Successful use of Laparoscopic Myomectomy to remove a giant Uterine Myoma
in Max Super Speciality Hospital, Dehradun
Jan 11 , 2023
A 38-year-old woman came to the Gynaecology Department of Max Super Speciality Hospital, Dehradun, with complaints of intermittent abdominal pain that had intensified during the previous three months and progressive abdominal swelling during the past two years. She was a mother of 2 (both by caesarean section) and suered from Menometrorrhagia leading to severe anaemia and a history of blood transfusion in other hospitals.
A physical examination revealed a firm giant palpable abdominal mass with identifiable borders. The mass extended to her umbilicus and measured 15 cm above her symphysis pubis. These findings were confirmed by abdominal sonography. The abdominal ultrasonic examination revealed a markedly enlarged uterus containing intramural uterine leiomyoma measuring 10.3 × 10.8 cm without ascites in her abdominal cavity. No additional pathology was noted in the remainder of her pelvis or abdomen. The results of the routine laboratory testing, including a complete blood count, serum electrolyte levels and biochemical tests, were within the normal limits. Based on these findings, a giant intramural Myoma was assumed, and myomectomy was selected as the treatment.
The patient was oered laparoscopic removal of the Myoma. Pneumoperitoneum was achieved using a supraumbilical Veress needle until an intra-abdominal pressure of 12 mmHg was reached. The doctors first placed a midline supraumbilical 10 mm port for the telescope, and then two 5 mm accessory trocars were positioned in the left and right lateral quadrants visualized via a 10 mm telescope inserted through the supraumbilical port. The left and right accessory ports were inserted lateral to her deep inferior epigastric arteries and higher than usual; the accessory trocars were inserted suciently high enough to provide an unobstructed passage to the Myomas for the laparoscopic instruments. Intra-abdominal visualisation revealed an enlarged, globular uterus containing a fundal intramural Myoma with a maximum diameter of 14 cm x 13 cm, bigger than diagnosed by ultrasound.
The adnexa on both sides, round ligaments, and other pelvic and abdominal organs were normal. A myomectomy was performed. A transverse incision was made on the prominent part of the principal myoma using a monopolar hook. The cleavage plane between the Myoma and its surrounding connective tissues was then dissected. When the myoma was identified, it was fixed, and enucleation was then accomplished by traction on the myoma with a myoma screw associated with countertraction on the uterus-facilitated dissection. The myoma was completely enucleated and removed endometrial cavity also opened up due to a big fibroid.
A harmonic ultrasonic scalpel was used for most of the procedure. Bipolar coagulation was used when extra hemostasis was required. The myometrial defect and edges were closed with a continuous suture using a V-loc unidirectional barbed suture in two layers. The left accessory 5 mm port was converted to a 10 mm one for the safe retrieval of tissues. The entire Myoma was dissected into small pieces with the help of the harmonic scalpel, which took another 90 minutes and was removed using endobag. The total intra-operative blood loss was 220 mL, the total weight of the Myoma removed was 1325 grams, and the operation lasted for 180 minutes.
Despite this success, the use of a laparoscopic approach to treat large Myomas is still controversial and represents a significant surgical challenge. The diculties of cleavage, removal and repair of the myometrial defect, increased operative time, risk of peri-operative bleeding and conversion to laparotomy are the major concerns. The appropriate management of patients with very large myomas is complex and requires exceptional skills.
The entire myoma was successfully removed laparoscopically. The final histopathological examination confirmed the diagnosis of a giant uterine leiomyoma. The post-operative course was unremarkable, and the patient was discharged on the third post-operative day.
A physical examination revealed a firm giant palpable abdominal mass with identifiable borders. The mass extended to her umbilicus and measured 15 cm above her symphysis pubis. These findings were confirmed by abdominal sonography. The abdominal ultrasonic examination revealed a markedly enlarged uterus containing intramural uterine leiomyoma measuring 10.3 × 10.8 cm without ascites in her abdominal cavity. No additional pathology was noted in the remainder of her pelvis or abdomen. The results of the routine laboratory testing, including a complete blood count, serum electrolyte levels and biochemical tests, were within the normal limits. Based on these findings, a giant intramural Myoma was assumed, and myomectomy was selected as the treatment.
The patient was oered laparoscopic removal of the Myoma. Pneumoperitoneum was achieved using a supraumbilical Veress needle until an intra-abdominal pressure of 12 mmHg was reached. The doctors first placed a midline supraumbilical 10 mm port for the telescope, and then two 5 mm accessory trocars were positioned in the left and right lateral quadrants visualized via a 10 mm telescope inserted through the supraumbilical port. The left and right accessory ports were inserted lateral to her deep inferior epigastric arteries and higher than usual; the accessory trocars were inserted suciently high enough to provide an unobstructed passage to the Myomas for the laparoscopic instruments. Intra-abdominal visualisation revealed an enlarged, globular uterus containing a fundal intramural Myoma with a maximum diameter of 14 cm x 13 cm, bigger than diagnosed by ultrasound.
The adnexa on both sides, round ligaments, and other pelvic and abdominal organs were normal. A myomectomy was performed. A transverse incision was made on the prominent part of the principal myoma using a monopolar hook. The cleavage plane between the Myoma and its surrounding connective tissues was then dissected. When the myoma was identified, it was fixed, and enucleation was then accomplished by traction on the myoma with a myoma screw associated with countertraction on the uterus-facilitated dissection. The myoma was completely enucleated and removed endometrial cavity also opened up due to a big fibroid.
A harmonic ultrasonic scalpel was used for most of the procedure. Bipolar coagulation was used when extra hemostasis was required. The myometrial defect and edges were closed with a continuous suture using a V-loc unidirectional barbed suture in two layers. The left accessory 5 mm port was converted to a 10 mm one for the safe retrieval of tissues. The entire Myoma was dissected into small pieces with the help of the harmonic scalpel, which took another 90 minutes and was removed using endobag. The total intra-operative blood loss was 220 mL, the total weight of the Myoma removed was 1325 grams, and the operation lasted for 180 minutes.
Despite this success, the use of a laparoscopic approach to treat large Myomas is still controversial and represents a significant surgical challenge. The diculties of cleavage, removal and repair of the myometrial defect, increased operative time, risk of peri-operative bleeding and conversion to laparotomy are the major concerns. The appropriate management of patients with very large myomas is complex and requires exceptional skills.
The entire myoma was successfully removed laparoscopically. The final histopathological examination confirmed the diagnosis of a giant uterine leiomyoma. The post-operative course was unremarkable, and the patient was discharged on the third post-operative day.
