- Email: [email protected]
Broad ligament uterine fibroid: Management with Davinci robotic myomectomy
Middle East Fertility Society Journal (2015) xxx, xxx–xxx
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
CASE REPORT
Broad ligament uterine fibroid: Management with Davinci robotic myomectomy Ahmed Abdelaziz a b c
a,*
, Salem Joseph b, Mostafa Abuzeid
c
Hurley Medical Center, Michigan State University, 2 Hurley plaza, suite 209, Flint, MI 48503, United States IVF Michigan, 2 Hurley plaza, suite 209, Flint, MI 48503, United States IVF Michigan, Hurley Medical Center, Michigan State University, 2 Hurley plaza, suite 209, Flint, MI 48503, United States
Received 16 December 2014; accepted 26 March 2015
KEYWORDS Broad ligament; Fibroid; Robotic surgery
Abstract Background: We describe a patient with two fibroids; the largest was a broad ligament fibroid, which was managed successfully with robotic assisted laparoscopic myomectomy. It is well known that myomectomy of a large broad ligament fibroid presents a challenge to the surgeon with intraoperative complications such as excessive bleeding and ureteric injury or later complications such as pelvic hematoma and infection. Case report: A 40-year-old nulliparous white female presented with dysmenorrhea, menorrhagia and pelvi-abdominal mass and primary infertility. Trans-vaginal 2D ultrasound (US) revealed an enlarged uterus 9.6/6.1/7.9 cm in dimension. Two uterine fibroids, intramural sub-serous in nature were seen on trans-vaginal 2D US. Trans-vaginal US with Doppler flow study suggested that the larger fibroid is broad ligament in nature with minimal vascularity between the broad ligament fibroid and the uterus. The patient underwent robotic assisted laparoscopic myomectomy. First an intramural sub-serous fibroid was removed, then a large broad ligament fibroid was dissected from the uterus and the anterior leaf of the broad ligament was sutured. A diagnostic hysteroscopy was performed at the end of the procedure and revealed a normal endometrial cavity. Postoperative course was uneventful. Conclusion: The aim of presenting this case was to demonstrate that in patients with a large broad ligament fibroid, who want to preserve their reproductive potential, robotic assisted laparoscopic myomectomy is feasible and safe. Trans-vaginal US plays an important role in determining the
* Corresponding author. E-mail addresses: [email protected] (A. Abdelaziz), salemkj@ gmail.com (S. Joseph), [email protected] (M. Abuzeid). Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier http://dx.doi.org/10.1016/j.mefs.2015.03.003 1110-5690 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
2
A. Abdelaziz et al. degree of attachment, location and vascularity between the uterus and the broad ligament fibroid, which in turn helps in the choice of surgical procedure and technique. 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction Uterine leiomyomata, or myomas, are one of the most common benign tumors of the reproductive tract, affecting more than 70% of women in their lifetime (1). Approximately 25% of reproductive-aged women have myomas. Definitive surgical treatment of myoma is hysterectomy while myomectomy is the treatment for those women who have symptomatic myomas and desire uterine or fertility preservation (2,3). Leiomyomas can arise from any tissue including the broad ligament. The incidence of broad-ligament leiomyoma is <1%. Myomectomy can be either done abdominally, laparoscopically or hystroscopically. Recent trends toward minimally invasive surgery have resulted in increasing numbers of laparoscopic and robotic-assisted myomectomies (4–6). Although minimally invasive surgery has known advantages over open surgery, including shorter hospital stay, quicker recovery, less blood loss, and fewer postoperative adhesions, most of the myomectomies are done abdominally. This is due to the complexity and the necessity of extensive suturing for the desired multi-layered uterine closure, which is technically hard to do laparoscopically (7,8). Traditional laparoscopic myomectomy requires advanced surgical skills and thus may only be offered to select patients on the basis of myoma characteristics and surgeons’ expertise. The introduction of robotic surgery has allowed more surgeons to perform complex laparoscopic procedures (9). The robotic surgical system allows 3-dimensional perception of the surgical field and improved ease of multilayered uterine closure. This has led to an increase in the number of robotic-assisted laparoscopic myomectomies performed worldwide (5,10,11).
