Parasitic Myomas: An Unusual Risk after Morcellation.

A 24-year-old unmarried woman had undergone laparoscopic myomectomy for single degenerated myoma of size 15 cm. Uncontained morcellation of the myoma was done with an electromechanical morcellator. Two years later, she presented with abdominal pain, and laparoscopy revealed enlarged uterus (20 weeks) with multiple degenerated myomas. There were multiple parasitic myomas measuring 1-3 cm in the pelvis and anterior abdominal wall which were removed laparoscopically. Histopathology of all the myomas including parasitic myomas confirmed the diagnosis of leiomyoma. The formation of parasitic myomas was assumed to be due to the myomatous fragments which were left behind during morcellation at the time of initial myomectomy. Methods to prevent this complication are colpotomy, mini-laparotomy, or in-bag morcellation.

Thirteen Years of Experience with Opportunistic Bilateral Salpingectomy During TLH in Low-Risk Premenopausal Women.

BACKGROUND: Opportunistic bilateral salpingectomy (OBS), also called as prophylactic salpingectomy or risk-reducing salpingectomy is the concurrent removal of the fallopian tubes in premenopausal women. Though there are some studies comparing the intraoperative complications and effect of salpingectomy on ovarian reserve, limited data are available on long-term follow-up after OBS. PURPOSE OF THE STUDY: To evaluate the surgical outcome of routine bilateral salpingectomy during total laparoscopic hysterectomy (TLH) in terms of intraoperative and postoperative complications. We also evaluated the incidence and reoperation rate for adnexal pathology after TLH. METHODS: A retrospective study of 1470 patients undergoing total laparoscopic hysterectomy (TLH) with opportunistic bilateral salpingectomy (OBS) over 13 years was carried out at Paul's Hospital. RESULTS: The mean age of the subjects was 43.6 ± 4.2 years, mean body mass index was 27 ± 5.4 kg/m2, and median parity was 2 (range 0-7). 43% of women had at least one previous surgery. The most common indication for surgery was fibroid uterus (67%, n = 985). The total complication rate was 4.4% (n = 65). One specimen showed paratubal borderline serous malignancy. The follow-up period ranged from 6 months to 13 years during which 17 (1.1%) women had adnexal pathology, and eight women (1.1%) needed resurgery for it. No ovarian malignancies were reported on follow-up. CONCLUSIONS: OBS is a simple and short surgical step during TLH without increasing morbidity. OBS eliminates the risk of future diseases of tubal origin, and there might be a possible reduction in incidence and reoperation rate for future ovarian pathologies.

Extrauterine adenomyoma: a review of the literature.

Adenomyosis is the presence of endometrial glands and stroma within the myometrium. The focal and localized form of adenomyosis is known as adenomyoma. It is rarely located outside the uterus which is termed as extrauterine adenomyoma. We describe three cases of extrauterine adenomyomas which were located in pararectal space, round ligament and ovary. These cases were treated by laparoscopic excision and diagnosis was confirmed by histopathological examination. A review of the literature identified 34 cases of extrauterine adenomyomas. The most common locations were pararectal space, ovary and broad ligament. Other pelvic locations included the round ligament, paraovarian, parametrial and pelvic wall. Extrapelvic adenomyomas were located in the liver, upper abdomen, inguinal scar, appendix and small bowel mesentery. The abdominopelvic pain was the most common clinical presentation of extrauterine adenomyoma. Various imaging modalities were used to identify extrauterine masses, but a definitive diagnosis could not be made preoperatively in any of the cases. Although rare, a possible diagnosis of adenomyoma must be contemplated while dealing with extrauterine masses. Surgical excision is the mainstay of treatment. Since malignancy has been reported in extrauterine adenomyomas, this possibility must be kept in mind while offering treatment.

Postoperative Pulmonary Complications Following Laparoscopy.

Postoperative pulmonary complications (PPCs) unrelated to anesthesia, especially hydropneumothorax, are rare after gynecologic laparoscopy. Hydropneumothorax can cause respiratory failure and be life-threatening, however. Awareness, prompt diagnosis, and timely intervention are crucial for clinical management. We review the literature for PPCs, including pneumothorax, hydrothorax, hydropneumothorax, and pleural effusion following laparoscopy, and also present a recent case of hydropneumothorax seen at our institution.

Laparoscopic Myomectomy for a Plethora of Submucous Myomas.

STUDY OBJECTIVE: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. DESIGN: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). SETTING: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. INTERVENTIONS: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. CONCLUSION: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.