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132 Multifocal Solitary Subungual Glomus Tumors in a Patient with Neurofibromatosis Type 1 June 2011 purple discoloration of nail beds. It is also possible that glomus tumors are not always diagnosed in neurofibromatosistype1patientsbecausethesymptoms might be attributed to the presence of cutaneous neurofibromas in the same region and resection of the superficial nodules (cutaneous neurofibromas) is insufficient to diagnose and resolve the problem. The intense pain associated with this tumor may even lead to disuse atrophy of the upper limb [12] . Therefore, it is important to be aware of the possibility of glomus tumors in neurofibromatosis type 1 patients with pain in the fingers because surgical intervention to remove the glomus tumor cures the pain as well as improves the quality of life. CONCLUSION Intense pain in multiple fingersinneurofibromatosis type 1 patients should alert clinicians about the possibility of multifocal glomus tumors which are completely curable with surgical excision. ACKNOWLEDGMENT We wish to thank Dr Theeb Shaher for his help in the diagnosis of this case. REFERENCES 1. De Maerteleire W, Naetens P, De Smet L. Glomus tumors. Acta Orthop Belg 2000; 66:169-173. 2. Conant MA, Wiesenfeld SL. Multiple glomus tumors of the skin. Arch Dermatol 1971; 103:481-485. 3. Boon LM, Brouillard P, Irrthum A, et al. A gene for inherited cutaneous venous anomalies (“glomangiomas”) localizes to chromosome 1p21-22. Am J Hum Genet 1999; 65:125-133. 4. Vikkula M, Brouillard P, Mulliken JB, et al. Truncating mutations in the glomulin gene cause glomuvenous malformations. Am J Hum Genet 2001; 69S, Abstract # 41. 5. Kim YC. An additional case of solitary subungual glomus tumor associated with neurofibromatosis 1. J Dermatol 2000; 27:418-419. 6. Okada O, Demitsu T, Manabe M, Yoneda K. A case of multiple subungual glomus tumors associated with neurofibromatosis type 1. J Dermatol 1999; 26:535-537. 7. Sawada S, Honda M, Kamide R, Niimura M. Three cases of subungual glomus tumors with von Recklinghausen neurofibromatosis. J Am Acad Dermatol 1995; 32:277- 278. 8. L De Smet, R Sciot, E Legius. Multifocal glomus tumours of the fingers in two patients with neurofibromatosis type 1. J Med Genet 2002; 39:e45. 9. Morrison SJ, White PM, Zock C, Anderson DJ. Prospective identification, isolation by flow cytometry, and in vivo self-renewal of multipotent mammalian neural crest stem cells. Cell 1999; 96:737-749. 10. Maalla R, Hmid M, Mellouli O, Klila M. Glomus tumours of the hand. About 10 cases (Article in French). Tunis Med 2007; 85:469-472. 11. Ozdemir O, Coşkunol E, Ozalp T, Ozaksar K. Glomus tumors of the finger: a report on 60 cases (Article in Turkish). Acta Orthop Traumatol Turc 2003; 37:244-248. 12. Murthy PS, Rajagopal R, Kar PK, Grover S. Two cases of subungual glomus tumor. Indian J Dermatol Venereol Leprol 2006; 72:47-49.
June 2011 KUWAIT MEDICAL JOURNAL 133 Case Report Laparoscopic Appendectomy in the Third Trimester of Pregnancy: Report of Two Cases and Description of Technique Waleed Al-Bastaki, Waleed Buhaimed, Khalid Al-Zamel Department of Surgery, Al-Amiri Hospital, Kuwait Kuwait Medical Journal 2011; 43 (2): 133-135 ABSTRACT Acute appendicitis is the most common cause of acute abdomen during pregnancy. Its prevalence is equally distributed throughout the three trimesters. Although laparoscopic appendectomy is a safe and effective procedure for management of acute appendicitis, data about the feasibility and safety during pregnancy are limited, especially the role of laparoscopic appendectomy in the third trimester. In fact, some authors have advocated a gestational age of 28 weeks to be the upper gestational limit for successful completion of laparoscopic surgery. In this paper, we present two cases of successful laparoscopic appendectomy during the third trimester without complication to mother or fetus along with a description of our operative technique. KEYWORDS: appendicitis, laparoscopic surgery, operative technique INTRODUCTION Acute appendicitis is the most common cause of acute abdomen in pregnancy. The prevalence is equally distributed throughout all trimesters with an incidence ranging between 0.05 to 0.13% [1] . The objective of this case report is to demonstrate that laparoscopic surgery in the third trimester is feasible and can be performed safely [2,3] . This is contrary to the belief by some authors that the 26 th to the 28 th week should be the upper gestational limit for successful completion of laparoscopic surgery [4] . There are limited data in the English literature on third trimester laparoscopic appendectomy. Most publications on laparoscopic surgery in the third trimester of pregnancy include either single case reports or small case series involving two to four cases [3] . In this paper we present two cases of successful laparoscopic appendectomy in the third trimester with a description of our operative technique. CASE HISTORY Case 1 A 39-year-old woman was admitted to our hospital with sudden onset right lower quadrant abdominal pain. Gestational age was estimated to be 30 weeks. There were no associated symptoms and there was no vaginal bleeding. The patient was afebrile and her vitals were stable. Her physical examination showed a gravid uterus along with right lower quadrant tenderness and guarding. The clinical diagnosis was acute appendicitis. Laboratory evaluation showed a white blood cell count of 14.2 x 10 9 /l, and her ultrasound was equivocal. A diagnostic laparoscopy was performed. There was torsion of appendices epiploica around the cecal area which was excised along with excision of a normal looking appendix. The surgical procedure that we have performed was as per the guidelines of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). The procedure was performed under general anesthesia. The patient was positioned in supine decubitus and tilted 20 to 30 degrees to the left. This position frees the vena cava from compression and exposes the appendicular area. Compression devices were placed on both lower extremities. Foley catheter and orogastric tube were placed and the abdomen was draped using sterile technique. Antibiotic prophylaxis was administered intravenously at the time of induction. The uterine fundus was palpated and a 10 mm camera port was inserted using the open technique 3 - 4 cm above the superior margin of the uterus. A 10 mm working port was inserted under visual guidance of a Address correspondence to: Dr. Waleed Al-Bastaki, FRCSEd, P O Box 38622, Dahiat Abdulla Al Salem, Kuwait 72257. E-Mail: frcs98@hotmail.com
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