Case Study: Broad Ligament Fibroid with Ureteral Dissection: Laparoscopic Myomectomy

History
A 39 year-old woman presented with urinary frequency and pelvic pressure. On pelvic examination, a large pelvic mass was felt adjacent to the uterus, deep in the pelvis. MRI showed a 12 cm subserosal fibroid adjacent to the right side of the uterus (see figure LS 2012). The patient requested a laparoscopic myomectomy.

Figure LS 2012: Subserosal Fibroid MRI

Procedure
Incisions were made in the umbilicus, in the right lower quadrant superior and medial to the iliac crest, midway between the right lower quadrant incision and in the left lower quadrant. The fibroid was seen in the right broad ligament (figure: broad ligament a) and the ureter was identified on the right pelvic sidewall down to the level of the uterine artery where it appeared to course lateral to the fibroid.

Figure a: Broad Ligament

The round ligament was severed near the uterus and a vertical incision was made in the peritoneum medial to the fibroid and away from the pelvic sidewall (figure: broad ligament b).

Figure b: Broad Ligament

The dissection was carried down into the pelvis using traction to enucleate the fibroid. As the fibroid was separated from the peritoneum, the ureter was unexpectedly found on the inferior and medial side of the peritoneal incision (figure: broad ligament c, arrow).

Figure c: Broad Ligament, arrow
Careful dissection continued until the fibroid was removed and placed near the cecum. The peritoneal defect can be seen in figure: broad ligament d.

Figure d: Broad Ligament

Interrupted sutures were placed to close the defect. A small hydrosalpinx was incidentally found in the right fallopian tube and the tube was removed. Morcellation was performed and the procedure was completed. Estimated blood loss was 50 ml. The patient was discharged home the same day and she made an uneventful recovery.