Hepatic-cell adenoma presenting with intraperitoneal haemorrhage in the puerperium.

incarceration at the site of laparoscope insertion that resulted in intestinal obstruction, and claimed that this was the first report of this complication of laparoscopy. Both patients eventually needed small bowel resection, 14 and 21 days after laparoscopy. These two patients, and the one described above, were initially well after laparoscopy and then started to vomit on the third and the sixth days after laparoscopy. Thompson and Wheeless' reported that burns or traumatic injury typically present between the third and seventh post-laparoscopic day and then need urgent surgical treatment. They recorded 11 bowel injuries in a series of 3600 laparoscopic sterilisa-tions. Thus, obstructive symptoms occurring a week or more after laparoscopy may be due to bowel incarceration at the site of laparo-scope insertion. Herniation may occur at the site of laparoscopic insertion, and Bishop and Halpin5 reported protrusion of omentum through an infraumbilical laparoscopy incision. This occurred on the third post-laparoscopy day after a coughing bout. These three reports of herniation and one of protrusion at the site of laparoscope insertion were all associated with either 11 or 12 mm-diameter instruments. These rare complications might be eliminated if smaller diameter instruments, which are available, were used. An association between hepatic-cell adenomas and the contraceptive pill was first suggested in 1973 by Baum et al,' and since then over 100) cases have been recorded.' We describe a case of fatal intraperi-toneal haemorrhage due to rupture of a hepatic-cell adenoma that presented five days after caesarean section and 13 months after stopping oral contraceptives. A 26-year-old woman presented at 15 weeks in her fourth pregnancy. After her third pregnancy she started lynestrenol and ethinyloestradiol (Minilyn) and continued for three and a half years. Her pregnancy started three months after stopping oral contraceptives and progressed normally until 38 weeks, when moderate pre-eclampsia developed and labour was induced. Fetal distress necessitated a caesarean section, and a healthy 3180 g girl was delivered through a lower segment incision. The puerperium was satisfactory until the fifth day, when the patient suddenly complained of weakness and epigastric pain. The patient rapidly became shocked. Laparotomy disclosed massive intraperitoneal haemorrhage caused by a ruptured ill-defined yellow tumour that affected both lobes of the liver. The tumour was biopsied, and the bleeding site was packed with surgicel and the capsule sutured. Histological examination showed multiple fragments of a hepatic-cell adenoma with considerable disruption of the tissue by haemorrhage. Typically, the …