagus for  esophageal speech .


A laryngectomized person is required to breathe through a permanent breathing hole in the neck, called a  tracheostoma . When a laryngectomized person occludes the tracheostoma, completely blocking exhaled air to leave the body through that pathway, exhaled air is directed through the voice prosthesis. This air enters the esophagus and escapes through the mouth. During this process, as the air passes through the upper tissues of the esophagus and lower throat, it allows for vibration of the tissues of the pharyngo-esophageal segment (also called PE-segment, neoglottis or pseudoglottis). This vibration creates a sound that serves to replace the sound the  vocal cords  previously produced. Other methods of  alaryngeal speech  (speech without vocal cords) are esophageal speech, and  electrolaryngeal speech . Studies show that tracheo-esophageal speech is found to be closer to normal speech than esophageal speech [ 1 ] [ 2 ] [ 3 ]  and is often reported to be better, both in terms of naturalness as well as how well it is understood, when compared to esophageal speech [ 4 ] [ 5 ]   and electrolarynx speech. [ 6 ]
The first report on a tracheo-esophageal puncture dates back to 1932 [ 7 ]  when a laryngectomized patient was said to use a hot ice pick to create a tracheo-esophageal puncture in himself. This enabled him to speak by forcing air through the puncture when closing off the tracheostoma with a finger.


There are two tracheo-esophageal puncture procedure types: Primary and secondary puncture. Initially, the procedure was described as a secondary procedure [ 8 ]  and later also as a primary procedure. [ 9 ]


This procedure is performed during the total laryngectomy surgery. After removal of the larynx and creation of the tracheostoma, the puncture is made through the back wall of the trachea into the front wall of the esophagus. The main advantages of a primary puncture are: 1) that a second surgery to create the puncture is avoided (including the related costs and risks) and: 2) that the patient will be able to speak within a few weeks after total laryngectomy. [ 10 ] [ 11 ]


There are cases where a primary procedure cannot be performed. For example, this procedure cannot be used when there is complete separation of the tracheo-esophageal wall where the puncture would otherwise be placed (for example, in case a portion of the esophagus is removed requiring an anastomosis, or “reconnection” of structures in the region).  In that case, a sufficient period of recovery and wound healing would be required. A secondary puncture could then be placed. [ citation needed ]


This procedure refers to a puncture that is placed anytime after the total laryngectomy surgery. The decision to use a primary or secondary puncture can vary greatly. Secondary puncture can be performed when: 1) primary puncture was not possible, 2) for re-puncture after closure of a previous tracheo-esophageal puncture, 3) because of physician or patient preference, and 4) in case failure of esophageal or electrolarynx speech if this was chosen as the initial speech option. [ citation needed ]


There are two different methods that can be used to place the  voice prosthesis :
Primary placement: A voice prosthesis is placed into the puncture [ 12 ] [ 13 ]  immediately after it is created. During the immediate postoperative period, the patient is fed through a feeding tube, either inserted directly into the stomach or through a more temporary version than extends from the nose into the stomach. This tube is removed when the patient is able to eat enough by mouth to maintain nutritional needs; this can be as early as the second day following surgery. [ 11 ]  Speech production with the voice prosthesis is initiated when the surgical area has healed, after clearance by the surgeon. The advantages of this method are:
1) the voice prosthesis stabilizes the TE wall,
2) the flanges of the device protect the puncture against leakage of fluids, stomach acids and other stomach contents,
3) there is no irritation or pressure from a stenting catheter, used to maintain the puncture opening until a voice prosthesis can be placed,
4) patients become quickly familiar with their prosthesis care as they receive instructions while hospitalized,
5) the patient will not have to undergo an outpatient procedure during which the voice prosthesis needs to be fitted,
6) many patients can learn to speak before the start of any post-operative radiation therapy (if indicated)
7) the patient can focus on voice production immediately, as wound healing allows. [ 11 ]


Another advantage is that generally, the voice prosthesis placed at the time of surgery lasts relatively long and requires no early frequent replacements. [ 14 ] [ 15 ]  The only disadvantage is that the patient will need to use a feeding tube for a few days.


Delayed placement: Instead of the voice prosthesis, a catheter (red rubber, Silastic Foley catheter,  Ryle's tube ) is introduced through the puncture into esophagus. [ 10 ]  The tube is sometimes utilized for feeding the patient during the immediate post operative period, or the patient has a standard feeding tube for feeding. The voice prosthesis is placed after the patient is able to eat sufficiently by mouth and speech production is initiated when healing has completed, after clearance by the surgeon. The advantage of this method is that the patient may be fed through the catheter, not requiring standard tube feeding. The primary disadvantage is that the patient will have to undergo an outpatient procedure to have the voice prosthesis placed. Another disadvantage can be the need for more frequent replacements early after fitting of the voice prosthesis due to changes in the length of the puncture. [ 16 ]


Indications  include voice rehabilitation for patients who are undergoing a total laryngectomy (primary puncture) or patients who have had a total laryngectomy in the past (secondary puncture).
 Contra-indications  are mainly related to the use of the voice prosthesis and not the puncture procedure itself. It is important to have healthy tissue at the puncture site. This  will help ensure the voice prosthesis is properly supported. Poor tissue condition at the puncture site can be a contra-indication for TE puncture. It is also important that the patient candidacy be taken into account. Patients must be able to understand and manage proper prosthesis maintenance and monitor for complications or device problems. Bleeding disorders, anxiety disorders, dementia, poor vision and poor manual dexterity are all factors that may negatively interfere with successful voice restoration using tracheo-esophageal techniques and should be discussed further with an appropriate healthcare provider who is knowledgeable in this topic. [ citation needed ]


Gynecological surgery  refers to surgery on the  female reproductive system  usually performed by  gynecologists . It includes procedures for  benign  conditions,  cancer ,  infertility , and incontinence. [ 1 ]  Gynecological surgery may occasionally be performed for optional or  cosmetic purposes , such as  hymenoplasty  or  labiaplasty .


