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All About Fibroids

This women’s day Apollo Hospitals want the woman to be more cautious of one of the most dangerous health problems that is becoming these days – fibroids. Read through to know what the expert in gynaecology, Dr. Meenakshi Sundaram has to say about this ailment.

Fibroids are the most frequently seen tumours of the female reporductive system. Also knows as uterine myomas, leiomyomas, or fibromas, the fibroids are firm, compact tumors that are made of smooth muscle cells and fibrous connective tissue that develop in the uterus.

Fibroids are non-cancerous swellings arising from teh womb or uterus. They occur in about one in four women of reproductive age group. Fibroids are classified depending on their location into Subserous (arising from the outer wall of the womb) and submucous (arising from teh inner lining of the womb). Fibroids cause increased bleeding during periods, heaviness or a lump in the belly and inability to concieve. Depending on the size and location of the fibroid, these symptoms can vary.

Fibroids are diagnoised by clinical examination and ultrasound. All fibroids don’t require surgery. Only those that are big, interfere with pregnancy and cause heavy bleeding need removal. Medcation may relieve symptoms of pain and heaviy bleeding to some extent, but do not make the fibroids disapper.

The conventional surgical treatment for fibroid removal is called myomectomy. This is traditionally done by taking a large incision in the abdomen. This procedure called laparoscopic myomectomy helos in early recovery, decreases hospital stay reduces pain and enables quick return to normal activities.

Women more than 45 years of age and those who have completed their family can undergo removal of fibroids along with the uterus through laparoscopic hysterectomy.

Robotic surgery is the latest advance in minimal access techniques which has helped in aking the fibroid removal or uterus removal more precise with less complications. It involves use of a computer interface to perform high precision surgery. Dont ignore menstrual problems; get examined, investigated and treated early! Opt for laparoscopic or Robotic removal!!!

Dr. Meenakshi Sundaram
MD, DNB (Obs&Gn) Diploma in Advanced Endoscopy-Kiel (Germany),
Diploma in Advanced Endoscopy – Beams (Mumbai) and Robotic traning (Florida)

Consultant Gynecological Endoscopic and Robotic Surgeon, Apollo Hospitals, Greams Road, Chennai.

Source: The Hindu, Thursday, March 8th, 2018

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Total Laparoscopic Hysterectomy for Large Uterus

Abstract

Aim: In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighing more than 500 grams. we have analyzed whether it is possible for an experienced laparoscopic surgeon to perform efficient TLH for large myomatous uteri regardless of the size, number and location of the myomas.

Design: Retrospective review ( Canadian Task Force Classification II-1 )

Setting: Dedicated high volume Gynecological laparoscopy centre.

Patients: 173 women with symptomatic myomas who underwent TLH at our centre. There were no exclusion criteria based on the size number or location of myomas.

Intervention: TLH and modifications of performing the surgery by ligating the uterine arteries prior, myomectomy followed by hysterectomy, direct morcellation after uterine artery ligation.

Results: 72% of patients has previous normal vaginal delivery and 28% had previous cesarean section. Average clinical size of the uterus was 18 weeks (10 , 32 ). The average weight of the specimen was 700 grams ( 500 ,  2240 ). The average duration of surgery was 107 min ( 40 , 300 ) and the average blood loss was 228ml ( 10 , 3200 ).

Conclusion: TLH is a technically feasible procedure. It can be performed by experienced surgeons for large uteri regardless of the size, number or location of the myomas.

Key words: Large uterus, multiple fibroids, total laparoscopic hysterectomy

 

 

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Total Laparoscopic Hysterectomy in Women with Previous Cesarean Sections

Abstract

Objective: To analyze the feasibility and technique of dissecting the urinary bladder from the lower uterine segment during total laparoscopic hysterectomy in women who have previously delivered by cesarean section.

Design: Retrospective review (Canadian Task Force classification II-1).

Setting: Dedicated high-volume gynecologic laparoscopy center.

