The Retroperitoneal Approach to a Broad Ligament Fibroid

Abstract

<h3>Video Objective</h3> To demonstrate a strategic retroperitoneal approach that gynecologic surgeons can employ when encountered with an obscuring broad ligament fibroid. <h3>Setting</h3> Academic medical center. <h3>Interventions</h3> This patient is a 38-year-old G3P3 with menorrhagia and dysmenorrhea secondary to uterine fibroids. Her ultrasound was significant for an 8.5 cm right broad ligament fibroid. She desired definitive management of her symptoms in the form of a total laparoscopic hysterectomy and bilateral salpingectomy. The location of the right broad ligament fibroid obscured visualization of the traditional approach to the uterine artery at the level of the internal os, thus it was necessary to secure the uterine blood supply at its origin off the internal iliac artery. The retroperitoneal space was opened, and the pararectal and paracervical spaces were identified in order to complete this step. The course of the ureter ran in close proximity to the lateral aspect of the fibroid, necessitating mobilization of the ureter laterally. This allowed the fibroid to be safely dissected and the procedure to be safely completed. <h3>Conclusion</h3> This video displays a strategic method for accessing and dissecting the retroperitoneal space in order to safely complete a hysterectomy in a patient with an obstructing broad ligament fibroid. Using this technique, hemostasis is ensured by locating and securing the uterine artery at its origin off the internal iliac artery, and the safety of the ureter is maintained by mobilizing this structure laterally.