Minimally invasive surgical management of intraligamentous leiomyomas made ridiculously easy

Abstract

To describe a minimally invasive systematic surgical approach to manage large intraligamentous leiomyomas. Intraligamentous myomas account for 6% of all leiomyomas according to Sizzi et al. Ambrosio et al found that transvaginal ultrasound has a sensitivity and specificity of 52% and 93%, respectively, for the diagnosis of intraligamentous leiomyomas. The surgical approach to these patients is discussed with easy to replicate steps highlighted in this video. Two cases of symptomatic women with intraligamentous myomas are described in this video, one measuring 8 cm and the other 6 cm in largest diameter. Both patients underwent an uncomplicated total robotic hysterectomy, bilateral salpingectomy, and cystoscopy. EBL was 50 ml and 25 ml, respectively. Key take home steps are as follows: 1. Perform a systematic evaluation of the abdomen and pelvis confirming location of bilateral ureters 2. Coagulate and transect the round ligaments 3. Open anterior and posterior broad ligament leaflets of the broad ligament to reveal the colpotomy cup 4. Skeletonize uterine vessels 5. Peel the intraligamentous myoma out of the pelvis and towards the operative scope 6. Coagulate and transect the uterine vessels above the colpotomy cup 7. Perform colpotomy 8. Perform a sharp vaginal morcellation or in bag morcellation as appropriate based on individual patient characteristics In conclusion, the incidence of leiomyomas has been reported to be as high as 80% by age 50. Only 6% of leiomyomas are intraligamentous myomas. This video reviews easy to replicate steps to successfully navigate the pelvis in the presence of intraligamentous myomas.