Archives of Gynecology and Obstetrics

, Volume 279, Issue 4, pp 607–608

Laparoscopic extirpation of a 3-kg uterus

Authors

    • Medical Center of Central Georgia
  • Richard L. Heaton
    • Heart of Georgia Women’s Center
Letter to the Editor

DOI: 10.1007/s00404-008-0827-9

Cite this article as:
Walid, M.S. & Heaton, R.L. Arch Gynecol Obstet (2009) 279: 607. doi:10.1007/s00404-008-0827-9

Abstract

Uterine fibroids are remarkably common and may rarely grow to a large volume. The standard treatment in this situation is abdominal hysterectomy. We are presenting the case of a large multiple fibroid uterus that was successfully treated with total laparoscopic hysterectomy and the problems associated with such an operation.

Keywords

Large multiple fibroid uterusTotal laparoscopic hysterectomy

Uterine fibroids are remarkably common, a problem from which 25% of reproductive age women suffer. In rare cases, uterine fibroids may grow to impressive sizes and cause blood stasis in the pelvic venous plexus which may ultimately trigger deep venous thrombosis and pulmonary embolism [1]. Traditionally, the standard treatment in cases of large uteri has been abdominal hysterectomy. However, because of the improvements in laparoscopic techniques and the advent of morcellators in the latest years, clinical feasibility and practicality of laparoscopic surgery to remove enlarged uteri has been demonstrated [2]. We are presenting the case of a total laparoscopic hysterectomy (TLH) with in situ morcellation of a large multiple fibroid uterus and discussing the problems that may arise when performing such a procedure.

A 47 year old patient with a known uterine fibroid presented with menometrorrhagia. She complained of painful and long menstruations (>8 days) with heavy bleeding and the passage of clots. The patient was G1P1 and weighed 206 lb. On pelvic exam, a 24 week uterus was palpated. Complete blood count revealed anemia. The condition, treatment options and risks and benefits were discussed with the patient. The senior author obtained the patient’s informed consent to proceed with laparoscopic hysterectomy and salpingo-oophorectomy.

With the patient in the ski position, under general endotracheal anesthesia, a direct view trocar was placed in the left upper quadrant and additional punctures were performed (Fig. 1). The infundibulopelvic (IP) ligament (after identifying the ureter and verifying that it was separate from the IP), and round ligaments were cauterized and transected, the anterior broad ligament peritoneum was undermined and transected from round ligament to round ligament, and the posterior broad ligament peritoneum was undermined and transected to the uterosacral ligaments. The uterine vessels were skeletonized, cauterized and transected and a good blanche was obtained in the uterus showing that it was devascularized. No fibroid looked suspicious so a 15 mm Storz Steiner morcellator was passed through the left paraumbilical puncture and morcellation was begun. Due to the small size of the available morcellator, motor overheating, and problems with the grasper that goes with the morcellator, which broke several times during the operation, morcellation took quite a long time. The case was continued until the morcellator could no longer be used toward the end of the operation. It was felt that enough of the uterus had been morcellated to complete the operation. The operation was then continued with opening the vagina, freeing the cervix and pulling the remaining uterus out through the vagina. Good hemostasis, suspension and closure were secured. Cystoscopy was performed with IV Indigo Carmine which was seen coming from both ureteral orifices. The laparoscopy lasted 5 h 57 min and the blood loss was estimated at 800 cc. The specimen “uterus-cervix, right and left ovaries and fallopian tubes” consisted of more than 200 fragments of tissue with a total weight of 3,043 g. The patient was discharged home the next day. She was readmitted 3 days later with nausea, vomiting and abdominal distension despite flatus and good bowel sounds. Laboratory revealed white blood count of 15.4 × 103/μL, hemoglobin 8.6 g/dl and hematocrit 26.1%. Pelvic cellulitis was suspected. The patient was treated with hydration, antiemetic therapy and antibiotics (levofloxacin and metronidazole). She was discharged on the third day in good condition.
https://static-content.springer.com/image/art%3A10.1007%2Fs00404-008-0827-9/MediaObjects/404_2008_827_Fig1_HTML.jpg
Fig. 1

Laparoscopic picture of the large myoma taken from the left upper quadrant

In the past, cases of large uteri have been considered a relative contraindication to laparoscopic hysterectomy due to limited visibility and access to uterine vascular pedicles associated with the high risk of complications such as hemorrhage, bowel and urinary injury, difficulty in extracting the uterus and extended duration of the procedure. Most intraoperative conversions of laparoscopic myomectomy or hysterectomy to laparotomy occur because of intraoperative bleeding. Devascularization of the uterus or myoma at the start of procedure markedly reduces blood loss. The injection of dilute pitressin solution around the myoma prior to beginning myomectomy is very useful in controlling capillary bleeding making it easier to identify larger vessels for coagulation with bipolar cautery to keep the field dry and maintain good exposure. Pretreatment with a GnRH agonist is also very useful because of uterine tissue shrinkage and decreased vascularity. The blood supply to the uterus should be controlled prior to morcellation of enlarged fibroid uterus at the time of laparoscopic hysterectomy. However, this is not always possible and morcellation has sometimes to be started on a single fibroid before gaining full control of the uterine vascular pedicle.

Several systems for electromechanical morcellation have been introduced since the development of the Steiner morcellator in 1993 [3]. It is important to use a 20 or 25 mm morcellator for large myomas [4]. A 20 or 25 mm morcellator was not available when the described case was done; the latter was not obtainable at that time in the USA (Wisap, Sauerlach, Germany). This would have reduced operative time and prevented problems such as motor overheating, which in our case required changing out two different motors and waiting in between while both of the motors were overheated until one of them cooled off. Nevertheless, an increase in operative time, intraoperative blood loss, hospital stay length, and postoperative minor complications can be expected as the uterine weight increases. In the Sinha et al. 2003 study with myomas as big as 3,400 g the operating time was as long as 270 min and blood loss as high as 2,000 ml [5].

A final word of caution, suspicious fibroids growing after menopause, growing on Lupron or other GNRH agonist, rapidly growing over a short time frame in premenopausal women, exceeding 10 cm in diameter, or that appear visibly dubious should be treated with prudence because of the possibility of a rare leiomyosarcoma.

In conclusion, TLH with in situ morcellation can be performed by experienced gynecologists in patients with large uteri. In these cases, it is important to secure optimal exposure of the pelvic field, safe separation of the vascular pedicles and use of wide morcellators for large myomas.

Conflict of interest statement

None.

Copyright information

© Springer-Verlag 2008