Excision of an Occult, Obstructed Hemivagina Under Laparoscopic Ultrasound Guidance in a Patient with Ohvira Syndrome

Abstract

<h3>Study Objective</h3> To demonstrate the use of laparoscopic ultrasound guidance for identification and excision of an oblique vaginal septum in a patient with a congenital uterine anomaly. <h3>Design</h3> Case presentation. <h3>Setting</h3> Academic-affiliated tertiary care center. <h3>Patients or Participants</h3> A 27-year-old P0000 who presented to an outside facility with 7 months of abnormal uterine bleeding, pelvic pain, and increased vaginal discharge. A complex left adnexal mass was seen on ultrasound. The patient was taken to the OR and found to have a uterine didelphys, pelvic wall adhesions, and a 3cm left ovarian cyst. Three months later, when the patient had persistent LLQ pain, MRI demonstrated presence of a double cervix, obstructed and dilated left hemivagina, and left renal agenesis. Referral to a tertiary center was made for further evaluation. <h3>Interventions</h3> At the tertiary center, diagnostic hysteroscopy through the single visible cervix demonstrated a right uterine cavity and ostium. Transvaginal ultrasound did not identify the hematocolpos in a way that aided surgical exploration. During diagnostic laparoscopy, a BK 4-way 10mm OD articulated laparoscopic ultrasound transducer (I12C4F) was attached to the BK 5000 imaging system. The transducer was directed toward the pelvic floor revealing the minimally dilated hematocolpos allowing for image-guided positioning of a needle and injection of sterile water making the mass adequately tense to allow easy identification via the vagina. A portion of the oblique vaginal septum was removed, the opening was secured with interrupted absorbable sutures, and hysteroscopy was performed on the left side through the exposed left cervix demonstrating a left uterine cavity and ostium. <h3>Measurements and Main Results</h3> The patient did well postoperatively. Both cervices were readily seen and the area of resection healed appropriately. No further interventions anticipated. <h3>Conclusion</h3> This video demonstrates the utility of laparoscopic ultrasound to assist with the management of selected Müllerian anomalies, particularly when important features may not be palpable or visible vaginally, hysteroscopically, or laparoscopically.