Following are different types of gynecologic procedures- [ 2 ]


Gynecological surgery includes: [ medical citation needed ]


With the advancement of technology there has been robot-assisted surgery in many areas. [ 3 ]  It helps in avoiding extra testing and other instruments. [ 4 ]


Cervical cerclage , also known as a  cervical stitch , is a treatment for  cervical weakness , when the  cervix  starts to shorten and open too early during a pregnancy causing either a late miscarriage or preterm birth. In women with a prior spontaneous preterm birth and who are pregnant with one baby, and have shortening of the cervical length less than 25 mm, a cerclage prevents a  preterm birth  and reduces death and illness in the baby. [ 1 ]


The treatment consists of a strong  suture  sewn into and around the cervix early in the pregnancy, usually between weeks 12 to 14, and then removed towards the end of the pregnancy when the greatest risk of miscarriage has passed. The procedure is performed under local  anaesthesia , usually by way of a  spinal block . It is typically performed on an outpatient basis by an  obstetrician-gynecologist . Usually the treatment is done in the first or second trimester of pregnancy, for a woman who has had one or more late miscarriages in the past. [ 2 ]  The word "cerclage" means encircling, hooping or banding in French. [ 3 ]


The success rate for cervical cerclage is approximately 80–90% for elective cerclages, and 40–60% for emergency cerclages. A cerclage is considered successful if labor and delivery is delayed to at least 37 weeks (full term). After the cerclage has been placed, the patient will be observed for at least several hours (sometimes overnight) to ensure that she does not go into premature labor. The patient will then be allowed to return home, but will be instructed to remain in bed or avoid physical activity (including sexual intercourse) for two to three days, or up to two weeks. Follow-up appointments will usually take place so that her doctor can monitor the cervix and stitch and watch for signs of premature labor. [ citation needed ]


For women who are pregnant with one baby (a singleton pregnancy) and at risk for a preterm birth, when cerclage is compared with no treatment, there is a reduction in preterm birth and there may be a reduction in the number of babies who die ( perinatal mortality ) [ 2 ]  There is no evidence that cerclage is effective in a multiple gestation pregnancy for preventing preterm births and reducing perinatal deaths or neonatal morbidity. [ 4 ]  Various studies have been undertaken to investigate whether cervical cerclage is more effective when combined with other treatments, such as antibiotics or vaginal pessary, but the evidence remains uncertain. [ 5 ]


There are three types of cerclage: [ 6 ]


While cerclage is generally a safe procedure, there are a number of potential complications that may arise during or after surgery. These include: [ citation needed ]


The Arabin Pessary is a silicone device that has been suggested to prevent spontaneous preterm birth without the need for surgery. [ 11 ]  The leading hypotheses for its mechanisms were that it could help keep the cervix closed similarly to the cerclage, as well as change the inclination of the cervical canal so that the pregnancy weight is not directly above the internal  os . However, large randomized clinical trials in singleton [ 12 ]  and twin pregnancies [ 13 ]  found that the cervical  pessary  did not result in a lower rate of spontaneous early preterm birth. Therefore, the Society for Maternal-Fetal Medicine recommendation is that placement of cervical pessary in pregnancy to decrease preterm birth, should be used only in the context of a clinical trial or research protocol. [ 14 ]


Chromopertubation  is a method for the study of  fallopian tube   patency  (a state of being open or unobstructed) for suspected infertility in women caused by  fallopian tube obstruction . Occlusion or pathology of the fallopian tubes is the most common cause of suspected infertility. [ 1 ]  Chromopertubation is sometimes commonly referred to a "laparoscopy and dye" test. [ 2 ]  It is currently one of the standard procedures in this field. [ 3 ]  In most cases, chromopertubation is performed to assess and determine the cause of someone's difficulties in getting pregnant. [ 4 ]


Chromopertubation is a medical procedure in which blue dye is injected into the fallopian tubes to detect if there are any blockages. It is performed as a  laparoscopy , a minimally invasive procedure with small incisions. A laparoscope, a long, fine instrument is inserted into the abdomen close to the umbilicus in order to see one's internal organs, in particular the fallopian tubes. There is also a device called a uterine manipulator that is placed through the vagina and cervix into the uterus. [ 5 ]  As part of a laparoscopy, a blue dye solution ( methylene blue  or  indigo carmine ) is introduced into the uterine cavity. The dye solution will help determine if the fallopian tubes are open or blocked. If the fallopian tubes are open, the dye solution will enter and drain out into the pelvic cavity through the ends of the tubes. A tubular blockage is suspected if the fluid does not enter into the fallopian tubes or enters, but does not drain out of the fallopian tubes. [ 5 ]  Blocked fallopian tubes can be a factor of infertility in which the fallopian tubes will not allow the egg and sperm to meet.


