Laparoscopic Myomectomy for 16cm Pedunculated Myoma with Extensive Small and Large Bowel Adhesions Using Honda Lasso Knot

Abstract

Study Objective To describe a technique for laparoscopic loop ligation of a large pedunculated myoma using a Honda knot for hemostasis when attempting myomectomy with massive myoma. Design Surgical video detailing indications, evidence, technique and course of a single patient treated with loop myoma ligation. Setting Conventional laparoscopy within academic hospital operating room. Patients or Participants Single patient. Interventions A Honda slipknot was prepared using 0 polyglactin suture. The free end was passed through a laparoscopic trocar and around the myoma base. The Honda knot end was brought into the peritoneal cavity and the free end passed through this loop. This was tightened around the base of the myoma until it blanched. Measurements and Main Results We describe a 38-year-old G5P1041 who presented with multiple emergency visits for lower abdominal pain in the month following an 8-week termination of pregnancy. Ultrasound confirmed a 16cm pedunculated myoma and myomatous uterus but no retained products of conception. She was added for laparoscopic myomectomy and D&C after failing endometritis antibiotics and NSAIDs. Laparoscopy revealed extensive small and large bowel adhesions to the 16cm myoma. A Honda knot was placed around the base of the myoma to facilitate a lysis of bowel adhesions in a plane close to the myoma serosa. After injecting vasopressin into the pseudocapsule, laparoscopic myomectomy was completed, and the specimen removed through a 3-cm umbilical incision via manual in-bag morcellation. The patient recovered well after a 600mL intraoperative blood loss and reported resolution of all symptoms at follow-up. Conclusion Loop ligature around the base of a pedunculated myoma can aid in hemostasis prior to complex lysis of adhesions and during laparoscopic myomectomy. Hemostatic benefits were previously shown in a small, randomized trial of patients undergoing laparoscopic myomectomy for lesions averaging 5cm. To describe a technique for laparoscopic loop ligation of a large pedunculated myoma using a Honda knot for hemostasis when attempting myomectomy with massive myoma. Surgical video detailing indications, evidence, technique and course of a single patient treated with loop myoma ligation. Conventional laparoscopy within academic hospital operating room. Single patient. A Honda slipknot was prepared using 0 polyglactin suture. The free end was passed through a laparoscopic trocar and around the myoma base. The Honda knot end was brought into the peritoneal cavity and the free end passed through this loop. This was tightened around the base of the myoma until it blanched. We describe a 38-year-old G5P1041 who presented with multiple emergency visits for lower abdominal pain in the month following an 8-week termination of pregnancy. Ultrasound confirmed a 16cm pedunculated myoma and myomatous uterus but no retained products of conception. She was added for laparoscopic myomectomy and D&C after failing endometritis antibiotics and NSAIDs. Laparoscopy revealed extensive small and large bowel adhesions to the 16cm myoma. A Honda knot was placed around the base of the myoma to facilitate a lysis of bowel adhesions in a plane close to the myoma serosa. After injecting vasopressin into the pseudocapsule, laparoscopic myomectomy was completed, and the specimen removed through a 3-cm umbilical incision via manual in-bag morcellation. The patient recovered well after a 600mL intraoperative blood loss and reported resolution of all symptoms at follow-up. Loop ligature around the base of a pedunculated myoma can aid in hemostasis prior to complex lysis of adhesions and during laparoscopic myomectomy. Hemostatic benefits were previously shown in a small, randomized trial of patients undergoing laparoscopic myomectomy for lesions averaging 5cm.