Laparoscopic Management of Huge Myoma Nascendi

Study objective: To demonstrate the feasibility of laparoscopic management of a huge myoma nascendi.

Design: Step-by-step video demonstration of the surgical procedure (Canadian Task Force classification III-C).

Setting: Uterine myoma is the most common benign neoplasm of the female reproductive tract, with an estimated incidence of 25% to 30% at reproductive age [1,2]. Patients generally have no symptoms; however, those with such symptoms as severe pelvic pain, heavy uterine bleeding, or infertility may be candidates for surgery. The traditional management is surgery; however, uterine artery embolization or hormonal therapy using a gonadotropin-releasing hormone agonist or a selective estrogen receptor modulator should be preferred as the medical approach. Surgical management should be performed via laparoscopy or laparotomy; however, the use of laparoscopic myomectomy is being debated for patients with huge myomas. Difficulties in the excision, removal, and repair of myometrial defects, increased operative time, and blood loss are factors keeping physicians away from laparoscopic myomectomy [1,2].

Interventions: A 35-year-old woman was admitted to our clinic with complaints of chronic pelvic pain and heavy menstrual bleeding. Her medical history included multiple hospitalizations for blood transfusions, along with a recently measured hemoglobin level of 9.5 g/dL and a hematocrit value of 29%. She had never been married and had no children. Pelvic ultrasonography revealed a 12 × 10-cm uterine myoma located on the posterior side of the corpus uteri and protruding through to the cervical channel. This was a huge intramural submucous myoma in close proximity to the endometrial cavity and spreading through the myometrium. On vaginal examination, the myoma was found to extend into the vagina through the cervical channel. Laparoscopic myomectomy was planned because of the patient's desire for fertility preservation. Abdominopelvic exploration revealed a huge myoma filling the posterior side of the corpus uteri and extending to the isthmus uteri and cervical channel. A myomectomy was performed using standard technique as described elsewhere. A vertical incision was made using a harmonic scalpel. The myoma was fixed with a corkscrew manipulator and enucleated. During the procedure, the endometrial cavity was torn and was closed with 2-0 Vicryl separately. Total intraoperative blood loss was 250 mL, the total weight of the myoma was 245 g, and the operation lasted about 120 minutes. The patient experienced no intraoperative complications. She was discharged on postoperative day 1 and did not exhibit any problems at follow-up. The final histopathological examination confirmed the diagnosis of uterine leiomyoma.

Conclusion: Laparoscopic management of huge myomas in difficult locations appears to be a feasible and safe surgical option, especially in experienced hands.