Multiple symptomatic leiomyomas and large leiomyomas are better treated by hysterectomy, preferably laparoscopic hysterectomy, even in young women, because if infertility is the primary complaint, then uterine artery embolization, IVF, surrogacy, etc. and not myomectomy should be considered as the first option [1]. The successful removal of leiomyomas and conception are two different issues. However, should myomectomy be done for improving fertility, the leiomyoma(s) must be removed without incising the uterine cavity or must be removed through a single incision in the uterine cavity. The risks of preterm labor, uterine rupture, placenta previa, and placenta accreta are high if the uterine cavity was opened during myomectomy [2]. Uterine artery embolization is not a good option if hysterectomy is not desired and has to be avoided at any cost, and neither is it a good option if infertility is the main complaint.

Endometriosis is a common cause of frozen pelvis [3]. Cervical and broad ligament leiomyomas are known for their proximity to the ureters, and uretric injuries are common while operating in these situations. Preoperative imaging might show hydroureters if the ureteric compression is long-standing. There could be additional challenges like densely adherent bladder due to previous LSCS, and there could also be adhesions due to previous fertility sparing/suboptimal surgery. Endometriosis can involve the rectum and may be extensive [3, 4]. If ureteric reimplantation, resection, and anastomosis of affected segment of bowel need to be done, then the surgery should be planned with a urologist and/or surgeon scrubbed in from the beginning. If infertility and not pain is the main symptom and the surgery is planned for improving fertility, then the options of IVF and surrogacy should be discussed [1]. Surgery can guarantee permanent removal of the disease and not of fertility, since other factors like ovulation defects, tubal block, partner’s fertility, etc. may also coexist.

The principles of dissection are fundamentally the same—sharp dissection.

Take a vertical incision if there has been a previous failed, suboptimal surgery. Do not directly go for a transverse incision. Use laparoscopy as a diagnostic tool to assess and then decide if the surgery can be done laparoscopically or which incision would be better for an open surgery.

Locate the ureters after dividing the round ligament. If round ligaments cannot be located due previous surgery, then hold the peritoneum on the lateral side of pelvis and open the retroperitoneal space. Locate the iliac vessels and the ureter. Take the ureter on a tape, if required. Take care not to pull the tape. At every point of dissection, check if ureter is away and is well protected. Check all the points where stitches have been taken and cautery has been applied. Are they well away from the ureter? Gently stimulate the ureter and look for peristalsis.

Separate the bowel adhesions by sharp dissection only. Make sure you do not cut the mesentery away from the bowel. Dissect along the antimesenteric side of the bowel.

At the end of the procedure, trace the small bowel from the duodenojejunal flexure to ileocaecal junction, in case of extensive endometriosis involving the bowel and if extensive dissection has been done. Check caecum, transverse colon, sigmoid, and rectum. If a bowel injury is suspected, pour copious amount of warm saline inside the peritoneal cavity and look for bubbles coming out of the submerged bowel loops. Ask an assistant to push a jet of air into the rectum and see if there are any bubbles coming out.

Now let us analyze some photographs taken during live surgery of endometriosis, cervical leiomyoma, and broad ligament leiomyoma.

Endometriosis (Fig. 7.1a–f)

The abdomen has been inadvertently opened by a transverse incision (Fig. 7.1a). The author was called after the abdomen was opened. This is a case of suspected endometriosis, and the patient had undergone one previous suboptimal surgery. Either the abdomen should have been opened by a vertical incision, or a laparoscope should have been inserted by the open technique and the extent of disease should have been assessed. However, the surgery was accomplished without any injury to any of the vital structures.

One can see dense adhesions between the posterior uterine surface and the rectum. Also, there are dense adhesions between the omentum, pelvic organs, and the anterior abdominal wall. The omentum has been divided and the portion which is adherent to the dome of bladder is being held by an Allis forceps. The spherical structure lying between both the Deavor’s retractors looks like the uterine fundus? Or is it the ovary with endometriotic cyst? Endometriosis need not present as typical chocolate cysts. It can be reddish, yellowish, or even normal pink in color [5]. However, finding chocolate cysts with the typical thick brown contents is pathognomonic of endometriosis.

Dissection has begun (Fig. 7.1b). The dense adhesions between rectum and uterus can be appreciated. The right ovary can be seen, but the left ovary is hidden and is seen partially.

The fundus is not visible, probably removed during previous surgery (Fig. 7.1b). There were no records as to what was removed during previous surgery.

The first step in such situations is to locate the ureter lest it gets damaged (Fig. 7.1c). The arrow is pointing to the point in the lateral wall of the pelvis, where one can find some space to lift a fold of peritoneum. This will be opened to gain access to the retroperitoneal space to locate the left ureter. As one can see, there is no identifiable round ligament. The round ligament is the most consistent landmark in a female pelvis, and a stay suture can be taken on it. It can be divided and the retroperitoneal space opened. The ureter can be found along the medial fold of the broad ligament. But when there is no recognizable round ligament, one can hold a fold of peritoneum laterally and open it to gain access to the retroperitoneum as is being done above.

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Related posts:

1. of Being an Obstetrician-Gynecologist: How Vulnerable Are We?
2. Pelvis: How to Proceed?
3. Tumor: Challenges During Surgery
4. Hysterectomy: How to Accomplish

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