Chromopertubation with laparoscopy is considered the "gold standard" to evaluate tubal patency. [ 6 ]  It is the most accurate way to look at the abdominal cavity and other pelvic structures. Other problems that can be viewed during the procedure are malformations of the uterus, adhesions, blocked fallopian tubes, or  endometriosis . Slight adhesions inside a fallopian tube can be observed by the flow of dye solution and removed during the procedure. [ 6 ]  Other findings, such as endometriotic lesions, may also be treated as part of laparoscopy. [ 6 ]   If laparoscopy with chromopertubation shows a mild blockage within one or both of the fallopian tubes, surgical reconstruction of the tubes can be performed. [ 2 ]  Studies have shown that tubal flushing with a contrast medium could be used as a treatment for infertility, as it was noted that many women were able to conceive within the first 3–6 months after the procedure. [ 7 ]


Oil-based contrast medium is typically used in hysterosalpingography (HSG), while water-based contrast medium is regularly used in hystero contrast sonography (HyCoSy), hysterosalpingo-foam sonography (HyFoSy), laparoscopy with chromopertubation, and HSG. [ 8 ]  A meta-analysis that combined the results of five studies found that tubal flushing in HSG with an oil-based contrast medium moderately increased the odds of having a live-birth within six months. [ 8 ]  The benefit of a water-soluble contrast medium in tubal flushing is unclear. [ 7 ]  The effects of tubal flushing with either type of contrast media beyond six months are unknown and more research is needed to see if there is a difference in contrast media when used for tubal flushing in laparoscopy with chromopertubation. [ 8 ]


Chromopertubation is done during laparoscopy, which requires  general anesthesia . General anesthesia is usually safe, but problems, such as pain, nausea and vomiting, sore throat, and muscle aches may arise. Around the small incisions on the abdomen, there will be some pain and may also be some bruising around the lower abdomen. [ 5 ]  There is a risk of procedural complications, such as bleeding or abdominal injury, which may result in longer recovery times. [ 6 ]  Also, some bleeding in the vagina can be from the placement of the instrument during the dye test. Minor bleeds should stop within a couple of days. [ 5 ]  Another issue is the chance of cornual spasms, which often occur if the injection of dye is done too quickly. [ 1 ]  These spasms, or contractions, can block off the interstitial region (proximal portion) of the fallopian tubes, leading to an incorrect diagnosis of proximal tube occlusion. [ 1 ]  Furthermore, the insertion of the instruments into the abdomen can potentially injure major abdominal organs, such as the small and large intestines, bladder, and blood vessels. Previous surgeries or procedures, such as Caesarean surgery, ovarian cyst removal, bladder surgery, or appendix removal can increase the chances of abdominal organs damage during chromopertubation. Difficulties with the insertion of the laparoscope can rarely happen. These difficulties usually occur in those who are overweight or who have had previous abdomen scarring from another procedure. If the instrument cannot be inserted into the abdominal cavity, chromopertubation will not be recommended. Instead, alternative methods of checking the fallopian tubes will be taken into consideration. Because laparoscopy with chromopertubation is a more time intensive diagnostic procedure, if no significant findings are found, then there may be a delay in starting other infertility therapies. [ 6 ]


Allergic-like reactions and  methemoglobinemia  have been documented after the use of methylene blue dye in chromopertubation. [ 9 ]  These reported symptoms vary from blue discoloration of body fluids to anaphylactic shock. [ 10 ]  Methemoglobinemia is a blood disorder that can potentially result in various levels of  cyanosis . [ 11 ]  High levels of methylene blue dye can also result in  hemolysis . In particular, methylene blue dye should be avoided in people using serotonergic drugs, such as  selective serotonin reuptake inhibitors (SSRIs)  and antidepressants, since this interaction may cause fatal  serotonergic syndrome . [ 12 ]  Serotonergic syndrome presents as changes in mental status, in addition to overactivation of the neuromuscular and nervous systems. [ 13 ]  Common symptoms of fatal serotonergic syndrome include high fevers, seizures, and tremors. [ 14 ]  Other reported features of fatal serotonergic syndrome include  hyperthermia , respiratory failure,  rhabdomyolysis ,  metabolic acidosis ,  myoglobinuria , renal failure, coma, and death. [ 13 ]


While there have been recent studies showing an increased odds of clinical pregnancy when an oil-based contrast medium is used for tubal flushing, there is also an increased risk for intravasation. [ 15 ]  Intravasation of oil-based contrast is the process of small oil droplets entering the blood circulation and causing inflammation of blood vessels or blocking blood vessels, potentially in the lungs or brain. [ 15 ]  Oil-based contrast medium also has a higher amount of iodine, as compared to water-based contrast medium, and this higher iodine exposure could lead to subclinical hypothyroidism. [ 15 ]


The cost of fallopian tube surgeries can range from $3,000 to up to about $13,000. [ 16 ]  The costs of the procedures and surgeries depends on insurance coverage, complications, and the type of fallopian tube surgery. In the female reproductive system, the fallopian tubes are one of the most important parts because the tubes connect to the ovaries where the eggs are released. To check if the fallopian tubes are blocked or damaged, a laparoscopy will cost from $1,700 to $5,000. [ 17 ]  If the fallopian tubes are blocked, there will be no fertilization and therefore, the egg and sperm cannot meet. If an individual wants to open up their fallopian tubes, a procedure called fallopian tube recanalization can be performed. During this procedure, cuts or incisions are not necessary, instead a catheter is inserted into the womb and fallopian tubes to make sure a blockage is confirmed, and then a second catheter is inserted to clear that blockage. This can cost about $3,000–$5,000. [ 16 ]  In addition, there is another procedure called salpingostomy when the fallopian tubes are filled with fluid. This procedure costs about $5,000–$7,000. The doctor opens the tube to remove the blockage, but does not disturb the position of the fallopian tube. [ 16 ]


There are also other procedures to determine whether or not someone's fallopian tubes are blocked. While laparoscopy with chromopertubation is considered to be the first-line practice for the diagnosis of tubal occlusion, it is generally a more expensive and invasive procedure, and it is recommended for women with comorbidities of both tubal occlusion and another pelvic pathology. [ 18 ]


