Case notes

A 43-year old perimenopausal multiparous woman was posted for removal of a large, asymptomatic 32-week size pedunculated myoma, diagnosed during her routine health checkup and confirmed radiologically. Following a midline vertical incision, on opening the peritoneum, a cluster of worm-like engorged veins protruded out ( Figure 1 ). On careful dissection, the hypertrophied veins were arising from the greater omentum and took the shape of a hypervascular hood covering the top of the pedunculated myoma ( Figure 2 ). The large pedunculated myoma along with its hypervascular top was dissected out. Pathological examination of the mass demonstrated a degenerated myoma.

A cluster of veins popped up on opening the peritoneum

Bhattacharyya. Medusa-headed myoma. Am J Obstet Gynecol 2015 .

The medusa-headed myoma

Bhattacharyya. Medusa-headed myoma. Am J Obstet Gynecol 2015 .

Comment

Apart from uterine arteries, rarely myomas may receive blood supply from other sources. This can be suspected when myomas do not shrink as expected following uterine artery embolization. The protrusion of clustered engorged veins initially raised concerns about whether our preoperative diagnosis was correct and about the optimal surgical approach because there was a possibility of injury to the pulsating hypervascular plexus. However, after extending the incision, it was clear that this anomalous vascularization arose from the greater omentum. We were able to safely ligate and separate each vessel using a suture.

The ovarian artery and inferior mesenteric artery have been reported to provide blood supply to pedunculated myomas. These nongonadal vascular contributors to myomas, if suspected, can be detected by aortography and can be embolized. However, aberrant vasculature from the greater omentum is uncommon. The hypertrophied, hypervascular plexus could easily be injured when opening the peritoneum. We suggest opening the abdomen carefully when a myoma is pedunculated, fundal, superficial, and large.