vessels. The patient underwent robotic assisted laparoscopic myomectomy (Figs. 3a–3d. First a 4 cm intramural subserous fundal fibroid was removed. Then the broad ligament was opened showing a large broad ligament fibroid (9 cm in diameter) attached to the lower uterine segment with no attachment to the cervix and with a wide stalk measuring about 4 cm (Fig. 3b). Using both monopolar and bipolar cautery the fibroid was dissected from the uterus. There was no need to take any uterine sutures as complete hemostasis in the pedicle was achieved using the bipolar cautery (Fig. 3c). The anterior leaf of the broad ligament was sutured. Care was taken to avoid injury of the right ureter and uterine vessels. Blood loss during the procedure was minimal. The fibroids were morcellated and removed from the peritoneal cavity. Diagnostic hysteroscopy, performed at the end of the procedure, to rule out any small submucous fibroids or polyps
2. Case description A 40-year-old nulliparous white female presented with dysmenorrhea, menorrhagia, pelvi-abdominal mass measuring about 9 cm and primary infertility. Trans-vaginal 2D US revealed an enlarged uterus 9.6 · 6.1 · 7.9 cm in dimension. Two uterine fibroids intramural sub-serous in nature were seen on transvaginal 2D US measuring 7.1 · 6.2 cm, 3.6 · 4.2 cm in diameter. Trans-vaginal US with Doppler flow study suggested that the larger fibroid is a broad ligament in nature and that there was minimal vascularity in the area of attachment between the broad ligament fibroid and the uterus (Fig. 1). Trans-vaginal 2D US with saline infusion hysterosonogram (SIH) showed that the endometrial cavity was not affected .Trans-vaginal 3D US confirmed the presence of a large broad ligament fibroid (Fig. 2). Minimally invasive surgery was selected as per the patient request and based on the assessment and experience of our group. Robotic myomectomy was selected in this case as it provides better visualization, dissection and hemostasis than operative laparoscopy, especially in this critical area where the myoma is in close proximity to the ureter and the uterine
Figure 1 Trans-vaginal US with Doppler showing minimal vascularity between the broad ligament fibroid and the uterus.
Figure 2
Trans-vaginal US showing large broad ligament fibroid.
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
Broad ligament uterine fibroid
Figure 3a Broad ligament fibroid stretching the round ligament (arrow is pointing to the anterior surface of the broad ligament fibroid).
Figure 3b Dissection of the broad ligament fibroid from its attachments.
3
Figure 3d The uterus after removal of the fundal fibroid and the broad ligament fibroid.
Figure 4 HSG showing normal endometrial cavity with bilateral corneal block.
of morcellated leiomyomata tissue). Post-operative course was uneventful and the patient was discharged home the next day. Hysterosalpingogram (HSG) was performed 3 month post-operatively to determine the status of the fallopian tubes following the surgery to counsel the patient regarding her fertility potential. The HSG revealed a normal endometrial cavity and possible bilateral cornual blockage versus a spasm (Fig. 4). Another reason for failure of filling of the fallopian tubes on HSG was leakage of radio-opaque material in the cervical canal and upper vagina due to the acutely anteverted position of the uterus. 3. Discussion
Figure 3c Showing the sutured round ligament after dissecting the fibroid and the anterior leaflet of the broad ligament before suturing it.
that may have been missed by radiological tests, revealed a normal endometrial cavity. The pathology report confirmed the diagnosis of uterine fibroid weighing 300 g. and measuring 13 · 10 cm (aggregate
Myomectomy is indicated if preservation of fertility is wanted, and can be performed through laparotomy, laparoscopy, or hysteroscopy. Myomectomy is reported to result in pregnancy rates up to 70% (12–14). Careful preoperative investigations using trans-vaginal US and possible MRI is helpful to select the most appropriate surgical approach (15). A hysteroscopic resection may be the best choice for predominantly submucous myomas, whereas a myomectomy by laparotomy is often the choice if the myomas are numerous or large (16). Laparoscopy is associated with shorter hospital stay and
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
