8499 Laparoscopic Myomectomy for Symptomatic Pedunculated Fibroid with Degeneration and Subserous Fibroids in Second Trimester of Pregnancy

Abstract

Study Objective To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Design Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Setting Tertiary care hospital. Patients or Participants A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Interventions Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. Measurements and Main Results The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Conclusion Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise. To demonstrate the feasibility of emergency laparoscopic myomectomy for a large pedunculated fibroid (FIGO type 7) with degeneration and multiple subserous fibroids (FIGO type 6) in a patient with pregnancy of 12.4 weeks. Stepwise demonstration of laparoscopic myomectomy in a patient with gravid uterus with narrated video footage with sonographic images. Tertiary care hospital. A 27 years primigravida with 12.4 weeks of gestation presented with severe pain in right lower abdomen and vomiting for three days. Abdominal ultrasound showed gravid uterus with multiple subserous fibroids of size 30 × 30mm, 23 × 26mm, 24 × 21mm and a large avascular lesion showing central degeneration of size 117 × 93 mm in right hypochondriac region separately from uterine fundus suggestive of pedunculated fibroid. Patient counselling was done about the risks and benefits of surgery during pregnancy. Laparoscopic myomectomy of a large pedunculated myoma and other multiple subserous fibroids was done. The base of pedunculated fibroid ligated with two sutures and rest of fibroids enucleated out. Myometrial walls sutured. Use of vasopressin was avoided during myomectomy. The fibroids were removed by in bag morcellation with morcellator. The myomas were removed with very minimal blood loss of 50 ml. The pedunculated large myoma measured 10 × 12 cm and six subserosal fibroids measured 2 × 2 cm to 2 × 3 cm each. Histopathological reports revealed degeneration in large pedunculated fibroid. The patient had complete resolution of right lower abdominal pain and recovered well post operatively and underwent vaginal delivery at term with healthy baby. Laparoscopic myomectomy can be done selectively for patients with only symptomatic pedunculated and subserous fibroids. Minimal handling of the gravid uterus is necessary to minimize the chances of abortion and preterm delivery. Proper selection of patients for this type of surgery during pregnancy is very important and requires surgical expertise.