Hysterosalpingography  (HSG), a different diagnostic procedure for tubal occlusion, is commonly performed in women without suspected comorbidities. [ 18 ]  HSG is done initially with an X-ray examination performed by a radiologist. While the main purpose of HSG is to evaluate the fallopian tubes, HSG does not provide an explanation for why the tubes are blocked. The examination should be scheduled between 7–12 days of an individual's menstrual cycle. [ 19 ]  Ideally, it should be completed within 2–5 days after menses is over. [ 1 ]  Radiographic dye is used to assess the uterine cavity and fallopian tubes. It can be used to study suspected infertility, as well as tubal disease. [ 20 ]  During a HSG procedure, the uterus is injected with contrast dye, which can be observed via fluoroscopy. [ 21 ]  The test results are normal if the X-ray shows a normal uterine shape, and the dye spills out from the ends of the fallopian tubes. There may be a problem if the dye shows an abnormally shaped uterus, and the dye does not flow freely from the fallopian tubes. [ 19 ]  While this method can be completed relatively quickly since anesthesia is not needed, there is a risk of tubal spasm, which typically occurs during injection of the contrast dye due to increased pressure. [ 20 ]  With tubal spasm, the fallopian tubes can close, and this may give a false diagnosis of tubal occlusion. [ 20 ]  While both HSG and chromopertubation can cause spasms, it is more likely to happen with HSG. [ 1 ]  HSG also has the disadvantage of exposing the patient to radiation from the X-ray that is performed. [ 2 ]  The radiographic dye, which is iodine-based, can also cause allergic reactions. [ 22 ]  Though this generally does not occur, there is an increased risk of genital tract infections so patients may be prescribed antibiotics.


Sonohysterosalpingography (SHG), a type of ultrasound exam, is another procedure that assesses patency through the use of  varying contrast medium. One method is to introduce air into the uterine cavity and observe air bubbles in the fallopian tubes. [ 11 ]  The second method is to use distilled water or normal saline to observe the movement of fluid through the tubes. [ 23 ]  Here, fluid enters the uterus through the cervix via a plastic tube. [ 24 ]  The last method involves combining air with saline to make it easier to see on ultrasound. [ 23 ]  Images of the uterus lining are created through the use of sound waves, and the fluid introduced into the uterus serves to enhance the images. [ 24 ]  Side effects of this exam include cramping and a rare possibility of pelvic infection. [ 24 ]  Generally this procedure can be done quickly since no sedation is required and it tends to be a cheaper alternative compared to the other methods. [ 1 ]


Hystero contrast sonography  (HyCoSy) is another alternative to chromopertubation that allows for visualization of the uterine cavity, ovaries, and fallopian tubes. However, it is generally used as a screening test to assess the need for laparoscopy. [ 22 ]  The procedure includes an initial vaginal scan, with a subsequent injection of contrast agent via an intrauterine catheter. The contrast agent is taken up by the fallopian tubes. [ 22 ]  Since HyCoSy is performed using  transvaginal ultrasound , it is less invasive than chromopertubation. Using a contrast agent, the ultrasound image can be used to detect whether and how the contrast medium flows through the fallopian tubes. The contrast medium used is often a manufactured product with microbubbles or a gel-based product that creates foam when passing through the tubes. [ 23 ]  While the contrast medium is generally safe, there can still be allergic reactions as well as adverse effects. [ 22 ]  A positive result is recorded when contrast is not observed to pass through the fallopian tubes. In this case, laparoscopy can be considered as the next step to verify the diagnosis of tubal occlusion. [ 22 ]  This procedure does have contraindications which include reproductive tract cancer and current infections. [ 22 ]  One downside is that this method tends to be more challenging to interpret so it is more accurate when done by experienced sonographers. [ 22 ]


This method is often used as an alternative to hysterosalpingography. Using this method, a  Trocar  along with a scope is inserted into the vagina and allows for visualization of the fallopian tubes and the uterine cavity. [ 25 ]  Unlike HSG which visualizes the fallopian tubes using X-rays, transvaginal hydrolaparoscopy provides a closer look at the fallopian tubes since the scope can be threaded directly through the tubes. [ 25 ]  This procedure allows clinicians the ability to look at the inner structure of the tubes. During the procedure, topical anesthesia is often given before insertion of a needle into the vagina. [ 25 ]  Saline is flushed through the needle and the needle is replaced by the trocar. [ 25 ]  Depending on the clinician, Lactated Ringer's may be used instead of saline. [ 26 ]  Once the trocar is placed, an optic scope is inserted. [ 25 ]  Upon completion of the procedure, some patients may require sutures to stop any remaining bleeding. [ 25 ]  This method tends to be better for classifying tubal disease as inspection of the inner structure allows for visualization of any lesions, adhesions, and endometriomas. [ 26 ]  One benefit of this procedure is that no incisions are required and it can be completed in a clinic office. [ 25 ]  The disadvantages are the risk of bleeding, abdominal tenderness, and that insertion of the vaginal trocar can cause possible rectal injury. [ 26 ]  When the needle is initially inserted, it is also possible for accidental perforation to the uterus wall or bowels, though this is less likely to happen. [ 26 ]  While this method is extremely helpful, those with increased risk of bleeding, infections, or ovarian cysts should not undergo this procedure. [ 26 ]


Chlamydia  immunoglobulin G antibody tests (CAT) are used to explore tubal occlusions and injuries that may be caused by  Chlamydia trachomatis . [ 1 ]  These assays include  immunofluorescence  tests (including microimmunofluorescence) and  ELISA . [ 27 ]  While this method is noninvasive and easy to carry out, there is a chance of false-positive results. These tests can recognize antibodies to different species of  Chlamydia  as well as even other gram-negative bacteria. [ 28 ]  Therefore, these tests are usually used as a screening test. If negative, unnecessary testing is avoided; if positive, more invasive tests are required.  [ citation needed ]