4 recovery, and less intra-abdominal adhesions, which is an important goal if fertility is to be preserved (13,17). Moreover, complication rates with laparoscopic myomectomy are lower compared with abdominal laparotomy (13,18–20). Reported rates for re-operation, residual myomas, and recurrence of myomas are equal for laparoscopic myomectomy compared with laparotomy (21). Laparoscopic myomectomy even with an experienced laparoscopist may find major parts of the procedure to be challenging, as precise dissection and suturing is particularly difficult when the myomas have a deep intramural or another unfavorable localization such as broad ligament. Unfortunately, those are the myomas that also have a probable impact on fecundity. The da-Vinci system (da-Vinci Surgical System, Intuitive Surgical Inc., CA, USA) is now widely used in gynecological operation. Its use in the field of gynecological surgery was first introduced in 2005. With an increasing use of it, the system provides instruments with a wrist function at the tip, movement downgrading, tremor elimination and a stable 3Dimension view. In all, these features of the robot may theoretically help the surgeon to overcome some of the difficulties associated with traditional laparoscopic surgery. A disadvantage of the da-Vinci system is the high cost of investment and maintenance. Preparation time is relatively long. Probably this will diminish when all staff has gained more experience. In comparison with traditional laparoscopy the increased number and size of the incisions augments the risk of trocar hernias and patient complaints. The alternative approved method for the surgical management of our patient would have been a laparotomy. To our knowledge, this is the first case described in the literature for removal of broad ligament myoma through robotic route. 4. Conclusion The aim of presenting this case was to demonstrate that in infertile patients with a large broad ligament fibroid, who want to preserve their reproductive potential, robotic assisted laparoscopic myomectomy is possible. Pre-operative planning and surgical expertise are mandatory to achieve this goal. Trans-vaginal US and Doppler study play an important role in determining the degree of attachment, location and vascularity between the uterus and the broad ligament fibroid. This can help in planning the surgical approach for each particular patient. Author Disclosure Statement 1. Ahmed Abdel Aziz, MD has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. 2. Salem K. Joseph BS has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. 3. Mostafa I. Abuzeid MD has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. Conflict of interest
A. Abdelaziz et al. References (1) Day Baird D, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–7. (2) Practice Committee of American Society for Reproductive Medicine in Collaboration with Society of Reproductive Surgeons. Myomas and re-productive function. Fertil Steril. 2006 Nov; 86:S194–S199. (3) Walker CL, Stewart EA. Uterine fibroids: the elephant in the room. Science 2005;308:1589–92. (4) Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004;11:511–8. (5) Advincula AP, Xu X, Goudeau St, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14:698–705. (6) Bocca S, Stadtmauer L, Oehninger S. Current status of robotically assisted laparoscopic surgery in reproductive medicine and gynaecology. Reprod Biomed Online 2007;14:765–72. (7) Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654–8. (8) Doridot V, Dubuisson JB, Chapron C, et al. Recurrence of leiomyomata after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:495–500. (9) Schreuder HW, Verheijen RH. Robotic surgery. BJOG 2009;116:198–213. (10) Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008;112:1369–84. (11) Advincula AP, Song A. Endoscopic management of leiomyomata. Semin Reprod Med 2004;22:149–55. (12) Malzoni M, Sizzi O, Rossetti A, Imperato F. Laparoscopic myomectomy: a report of 982 procedures. Surg Technol Int 2006;15:123–9. (13) Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15:2663–8. (14) Seracchioli R, Manuzzi L, Vianello F, Gualerzi B, Savelli L, Paradisi R, et al. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy. Fertil Steril 2006;86:159–65. (15) Cohen LS, Valle RF. Role of vaginal sonography and hysterosonography in the endoscopic treatment of uterine myomas. Fertil Steril 2000;73:197–204. (16) Polena V, Mergui JL, Perrot N, Poncelet C, Barranger E, Uzan S. Long term results of hysteroscopic myomectomy in 235 patients. Eur J Obstet Gynecol Reprod Biol 2007;130:232–7. (17) Davey AK, Maher PJ. Surgical adhesions: a timely update, a great challenge for the future. J Minim Invasive Gynecol 2007;14:15–22. (18) Sizzi O, Rossetti A, Malzoni M, Minelli L, La Grotta F, Soranna L, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:453–62. (19) Altgassen C, Kuss S, Berger U, Lo¨ning M, Diedrich K, Schneider A. Complications in laparoscopic myomectomy. SurgEndosc 2006;2(0):614–8. (20) Advincula AP, Xu X, Goudeau S, Ransom 4th SB. Robotassisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14:698–705. (21) Yoo EH, Lee PI, Huh CY, Kim DH, Lee BS, Lee JK, et al. Predictors of leiomyoma recurrence after laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:690–7.
The authors declare no conflict of interest.
