8569 Approach to a Giant Pedunculated Fibroid

Abstract

<h3>Study Objective</h3> This video reviews the surgical approach to a large pedunculated fibroid including preoperative assessment and intraoperative considerations for performing a laparoscopic myomectomy with contained tissue extraction. <h3>Design</h3> Surgical technique demonstration. <h3>Setting</h3> The patient was seen in an academic medical center. In the outpatient setting, she was consulted by a minimally invasive gynecologic surgeon with expertise in fibroid management. The surgery was performed in the outpatient surgery center. <h3>Patients or Participants</h3> A 37-year-old nulliparous female with a fibroid uterus. Based on preoperative imaging, the predominant fibroid was a posterior, pedunculated fibroid with an estimated weight of 1300 grams. The patient agreed to the use of photos and videos for educational purposes via an informed consent process. <h3>Interventions</h3> Preoperatively, the patient received leuprolide acetate injection in effort to decrease the size and vascularity of the large, broad-stalked, pedunculated fibroid. Eight weeks later she underwent laparoscopic myomectomy with a minilaparotomy for contained tissue extraction. Prior to the start of the surgery, she received misoprostol and tranexamic acid to aid in hemostasis. The video demonstrates the intraoperative use of vasopressin in addition to the surgical approach to the primary myomectomy. Use of the minilaparotomy for surgical assistance, open myomectomy of an additional fibroid, and contained morcellation is portrayed in the video. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> This video reviews the surgical approach to a large, pedunculated fibroid via laparoscopic myomectomy with minilaparotomy. The surgery was without complication and the patient was discharged on the same day. Key learning points that lead to a successful case included: preoperative optimization when you expect to encounter high risk of blood loss, retention of a rim of serosa overlying a broad pedicle when performing myomectomy of an exophytic fibroid, and use of minilaparotomy to aid progression of case, not only for tissue extraction.