Colpocleisis  is a procedure involving closure of the  vagina , used to treat  vaginal prolapse . [ 1 ] [ 2 ]


In women who are no longer sexually active, a simple procedure for reducing prolapse is a partial colpocleisis. The procedure was described by Le Fort [ citation needed ]  and involves the removal of strip of anterior and posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other. This procedure may be performed whether or not the  uterus  and  cervix  are present. When it is completed, a small vaginal canal exists on either side of the septum, produced by the suturing of the lateral margins of the excision. [ citation needed ]


Dr.  Nathan Bozeman  and Prof. Gustave Simon had a controversial dispute in the 1870s, about the "wide and indiscriminate" use of the procedure that existed at that time. [ 3 ]


Comprehensive Gynecology  (4th ed.). Stenchever-Droegermueller. pp.  580– 581.


Colporrhaphy  (also  vaginal wall repair ,  anterior and/or posterior colporrhaphy ,  anterior and/or posterior vaginal wall repair , or simply  A/P repair  or  A&P repair ) is a  surgical procedure  in women that repairs a defect in the wall of the  vagina . It is the surgical intervention for both  cystocele  (protrusion of the  urinary bladder  into the vagina) and  rectocele  (protrusion of the  rectum  into the vagina). [ citation needed ]


The repair may be to either or both of the anterior (front) or posterior (rear) vaginal walls, thus the origin of some of its alternative names. [ 1 ] [ 2 ] [ 3 ]


Culdoscopy  is an  endoscopic   procedure  performed to examine the  rectouterine pouch  and  pelvic viscera  by the introduction of a  culdoscope  through the  posterior   vaginal  wall. [ 1 ]  The word culdoscopy (and  culdoscope ) is derived from the term  cul-de-sac , which means literally in  French  "bottom of a sac", and refers to the  rectouterine pouch  (or called the  pouch of Douglas ). [ 2 ]


The culdoscope is a non-flexible endoscope, basically a modified laparoscope. [ 3 ]  A  trocar  is first inserted through the vagina into the posterior cul-de-sac, the space behind the  cervix , allowing then the entry of the culdoscope. Due to the position of the patient intestines fall away from the pelvic organs which can then be inspected. Conditions diagnosable by culdoscopy include tubal adhesions (causing sterility),  ectopic pregnancy , and  salpingitis . Culdoscopy allows the performance of minor procedures such as  tubal sterilization . [ 4 ]


Culdoscopy is performed with the patient in a  knee chest position  under local or general anesthesia. There is no insufflation of the abdomen as necessary in laparoscopy. There is no abdominal incision, the entry point in the vagina is closed with a suture. [ citation needed ]


The procedure was inaugurated by Albert Decker in 1939 [ 3 ]  and became popular after his reported experience in 1944. [ 5 ]  Decker had his culdoscope made by American Cystoscope Makers (ACM). He published a textbook about culdoscopy in 1952. [ 6 ]
The use of culdoscopy faded in the 1970s as the laparoscopic approach was recognized to be superior due to technological advancements. [ 3 ]


Endocervical curettage  is a procedure in which the  mucous membrane  of the  cervical canal  is scraped using a spoon-shaped instrument called a  curette . The procedure is used to test for abnormal, precancerous conditions, or cervical cancer. [ 1 ]  The procedure is generally performed after an abnormal  pap smear  to further assess the tissue. Other common indications to perform endocervical curettage include evaluation of persistent  human papillomavirus infection  infections, workup of unexplained  abnormal uterine bleeding , and follow up of inconclusive  colposcopy .


Colposcopy  was first performed by physician Hans Hinselmann, a German  gynecologist , in 1925. He utilized a bright light and low-power microscope to directly visualize atypical cervical cells. [ 2 ]  However, the first use of endocervical curettage is not clearly delineated in the medical literature. The use of curettage as a method to extract biological tissue dates back to the 19th century. Dr.  Ernst Wertheim , an Austrian gynecologist, who pioneered many surgical interventions and techniques in  gynecology  may have been the first to implement endocervical curettage in its earliest forms. [ 3 ]


Use of endocervical curettage became widespread by the mid-20th century as understanding and methods of cervical pathology rapidly advanced. Over the decades endocervical curettage and its inclusion in guidelines have been the subject of debate by medical societies, with some arguing its diagnostic use is limited. [ 4 ]  However, endocervical curettage  has retained its value as a less invasive method to biopsy the endocervical canal. [ 5 ]


Endocervical curettage is a medical procedure used to extract cells of the endocervix to visualize under a microscope. Direct cervical visualization, colposcopy, and even endocervical colposcopy are not enough to fully analyze all areas of the endocervical epithelium and thus endocervical curettage is the method of choice in cases where this is necessary.


Generally the next step in workup of an abnormal pap smear includes a colposcopy which involves the direct visualization of the cervix. However, the cervical epithelium of the endocervix cannot be visualized and endocervical curettage may be used to biopsy the endocervix epithelium. Endocervical curettage is particularly useful in cases of colposcopy where the squamocolumnar junction is not visualized. [ 6 ] [ 7 ]


The indications to perform endocervical curettage vary by medical society recommendations but some commonly accepted indications include: [ 4 ]


The efficacy of endocervical curettage has long been debated with discussions around its value dating back to when its use first became widespread back in the mid-20th century. Numerous studies and meta-analyses have been performed over the centuries to assess the diagnostic value of endocervical curettage in the workup of cervical dysplasia and to determine its sensitivity and specificity. Most recent studies retain its value in the diagnostic workup as an intermediate step between pap smear and cone biopsy. It also maintains value as a less invasive method to analyze the endocervical canal. [ 5 ] [ 9 ]