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com
CASE REPORT
Broad ligament uterine fibroid: Management with Davinci robotic myomectomy Ahmed Abdelaziz a b c
a,*
, Salem Joseph b, Mostafa Abuzeid
c
Hurley Medical Center, Michigan State University, 2 Hurley plaza, suite 209, Flint, MI 48503, United States IVF Michigan, 2 Hurley plaza, suite 209, Flint, MI 48503, United States IVF Michigan, Hurley Medical Center, Michigan State University, 2 Hurley plaza, suite 209, Flint, MI 48503, United States
Received 16 December 2014; accepted 26 March 2015
KEYWORDS Broad ligament; Fibroid; Robotic surgery
Abstract Background: We describe a patient with two fibroids; the largest was a broad ligament fibroid, which was managed successfully with robotic assisted laparoscopic myomectomy. It is well known that myomectomy of a large broad ligament fibroid presents a challenge to the surgeon with intraoperative complications such as excessive bleeding and ureteric injury or later complications such as pelvic hematoma and infection. Case report: A 40-year-old nulliparous white female presented with dysmenorrhea, menorrhagia and pelvi-abdominal mass and primary infertility. Trans-vaginal 2D ultrasound (US) revealed an enlarged uterus 9.6/6.1/7.9 cm in dimension. Two uterine fibroids, intramural sub-serous in nature were seen on trans-vaginal 2D US. Trans-vaginal US with Doppler flow study suggested that the larger fibroid is broad ligament in nature with minimal vascularity between the broad ligament fibroid and the uterus. The patient underwent robotic assisted laparoscopic myomectomy. First an intramural sub-serous fibroid was removed, then a large broad ligament fibroid was dissected from the uterus and the anterior leaf of the broad ligament was sutured. A diagnostic hysteroscopy was performed at the end of the procedure and revealed a normal endometrial cavity. Postoperative course was uneventful. Conclusion: The aim of presenting this case was to demonstrate that in patients with a large broad ligament fibroid, who want to preserve their reproductive potential, robotic assisted laparoscopic myomectomy is feasible and safe. Trans-vaginal US plays an important role in determining the
* Corresponding author. E-mail addresses: [email protected] (A. Abdelaziz), salemkj@ gmail.com (S. Joseph), [email protected] (M. Abuzeid). Peer review under responsibility of Middle East Fertility Society.
Production and hosting by Elsevier http://dx.doi.org/10.1016/j.mefs.2015.03.003 1110-5690 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
2
A. Abdelaziz et al. degree of attachment, location and vascularity between the uterus and the broad ligament fibroid, which in turn helps in the choice of surgical procedure and technique. 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-ncnd/4.0/).
1. Introduction Uterine leiomyomata, or myomas, are one of the most common benign tumors of the reproductive tract, affecting more than 70% of women in their lifetime (1). Approximately 25% of reproductive-aged women have myomas. Definitive surgical treatment of myoma is hysterectomy while myomectomy is the treatment for those women who have symptomatic myomas and desire uterine or fertility preservation (2,3). Leiomyomas can arise from any tissue including the broad ligament. The incidence of broad-ligament leiomyoma is <1%. Myomectomy can be either done abdominally, laparoscopically or hystroscopically. Recent trends toward minimally invasive surgery have resulted in increasing numbers of laparoscopic and robotic-assisted myomectomies (4–6). Although minimally invasive surgery has known advantages over open surgery, including shorter hospital stay, quicker recovery, less blood loss, and fewer postoperative adhesions, most of the myomectomies are done abdominally. This is due to the complexity and the necessity of extensive suturing for the desired multi-layered uterine closure, which is technically hard to do laparoscopically (7,8). Traditional laparoscopic myomectomy requires advanced surgical skills and thus may only be offered to select patients on the basis of myoma characteristics and surgeons’ expertise. The introduction of robotic surgery has allowed more surgeons to perform complex laparoscopic procedures (9). The robotic surgical system allows 3-dimensional perception of the surgical field and improved ease of multilayered uterine closure. This has led to an increase in the number of robotic-assisted laparoscopic myomectomies performed worldwide (5,10,11).
