Herlyn-Werner-Wunderlich syndrome (HWWS), defined by the triad of uterus didelphys, obstructed hemivagina and ipsilateral renal agenesis, is a rare Mullerian duct malformation, usually diagnosed after menarche, when symptoms related to haematocolpos arise. We report a case of a 14-year-old patient who presented to the emergency department complaining of proctalgia and pelvic pain treated in our medical centre. Ultrasound and abdomino-pelvic MRI imaging studies confirmed the diagnosis. Treatment was surgical incision of the vaginal septum. At the follow-up visit, after the initial procedure, excess vaginal tissue was excised using a hysteroscopic approach during diagnostic vaginoscopy. Vaginoscopy-assisted treatment of the patient proved to be a safe and effective minimally invasive treatment modality that resulted in symptomatic relief and fertility preservation. In conclusion, although premenarche is asymptomatic in the vast majority of cases, HWWS would be optimally diagnosed in childhood to avoid acute late complications, although it is usually first diagnosed after menarche as a result of haematocolpos. Gynaecologists should consider the syndrome in the presence of pelvic mass, renal agenesis, menstrual changes and cyclic pelvic pain.
Availability of minimally invasive abdominal procedures can be restricted in cases of painful procedures, due to limited access to anesthesia support or the more recent avoidance of aerosol generating medical procedures such as intubation. Intravenous sedation, in many cases is insufficient to effectively control the pain, leaving patients to suffer undue discomfort and a medical team stressed by the situation. Regional nerve blocks can offer a solution but are underutilized, likely in large part due to a lack of knowledge of available options.This manuscript describes four different nerve blocks that can be useful for analgesia related to upper abdominal procedures. Available data are reviewed regarding their effectiveness and the technique used to perform them is described. Information provided aims to help decide which is likely to provide the best analgesia depending on the procedure being done. Increase use of these blocks has the potential to improve patient's accessibility to minimally invasive upper abdominal procedures.
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