1400 gram multiple myomectomy using Chardonnens knife and colpotomy

  • Abstract
    We present the case of a 36-year-old woman with a palpable voluminous mass above the umbilicus. The symptoms were mainly digestive, additionally to the visible abdominal deformity; the menstrual periods were regular, but abundant. The ultrasound exam reported a 17cm myoma. The patient was reluctant to laparotomy. When she came to the presurgical consultation, she was advised that a laparoscopic approach had a high risk of conversion. Finally, she accepted to take the risk. This video demonstrates how important the surgical diagnosis is for making a final decision about the surgical approach.
  • 00'31" First glance at the fibroids
    We get a first view of the abdominal cavity, which is completely occupied by the myomas, and the omentum is adherent at the right side. At this moment, we see that almost all the fibroids are pedunculated and that the laparoscopic approach is feasible.
  • 00'48" Suturing the fibroid pedicles
    The first suture is introduced to get the first pedicle, a loop is created using the Cinch technique, it is applied and tightened in an extracorporeal fashion, and the suture is then cut. A second suture is introduced to tie the biggest fibroid by its pedicle with a simple extracorporeal knot. Once it is performed, an extra suture is made in the same way.
  • 02'15" Cutting the fibroid pedicles
    The pedicle of the biggest fibroid is cut without bleeding. The other myoma has a big vein that is coagulated before cutting the pedicle with monopolar current, enucleating the tumor. A bipolar forceps is used to achieve hemostasis of the serosa. The adhesion of the omentum is coagulated and cut from its attachment.
  • 03'30" Morcellation attempt
    An electrical morcellator is introduced in the central port and morcellation begins in the usual way. The size and consistency of the fibroid wear away the blade sharpness of two morcellators.
  • 03'56" Subserosal fibroid enucleation
    Another subserosal fibroid is being enucleated through traction by means of a laparoscopic Museux forceps and monopolar scissors. Hemostasis is carried out simultaneously. Other smaller myomas are detached of the uterus body by coagulation and cutting of the pedicles.
  • 05'00" Suturing the fibroid bed
    The defect that was left by the extraction of the subserosal fibroid is closed using two separate figure-of-eight stitches and extracorporeal knotting, using a polyglactine 910 0 suture.
  • 05'44" Chardonnens knife
    Because of the size and of the hard consistency of the myomas, the electric morcellators were not a good option. Therefore, the surgeon begins to use the Chardonnens knife in the central port, while keeping divergent traction on the fibroids from the two lateral ports. The knife should always be managed in this way, and always under direct vision, taking care of the structures that are near the cutting zone. The myoma is manually morcellated into pieces of an adequate size so as to be extracted by a colpotomy. A good practice tip is to make long tissue strips instead of many pieces to make the extraction easier and faster.
  • 06'37" Uterine fixation and colpotomy
    Before doing the colpotomy, the uterine manipulator is extracted, and the uterus is fixed to the anterior wall to keep it anteverted. The T-Lift™ device is used over one of the remaining pedunculated fibroids. For the colpotomy, a forceps with gauze is introduced to push over the posterior vaginal fornix. A transverse incision is performed using the monopolar hook.
  • 07'34" Fibroids extraction
    The fibroids are extracted one by one through the colpotomy. The big myomas that were stripped and morcellated are then extracted too.
  • 08'09" Completing the myomectomy
    Other pedunculated myomas are coagulated and excised from the uterus using traction and bipolar Kelly forceps. They are also extracted through the colpotomy.
  • 08'35" Colporrhaphy
    The colporrhaphy is carried out with a polyglactine 910 2/0 suture, using two figure-of-eight stitches and extracorporeal knotting.
  • 09'34" Final view
    The last myoma that is holding the uterus in forced anteversion is coagulated ant cut. The T-Lift™ device is pulled out and the myoma is extracted through the central 12mm port. At the end, hemostasis is checked and a washing is performed. The uterus is seen with an almost normal anatomy and no fibroids are left behind. Surgery is completed without any complications.
  • Related medias
    We present the case of a 36-year-old woman with a palpable voluminous mass above the umbilicus. The symptoms were mainly digestive, additionally to the visible abdominal deformity; the menstrual periods were regular, but abundant. The ultrasound exam reported a 17cm myoma. The patient was reluctant to laparotomy. When she came to the presurgical consultation, she was advised that a laparoscopic approach had a high risk of conversion. Finally, she accepted to take the risk. This video demonstrates how important the surgical diagnosis is for making a final decision about the surgical approach.