vessels. The patient underwent robotic assisted laparoscopic myomectomy (Figs. 3a–3d. First a 4 cm intramural subserous fundal fibroid was removed. Then the broad ligament was opened showing a large broad ligament fibroid (9 cm in diameter) attached to the lower uterine segment with no attachment to the cervix and with a wide stalk measuring about 4 cm (Fig. 3b). Using both monopolar and bipolar cautery the fibroid was dissected from the uterus. There was no need to take any uterine sutures as complete hemostasis in the pedicle was achieved using the bipolar cautery (Fig. 3c). The anterior leaf of the broad ligament was sutured. Care was taken to avoid injury of the right ureter and uterine vessels. Blood loss during the procedure was minimal. The fibroids were morcellated and removed from the peritoneal cavity. Diagnostic hysteroscopy, performed at the end of the procedure, to rule out any small submucous fibroids or polyps
2. Case description A 40-year-old nulliparous white female presented with dysmenorrhea, menorrhagia, pelvi-abdominal mass measuring about 9 cm and primary infertility. Trans-vaginal 2D US revealed an enlarged uterus 9.6 · 6.1 · 7.9 cm in dimension. Two uterine fibroids intramural sub-serous in nature were seen on transvaginal 2D US measuring 7.1 · 6.2 cm, 3.6 · 4.2 cm in diameter. Trans-vaginal US with Doppler flow study suggested that the larger fibroid is a broad ligament in nature and that there was minimal vascularity in the area of attachment between the broad ligament fibroid and the uterus (Fig. 1). Trans-vaginal 2D US with saline infusion hysterosonogram (SIH) showed that the endometrial cavity was not affected .Trans-vaginal 3D US confirmed the presence of a large broad ligament fibroid (Fig. 2). Minimally invasive surgery was selected as per the patient request and based on the assessment and experience of our group. Robotic myomectomy was selected in this case as it provides better visualization, dissection and hemostasis than operative laparoscopy, especially in this critical area where the myoma is in close proximity to the ureter and the uterine
Figure 1 Trans-vaginal US with Doppler showing minimal vascularity between the broad ligament fibroid and the uterus.
Figure 2
Trans-vaginal US showing large broad ligament fibroid.
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
Broad ligament uterine fibroid
Figure 3a Broad ligament fibroid stretching the round ligament (arrow is pointing to the anterior surface of the broad ligament fibroid).
Figure 3b Dissection of the broad ligament fibroid from its attachments.
3
Figure 3d The uterus after removal of the fundal fibroid and the broad ligament fibroid.
Figure 4 HSG showing normal endometrial cavity with bilateral corneal block.
of morcellated leiomyomata tissue). Post-operative course was uneventful and the patient was discharged home the next day. Hysterosalpingogram (HSG) was performed 3 month post-operatively to determine the status of the fallopian tubes following the surgery to counsel the patient regarding her fertility potential. The HSG revealed a normal endometrial cavity and possible bilateral cornual blockage versus a spasm (Fig. 4). Another reason for failure of filling of the fallopian tubes on HSG was leakage of radio-opaque material in the cervical canal and upper vagina due to the acutely anteverted position of the uterus. 3. Discussion
Figure 3c Showing the sutured round ligament after dissecting the fibroid and the anterior leaflet of the broad ligament before suturing it.
that may have been missed by radiological tests, revealed a normal endometrial cavity. The pathology report confirmed the diagnosis of uterine fibroid weighing 300 g. and measuring 13 · 10 cm (aggregate
Myomectomy is indicated if preservation of fertility is wanted, and can be performed through laparotomy, laparoscopy, or hysteroscopy. Myomectomy is reported to result in pregnancy rates up to 70% (12–14). Careful preoperative investigations using trans-vaginal US and possible MRI is helpful to select the most appropriate surgical approach (15). A hysteroscopic resection may be the best choice for predominantly submucous myomas, whereas a myomectomy by laparotomy is often the choice if the myomas are numerous or large (16). Laparoscopy is associated with shorter hospital stay and
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003
