Unilateral vulvar edema after operative laparoscopy: a case report and literature review George Pados, M.D., Dimitrios Vavilis, M.D., Konstantinos Pantazis, M.D., Theodoros Agorastos, M.D., and John N. Bontis, M.D., Ph.D. 1st Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, “Hippocration Hospital,” Thessaloniki, Greece
Objective: To report a case of unilateral vulvar edema occurring after operative laparoscopy and to review the relevant literature. Design: Case report. Setting: University hospital. Patient(s): An 18-year-old woman with a single ovarian cyst. Intervention(s): The patient underwent laparoscopic ovarian cystectomy and 1,000 mL of adhesion barrier solution was instilled in the peritoneal cavity at the end of the procedure. Main Outcome Measure(s): Treatment of ovarian cyst and prevention of adhesion formation with adhesion barrier solution. Result(s): Development of unilateral vulvar edema 3 hours postoperatively. Conclusion(s): Vulvar edema after operative laparoscopy is an uncommon complication, the mechanism of which remains unclear. The condition is self-limited and resolves with conservative management. (Fertil Steril威 2005; 83:471–3. ©2005 by American Society for Reproductive Medicine.) Key Words: Vulvar edema, operative laparoscopy, adhesion barrier solution
Vulvar edema has been reported in patients with ascites of hepatic origin, ovarian hyperstimulation syndrome, pregnancy complicated by pre-eclampsia, and tocolysis for preterm labor (1– 4). Vulvar edema as a complication of operative laparoscopy has been reported rarely in the literature (5–7). We present a case of a patient who underwent laparoscopic ovarian cystectomy and developed vulvar edema a few hours postoperatively. CASE REPORT An 18-year-old nulligravida virgin woman presented with mild lower abdominal pain. Examination by ultrasound revealed a single ovarian cyst with a maximum diameter of 45 mm, which was noted to have a thin diaphragm. She was subsequently scheduled for elective laparoscopy. The laparoscopic procedure was performed with the fourpuncture technique. One 10-mm trocar was introduced through the umbilicus for the camera telescope, two 5-mm trocars were introduced in the lower abdomen laterally, and another 5-mm trocar was introduced in the midline, 3 cm above the pubis. After thorough inspection of the pelvis and the peritoneal cavity, the ovarian capsule was incised by scissors, avoiding rupture of the cyst. The cyst wall was carefully examined, and then the cyst was teased away from the ovarian stroma by hydrodissection Received November 14, 2003; revised and accepted June 6, 2004. Reprint requests: George Pados, M.D., 40 Mitropoleos Str, Thessaloniki 546 23, Greece (FAX: 0030-231-241133; E-mail:
[email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.06.078
and removed intact. The ovarian cortex was carefully inspected while being irrigated with normal saline, and precise hemostasis was performed by bipolar electrocoagulation. A 3/0 polyglactin suture with intracorporeal knot was used to approximate the edges of the ovary. The cyst was placed in a bag and removed intact from the peritoneal cavity through an ancillary 10-mm trocar. The patient was turned to anti-Trendelenburg position, and the irrigation fluid was aspirated thoroughly from the peritoneal cavity. Finally, 1,000 mL of 4% icodextrine solution (Adept; Shire Pharmaceuticals, Hampshire, United Kingdom) was instilled into the peritoneal cavity via a 5-mm trocar, to prevent the formation of adhesions, and all ports were sutured to minimize leakage. Three hours postoperatively the patient complained of discomfort in the vulvar area, and a profound swelling of the right labia was noted on examination (Fig. 1). There were no signs of venous or lymphatic obstruction, peripheral edema, trauma, or allergic reaction. Because the condition was worsening rapidly, we inserted a Foley urethral catheter to prevent urinary retention and bandaged the swelling tightly after local application of a steroid-antibiotic cream (Celestoderm-V with Garamycin; Schering-Plough, Hellas, Greece). Additionally, ice packs locally and bed rest were advised. The patient reported a comfortable night’s rest, and the bandage was removed on the next day. The swelling relapsed within a few minutes. Ultrasonography revealed free fluid in the peritoneal cavity, which was presumed to be the adhesion
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FIGURE 1 Right vulvar edema at 3 hours after laparoscopy. A Foley urethral catheter has been placed to prevent retention of urine.
