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Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report
Case Report
Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report Francesco Fanfani, MD*, Cristiano Rossitto, MD, Anna Fagotti, MD, Paolo Rosati, MD, Valerio Gallotta, MD, and Giovanni Scambia, MD From the Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy (all authors).
ABSTRACT We performed laparoscopic myomectomy for treatment of a large, twisted, subserous myoma at 25 weeks of pregnancy in a woman with acute abdominal pain that did not respond to analgesic therapy. There are few reports in literature about laparoscopic management of uterine leiomyoma during the first half of pregnancy that demonstrate its feasibility in selected cases. Laparoscopic myomectomy can be considered a minimally invasive alternative to the traditional laparotomy when myomectomy is necessary during the second half of pregnancy, resulting in less postoperative pain and shorter recovery time. Journal of Minimally Invasive Gynecology (2010) 17, 91–93 Ó 2010 AAGL. All rights reserved. Keywords:
Laparoscopy; Myomectomy; Pregnancy
Abdominal pain is common during complication of pregnancy and produces difficulty in diagnosis and determination of therapeutic approach [1]. Moreover, the anatomical changes due to the enlarging uterus and displacement of organs, first from the pelvis and then from the abdomen, may influence the case history. Myomas are usually asymptomatic in pregnancy; however, occasionally acute abdominal pain occurs due to rapid abnormal increase in size, torsion, or other superimposed complications [2,3]. When analgesic therapy fails, the patient must undergo surgery. We report a case with unexpected acute torsion of a large subserous myoma at 25 weeks of pregnancy that required surgical treatment performed at laparoscopy. Case Report A 39-year-old nulliparous woman with a history of subserous pedunculated uterine myoma was referred to our emergency room at 25 weeks of gestation because of acute abdominal pain that did not respond to analgesic therapy. An acute abdomen with pain localized in the left periumbilical region was noted at clinical examination. No fever and The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Francesco Fanfani, MD, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, 00168 Rome, Italy. E-mail: [email protected] Submitted June 23, 2009. Accepted for publication August 20, 2009. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2009.08.004
a normal white blood cell count were recorded. An ultrasound examination performed at admission to the hospital confirmed the presence of a singleton normal pregnancy (corresponding to date) and a subserous myoma in the lateral fundus side of the uterus, with a 1.5-cm penduncle that had increased in the last 5 days from 7.8 ! 6.2 ! 3.5 cm to 9.0 ! 5.0 ! 7.4 cm. Volume was calculated using the standard formula for ellipsoid masses, V 5 4pabc/3, where abc are the radii and p 53.14 [4]. No other ultrasonographic sign related to the symptoms such as hemoperitoneum or area of degeneration in the myoma was noted. The acute abdominal symptoms suggested torsion of the myoma. Urgent open laparoscopic surgery 5 cm above the umbilicus was performed with the patient under general anesthesia. Once pneumoperitoneum (10 mm Hg) was achieved, intraabdominal visualization was possible using a 10-mm, 30-degree, highdefinition telescope (HD Endo-Eye; Olympus Winter and Ibe GmbH, Hamburg, Germany). Performance of laparoscopic myomectomy was difficult because of the uterine size. Two ancillary trocars were positioned under laparoscopic visualization, 1 in the left subcostal region and 1 in the left pelvic region. A pedunculated uterine leiomyoma covered with omentum was detected in the left uterine wall. Using cold scissors, the omentum was mobilized and separated from the myoma. The torsed base of the myoma was identified in the left uterine fundus region (Fig. 1). Using bipolar forceps, the base of the peduncle, 1 cm from the uterine wall, was coagulated and dissected. The entire myoma was dissected and removed from the abdominal cavity using morcellation. No defect on the uterine wall was observed.
92
Fig. 1. Operative field. Base of the myoma.