4 recovery, and less intra-abdominal adhesions, which is an important goal if fertility is to be preserved (13,17). Moreover, complication rates with laparoscopic myomectomy are lower compared with abdominal laparotomy (13,18–20). Reported rates for re-operation, residual myomas, and recurrence of myomas are equal for laparoscopic myomectomy compared with laparotomy (21). Laparoscopic myomectomy even with an experienced laparoscopist may find major parts of the procedure to be challenging, as precise dissection and suturing is particularly difficult when the myomas have a deep intramural or another unfavorable localization such as broad ligament. Unfortunately, those are the myomas that also have a probable impact on fecundity. The da-Vinci system (da-Vinci Surgical System, Intuitive Surgical Inc., CA, USA) is now widely used in gynecological operation. Its use in the field of gynecological surgery was first introduced in 2005. With an increasing use of it, the system provides instruments with a wrist function at the tip, movement downgrading, tremor elimination and a stable 3Dimension view. In all, these features of the robot may theoretically help the surgeon to overcome some of the difficulties associated with traditional laparoscopic surgery. A disadvantage of the da-Vinci system is the high cost of investment and maintenance. Preparation time is relatively long. Probably this will diminish when all staff has gained more experience. In comparison with traditional laparoscopy the increased number and size of the incisions augments the risk of trocar hernias and patient complaints. The alternative approved method for the surgical management of our patient would have been a laparotomy. To our knowledge, this is the first case described in the literature for removal of broad ligament myoma through robotic route. 4. Conclusion The aim of presenting this case was to demonstrate that in infertile patients with a large broad ligament fibroid, who want to preserve their reproductive potential, robotic assisted laparoscopic myomectomy is possible. Pre-operative planning and surgical expertise are mandatory to achieve this goal. Trans-vaginal US and Doppler study play an important role in determining the degree of attachment, location and vascularity between the uterus and the broad ligament fibroid. This can help in planning the surgical approach for each particular patient. Author Disclosure Statement 1. Ahmed Abdel Aziz, MD has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. 2. Salem K. Joseph BS has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. 3. Mostafa I. Abuzeid MD has no competing financial interests to claim, nor does he have any commercial associations that might create a conflict of interest to disclose. Conflict of interest
A. Abdelaziz et al. References (1) Day Baird D, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–7. (2) Practice Committee of American Society for Reproductive Medicine in Collaboration with Society of Reproductive Surgeons. Myomas and re-productive function. Fertil Steril. 2006 Nov; 86:S194–S199. (3) Walker CL, Stewart EA. Uterine fibroids: the elephant in the room. Science 2005;308:1589–92. (4) Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2004;11:511–8. (5) Advincula AP, Xu X, Goudeau St, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14:698–705. (6) Bocca S, Stadtmauer L, Oehninger S. Current status of robotically assisted laparoscopic surgery in reproductive medicine and gynaecology. Reprod Biomed Online 2007;14:765–72. (7) Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 1996;174:654–8. (8) Doridot V, Dubuisson JB, Chapron C, et al. Recurrence of leiomyomata after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 2001;8:495–500. (9) Schreuder HW, Verheijen RH. Robotic surgery. BJOG 2009;116:198–213. (10) Visco AG, Advincula AP. Robotic gynecologic surgery. Obstet Gynecol 2008;112:1369–84. (11) Advincula AP, Song A. Endoscopic management of leiomyomata. Semin Reprod Med 2004;22:149–55. (12) Malzoni M, Sizzi O, Rossetti A, Imperato F. Laparoscopic myomectomy: a report of 982 procedures. Surg Technol Int 2006;15:123–9. (13) Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 2000;15:2663–8. (14) Seracchioli R, Manuzzi L, Vianello F, Gualerzi B, Savelli L, Paradisi R, et al. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy. Fertil Steril 2006;86:159–65. (15) Cohen LS, Valle RF. Role of vaginal sonography and hysterosonography in the endoscopic treatment of uterine myomas. Fertil Steril 2000;73:197–204. (16) Polena V, Mergui JL, Perrot N, Poncelet C, Barranger E, Uzan S. Long term results of hysteroscopic myomectomy in 235 patients. Eur J Obstet Gynecol Reprod Biol 2007;130:232–7. (17) Davey AK, Maher PJ. Surgical adhesions: a timely update, a great challenge for the future. J Minim Invasive Gynecol 2007;14:15–22. (18) Sizzi O, Rossetti A, Malzoni M, Minelli L, La Grotta F, Soranna L, et al. Italian multicenter study on complications of laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:453–62. (19) Altgassen C, Kuss S, Berger U, Lo¨ning M, Diedrich K, Schneider A. Complications in laparoscopic myomectomy. SurgEndosc 2006;2(0):614–8. (20) Advincula AP, Xu X, Goudeau S, Ransom 4th SB. Robotassisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol 2007;14:698–705. (21) Yoo EH, Lee PI, Huh CY, Kim DH, Lee BS, Lee JK, et al. Predictors of leiomyoma recurrence after laparoscopic myomectomy. J Minim Invasive Gynecol 2007;14:690–7.
The authors declare no conflict of interest.
Please cite this article in press as: Abdelaziz A et al. Broad ligament uterine fibroid: Management with Davinci robotic myomectomy, Middle East Fertil Soc J (2015), http://dx.doi.org/10.1016/j.mefs.2015.03.003