Laparoscopic Myomectomy Assisted by Hysteroscopy: A Case Report

Abstract

Study Objective To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Design Case report for surgical technique and description of the procedure using video. Setting Tertiary hospital. Patients or Participants A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. Interventions We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. Measurements and Main Results In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. Conclusion We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing. To demonstrate the benefits of laparoscopic myomectomy assisted by hysteroscopy to minimize endometrium damage, therefore providing a better fertility outcome. Case report for surgical technique and description of the procedure using video. Tertiary hospital. A 30-year-old nulliparous woman presents with abnormal uterine bleeding and pelvic pain for a year and a half. She previously tried clinical treatment with Tranexamic Acid and Oral Progesterone without symptoms remission. In the physical examination there weren't any irregular findings. The MRI evidenced multiple nodular formations: a 2 cm submucous fibroid on the fundus with cavity distortion and 8mm of myometrial free margin and others intramural and subserous fibroids measuring up to 1.7cm. We performed a diagnostic hysteroscopy to locate the submucous fibroid and used the hysteroscope's pressure and light to guide de surgeon on the laparoscopy towards that fibroid. We did a vertical incision and proceeded to enucleate the fibroid. We also excised other subserous and intramural nodules along the surgery. Uterine suture was done with a 2-0 barbed suture in two layers. We finished the procedure with another diagnostic hysteroscopy to evaluate endometrium damage. In the final hysteroscopy we could see little endometrium damage. The patient was discharged on the first postoperative day without significant pain. We were able to achieve minimal endometrium damage in a Type 2 FIGO staging fibroid, which would not be possible if we had performed a hysteroscopic myomectomy. On the other hand, if we had done only a laparoscopic procedure, we would have had a significant higher degree of difficulty at finding the fibroid due to its deep placement. Therefore, we reached a favorable outcome regarding the surgical approach in resecting a submucous fibroid in a patient with intention of childbearing.