Pados. Vulvar edema after operative laparoscopy.
barrier solution, and the same management was repeated. The bandage and the urethral catheter were permanently removed 48 hours postoperatively. No further swelling was observed, and the patient was uneventfully discharged from the hospital. Relevant hematologic and biochemical blood tests were normal preoperatively and during the hospital stay. The patient was examined in the outpatient clinic 2 weeks later, and she reported no further complications. DISCUSSION To the best of our knowledge, vulvar edema as a complication of laparoscopic surgery has been reported rarely in the literature. At the 20th Annual Meeting of the American Association of Gynecologic Laparoscopists in 1993, a list of 4,400 laparoscopic cases was presented, and vulvar edema was referred to as a possible complication (8). The first description of this complication was made in 1996 (5). In three women who underwent operative laparoscopy for ovarian cystectomy, pelvic adhesions, and oocyte retrieval for GIFT, respectively, vulvar edema developed 472
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within 24 hours postoperatively. In all three cases the management was conservative, with Foley urethral catheter because of inability to void, ice packs, and bed rest, and the condition resolved in 1–3 days, allowing for discharge from hospital. According to the investigators, the complication could be attributed to an escape of irrigation fluid (Ringer’s Lactated), either intraoperatively or postoperatively through a suprapubic puncture site, which might then have traveled through the subcutaneous tissue to the vulva, the most dependent and accessible area. The investigators concluded that vulvar edema is a possible complication of laparoscopy that is self-limited but that requires hospitalization owing to the patient’s inability to void. In another report, in which either 250 mL of 32% dextran 70 (five patients) or 250 mL of Ringer’s Lactated (eight patients) were instilled intraperitoneally at the end of operative laparoscopy, one patient (in the dextran group) developed severe vulvar edema 24 hours postoperatively (6). Hospitalization of the patient with an indwelling Foley catheter was required for 9 days because of inability to void. Pathogenesis of the complication was thought by the investigators to be an escape of anti-adhesion solution through one of the lower 5-mm trocar sites, with dissection subcutaneously into dependent regions of the body.
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Most recently, in 2003, two cases of vulvar edema were reported that developed after laparoscopic presacral neurectomy and that were associated with massive chylous ascites (7). In the first case, left vulvar edema developed 12 hours after the drainage tube was removed, and massive ascites developed. A second laparoscopy was performed with the thought that there might be a patent canal of Nuck, but instead a leaking point was found in the presacral area; it was coagulated to successfully treat the condition. In the second case, right vulvar edema developed 1 day postoperatively, and sonography disclosed massive ascites. The patient was managed conservatively, and the edema resolved in 2 days, although the ascites persisted for more than 1 week. In this case, the vulvar edema was attributed to leakage of ascites through a trail in the subcutaneous tissue created by the puncture needle. The investigators suggest that, to prevent this rare complication, one must either ensure that there is no fluid left in the peritoneal cavity or that the trocar wounds are closed precisely and even layer by layer. In our case, there was no history or clinical evidence of venous or lymphatic obstruction, trauma, or local allergic reaction that could justify the development of vulvar edema. The edema was evident within 3 hours after the end of the operation and the instillation of the adhesion barrier solution in the peritoneal cavity. This fact could support the relationship between the instillation