Laparoscopic Myomectomy for a Large Incarcerated Posterior Myoma

Abstract

<h3>Study Objective</h3> To demonstrate a technique for laparoscopic myomectomy with a large posterior fibroid and incarcerated uterus. <h3>Design</h3> We present a stepwise narrated demonstration of our technique for posterior myomectomy. <h3>Setting</h3> Referral Center in Upstate NY. <h3>Patients or Participants</h3> A 35-year-old with large posterior fibroid desiring fertility sparing treatment. <h3>Interventions</h3> Bilateral retroperitoneal dissections are performed, demonstrating both lateral and anterior approaches for isolation of uterine blood supply. Hemostatic control is achieved with the use of rectal misoprostol, intrauterine vasopressin and temporary occlusion of the uterine blood supply. A high hysterotomy is made and the fibroid is dissected away from the pseudocapsule, eventually allowing displacement of the uterus out of the posterior cul-de-sac with a vaginal hand as the dissection continues, demonstrating an approach to hysterotomy when the ideal location is inaccessible. On completion of the myomectomy, a uterine manipulator is placed, and excess serosa is trimmed. The myometrium is repaired with a 3-layer closure followed by a single layer on the uterine serosa. <h3>Measurements and Main Results</h3> Successful laparoscopic myomectomy for a 669-gram fibroid with estimated blood loss of 100ml and benign pathology. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up ultrasound. <h3>Conclusion</h3> Laparoscopic myomectomies can be safely performed on large posterior uterine fibroids even in the setting of an incarcerated uterus. The above techniques can improve hemostasis, access to the fibroid and repair of atypical hysterotomy.