Endocervical curettage is a type of cervical biopsy that is performed with a curette to scrape cells from endocervical canal. The procedure is generally performed in the outpatient setting and begins with the patient laying flat on their back with feet usually in  stirrups . This is the position for most  pelvic exams. [ 9 ] [ 10 ]


The provider will first use a  speculum , which is inserted in the vaginal canal, for visualization of the cervix. Anesthetics should be used to ensure that the patient is comfortable during the procedure. A colposcope, a magnifying tool, is used to directly visualize the cervical, vaginal, or vulvar tissue under a low-powered microscope. Once the entire cervix is visualized, an acetic acid solution or lugol's iodine solution may be applied to the cervical canal to identify abnormal lesions. Forceps can be used during the procedure to grasp the cervix. Once these steps of the colposcopy are completed, the provider will proceed with endocervical curettage if the findings indicate that biopsy of the endocervical canal is necessary. [ 7 ]


Endocervical curettage is generally the last step of the colposcopy procedure. It is when the curette is inserted and passed through the  cervical os , the opening in the cervix that leads into the uterus, and used to scrape cells from the inside of the cervical canal. The curette is firmly held like a pen, and should scrape the endocervical canal in small strokes. [ 7 ]   The curette should be carefully removed from the canal once the entire area is sampled so the sample is not lost. These biopsied cells should be immediately placed into  formalin  to ensure their preservation. They are then later viewed under a microscope by a  pathologist  to assess for any abnormalities. [ 9 ] [ 11 ]


Guidelines reveal good evidence that endocervical curettage is contraindicated in pregnancy. [ 10 ]  There is a risk of damage to fetal membranes or placenta along with an increased risk of cervical perforation due to the softening of the cervix during pregnancy. [ 6 ]  For these reasons, pregnancy is a well established contraindication to performing endocervical curettage. [ 10 ]  Other relative contraindications to the procedure include severe cervical stenosis and acute uterine or cervical infections.


Rare risks of the procedure include cervical perforation though the incidence of perforation is extremely low. Other risks for the procedure include bleeding, infection, and pain. [ 9 ]  Though sterilization techniques, anesthetics, and hemostasis tools greatly mitigate these risks and the procedure is generally very tolerated aside from discomfort.


After endocervical curettage, cells are viewed under a high-powered microscope by a pathologist. The pathologist analyzes the cells for any atypical features such as  hyperplasia ,  dysplasia , or  neoplasm . [ 12 ]  Features that are analyzed include nuclear size, evidence of  pleomorphism , anisokaryosis, hyperchromasia, and mitotic features.


Grades for  cervical dysplasia  include low-grade squamous intraepithelial lesion to high-grade squamous intraepithelial lesion. The dysplasia can be rated on the Bethesda System of cervical grades of increasing atypical nature summarized below: [ 13 ]


Ratings of cervical intraepithelial neoplasia are also commonly used to grade cytology of cervical epithelium. Cervical intraepithelial neoplasia 1 is the most moderate and are low-grade squamous intraepithelial lesions while cervical intraepithelial neoplasia 2 and 3 are moderate to severe and are high-grade squamous intraepithelial lesions. [ 14 ]


Endometrial ablation  is a surgical procedure that is used to remove ( ablate ) or destroy the  endometrial lining  of the  uterus . The goal of the procedure is to decrease the amount of blood loss during  menstruation  (periods). Endometrial ablation is most often employed in people with excessive menstrual bleeding following unsuccessful medical therapy. [ 1 ]  It is less effective than  hysterectomy , but with a lower risk of adverse events. [ 2 ]


Endometrial ablation is typically done in a  minimally invasive  manner with no external incisions. Slender tools are inserted through the vagina and into the uterus. In some forms of the procedure, one of these tools may be a camera ( hysteroscope ) to assist with visualization. Other tools include those that harness  electricity ,  high-energy radio waves , heated fluids, or  cold temperature  to destroy the endometrial lining. [ 3 ]


The procedure is almost always performed as an  outpatient  treatment, either at a hospital, ambulatory surgery center, or physician office. Patients will most commonly undergo local and/or light sedative  anesthesia , or if necessary, general or spinal anesthesia. [ 4 ]


After the procedure, the endometrium heals by  scarring  over, thus reducing or eliminating future uterine bleeding. [ 5 ]  The patient's hormonal functions will remain unaffected because the  ovaries  are left intact. Due to the uterine changes that take place after undergoing ablation, patients are unlikely to be able to become  pregnant  after the procedure, and of pregnancies that do occur, complication risk is high. To reduce the associated mortality risks, it is often recommended for patients to adhere to  birth control  methods after undergoing endometrial ablation. [ 4 ]


The primary  indication  for endometrial ablation is abnormal uterine bleeding, including chronic heavy menstrual bleeding, in premenopausal patients. [ 6 ]  Typically, these are patients for whom first-line medical therapy was unsuccessful or  contraindicated . [ 1 ]


In some cases, endometrial ablation is use to treat small  uterine fibroids . [ 7 ]


Absolute contraindications for undergoing endometrial ablation include endometrial  carcinoma , current pregnancy, and desire for future pregnancy. [ 5 ]


Prior to undergoing endometrial ablation, patients will go through a pre-procedure evaluation and risk assessment. Components of this often include  informed consent , anesthesia evaluation, and a  pregnancy test  (as current pregnancy is a contraindication to the procedure). All patients will undergo endometrial  sampling  to test for endometrial carcinoma, as this is an absolute contraindication to endometrial ablation. Some patients may also require further assessment of the uterus through  hysteroscopy  or saline infusion  sonohysterography , and/or removal of any current  IUD .


