Posted Friday, August 15, 2008 @ 10:33 AM 
A patient with a fibroid that she has for already 10 years, where she didn’t let a surgery performed, as doctors wanted to remove her uterus. The fibroid grew over ten years and doctors presented to her only a longitudinal laparotomy, which she wanted to avoid. The fibroid was now around 50 cm long and 35 cm width and made already many symptoms like short breath, pain in the whole abdomen. She also got problems with breathing while there was a pressure on the diaphragm and she is a professional opera singer. Inside the fibroid many fluid filled areas were detected, that contained necrotic material and cell detritus.
The sonographic examination showed the possibility that it could be a subserous fibroid and so a lift-laparoscopy in combination with a Pfannenstiel laparotomy could be possible.
At this pictures one can see, that the fibroid is growing already in the upper abdominal cavity and it’s volume is around 45 x 35 x 35 centimetres:
With the help of Lift-Laparoscopy we could detect the pedicel of the fibroid and a ligature of the pedunculated fibroid was performed by a silicone tube / drain. After that the fibroid was dissected from the uterus.
As the patient wishes to maintain her cervix, a supracervical hysterectomy was performed. On the uterus one can see the silicon tube / drain, that was applied to avoid bleeding bevore dissection of the fibroid.
The uterus itself was 15 x 18 x 15 centimetres.
How could we take a 40 centimetres big fibroid via a 12 cm incision ?
The fibroid has to be morcellated and piece by piece retrieved from the abdominal cavity.
One can recognise the necrotic tissue with fluid.
Here the entire fibroid is presented on the operating table.
Multiple necrotic areas can be detected. It is amazing, how big fibroids can grow:
The weight is 4.2 kilograms, but as the fluid is already out, the original weight was around 4.6 kilograms.
It is as far as we know the largest fibroid that was taken via a Pfannenstiel laparotomy. In the University of Linz a 9 kilograms fibroid was taken via a longitudinal laparotomy.
The surgery took 4 hours with 2.5 hours for morcellation. The entire abdominal cavity was than rinsed with 15 litres of warm Ringer’s lactate.
The pain in the abdomen was probably additionally caused by a chronic infection, which was presented on the omentum with reddish areas and increased vascularisation.
Postoperatively she developed some fever and diarrhoea. Even she had i.v. antibiotic treatment, we decided to perform a 2nd look laparoscopy to exclude any bowel complication or a peritonitis.
First of all: no adhesions could be detected!
Which means that even a laparotomy might remain without adhesions, if a good surgical technique was applied?
Anyway, we could exclude a bowel complication and peritonitis. The patient recovered uneventfully. She had only an influenza infection.
This is how laparotomy looks 12 days after original surgery:
Here once again before / after images:
The fibroid grew already under the rib case!. Without Lift-laparoscopy a dissection of the huge pedicle of the fibroid, which was located in the area of the umbilicus, was impossible. A longitudinal laparotomy had to be performed.
And this is how the laparotomy looks after 4 weeks:
We think, for such large fibroid the result is excellent.
We are thankful and appreciate the patient agreed to post her findings and images, in order to show patients how a longitudinal laparotomy and adhesions might be avoided.
This ist the type of incision she could avoid with our surgery:
Regardless cosmetic issues, she would need a much longer recuperation and singing in the opera after such short time would be impossible.
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Daniel Kruschinski, MD
www.endogyn.com
© by EndoGyn Ltd.
