A novel approach to hysterotomy using a verres needle with an innerdyne sheath: an unusual presentation of molar pregnancy requiring hysterotomy.

Abstract

Objective: To describe a novel approach to hysterotomy in management of a molar pregnancy in a patient with a large cervical fibroid. The fibroid, measuring 18 × 14 × 12 cm had stretched and attenuated the cervical canal, rendering a transcervical approach an unsafe option. Design: Case Report. Materials/Methods: A 28 year old primigravida presented at 8 weeks gestation with a non viable intrauterine pregnancy suspicious for a hydatidiform mole, a serum β hCG level of 100,000 mIU/ml and status post failed methotrexate treatment. The patient had a large cervical fibroid measuring 18 × 14 × 12 cm that had elongated and attenuated the cervical canal, precluding transcervical evacuation. A minilaparotomy and hysterotomy was performed for evacuation of products of conception. Under intraoperative transuterine ultrasound guidance, a verres needle with an innerdyne sheath was introduced through the uterine fundus into the uterine cavity. The innerdyne sheath was expanded to accommodate a 10 mm laparoscopic trocar sheath. An 8 mm flexible suction curette was introduced through the trocar sheath and the uterine contents were evacuated by suction curettage. Results: Complete evacuation of the uterine cavity was confirmed on intraoperative transuterine ultrasound. There was minimal bleeding during the procedure and virtually no spillage of uterine contents. Following removal of the trocar sheath, the resulting myometrial defect was less than 1 cm and closed with a single stitch of 0 chromic catgut. Conclusions: Utilization of the verees needle with the innerdyne sheath for hysterotomy provided an atraumatic entry with separation of myofibers rather than transection as seen with classic hysterotomy, minimizing the possibility of dehiscence in a subsequent pregnancy. A complete mole was confirmed on histopathology of products. The postoperative course was significant for a rapid decline in serum β HCG levels to normalization within 4 weeks post evacuation.