2679 Management of a Large Uterus and its Complications to a Successful Laparoscopic Surgery

Abstract

Video Objective Present and demonstrate a pre operative and surgical management of large uterus and its complications. Setting A 37-years-old, G2P2, who complained of progressive dysmenorrhea, genital pelvic and low-back pain without improvement with hormonal treatment. Complementary exams showed deep endometriosis on the posterior compartment, myomatosis uterus with 848cc of volume and an 139cc cystic right ovarian mass, which generated an extrinsically compression on the right ureter and ureterohydronephrosis. Interventions Pre operative management consisted in double J catheter in the right ureter and uterine artery embolization with prophylactic antibiotic 3 months before the surgery. Final complementary exams showed an uterine volume reduction to 313cc. Laparoscopic treatment consisted of inspecting pelvic and abdominal cavities. Right ovarian mass was adhered to the posterior compartment including ovarian fossa, rectovaginal septum and right uterossacral ligament. Strategy consisted of right ovariectomy, Latsko and Okabayashi space dissection to identify bilateral hypogastric nerves and ureters. After identifying anatomy landmarks, endometriotic lesions were removed from uterossacral ligament and ureter. Rectovaginal septum was dissecated and bowel superficial lesion identified. Hysterectomy and bilateral salpingectomy were performed as treatment. Linear stapler was used to remove bowel endometriotic lesion. Ureterohydronephrosis became absent and controlled and Double J catheter was removed right after the surgery. Double J catheter right after surgery. Conclusion Pre operative strategies are very important to a successful surgery. Double J catheter is a temporary intervention to prevent ureteres complications. Uterine artery embolization reduced more than 50% of the uterine volume. These strategies facilitated the access to the pelvis and promoted excellent laparoscopic view to completely treat myomatosis and deep endometriosis.