Klyuchenok T.V. Kazan State Medical Academy, Hospital No. 13, Kazan From 1994 to 1998, the Emergency Surgery Department of Kazan City Hospital No. 13 performed 111 operations for acute gynecological pathology, which accounted for 3% of all urgent surgeries. The pathology included pelvic peritonitis, acute adnexitis, torsion and rupture of uterine appendage cysts, and tubal pregnancy. Of the 111 operations, 51 (46%) were performed laparoscopically. The mortality rate was 1.8% for open surgeries. The aim of the study was to conduct a quantitative and qualitative analysis of urgent gynecological surgeries. Introduction Acute gynecological pathology occupies a certain place in the structure of patients admitted to emergency surgery departments. This is due to the similarity of the clinical presentation of some surgical and gynecological diseases, and the difficulty of their differential diagnosis. There is also a subjective factor—gynecologists' overcaution when suspecting acute appendicitis and referring such patients to the emergency surgery department. Therefore, surgeons must promptly diagnose and, most importantly, adequately treat patients with acute gynecological pathology. The aim of our study is to qualitatively and quantitatively analyze surgeries performed for acute gynecological pathology in the emergency surgery department. Materials and methods: From January 1, 1994, to December 31, 1998, 3,738 urgent surgeries were performed in the Emergency Surgery Department of the 13th City Hospital of Kazan, including 111 (3%) surgeries for acute gynecological pathology. Laparoscopic surgery was performed in 51 (46%) of the 111 patients, accounting for 1.36% of all emergency surgeries. All patients were operated on either immediately upon admission or after 2–4 hours of dynamic observation. Most of them were referred to the Emergency Surgery Department with suspected acute appendicitis. All patients were admitted only after consultation with a gynecologist. The average age was 30 years (range, 15–72 years). The results of the quantitative analysis of patients operated on for acute gynecological pathology are summarized in Table 1. Table 1. Distribution of morbidity by age in patients operated on for acute gynecological pathology in the Emergency Surgery Department of the 13th City Hospital in 1994–1998. laparoscopic (l) and open (o) method. Gynecological pathology Age (years) Total: 16–19 20–39 40–59 over 60 l l l l l l total l l Pelvioperitonitis 7 – 15 5 2 1 – – 30(27%) 24(21.6%) 6(5.4%) Cyst rupture 2 4 4 12 1 2 1 1 27(24.3%) 8(7.2%) 19(17%) Acute adnexitis 2 1 4 9 1 3 – 1 21(19%) 7(6.3%) 14(12.6%) Ovarian apoplexy 2 1 4 3 – 1 – – 11(9.9%) 6(5.4%) 5(54%) Tubal pregnancy – 1 1 4 – – – – 6 (5.4%) 1 (0.9%) 5 (5.4%) Diseases of the uterine wall – – 1 1 1 2 – 1 6 (5.4%) 2 (1.8%) 4 (3.6%) Torsion of ovarian cyst or appendages – – 2 – – 1 1 – 4 (3.6%) 3 (2.7%) 1 (0.9%) Genital tumor – – – 1 – 1 – 1 3 (2.7%) 1 (0.9%) 2 (1.8%) Genital trauma – 2 – 1 – – – – 3 (2.7%) – 3 (2.7%) Total: 13 9 31 36 5 11 2 4 111 (100%) 51 (46%) 60 (54%) Information on the type of intervention is presented in Table 2. Technique Operations: Since the preoperative diagnosis of most patients was suspected acute appendicitis, the Volkovich-Dyakonov approach was used for open operations, expanding downwards using the Bogoyavlensky approach if necessary. Local and general anesthesia was used. If an intact appendix was detected in the presence of blood, hemorrhagic, or purulent effusion in the abdominal cavity, a thorough revision of the pelvic organs and adequate support were performed depending on the findings using the standard technique. In two cases (Table 2), supravaginal amputation of the uterus was performed due to a tumor with wall necrosis in one case and a traumatic rupture in the other; the approach was lower midline laparotomy in both cases. In all cases of endoscopic interventions, the laparoscopic complex was installed to the right of the foot end of the operating table. In cases of a history of operations on the lower floor of the abdominal cavity, pneumoperitoneum was created using the "open" Hasson technique. After examining the abdominal organs, the presence, location, and nature of the effusion were assessed. A detailed examination of the appendix was then performed. Only after acute surgical pathology had been ruled out were the internal genitalia examined. For adequate examination, the patient should be placed in the Trendelenburg position and a bladder catheter inserted. Two trocars should then be inserted for manipulators, a coagulator, and an aspirator. The abdominal cavity should be drained, and bleeding vessels should be coagulated before proceeding to the main stage of the procedure. We would like to note that in all cases of acute gynecological pathology, it is advisable to drain the pelvic cavity at the end of the surgery using a single-lumen drainage system, and in cases of purulent diseases of the uterine adnexa, a double-lumen glove drainage system should be used. Laparoscopy should only be performed under general anesthesia. Table 2. Spectrum of surgical interventions performed for acute gynecological pathology in 1994–1998 (l — laparoscopic, o — open). Type of operation Number of operations Total: sanitation and drainage of the pelvic cavity 11 37 48 (43%) removal of adnexal cysts 17 3 20 (18.1%) tubectomy 13 3 16 (14.5%) adnexectomy 5 5 10 (9%) hemostasis of the cyst bed 6 1 7 (6.4%) suturing of ruptured adnexal cysts 6 – 6 (5.4%) amputation of the uterus 2 – 2 (1.8%) oophorectomy – 1 1 (0.9%) salpingotomy – 1 1 (0.9%) Total: 60 51 111 (100%) During the study period from 1994 to 1998, different ratios of open and laparoscopic operations were observed (Diagram 1). Results We divided the results of our study by the method of intervention. With open procedures, the postoperative hospital stay was 10-14 days. We observed complications in 