Laparoscopic Hysterectomy with Large Posterior or Upper Cervical Myomas

Abstract

Study Objective To present our approach to overcoming surgical challenges of a laparoscopic hysterectomy with a large posterior, upper cervical myoma. Design A guided explanation of the surgery using video. Setting A university hospital. Patients or Participants N/A. Interventions A 49-year-old woman with complaints of pelvic pain from a large posterior, upper cervical myoma desired surgical management with minimally invasive hysterectomy. Magnetic resonance imaging showed a 13 × 9 × 8 cm posterior wall myoma distending the cervical canal and displacing the rest of the uterus superiorly. After counseling, she proceeded with a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and cystoscopy. We present key strategies in managing distorted anatomy, minimizing blood loss, and safe dissection of the myoma. 1. Due to the myoma distortion, a uterine manipulator could not be placed. A laparoscopic tenaculum and vaginal sponge stick were used to mobilize the specimen throughout the case. 2. To minimize blood loss, we secured the four main blood supplies to the uterus before starting the myoma dissection. 3. When dissecting the myoma, the goal is to excise all the layers encasing the myoma. We present a systematic method of proper traction, dissecting on the surface of the myoma and frequent anatomical re-orientation to identify the appropriate surgical planes and prevent injury to surrounding structures. 4. It is important to note the close proximity of the myoma to the bladder and ureters. Backfilling the bladder and dissecting out the ureters are helpful strategies to avoid injury. The specimen was placed in a containment bag and hand morcellated through the umbilicus. The patient was discharged home on postoperative day 0 and recovered without any complications. Measurements and Main Results N/A. Conclusion Large posterior, upper cervical myomas that distort the lower uterine segment and cervix can be surgically challenging when performing a minimally invasive hysterectomy. We demonstrate applicable techniques and strategies to minimize blood loss and prevent complications. To present our approach to overcoming surgical challenges of a laparoscopic hysterectomy with a large posterior, upper cervical myoma. A guided explanation of the surgery using video. A university hospital. N/A. A 49-year-old woman with complaints of pelvic pain from a large posterior, upper cervical myoma desired surgical management with minimally invasive hysterectomy. Magnetic resonance imaging showed a 13 × 9 × 8 cm posterior wall myoma distending the cervical canal and displacing the rest of the uterus superiorly. After counseling, she proceeded with a laparoscopic supracervical hysterectomy, bilateral salpingectomy, and cystoscopy. We present key strategies in managing distorted anatomy, minimizing blood loss, and safe dissection of the myoma. 1. Due to the myoma distortion, a uterine manipulator could not be placed. A laparoscopic tenaculum and vaginal sponge stick were used to mobilize the specimen throughout the case. 2. To minimize blood loss, we secured the four main blood supplies to the uterus before starting the myoma dissection. 3. When dissecting the myoma, the goal is to excise all the layers encasing the myoma. We present a systematic method of proper traction, dissecting on the surface of the myoma and frequent anatomical re-orientation to identify the appropriate surgical planes and prevent injury to surrounding structures. 4. It is important to note the close proximity of the myoma to the bladder and ureters. Backfilling the bladder and dissecting out the ureters are helpful strategies to avoid injury. The specimen was placed in a containment bag and hand morcellated through the umbilicus. The patient was discharged home on postoperative day 0 and recovered without any complications. N/A. Large posterior, upper cervical myomas that distort the lower uterine segment and cervix can be surgically challenging when performing a minimally invasive hysterectomy. We demonstrate applicable techniques and strategies to minimize blood loss and prevent complications.