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Pelvic Schwannoma Masquerading as Broad Ligament Myoma

Abstract

Two cases of pelvic schwannoma appeared as broad ligament myoma. Laparoscopic myomectomy was planned for both patients in view of suspected broad ligament myoma. Intraoperative findings appeared to be degenerated myomas with suggestion of malignancy. Both patients underwent complete tumor excision laparoscopically and had uneventful postoperative recovery. Histopathologic examination confirmed them to be schwannomas. Solitary nerve sheath tumors such as benign schwannomas arising in pelvic retroperitoneum are infrequently reported and difficult to diagnose preoperatively. Complete surgical excision is the treatment of choice. Benign retroperitoneal schwannomas in 2 patients primarily given the diagnosis of myoma were treated by laparoscopic excision. A MEDLINE search did not reveal reports of removing these tumors laparoscopically. Journal of Minimally Invasive Gynecology (2008) 15, 217–219.

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Multiple Intraabdominal Parasitic Cystic Teratomas

Abstract

We report an interesting case of multiple intraabdominal dermoids in a patient who had undergone an excision of ovarian dermoid cyst earlier and presented with recurrence of symptoms. She had masses all over the abdominal wall, omentum, and pouch of Douglas and a dermoid cyst in the ovary as well. It is generally believed that autoamputation and reimplantation of an ovarian dermoid cyst is the most common cause of omental teratomas. Abdominal pain is the main presenting symptom of these tumors, and on physical examination a mobile abdominal or pelvic mass is often found. Both ultrasonography with colorflow Doppler ultrasonography and computed tomography are helpful in the diagnosis of dermoid tumors, but the correct diagnosis of omental localization is extremely difficult. We removed all the masses laparoscopically. Literature search did not reveal such extensive parasitic dermoids in any patient. Journal of Minimally Invasive Gynecology (2009) 16, 789–791.

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Multiple leiomyomas after laparoscopic hysterectomy

Abstract

We report on 2 cases of multiple leiomyomas arising in the pelvis after laparoscopic hysterectomy. One patient underwent laparoscopic myomectomy at 41 years of age and subsequently had a total laparoscopic hysterectomy for myomas 4 years later. Three years post-hysterectomy, she presented with pelvic masses that were removed laparoscopically and were leiomyomas on histopathologic examination. The other patient underwent supracervical hysterectomy for myomas with removal of a parasitic myoma from underneath the dome of the diaphragm. Eight months post-hysterectomy, she came to our office with a pelvic mass with a large myoma that was removed laparoscopically. Disseminated leiomyomas may occur after hysterectomy; and though various theories have been proposed to explain this remarkable entity, none has found universal acceptance.  A thorough MEDLINE
search did not reveal any reports of large pelvic masses of this size after hysterectomy or their management laparoscopically, and these are probably the first reported cases.

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Recurrent Leiomyomatosis

An 18-year-old woman came to our clinic in November 2008 with an abdominal mass that had been increasing in size over the last 6 months. In 2005, she had undergone laparoscopic myomectomy because of a 6!5-cm fibroid in the anterior wall. The myoma was removed via morcellation. Histopathologic analysis confirmed that the mass was a benign leiomyoma. In 2006, the patient again had pain and an abdominal mass. Ultrasonic examination revealed a 6-cm myoma, and laparoscopic myomectomy was performed. The myoma, which showed degenerative changes intraoperatively, was removed via morcellation. Histopathologic analysis revealed a benign leiomyoma with degeneration. The patient was symptom-free for 6 months before again exhibiting an abdominal mass that was increasing in size. Magnetic resonance imaging revealed an 8!7-cm mass. Laparoscopy was performed.

Intraoperatively, we found that the uterus was studded with multiple soft fibroids (Fig. 1), the largest of which extended up to the liver. Most were subserous fibroids with vascular pedicles. Multiple masses were seen all over the abdominal wall (Figs. 1 and 2). Because the entire abdomen was studded with fibroids and to rule out the possibility of malignancy, biopsy samples of 1 vascular fibroid and 1 large abdominal wall mass were sent for histopathologic analysis. We decided not to proceed with laparoscopic myomectomy immediately. The histopathologic report described a benign leiomyoma with edematous stroma. The estrogen and progesterone receptor status of the tumor was positive. Abdominal open myomectomy is planned.

Leiomyomas are benign smooth-muscle tumors that are clinically apparent in 20% to 25% of women of reproductive age. Exposure of these tumors to steroid hormones and growth factors has an important role in their growth. In our patient, in view of the extensive lesion, one possibility is disseminated leiomyomatosis peritonealis. This rare condition, first described by Willson and Peale [1] in 1952, is characterized by the presence of multiple subperitoneal nodules of benign smooth muscle. Smooth-muscle metaplasia of the subperitoneal mesenchyme is the proposed cause of this condition. Reports of disseminated leiomyomatosis peritonealis suggest removal of the mass as a treatment option. In our patient, multiple leiomyomas were developing not only in the uterus but also in the abdominal wall peritoneum. Whether the ovaries also should be removed is debatable in this young patient. We have previously reported 2 cases of large multiple leiomyomas after laparoscopic hysterectomy with a similar proposed cause [2].