Operating time was 43 minutes. No intraoperative blood loss or anesthesia-related complications occurred. The postoperative course was uneventful. Perioperative fetal examination yielded normal findings. The patient was discharged 3 days after surgery. Routine follow-up after surgical treatment was performed. Definitive pathologic analysis confirmed the diagnosis of a myoma weighing 95 g. At gestational week 40, the patient spontaneously delivered a healthy female infant weighing 2950 g. Discussion Analysis of cases reported in literature suggests that myomectomy during pregnancy may be considered safe. Most myomectomies reported were performed as elective surgery at between 15 and 19 weeks of gestation [2]. The open technique is usually preferred for entrance to the peritoneal cavity. Laparoscopy, once considered an absolute contraindication in pregnancy [5], has in recent years been safely performed to treat abdominopelvic diseases during pregnancy but rarely in the second half of gestation. Pregnant patients would benefit from laparoscopic surgery because of earlier postoperative ambulation, minimal postoperative pain, and reduced narcotic requirement. However, laparoscopy performed during pregnancy may have specific problems. Two focal points, the level of the uterine fundus and the fetus, must be considered to avoid injuring the uterus or fetus during blind attempts at insufflation using the Veress needle [6,7]. Thus, opening the abdominal wall layer by layer and inserting the blunt trocar under direct visualization (open technique) is preferred. The size of the uterine body can influence visualization and instrumentation during the surgical procedure. Therefore, it is important to position the ancillary trocars using direct vision after laparoscopic diagnosis. Minimal manipulation of the uterus is important; retracting, pulling, and pushing the uterus should be avoided. Even placement of the trocar must be modified according to the stage of the pregnancy. At 20 weeks, the optic access, usually transumbilical, must be moved cranially. Placement of acces-
Journal of Minimally Invasive Gynecology, Vol 17, No 1, January/February 2010
sory trocars should be done after visualization of the abdominal cavity. During laparoscopy, the primary risk of uterine hypoperfusion occurs when the position of the patient is changed [8]. Thus, change to the Trendelenburg position should be slow and the inclination slight. The operating table must be rotated toward the left side of the patient to improve vascular perfusion of the uterus. So as not to increase the carbon dioxide (CO2) blood level, intraabdominal insufflation should be slow, the inclination slight, and the CO2 pressure low. Exsufflation and return of the patient to the decubitus position should be slow as well. The fetal heart rate must be monitored before and after surgery. Another problem concerning laparoscopy with insufflation of CO2 in the abdomen is the possibility of fetal hypercarbia and perturbation of the acid-base balance in relation to fetal absorption of CO2. Barnard et al [9] showed in a sheep model that the fetus has sufficient reserves and a compensatory mechanism to maintain adequate gas exchange during maternal pneumoperitoneum of 20 mm Hg for 1 hour. To overcome the CO2 problem, some authors [10–12] have suggested use of a gasless technique for laparoscopy. According to our experience, performing gasless surgery is not easier than using gas, especially in pregnant patients because of the encumbrance of the enlarged uterus. We agree with Sentilhes et al [13] that monopolar electric current should be avoided near the gravid uterus, especially during laparoscopic surgery, because the increased vascularization and the tissue impedance could increase the risk of electrosurgical damage. During surgical treatment, we limited the use of bipolar electric current for coagulation at the base of the myoma. No complications occurred during the remainder of the pregnancy. In the absence of large series and randomized trials, we suggest that laparoscopic myomectomy is a valid option in the surgical management of pregnant women with symptomatic pedunculated myoma. References 1. Kammerer WS. Non-obstetric surgery during pregnancy. Med Clin North Am. 1979;63:1157–1163. 2. Bhatla N, Dash BB, Kriplani A, Agarwal N. Myomectomy during pregnancy: a feasible option. J Obstet Gynaecol Res. 2009;35:173–175. 3. De Carolis S, Fatigante G, Ferazzani S, et al. Uterine myomectomy in pregnant women. Fetal Diagn Ther. 2001;16:116–119. 4. Rosati P, Exacoustos C, Mancuso S. Longitudinal evaluation of uterine myoma growth duringpregnancy: a sonographic study. J Ultrasound Med. 1992;11:511–515. 5. Gadacz TR, Talamini MA. Traditional versus laparoscopic cholecystectomy. Am J Surg. 1991;161:336–338. 6. Barnett MB, Lui DT. Complications of laparoscopy during early pregnancy. BMJ. 1974;1:328. 7. Nezhat FR, Tazuke S, Nezhat CH, Seidman DS, Philips DR, Nezhat CR. Laparoscopy during pregnancy: a literature review. JSLS. 1997;1:17–27. 8. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynaecol Reprod Biol. 2003;108:217–222. 9. Barnard JL, Chaffin D, Droste S, Tierney A, Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol. 1995;85:669–674.
Fanfani et al.
Laparoscopic Myomectomy in Pregnancy
10. Melgrati L, Damiani A, Franzoni G, Marziali M, Sesti F. Isobaric (gasless) laparoscopic myomectomy during pregnancy. J Minim Invasive Gynecol. 2005;12:379–381. 11. Inoue H, Nabuchi K, Ishihara Y, Fukumoto Y, Kobayashi M. Gasless laparoscopic ovarian cystectomy with minilaparotomy during pregnancy. Gynecol Endosc. 1998;7:95–99.
93 12. Akira S, Yamanaka A, Ishihara T, Takeshita T, Araki T. Gasless laparoscopic ovarian cystectomy during pregnancy: comparison with laparotomy. Am J Obstet Gynecol. 1999;180:554–557. 13. Sentilhes L, Sergent F, Verspyck E, Gravier A, Roman H, Marpeau L. Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium. BJOG. 2003;110:876–878.