Patients: Two hundred sixty-one women who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size of the uterus or the number of previous cesarean section deliveries.

Intervention: All patients underwent total laparoscopic hysterectomy and lateral dissection of the bladder.

Measurements and Main Results: Of the study cohort, 52% had undergone 1 cesarean section, 42% had undergone 2 cesarean sections, and 6% had undergone 3 caesarean sections. Median (range) clinical size of the uterus was 12 (6–30) weeks; weight of the specimen was 200 (40–2200) g; total duration of surgery was 80 (30–240) min; and total blood loss was 50 (10–2000) mL.

Conclusion: Total laparoscopic hysterectomy in patients with previous cesarean section deliveries is technically feasible. It can be performed by experienced surgeons irrespective of the size of the uterus or the number of previous cesarean sections. Journal of Minimally Invasive Gynecology (2010) 17, 513–517.

Keywords: Bladder adhesions; Bladder injury; Cesarean section; Total laparoscopic hysterectomy

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Total Laparoscopic Hysterectomy in Women with Previous Cesarean Sections

Abstract

Objective: To analyze the feasibility and technique of dissecting the urinary bladder from the lower uterine segment during total laparoscopic hysterectomy in women who have previously delivered by cesarean section.

Design: Retrospective review (Canadian Task Force classification II-1).

Setting: Dedicated high-volume gynecologic laparoscopy center.

Patients: Two hundred sixty-one women who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size of the uterus or the number of previous cesarean section deliveries.

Intervention: All patients underwent total laparoscopic hysterectomy and lateral dissection of the bladder.

Measurements and Main Results: Of the study cohort, 52% had undergone 1 cesarean section, 42% had undergone 2 cesarean sections, and 6% had undergone 3 caesarean sections. Median (range) clinical size of the uterus was 12 (6–30) weeks; weight of the specimen was 200 (40–2200) g; total duration of surgery was 80 (30–240) min; and total blood loss was 50 (10–2000) mL.

Conclusion: Total laparoscopic hysterectomy in patients with previous cesarean section deliveries is technically feasible. It can be performed by experienced surgeons irrespective of the size of the uterus or the number of previous cesarean sections. Journal of Minimally Invasive Gynecology (2010) 17, 513–517.

Keywords: Bladder adhesions; Bladder injury; Cesarean section; Total laparoscopic hysterectomy

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Laparoscopic Management of Large Myomas

Abstract

The objective of this article is to review the different techniques that have been adopted for removal of large myomas laparoscopically. We have also quoted literature about the impact of myomas on Pregnancy and obstetrical outcome and the effect of laparoscopic myomectomy on the same. Technical modifications to remove large myomas have been described along with methods to reduce intraoperative bleeding. This comprehensive review describes all possibilities of laparoscopic myomectomy irrespective of size, site and number.

Key words: Laparoscopic myomectomy, large myomas, flbroids, uterine artery ligation, pregnancy after myomectomy

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Laparoscopic removal of large submucous myomas

Abstract

The aim of this study was to analyze the feasibility and technique of removing large submucous myomas laparoscopically. This technique decreases the complications of removing the submucous myoma hysteroscopically. The design was based on a retrospective review (Canadian Task Force Classification II-1) in a dedicated high volume gynecological laparoscopy centre. The subjects were twenty-two women who underwent laparoscopic removal of submucous myomas at our center. Laparoscopic removal of submucous myoma was done in all patients in whom the size of the myoma was more than 5 cm. The results revealed the following: (1) median clinical size of the uterus was 12 weeks (6, 18); (2) median size of the myoma was 7 cm (5, 10); (3) median weight of the specimen was 200 g (60, 460); (4) median total duration of surgery was 75 min (40, 120); (5) median total blood loss was 50 ml (10, 500); and the total morcellation time was 15 min (5, 45). Laparoscopic myomectomy for large submucous myomas is a technically feasible procedure. It can be performed by experienced surgeons irrespective of the size or depth of the myoma. It prevents the complications of hysteroscopic removal of the myoma.

