Management of Big Submucus Fibroid

Management of Big Submucus Fibroid (More than 5 cms)
Report of Case: Big (7 cms) submucus fibroid removed Hysteroscopically & Laparoscopically. :

Pragnesh Shah, MD, FICOG, Parulben Shah, MD.
From Jyoti Hospital & Minimum Invasive Surgery Center, Ahmedabad, India.
Email: pragnesh@laparoscopyexpert.com
Website; http://www.laparoscopyexpert.com

Abstract:
A 28 years old, Primary Infertility Patient, referred to us in our tertiary referral center with Big Submucus fibroid for Hysteroscopic removal by Gynaecologist. She was having menorrhagia & was on treatment for Primary Infertility since last one year. Patient searched on net and was insisting for Hysteroscopic removal only from the information's she gathered from Internet. Uterus was 12-14 weeks size, with 40% intra-cavitary submucus fibroid in USG.
She was explained about three options of fibroid removal: Laparoscopic removal, Hysteroscopic removal in 2-3 sittings, partly hysteroscopic safe removal and remaining fibroid removed laparoscopically in the same sitting/anesthesia after stabilizing the patient from early TUR syndrome.

KEYWORDS:
Fibroid
Submucus fibroid
Leiomyomatosis;
Laparoscopic removal
Hysteroscopic removal
Myoma
Leiomyomas
TUR Syndrome
Hyponatremia
Safe Fibroid surgery

Operative planning:

(1) First Diagnostic hysteroscopy done and big anterior and right side submucus fibroid and both cornual ends noticed.
(2) Diagnostic Laparoscopy done, 12-14 weeks fibroid, uniformly enlarged uterus noticed. Tubal testing done and both tubes found to be patent.
(3) Hysteroscopic resection of big submucus fibroid started with Resectoscope with loop electrode, 80 watt unmodulating/cutting current with close watch on Fluid deficit, Multipara monitoring and operative timing as 1.5% Glycine was used for uterine distention during Hysteroscopic surgery..... After 30 minutes, fluid deficit was more than 1 liter with Multipara showing signs suggestive of early TUR syndrome and procedure stopped, patient stabilized and than
(4) Laparoscopic removal of remaining fibroid done after pitressin injection, incision with Monopolar hook, manipulation of fibroid with myoma screw and closing the uterine defect with No.1 Vicryl and appropriate approximation of the edges of myometrial defect after fibroid removal.
(5) Patent had recovered well and tried pregnancy after two months following fibroid surgery with history of FT LSCS delivered after 1.5 years after fibroid surgery without any complications afterwards.

Discussion:
The gold standard Treatment for submucus fibroid is hysteroscopic resection by Resectoscope today but we must understand the limitation of the procedure.
Big submucus fibroid (5 cms) resection operation takes more than 30 minutes for the completion of the procedure and in such a case patient is likely to develop TUR syndrome (Hyponatremia, S.Na 130- 135 mEq/l), as when 1.5% Glycine is used as distention medium during the procedure, about 80-100 ml of 1.5% Glycine/Min. is absorbed into the vascular system and patient is definitely likely to develop Hyponatremia.

Conclusion:
(1) So it's always advisable to remove such a big submucus fibroid (5 cms) by laparoscopically directly. With the review of scientific literature, it has been found that single layer closure with Endometrium included in closure is not having any adverse effect in future obstetric outcome if closure of uterine defect after fibroid removal is done adequately by expert laparoscopic surgeon.
(2) If the size of sub mucus fibroid is more than 5 cms size or if they are more than 3 in nos. patient should be counseled well before operation regarding fluid overload because of intravasation of 1.5% Glycine as the removal of sub mucus fibroid removal may be abandoned if patient becomes serious or removal in more than one sitting or if patient settles down after sometime remaining sub- mucous fibroid can be removed laparoscopically in the same sitting.

Category:

Education

Tags:

• Fibroid
• Submucus fibroid
• leiomyomatosis
• Laparoscopic removal
• Hysteroscopic removal
• Myoma
• Leiomyomas
• TUR Syndrome
• Hyponatremia
• Safe Fibroid surgery
• Intrauterine Mass
• Big Fibroid
• menorrhagia

[ppshah11]

Wow ! what a educational video for Doctor & patient both ?

[NismoCJ]

Medicine of XXI century. unbeliavable!!!

[scot0129]

eew, but cool