Laparoscopic Myomectomy at 25 Weeks of Pregnancy: Case Report Francesco Fanfani, MD*, Cristiano Rossitto, MD, Anna Fagotti, MD, Paolo Rosati, MD, Valerio Gallotta, MD, and Giovanni Scambia, MD From the Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy (all authors).
ABSTRACT We performed laparoscopic myomectomy for treatment of a large, twisted, subserous myoma at 25 weeks of pregnancy in a woman with acute abdominal pain that did not respond to analgesic therapy. There are few reports in literature about laparoscopic management of uterine leiomyoma during the first half of pregnancy that demonstrate its feasibility in selected cases. Laparoscopic myomectomy can be considered a minimally invasive alternative to the traditional laparotomy when myomectomy is necessary during the second half of pregnancy, resulting in less postoperative pain and shorter recovery time. Journal of Minimally Invasive Gynecology (2010) 17, 91–93 Ó 2010 AAGL. All rights reserved. Keywords:
Laparoscopy; Myomectomy; Pregnancy
Abdominal pain is common during complication of pregnancy and produces difficulty in diagnosis and determination of therapeutic approach [1]. Moreover, the anatomical changes due to the enlarging uterus and displacement of organs, first from the pelvis and then from the abdomen, may influence the case history. Myomas are usually asymptomatic in pregnancy; however, occasionally acute abdominal pain occurs due to rapid abnormal increase in size, torsion, or other superimposed complications [2,3]. When analgesic therapy fails, the patient must undergo surgery. We report a case with unexpected acute torsion of a large subserous myoma at 25 weeks of pregnancy that required surgical treatment performed at laparoscopy. Case Report A 39-year-old nulliparous woman with a history of subserous pedunculated uterine myoma was referred to our emergency room at 25 weeks of gestation because of acute abdominal pain that did not respond to analgesic therapy. An acute abdomen with pain localized in the left periumbilical region was noted at clinical examination. No fever and The authors have no commercial, proprietary, or financial interest in the products or companies described in this article. Corresponding author: Francesco Fanfani, MD, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Largo Agostino Gemelli 8, 00168 Rome, Italy. E-mail: [email protected] Submitted June 23, 2009. Accepted for publication August 20, 2009. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2009.08.004
a normal white blood cell count were recorded. An ultrasound examination performed at admission to the hospital confirmed the presence of a singleton normal pregnancy (corresponding to date) and a subserous myoma in the lateral fundus side of the uterus, with a 1.5-cm penduncle that had increased in the last 5 days from 7.8 ! 6.2 ! 3.5 cm to 9.0 ! 5.0 ! 7.4 cm. Volume was calculated using the standard formula for ellipsoid masses, V 5 4pabc/3, where abc are the radii and p 53.14 [4]. No other ultrasonographic sign related to the symptoms such as hemoperitoneum or area of degeneration in the myoma was noted. The acute abdominal symptoms suggested torsion of the myoma. Urgent open laparoscopic surgery 5 cm above the umbilicus was performed with the patient under general anesthesia. Once pneumoperitoneum (10 mm Hg) was achieved, intraabdominal visualization was possible using a 10-mm, 30-degree, highdefinition telescope (HD Endo-Eye; Olympus Winter and Ibe GmbH, Hamburg, Germany). Performance of laparoscopic myomectomy was difficult because of the uterine size. Two ancillary trocars were positioned under laparoscopic visualization, 1 in the left subcostal region and 1 in the left pelvic region. A pedunculated uterine leiomyoma covered with omentum was detected in the left uterine wall. Using cold scissors, the omentum was mobilized and separated from the myoma. The torsed base of the myoma was identified in the left uterine fundus region (Fig. 1). Using bipolar forceps, the base of the peduncle, 1 cm from the uterine wall, was coagulated and dissected. The entire myoma was dissected and removed from the abdominal cavity using morcellation. No defect on the uterine wall was observed.
92
Fig. 1. Operative field. Base of the myoma.