Keywords:  Myomas . Myomectomy . Submucous myomas . Laparoscopic myomectomy . Hysteroscopic myomectomy

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Single-incision total laparoscopic hysterectomy

Abstract
Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden
in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We
perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.

Key words: E-NOTES, single-incision laparoscopic surgery, single-port surgery, SILS, transumbilical surgery

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Vaginal vault dehiscence with evisceration after total laparoscopic hysterectomy

Keywords Total laparoscopic hysterectomy. Evisceration . Vault dehiscence

Vault dehiscence and evisceration of peritoneal contents is a rare complication following total hysterectomy. A 43-yearold lady presented with history of something soft coming out per vaginum. She underwent total laparoscopic hysterectomy 2 months back for 16-week fibroid uterus.

The surgery was uneventful, vaginal vault was sutured laparoscopically with no 1 polyglactin, interrupted figure of eight sutures. She was discharged after 48 h with uneventful recovery and subsequently presented with mass protruding per vaginum. Speculum examination showed loops of small bowel protruding in the vagina (Fig. 1). She was hospitalized and scheduled for reduction of the prolapsed bowel with vault repair.

On examination under anaesthesia, there was complete dehiscence of the vaginal vault with loops of small bowel protruding through the defect. To maintain the pneumoperitoneum vagina was blocked using a simple vaginal
tampon soaked in betadine solution (Fig. 2) [1].

On Laparoscopic evaluation the entire vault was deficient. There were no bowel, bladder or omental adhesions to the vault. The prolapsed ileal loops were seen just at the vault, with healthy pink colour and regular peristalsis.
On giving Trendelenburg’s position the reposition was smooth. After confirming that the vault was free of any adhesions, the vault was closed vaginally using interrupted no 1 Polydioxone II sutures (Fig. 3). Patient was discharged on the third post-operative day and is asymptomatic at 6-month follow-up.

Vaginal vault dehiscence with evisceration posthysterectomy can occur up to few weeks to even few years after hysterectomy. The commonest organ to eviscerate is small bowel, particularly terminal ileum. Several factors
which may contribute to weakness of vaginal apex are poor surgical techniques, post-operative wound haematoma and cuff infection, post-menopausal status, any activity resulting in increased intra-abdominal pressure, early resumption of sexual activity, chronic steroid administration, history of previous radiotherapy in cases of radical hysterectomy [2] and systemic illness like diabetes mellitus and immunecompromised status [3].

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Multiple and Bilateral Dermoids

Abstract

A 27-year-old nulliparous woman presented with pain in the lower abdomen for six months. She was diagnosed to have bilateral dermoid cysts. Ovarian dermoid tumors can be bilateral in up to 15% of cases. After laparoscopy, we found that she had 7 dermoid cysts on the left side and 2 dermoid cysts on the right side, which is a rare occurrence. All the dermoid cysts were enucleated laparoscopically. The cysts were placed in an endobag and retrieved by morcellation. A one year follow up showed no evidence of recurrence or granulomatous peritonitis. Journal of Minimally Invasive Gynecology (2010) 17, 235–238.

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Retained Uterine Fundus after Vaginal Hysterectomy

Abstract

We report a case of retained uterine fundus after vaginal hysterectomy that was subsequently removed at laparoscopy. The patient had undergone vaginal hysterectomy 8 years previously and came to our hospital with abdominal pain. Examination revealed a supravesical mass. Laparoscopy was performed and showed the uterine fundus with its cornual attachments. The mass was excised and sent for histopathologic analysis, which confirmed that it was uterine tissue. Retained uterine tissue or myoma tissue has been reported, usually after morcellation. However, to our knowledge, our case is only the second reported case of retained fundus after complete vaginal hysterectomy. Because of adhesions, it is possible that the uterus was not completely removed. In such cases, laparoscopic assistance is extremely useful. Journal of Minimally Invasive Gynecology (2010) 17, 94–96.

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