7% of patients operated on for pelvic peritonitis, in the form of postoperative wound suppuration, attributing this to the inevitable contact of purulent exudate with the subcutaneous tissue. Therefore, in 1996, we expanded the indications for the laparoscopic method, assuming a lower incidence of postoperative wound suppuration (contact of the exudate with the subcutaneous tissue is virtually absent). The results exceeded all expectations: the recovery period for pelvic peritonitis and other acute gynecological pathologies was reduced to 3-7 days, and wound infection and other complications were 0%. The cosmetic results after laparoscopic surgery are obvious. The mortality rate was 1.8%, including two cases of open supravaginal hysterectomy. In both cases, diffuse purulent peritonitis occurred; both patients died within the first days after surgery. Discussion. As can be seen from the quantitative analysis, the proportion of patients with acute gynecological pathology among all patients undergoing surgery reaches 3%, which is a significant figure for a related specialty. Therefore, for adequate treatment of these patients, two options exist: having a consultant gynecologist on staff ready to help at any time or treating these patients themselves, which requires appropriate training of surgeons. The first option is not always feasible in practice. Among the observed pathologies, three diseases are most common: pelvic peritonitis (27%), ovarian cyst rupture (24.3%), and acute adnexitis (19%). The adequate treatment method for these diseases is mainly hemostasis, debridement, and drainage of the pelvic cavity (43%). In addition to the technical simplicity of these operations, the advantages include good postoperative results, especially after the introduction of the laparoscopic method. Laparoscopic removal of the uterine appendages, fallopian tubes in ectopic pregnancy, and electrocoagulation of the cyst bed present no significant difficulties. In one case, we laparoscopically removed a torsed 20-cm-diameter ovarian cyst from a 72-year-old woman. A case of organ-preserving laparoscopic surgery is of interest: a 29-year-old woman underwent laparoscopic salpingotomy for acute purulent salpingitis. Analyzing the range of surgical interventions in Table 2 and taking into account the data in Diagram 1, we can identify a trend toward an increasing proportion of laparoscopic procedures from the time of its adoption (1994) to its widespread use (1997–1998), as well as an expansion in the scope of laparoscopic interventions for acute gynecological pathology. These range from diagnostic laparoscopy and pelvic cavity sanitation to tubectomy and adnexectomy. Until the 1980s, laparoscopy was used primarily by gynecologists, with the exception of a few centers that utilized laparoscopy in general surgery. Until then, most advances in laparoscopy were based on research by gynecologists, but in the last 10 years, the method has become widely accepted by general surgeons. Acute purulent-inflammatory diseases of the uterine appendages, which emergency surgeons encounter in their practice, were previously considered a contraindication to laparoscopy due to the risk of generalized purulent infection. Subsequently, surgeons and gynecologists demonstrated that acute inflammatory diseases of the small organs are precisely an indication for laparoscopy, avoiding diagnostic difficulties and associated complications. All patients consulted preoperatively in the emergency gynecology department were diagnosed with acute appendicitis. Interestingly, in acute gynecological pathology, we observed inflammation of the appendix in 18 cases (16.2%), of which the histological diagnosis was superficial appendicitis in 16 (14.4%) cases, and gangrenous appendicitis in 2 (1.8%) cases. In both cases, the gynecological pathology was a ruptured ovarian cyst. Based on these data, we believe that appendicitis as an independent disease occurred only in the latter two cases, and as a secondary process in the remaining cases. Some authors describe a non-permanent formation—the appendicoovarian ligament (lig. appendiculoovaricum), which runs as a fold of the peritoneum from the appendix to the right ovary. It contains connective tissue, blood vessels, and lymphatic vessels, due to which either of the two adjacent organs may be secondarily involved in the inflammatory process. Of interest are the data provided by S.V. Shtyrov regarding the proportion of patients with acute appendicitis in urgent gynecology—4.6%. These figures are a mirror image of our data in a related specialty. Some authors believe that when performing appendectomy for secondary appendicitis simultaneously with genital interventions, the appendiceal stump may cause infection of the pelvic cavity, leading to the development of postoperative pelvic peritonitis. We have not observed such complications. Therefore, we believe that in cases of obvious (even secondary) changes in the vermiform appendix accompanying acute gynecological pathology, a combined appendectomy (or, in the case of a laparoscopic approach, a laparoscopic appendectomy) should always be performed. Conclusions: Patients with acute gynecological pathology constitute at least 3% of the patient population admitted to the emergency surgery department. Laparoscopy allows for an accurate diagnosis and selection of the optimal treatment strategy for acute gynecological pathology in most cases. An emergency surgeon should be proficient in basic open and basic laparoscopic techniques for pelvic surgery, including tubectomy, adnexectomy, cystectomy, and laparoscopic appendectomy. In conclusion, I would like to share Philippe Mourret's opinion on the topic we've touched upon. He believes that both surgeons and gynecologists work within the same abdominal cavity, and therefore both should possess basic skills in related specialties, including laparoscopic procedures.