In this video, we demonstrate our approach to the excision of multiple parasitic fibroids present two years after paramorsalation for an enlarged fibroid uterus. In 2013, the FDA presented a communication stating that paramorsalation is contraindicated for the removal of uterine tissue containing suspected fibroids in patients who are peri- or postmenopausal. A later review of the literature revealed that approximately 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma. We present a case of a 40-year-old para 3 with a history significant for robotic supra-cervical hysterectomy for a large fibroid uterus and heavy menstrual bleeding at another institution. Removal of the specimen was performed with paramorsalation. One year after her original surgery, a robotic sacrocopal pexy was performed at an outside institution. She presented to our office two years later with complaints of chronic pelvic pain, abdominal bloating, and pelvic pressure and fullness. CT scan was performed revealing multiple fibroids ranging from 3 to 4 centimeters throughout the pelvic cavity. Due to continued chronic pain despite conservative management, the decision was made to perform a robotic-assisted laparoscopic excision of the fibroid masses. The four fibroids excised in this video are located in the right perivesical space, the sacral promontory, the sigmoid colon, and the left psoas muscle. To start the right salpinga oophorectomy, an incision is made lateral to the infundibular pelvic ligament. The peritoneum is then dissected up, skeletonizing the IP ligament. After cauterization, the ligament is then cut, and the dissection is continued until we reach the junction of the first fibroid, which is located in the right perivesical space. The first fibroid is located medial to the external iliac vessels and lateral to the bladder. The dissection is performed by staying in the plane of the multiloculated fibroid until it is confirmed that there is no communication between the fibroid vasculature and the external iliac vessels. Once the fibroid is multiloculated, it spans up to the median umbilical fold. During this dissection, we are able to visualize the inferior epigastric artery, the external iliac artery and vein, and the superior vesicle artery. After being excised, all myomas are placed in the right upper quadrant. The second fibroid is located on the left common iliac vessels at the level of the sacral promontory. An incision is made on the fibroid first so that we can determine if there is a communication present between the fibroid and the common iliac vessels. Once we have determined that there is no communication present, we continue to dissect layer by layer in a circumferential manner, always keeping the plane of the dissection over the fibroid tissue. This is continued until the fibroid is completely excised. We utilize a tenaculum to elevate the fibroid off the vessels, allowing traction towards the pelvic wall. Hemostasis was achieved using a combination of corduroy and surgical snow. The third set of fibroids is attached to the sigmoid epiploica. Traction is placed between the epiploica and the fibroids so that we can successfully dissect between the two. This also allows us to be in a safe plane to avoid thermal injury to the sigmoid colon. The fourth fibroid is located on the left lateral side wall attached to the psoas muscle and sigmoid colon. Careful attention is paid while dissecting to keep as close as possible to the fibroid to avoid injury to the surrounding vessels and bowel. As you can see, there is chocolate colored fluid emerging from the myoma. At the end of the procedure, all the fibroids were tied together using bico suture to form a bundle. This was then placed into an endocatch bag and removed through the umbilical incision. As shown in this video, parasitic fibroids can be successfully excised in a minimally invasive approach. The patient in this video recovered well postoperatively and the pelvic pain has resolved.

excision

parasitic fibroids

40-year-old patient

fibroid uterus

heavy menstrual bleeding