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

October 10, 2011

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.

 

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)

  • 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.

 

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.

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References:

José M Palacios Jaraquemada MD, Ph.D

Av. Corrientes 5087 4º A

C1414AJD Ciudad de Buenos Aires, Argentina

jpalacios@ciudad.com.ar