Five tips and tricks for approaching large cervical fibroids with a broad ligament component

Abstract

This video will demonstrate five tips and tricks for robotic excision of cervical fibroids with a broad ligament component by utilizing two case examples. Tip number 1 is a thorough physical exam including speculum and bimanual exams. In our first case the physical exam reveals an obscured cervix by the large cervical fibroid and our second case reveals a markedly deviated cervix. These findings help the surgeon anticipate which uterine manipulator might be helpful during the case. Tip number 2 is a systematic review of MRI imaging. T2 weighted imaging in three planes is ideal for assessing fibroids size, location, and relationship to the endometrium, lower uterine segment, and lateral structures. Tip number 3 is to access the pararectal space and to demonstrate techniques of ureterolysis. In both cases, the round ligament is transected and the incision extended parallel to the infundibulopelvic ligament. The ureter is identified on the medial leaf of the broad ligament. Tip number 4 is to demonstrate skeletonization and occlusion of the uterine artery. The uterine artery is identified and skeletonized, either at its origin or crossing over the ureter. The borders of the pararectal space are reviewed and placement of a hem-o-lock clip is demonstrated. This technique allows for vascular control and safe resection of a large fibroid despite its proximity to the uterine artery and ureter. Tip number 5 is to show techniques for complete excision of large cervical fibroids. Important techniques employed include cephalad traction of the fibroid for good visualization and circumferential dissection. These five tips and tricks can be utilized to safely approach robotic excision of cervical fibroids with a broad ligament component as seen in our two case examples