Depending on the treatment that is chosen, endometrial ablation is sometimes conducted after treatment with hormones, such as  norethisterone  or  Lupron  to reduce the thickness of the endometrium. [ 8 ]


Endometrial ablation may be done in-office or in an operating room. The procedure begins with  cervical dilation , which temporarily stretches the cervix to make room for the ablation instruments and/or  hysteroscope  to enter the uterus. Dilation can be induced medically with  pharmacologic agents , or mechanically with a series of metal tools of increasing diameter. After sufficient dilation, the ablation instrument is introduced into the uterine cavity, which is used to partially or fully destroy the endometrial lining. A hysteroscope may be used to assist in visualization of this process and/or ensure that final results are adequate. [ 9 ]


The technique utilized to remove or destroy the endometrium varies with endometrial ablation operations. Options consist of:


After the ablation procedure is complete, any concomitant procedures that patients have opted for will also be completed. A common procedure after endometrial ablation is  IUD  insertion, as effective contraception following endometrial ablation is highly recommended. Other concomitant procedures may include  myomectomy  and/or  tubal ligation . [ 6 ]


Endometrial ablation is often an outpatient procedure that does not require an overnight hospital stay. Patients may experience cramping,  vaginal discharge , and/or urinary changes during the recovery process. [ 11 ]


A number of treatment options are available, all of which work by inserting tools into the cervix to destroy the ablate the endometrium. [ 12 ]  Commonly used ablation systems include:


Older methods utilize hysteroscopy to insert instruments into the uterus to destroy the lining under visualization using a  laser , or  microwave  probe.


The U.S.  Food and Drug Administration  approves and audits clinical studies to test and evaluate the effectiveness of all endometrial ablation treatments. Two patient effectiveness outcomes are measured at one year following treatment: 1) success rate = the % of people who have their bleeding reduced to a normal period level or less, and 2)  amenorrhea  rate = the % of people that have their bleeding eliminated.  According to the results of the  randomized controlled trials  performed for the FDA approval of the different treatment options, effectiveness success rates range from a high of 93% to a low of 67%, and the amenorrhea rates range from a high of 72% to a low of 22%. [ 15 ]  Compared with hysterectomy, ablation was less effective at reducing pain and excess bleeding; however, it also resulted in fewer adverse events. [ 2 ]  Satisfaction rates following hysterectomy and ablation were similar. [ 2 ]


Although rare, the procedure can have complications [ 5 ]  including:


A  hymenotomy  is a  medical procedure  involving the  surgical  removal or opening of the  hymen . It is often performed on patients with an  imperforate  or  septate  hymen, or other situations where the hymen is unusually thick or rigid such as microperforate hymen.  In the case of a female with a hymen without any opening, an opening may be created in order to facilitate  menstruation .  In situations where the opening is extremely small or the band(s) of a septate hymen limit access to the vaginal opening, the woman may elect for hymenotomy to allow for comfortable  sexual penetration  of her vagina, or to relieve pain or discomfort that occurs when inserting/removing tampons. Sexual intercourse would not normally be adversely affected by a hymenotomy. [ 1 ]


A  hysterotomy  is an incision made in the  uterus . [ 1 ]  This surgical incision is used in several medical procedures, including during termination of pregnancy in the second trimester (or  abortion ) and delivering the fetus during  caesarean section . It is also used to gain access and perform surgery on a fetus during pregnancy to correct  birth defects , and it is an option to achieve  resuscitation  if  cardiac arrest  occurs during pregnancy and it is necessary to remove the fetus from the uterus.


There are several types of incisions that can be made, including a midline vertical incision and a low transverse incision. The incision is made using a scalpel and is about 1-2 cm long, but it can be longer depending on the procedure that is performed. [ 2 ]  Other types of incisions are low transverse incision with T-extension in the midline, low transverse incision with J-extension, and low transverse incision with U-extension. These are used when low transverse incisions do not provide enough space in order to remove the contents in the uterus.


This incision also comes with possible risks and complications when the incision is made and during repair, including blood loss (possibly leading to  anemia ), wound infection, fertility problems,  premature labor , postoperative pain, and many others. [ 3 ]  In addition, a rare form of  ectopic pregnancy  known as scar ectopic pregnancy can occur. This is when there is abnormal implantation of an embryo onto the scar of the uterus. There is an increased risk of this complication occurring due to trauma from previous procedures utilizing hysterotomies, such as caesarean section and dilation, though the mechanism is unknown. [ 4 ]  Closure of the hysterotomy incision made can be done with either a staple or a suture. Sutures are most commonly used, specifically double layer sutures. [ 5 ] [ 3 ]


A hysterotomy is used to remove a fetus from the uterus, similar to a procedure known as  caesarean section , in order to terminate a pregnancy in the second trimester of later. [ 6 ]  It is typically used as last resort if  dilation and curettage , dilation and  electric vacuum aspiration , or manual vacuum aspiration fails to work. Dilation and curettage refers to the opening or widening of the cervix and scooping and scraping the tissues that are inside of the uterus. Electric vacuum aspiration utilizes a vacuum to remove the embryo that is in the uterus, but this method is more expensive than manual vacuum aspiration. [ 7 ]


Although fetal delivery through caesarean section is a very common surgery done in the world, it comes with several risks including bleeding, infection,  thromboembolism , and soft-tissue injury. During a caesarean section, a hysterotomy is utilized to make an incision in the uterus and remove the fetus. [ 8 ]  Gestational age, newborn birth weight, and danger presenting risks are all taken into account on whether or not a classic hysterotomy or low transverse incision will be made. [ 9 ]