Another possibility is that these extensive myomas are a consequence of remnants of morcellation. Our patient developed recurrent myomas within a short period and also had multiple myomas all over the abdominal wall. If myomas were present only in the morcellation port, the cause could be in our case, myomas were extensive, which made this case unique and challenging for the surgeon. There is also a report of parasitic peritoneal  leiomyomatosis after laparoscopic myomectomy with electrical morcellation [4].

We report a case of parasitic myoma under the diaphragm that was detected and managed laparoscopically [5]. There are few references to parasitic myomas in the literature. In our patient, whether these multiple myomas are parasitic is questionable. The rapidity of lesion recurrence and the disseminated findings make this case rare and interesting.

 

 

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Limiting Factors Laparoscopic Myomectomy

Limiting Factors Laparoscopic Myomectomy
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Abstract

Study Objective: To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas.

Design: Prospective observational study (Canadian Task Force classification II-1).

Setting: Tertiary endoscopy center.

Patients: A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas.

Interventions: Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization.
Measurements and Main Results: In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85  5.706 (95% CI 1.72–1.98). In all, 184 (36.4%) patients had multiple myomectomy.

The mean size of the myomas removed was 5.86  3.300 cm in largest diameter (95% CI 5.56–6.16 cm). The mean weight of the myomas removed was 227.74  325.801 g (95% CI 198.03–257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30–270 minutes). The median blood loss was 90 mL (range 40–2000 mL). Three comparisons were performed on the basis of size of the myomas (10 cm and 10 cm in largest diameter), number of myomas removed (4 and 5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy.

Conclusion: Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas. Journal of Minimally Invasive Gynecology (2008) 15, 292–300

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© 2008 AAGL. All rights reserved.

Keywords: Laparoscopic myomectomy; Myomas; Enucleation; Morcellation; Devascularization; Uterus

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Cervical Myomectomy with Uterine Artery Ligation at Its Origin

Cervical Myomectomy with Uterine Artery Ligation at Its Origin
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Abstract

This study was performed to examine the feasibility, blood loss, duration of surgery, and complications in patients with cervical myomas in whom the uterine artery was ligated before myomectomy. Laparoscopic cervical myomectomy was performed in 12 women with cervical myomas and menorrhagia. The uterine artery was ligated at its origin from the internal iliac as an initial step to reduce the blood loss. Myomectomy was subsequently performed, and the myomas were enucleated by incising the capsule anteriorly or posteriorly depending on their location. Hysterectomy was not necessary in any patient. Even large cervical myomas were removed with minimal blood loss. Laparoscopic cervical myomectomy is a minimally invasive and technicallysafe procedure. Journal of Minimally Invasive Gynecology (2009) 16, 604–8  2009 AAGL.

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Keywords: Cervical myomas; Laparoscopic myomectomy; Uterine artery ligation

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Laparoscopic Hysterectomy with Uterine Artery Ligation

Laparoscopic Hysterectomy with Uterine Artery Ligation
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We compared the feasibility, blood loss, duration of surgery, and complications between patients in whom both uterine arteries were sutured at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom suturing was done  after cornual pedicles. Using a prospective study (Canadian Task Force classification II-2) at a dedicated high-volume gynecologic laparoscopy center, a total of 350 women who underwent TLH from January 2005 through January 2007 were assigned into 2 groups. The indications for TLH were predominantly myomas and menorrhagia. In group A, TLH was done by suturing both uterine arteries at the beginning of the procedure. In group B, the uterine arteries were sutured after the cornual pedicles as done conventionally.

All the other pedicles were desiccated and cut either with harmonic ultracision or bipolar diathermy. The uterus with cervix was removed either vaginally or by morcellation. The median age of patients in group A was 46 years and in group B was 44 years. Mean uterine size, weight, estimated blood loss, total operating time, need for blood transfusion, and complications were analyzed. In group A the total duration of surgery was 60 minutes (range 20–210). In group B, the total duration of surgery was 70 minutes (range 30–190). In group A, the median total blood loss was 50 mL (range 10–2000). In group B the total blood loss was 60 mL (range 10–2500). The comparison between the 2 groups revealed a statistically significant difference (p .05, Mann–Whitney test). Need for blood transfusion was less in group A. One patient in group A had secondary hemorrhage 3 weeks later and the vaginal vault was resutured. In group B, 2 patients had blood loss more than 1500 mL (uterus weight  1000 g) and required 4 units of packed cell transfusion in each. One patient in group B with previous cesarean section had a bladder wall rent and this was sutured laparoscopically using 3-0 delayed absorbable sutures. Uterine artery ligation at the beginning of TLH as done in group A is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure. Journal of Minimally Invasive Gynecology (2008) 15, 355–359 © 2008 AAGL.

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Keywords: Total laparoscopic hysterectomy; Uterine artery ligation; Blood loss; Devascularization

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