of the adhesion barrier solution and the development of the vulvar edema. The same relationship is also supported by the results of the previously mentioned report (6) in which adhesion barrier solution was instilled after laparoscopy and by two other studies in which adhesion barrier solution was added at the end of laparotomy (9, 10). The mechanism of the leakage of fluid into the vulvar region could be either a patent canal of Nuck, as supported by the Adhesion Study Group (9), or a fistulous tract originating in a lower trocar puncture wound and dissecting downward subcutaneously by the force of gravity, as supported by others (5–7). The formation of a fistulous tract has also been suggested in postparacentesis vulvar edema in women with ascites of hepatic origin (1) or ovarian hyperstimulation syndrome (2, 11). This mechanism seems logical and attractive. It might, however, seem inadequate, considering the wide use of laparoscopy on the one hand and the small number of cases of vulvar edema as a complication of laparoscopic surgery that has been reported so far on the other. A patent canal of Nuck might well be an underlying or additional cause, in cases in which the vulvar edema is
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ipsilateral to the defect. It is noted, however, that the identification of a patent canal of Nuck at laparoscopy is technically difficult. Treatment with local application of a steroid–antibiotic cream and ice packs and bed rest is empirical. We previously used it in the similar case of a patient who suffered from severe ovarian hyperstimulation syndrome (11), on the basis of an older report in the literature (12). In conclusion, vulvar edema as a complication of operative laparoscopy does not seem to be common. The pathogenesis remains unclear. This complication is self-limited and might sometimes require hospitalization due to inability to void. REFERENCES 1. Marcks JW, Weil F. Conn’s sudden labial edema. Ann Intern Med 1971;75:810. 2. Luxman D, Cohen JR, Gordon D, Wolman I, Wolf Y, David MP. Unilateral vulvar edema associated with paracentesis in patients with severe ovarian hyperstimulation syndrome. A report of nine cases. J Reprod Med 1996;41:771– 4. 3. Bracero La Didomenico A. Massive vulvar edema complicating preeclampsia: a management dilemma. J Perinatol 1991;11:122–5. 4. Brittain C, Carlson JW, Gehlbach DL, Robertson AW. A case report of massive vulvar edema during tocolysis of preterm labor. Am J Obstet Gynecol 1991;165:420 –2. 5. Trout SW, Kemmann E. Vulvar edema as a complication of laparoscopic surgery. J Am Assoc Gynecol Laparosc 1996;4:81–3. 6. Sites CK, Jensen BA, Glock JL, Blackman JA, Badger GJ, Johnson JV, et al. Transvaginal ultrasonographic assessment of Hyskon or Lactated Ringer’s solution instillation after laparoscopy: randomized, controlled study. J Ultrasound Med 1997;16:195–9. 7. Yen CF, Wang CJ, Lin SL, Lee CL, Soong YK. Postlaparoscopic vulvar edema, a rare complication. J Am Assoc Gynecol Laparosc 2003;10:123– 6. 8. Nezhat C, Nezhat F, Silfen SL. Complications of 4400 operative laparoscopic procedures. In: Hunt RB, Martin DC, Phillips JM, eds. Endoscopy in gynecology: AAGL 20th Annual Meeting Proceedings. Santa Fe Springs, CA: American Association of Gynecologic Laparoscopists, 1993:278. 9. Adhesion Study Group. Reduction of postoperative pelvic adhesions with intraperitoneal 32% dextran 70: a prospective, randomized clinical trial. Fertil Steril 1983;40:612–9. 10. Magyar DM, Hayes MF, Spirtos NJ, Hull ME, Moghissi KS. Is intraperitoneal dextran 70 safe for routine gynecologic use? Am J Obstet Gynecol 1985;152:198 –204. 11. Vavilis D, Tzitzimikas S, Agorastos T, Loufopoulos A, Tsalikis T, Bontis NJ. Postaparacentesis bilateral vulvar edema in a patient with severe ovarian hyperstimulation syndrome. Fertil Steril 2002;77:841–3. 12. Coccia ME, Bracco GL, Cattaneo A, Scarcelli G. Massive vulvar edema in ovarian hyperstimulation syndrome. A case report. J Reprod Med 1995;40:659 – 60.
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