Successful use of laparoscopic myomectomy to remove a giant uterine myoma: a case report

A 33-year-old, white, gravida 2, para 2 woman was referred to our Gynecology Department with intermittent abdominal pain that had intensified during the previous 3 months and progressive abdominal swelling during the previous 2 years. Her past medical and gynecologic history was otherwise unremarkable. No familial history of any disease was reported. A physical examination revealed a firm giant palpable abdominal mass with identifiable borders. The mass extended to her umbilicus and measured 15 cm above her symphysis pubis. These findings were confirmed by abdominal sonography. The abdominal ultrasonic examination revealed a markedly enlarged and lobular uterus containing intramural uterine leiomyomas, the largest measuring 17×15 cm without ascites in her abdominal cavity. No additional pathology was noted in the remainder of her pelvis or abdomen. The results of the routine laboratory testing, including a complete blood count, serum electrolyte levels and biochemical tests, were within normal limits. On the basis of these findings, a giant intramural myoma was assumed, and myomectomy was selected as the treatment.

She was offered laparoscopic removal of the myoma. Pneumoperitoneum was achieved using a supraumbilical Veress needle until an intra-abdominal pressure of 12 mmHg was reached. We first placed a midline supraumbilical 10 mm port for the telescope, and then two 5 mm accessory trocars were positioned in the left and right lateral quadrants visualized via a 10 mm telescope inserted through the supraumbilical port. The left and right accessory ports were inserted lateral to her deep inferior epigastric arteries and higher than usual; the accessory trocars were inserted sufficiently high enough to provide an unobstructed passage to the myomas for the laparoscopic instruments. Intra-abdominal visualization revealed an enlarged, lobular uterus containing a fundal intramural myoma with a maximum diameter of 17 cm, as diagnosed by ultrasound (Fig. 1). The adnexa on both sides, round ligaments, and other pelvic and abdominal organs were normal. A myomectomy was performed using the standard technique as described elsewhere [13]. A vertical incision was made on the prominent part of the principal myoma using a monopolar hook. The cleavage plane between the myoma and its surrounding connective tissues was then dissected. When the myoma was identified, the myoma was fixed, and enucleation was then accomplished by traction on the myoma with a tenaculum clamp, associated with countertraction on the uterus-facilitated dissection. The myoma was completely enucleated and removed without disturbing the endometrial cavity. A Harmonic ultrasonic scalpel (Ethicon Endo-Surgery Inc, Cincinnati, OH, USA) was used for most of the procedure. Bipolar coagulation was used when extra hemostasis was required. The myometrial defect and edges were closed with a continuous suture using a V-loc unidirectional barbed suture (Covidien, UK) in two layers (Fig.2). The left accessory 5 mm port was converted to a 10 mm one for the insertion of the morcellator. The entire myoma was removed using an electromechanical Rotocut G1 tissue morcellator (Karl Storz, Tuttlingen, Germany). The total intraoperative blood loss was 720 mL, the total weight of the myoma removed was 2005 g and the operation lasted for 140 minutes.

There were no major intraoperative complications. The final histopathological examination confirmed the diagnosis of a uterine leiomyoma. The postoperative course was unremarkable, and the patient was discharged on the second postoperative day.

A literature search indicated that the use of a LM to remove of a leiomyoma of this size, with a maximum diameter of 17 cm (2005 g), is very rare. However, the entire myoma was successfully removed laparoscopically. Despite this success, the use of a laparoscopic approach to treat large myomas is still controversial and represents a significant surgical challenge. The difficulties of cleavage, removal and repair of the myometrial defect and the increased operative time and risk of perioperative bleeding and conversion to laparotomy are the major concerns regarding the use of a LM to treat large myomas [5]. Due to these compelling factors, the surgical treatment options and approaches are not standardized, and the appropriate management of patients with very large myomas is complex and requires exceptional skill.

Uterine leiomyomas are benign tumors that arise from the overgrowth of smooth muscle and connective tissue in the myometrium and are the most common solid benign neoplasm of the female genital tract. The size of leiomyomas varies from microscopic to lesions of considerable size. Although most myomas are asymptomatic and usually small in size, they can reach >10 cm in size [3]. Most myomas do not require intervention unless they cause symptoms. For symptomatic myomas, hysterectomy offers a definitive solution. However, it is not the preferred solution for women of reproductive age who desire to maintain their fertility or those who want to preserve their uterus for cultural, social, or emotional reasons. Myomectomy remains the treatment of choice and gold standard for these patients [4]. LM offers many advantages compared with an abdominal myomectomy due to its minimally invasive nature and potentially a woman’s fertility can be retained [5‐7]. However, the use of a laparoscopic approach to treat very large myomas is still controversial and technically very demanding [5].

The laparoscopic removal of giant uterine myomas is rare, and only a few cases have been published in the literature [10‐12]. The largest uterine myoma removed laparoscopically measured 21 cm and weighed 3400 g [10]. In 2003, Sinha et al. conducted a prospective study to evaluate the feasibility, complications, and conversion rate of laparoscopic excision of very large myomas [10]. The authors included 51 women with at least one myoma larger than 9 cm, and they removed 78 myomas laparoscopically in these 51 patients. The largest myoma removed was 21 cm in their prospective study. The authors reported that LM is a safe alternative to laparotomy for very large myomas. A similar study conducted by Yoon et al. demonstrated that a laparoscopic approach is an efficient and feasible myomectomy method to treat large myomas [11]. In this prospective study, 51 patients with myomas 8 cm or larger in diameter who underwent LM were investigated over a 3-year period. The largest myoma successfully removed in the study was 15.2 cm. In a case report in 2013, a 34-year-old infertile woman underwent diagnostic laparoscopy because of a large abdominal mass, and an 18 cm myoma was laparoscopically removed [12]. In our case, the maximum diameter of the myoma was 17 cm, and the entire myoma was successfully removed laparoscopically without disturbing the endometrial cavity.

On 24 November 2014, the US Food and Drug Administration (FDA) issued a statement warning against using laparoscopic power morcellators in women undergoing hysterectomy or myomectomy for uterine fibroids [13]. One of the major concerns over morcellation of an occult cancer is delayed diagnosis because of misinterpretation of the initial pathologic specimen [14]. Another major concern over morcellation of an occult malignancy is the possibility of the seeding of cancer throughout the peritoneal cavity. In the recent literature there exist retrospective cohort studies, which described up-staging of sarcoma secondary to peritoneal spread after morcellation [15, 16]. Minimally invasive gynecologic surgeons who perform laparoscopic intraperitoneal morcellation should be aware of the recent FDA warning and litigation arising from use of morcellation devices with claims of intraperitoneal dissemination of cancerous cells.

Strategies to continue to allow surgeons to provide minimally invasive surgery to patients while minimizing the risk of the spread of occult malignancy involve refinement of contained morcellation techniques. There are reports of power morcellation within an endoscopic bag [17, 18], extracorporeal morcellation [19, 20], and transvaginal insertion of the anchor tissue retrieval system [21]. New surgical methods are being investigated so that women with large uterine leiomyomata can still be offered laparoscopic surgery.

This case confirms the efficiency, reliability, and safety of a minimally invasive surgical approach to removing a giant uterine myoma. Thus, LM can be considered an alternative to the traditional abdominal myomectomy in patients with large myomas. Although a laparoscopic approach for large myomas has several challenges, it does represent a convenient option for the minimally invasive removal of very large myomas in the hands of an expert surgeon with appropriate surgical equipment.

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.