Innovatory uterine repair after surgery for a giant myoma in a nulliparous woman

Case report A 35-year-old nulliparous woman with a giant uterine myoma is described. During the past three years she had developed a intramural myoma and a subserous myoma. Although the lesions were excised, both reappeared and were treated with GnRH analogues for 6 months. The subserous myoma was then endoscopically excised, leaving the intramural myoma in situ. The remaining myoma grew uncontrollably and open surgery with possible hysterectomy was proposed. A physical examination revealed a displaced and enlarged uterus, matching a four-month pregnancy. As ultrasound studies showed an heterogeneous myoma measuring 15 cm in diameter, with poor uterine visualization, a T2-weighted MRI was performed. A conservative approach with uterine repair using a reabsorbable mesh and fibrin glue was planned. RMN 1) Right parasagittal image showing an anatomically normal uterus, with normal endometrial brightness and thickness. RMN 2) Axial image showing a myoma measuring 16 cm in diameter, displacing an otherwise normal uterus. Both uterine walls reveal a similar thickness (6 mm) and a bright and homogeneous endometrium. RMN 3) Coronal imaging showing the structurally preserved uterus and homogeneous myoma relationship. Pictures (images will open in a new browser window) The initial incision was extended (high level of adhesions) to avoid colonic and greater omentum lacerations. After posterior adhesions were incised the uterus and myoma could be released. The ovary and appendix were also released. The cleavage surface between the uterus and myoma is shown. The excision level and muscle layers are shown. Excision with myoma vessel ligation (using Ligasure™ vessels as small as 7 mm could be obliterated). Ligasure device. Ligasure device (Detail). Myoma ligation. Vicryl mesh and fibrin glue (Tissel™) placement. A double mesh was fixed with Vicryl 1 separate sutures to the myometrium and covered with fibrin glue. Fibrin glue without thrombin 4 to obtain fast coagulation was employed. Second step with continuous Vicryl-1 sutures. To avoid adhesions a Surgicel™ mesh was added. This mesh was fixed with Vicryl-000 separate sutures. The excised myoma weighted 980 g and measured 16 cm in diameter. Schematic diagram 1. Adhesions found at the beginning of surgery are shown. Firm sigmoid adhesions prevented uterine mobilization. Schematic diagram 2. After all adhesions were released an excision surface leaving a 2-cm margin of normal uterine tissue was established. Schematic diagram 3. Repair in detail. Schematic diagram 4. Ultimate repair in detail. Conclusions This is a new uterine muscle repair that includes a Vicryl mesh, fibrin glue, and collagen when required. The mesh may act as a support for the initial steps of repair and avoid unnecessary movements that may break the suture line. The fibrin glue and collagen shorten tissue healing processes. Benefits for both the patient and surgeon include a repair that prevents uterine ruptures after myomectomy or other surgeries. This approach may allow tension-free sutures and reduce the effects of uterine contractions on sutures and dead spaces. MRI Control After 3 Months Control MRI T2 Mode: The images obtained three months after the surgery have demonstrated a correct myometral repair. RMN Sagittal Control RMN Coronal Control RMN Axial Control Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19 Figure 20 Figure 21 Figure 22 Figure 23 Figure 24 References: JosÃ© M Palacios Jaraquemada MD, Ph.D Av. Corrientes 5087 4Âº A C1414AJD Ciudad de Buenos Aires, Argentina jpalacios@ciudad.com.ar