Operating time was 43 minutes. No intraoperative blood loss or anesthesia-related complications occurred. The postoperative course was uneventful. Perioperative fetal examination yielded normal findings. The patient was discharged 3 days after surgery. Routine follow-up after surgical treatment was performed. Definitive pathologic analysis confirmed the diagnosis of a myoma weighing 95 g. At gestational week 40, the patient spontaneously delivered a healthy female infant weighing 2950 g. Discussion Analysis of cases reported in literature suggests that myomectomy during pregnancy may be considered safe. Most myomectomies reported were performed as elective surgery at between 15 and 19 weeks of gestation [2]. The open technique is usually preferred for entrance to the peritoneal cavity. Laparoscopy, once considered an absolute contraindication in pregnancy [5], has in recent years been safely performed to treat abdominopelvic diseases during pregnancy but rarely in the second half of gestation. Pregnant patients would benefit from laparoscopic surgery because of earlier postoperative ambulation, minimal postoperative pain, and reduced narcotic requirement. However, laparoscopy performed during pregnancy may have specific problems. Two focal points, the level of the uterine fundus and the fetus, must be considered to avoid injuring the uterus or fetus during blind attempts at insufflation using the Veress needle [6,7]. Thus, opening the abdominal wall layer by layer and inserting the blunt trocar under direct visualization (open technique) is preferred. The size of the uterine body can influence visualization and instrumentation during the surgical procedure. Therefore, it is important to position the ancillary trocars using direct vision after laparoscopic diagnosis. Minimal manipulation of the uterus is important; retracting, pulling, and pushing the uterus should be avoided. Even placement of the trocar must be modified according to the stage of the pregnancy. At 20 weeks, the optic access, usually transumbilical, must be moved cranially. Placement of acces-
Journal of Minimally Invasive Gynecology, Vol 17, No 1, January/February 2010
sory trocars should be done after visualization of the abdominal cavity. During laparoscopy, the primary risk of uterine hypoperfusion occurs when the position of the patient is changed [8]. Thus, change to the Trendelenburg position should be slow and the inclination slight. The operating table must be rotated toward the left side of the patient to improve vascular perfusion of the uterus. So as not to increase the carbon dioxide (CO2) blood level, intraabdominal insufflation should be slow, the inclination slight, and the CO2 pressure low. Exsufflation and return of the patient to the decubitus position should be slow as well. The fetal heart rate must be monitored before and after surgery. Another problem concerning laparoscopy with insufflation of CO2 in the abdomen is the possibility of fetal hypercarbia and perturbation of the acid-base balance in relation to fetal absorption of CO2. Barnard et al [9] showed in a sheep model that the fetus has sufficient reserves and a compensatory mechanism to maintain adequate gas exchange during maternal pneumoperitoneum of 20 mm Hg for 1 hour. To overcome the CO2 problem, some authors [10–12] have suggested use of a gasless technique for laparoscopy. According to our experience, performing gasless surgery is not easier than using gas, especially in pregnant patients because of the encumbrance of the enlarged uterus. We agree with Sentilhes et al [13] that monopolar electric current should be avoided near the gravid uterus, especially during laparoscopic surgery, because the increased vascularization and the tissue impedance could increase the risk of electrosurgical damage. During surgical treatment, we limited the use of bipolar electric current for coagulation at the base of the myoma. No complications occurred during the remainder of the pregnancy. In the absence of large series and randomized trials, we suggest that laparoscopic myomectomy is a valid option in the surgical management of pregnant women with symptomatic pedunculated myoma. References 1. Kammerer WS. Non-obstetric surgery during pregnancy. Med Clin North Am. 1979;63:1157–1163. 2. Bhatla N, Dash BB, Kriplani A, Agarwal N. Myomectomy during pregnancy: a feasible option. J Obstet Gynaecol Res. 2009;35:173–175. 3. De Carolis S, Fatigante G, Ferazzani S, et al. Uterine myomectomy in pregnant women. Fetal Diagn Ther. 2001;16:116–119. 4. Rosati P, Exacoustos C, Mancuso S. Longitudinal evaluation of uterine myoma growth duringpregnancy: a sonographic study. J Ultrasound Med. 1992;11:511–515. 5. Gadacz TR, Talamini MA. Traditional versus laparoscopic cholecystectomy. Am J Surg. 1991;161:336–338. 6. Barnett MB, Lui DT. Complications of laparoscopy during early pregnancy. BMJ. 1974;1:328. 7. Nezhat FR, Tazuke S, Nezhat CH, Seidman DS, Philips DR, Nezhat CR. Laparoscopy during pregnancy: a literature review. JSLS. 1997;1:17–27. 8. Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynaecol Reprod Biol. 2003;108:217–222. 9. Barnard JL, Chaffin D, Droste S, Tierney A, Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol. 1995;85:669–674.
Fanfani et al.
Laparoscopic Myomectomy in Pregnancy
10. Melgrati L, Damiani A, Franzoni G, Marziali M, Sesti F. Isobaric (gasless) laparoscopic myomectomy during pregnancy. J Minim Invasive Gynecol. 2005;12:379–381. 11. Inoue H, Nabuchi K, Ishihara Y, Fukumoto Y, Kobayashi M. Gasless laparoscopic ovarian cystectomy with minilaparotomy during pregnancy. Gynecol Endosc. 1998;7:95–99.
93 12. Akira S, Yamanaka A, Ishihara T, Takeshita T, Araki T. Gasless laparoscopic ovarian cystectomy during pregnancy: comparison with laparotomy. Am J Obstet Gynecol. 1999;180:554–557. 13. Sentilhes L, Sergent F, Verspyck E, Gravier A, Roman H, Marpeau L. Laparoscopic myomectomy during pregnancy resulting in septic necrosis of the myometrium. BJOG. 2003;110:876–878.