Surgical techniques for excision of juvenile cystic adenomyoma

Abstract

The objectives of this video are to review causes of pelvic pain among adolescents and to discuss surgical techniques for safe and effective resection of juvenile cystic adenomyomas. We present a 16-year-old patient with chronic pelvic pain and ultrasound evidence of a 2.4cm adenomyoma. The lesion was specifically thought to represent a juvenile cystic adenomyoma (JCA), defined as a cystic lesion >1cm occurring in women under 30 years with severe dysmenorrhea that is distinct from the uterine cavity and surrounded by hypertrophic myometrium. Given minimal relief from medical therapy and high suspicion for co-existent endometriosis, our patient elected to undergo laparoscopic resection of adenomyoma and excision of pelvic lesions. Preoperative considerations discussed in this video include imaging to identify the location of the lesion and adjacent structures such as the uterine vessels, discontinuation of GnRH agonist for adequate intraoperative visualization, and the high likelihood of encountering endometriosis af the time of surgery. We review the following surgical techniques: 1) maximize visualization with use of a uterine manipulator and temporary oophoropexy, 2) optimize hemostasis via temporary uterine artery ligation and control of collateral blood vessels, 3) complete ureterolysis, 4) meticulous enucleation of adenomyoma, and 5) excision of co-existent endometriotic lesions. Surgical findings demonstrated a 2cm lesion along the left lower uterine segment and red-brown lesions along bilateral ovarian fossa, pathologically confirmed as adenomyoma and superficial endometriosis, respectively. This video presents strategies for safe and effective adenomyoma resection and treatment of refractory chronic pelvic pain in an adolescent.