A  resuscitative hysterotomy  is performed during or near the occurrence of a cardiac arrest, in which an incision is made to remove the fetus from the uterus. This is done in order to save the fetus, as well as to revive the person whose uterus was carrying the fetus. This is traditionally done if the fetus is of 24 weeks or older, at which it is viable outside of the uterus. [ 10 ]  The primary goal is to save the pregnant person, and in order to insure the highest survival rate, the goal of fetus delivery time is within 5 minutes after the patient goes under arrest and/or two cycles of CPR. [ 11 ]  During pregnancy, the pregnant uterus may compress the  inferior vena cava  and  abdominal aorta , causing reduced blood flow to the uterus and to the pregnant person. Removing the fetus can restore blood flow to the pregnant person. [ 12 ]


Hysterotomy is a technique used during  fetal surgery  to access the fetus in the pregnant uterus in order to treat a birth defect such as  spina bifida . [ 13 ]  A standard hysterotomy remains the gold-standard for the closure of a fetal spina bifida because it is the safest and most effective when compared to mini-hysterectomies and a percutaneous two-layer  fetoscopy . [ 14 ]  A mini-hysterotomy procedure is favored for extreme cases of preterm delivery and any complications regarding maternal, fetal, and/or neonatal because of the reduced risks and complications. [ 15 ]


The technique used to repair the hysterotomy is dependent on the surgeon's preference. The method of repair and type of suture affects the risks and complications of receiving a hysterotomy.  Hysterotomy incision repair can be done within the  intraperitoneal space  ( in situ ) or the uterus can be temporarily removed for repair (exteriorization). Both types of uterine positioning for repair yielded similar lengths of hospital stay, risk of infection, and estimated blood loss. Recovery following uterine exteriorization was found to induce more nausea [ 16 ]  and be more painful, requiring more post-operative  analgesia . Return of bowel function was faster with  in situ  repair. [ 17 ]  It was found that between unlocked single-layer closure and double-layer closure, there is no difference in risk of uterine rupture, [ 3 ]  however the risk of rupture is increased with a locked single-layer suture. [ 18 ]


Following the repair of the incision, a scar defect may form, which is defined as a thinning of uterine muscle at the incision site. These uterine scar defects are associated with increased risk of uterine rupture and scar separation. [ 19 ] [ 20 ]  Scar defects may increase the risk of complications such as abnormal bleeding, pain,  ectopic pregnancy , and  infertility . [ 3 ]


Caesarean sections require a large incision of the uterus, which can lead to complications such as blood loss, postoperative pain, anaemia due to continuing blood loss, fever and possible wound infection, breastfeeding issues, difficulty passing urine, future fertility problems, and/or possible complications in future pregnancies including uterine rupture. [ 3 ]


In fetal surgery, without inhibition of uterine contractions, uterine irritability and  premature labor  are complications that occur very frequently in of hysterotomy cases. [ 21 ]  It can be inhibited by  anti-contraction  medications. [ 22 ]  Preterm birth and early membrane rupture (PPROM) are common risks for fetal therapies. For most cases, fetoscopic surgery, which minimizes the damage to the uterus, is preferred to mitigate risks and complications. Membrane sealing and fixation has been investigated for reducing PPROM risk, but it has not been found to be clinically beneficial. [ 21 ]


Scar ectopic pregnancy is a rare form of ectopic pregnancy, however, when it does occur it causes complications in pregnancy such as abnormal uterine bleeding and uterine rupture. The mechanism of how scar ectopic pregnancy still remains unknown. However, the possibility that defects may form to the scarring from previous procedures/traumas such as caesarean section, dilation, hysterotomy, abnormal placentation can cause scar ectopic pregnancy. [ 4 ]


There are two categories of complications with surgical abortions, minor and major. Minor complications are procedural pain, bleeding, infection and common anesthesia complications. The more serious and major complications include hemorrhage, sepsis, peritonitis, deep vein thrombosis and death. [ 23 ]


There are many different types of hysterotomies depending on the location and direction of the incision. Typically, a low transverse incision is preferred during a caesarean section. This area of the uterus has less  vasculature  and therefore provides lower risk of hemorrhage during the procedure for the patient. Incisions in the lower area of the uterus is also associated with lower risks of uterine rupture. There may be times in which the lower transverse incision does not provide adequate space and therefore, expansions of the low transverse incisions have led to the creation of the low transverse incision with T-extension in the midline, low transverse incision with J-extension, and low transverse incision with U-extension. [ 3 ]  A low vertical incision and a midline incision, also known as a classic caesarean incision, may be preferred during a labor that is preterm. Since the lower uterine segment is not yet fully developed during a preterm labor, these two incisions are preferred in order to provide adequate space for manipulations during delivery of the fetus. A low transverse incision would not provide adequate space and could entrap the fetal head therefore risking intercranial hemorrhage, morbidity and mortality for the fetus. [ 2 ]  A midline incision may be preferred as well when the fetus lies transversely across the patient's uterus or if the placenta lies in the area where the low transverse incision is made. In practice, however, the midline incision is rarely used. [ 3 ]  Other hysterotomy incisions include a high transverse incision and a fundal incision. [ 2 ]  A fundal incision may be used if the placenta is placed behind the anterior wall of the uterus and therefore making typical incisions much more risky for hemorrhage. [ 24 ]


A hysterotomy can be performed by various methods. Typically a small incision is made with a scalpel about 1–2 cm long. During a blunt expansion, the incision is expanded by the surgeon's index fingers or other blunt dissection tools. During a sharp expansion, bandage scissors are used to cut a larger incision. [ 25 ]  Some professionals will say that the sharp expansion allows for a more controlled entry into the uterus and a faster delivery of the fetus. Other professionals will say the blunt expansion allows for reduced risk of hemorrhaging or excessive bleeding and improves healing for the patient. [ 3 ]