Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Minimally Invasive Approach to Chronic Uterine Inversion?
- What are the Risks of Minimally Invasive Approach to Chronic Uterine Inversion?
- Video Transcript
Video Description
This video presents a minimally invasive laparoscopic and vaginal approach to managing chronic uterine inversion, emphasizing vascular control, anatomical restoration, and safe surgical decision-making in a complex pelvic case.
Presented By
Affiliations
University of British Columbia
St. Paul’s Hospital
Watch on YouTube
https://youtu.be/b17lJ_L6bwI
Click here to watch this video on YouTube.
What is a Minimally Invasive Approach to Chronic Uterine Inversion?
A minimally invasive approach to chronic uterine inversion involves the use of laparoscopic and vaginal surgical techniques to manage a rare condition where the uterine fundus collapses inward, often due to an underlying pathology such as a fibroid. This approach focuses on restoring anatomy or safely proceeding to definitive treatment while minimizing blood loss and surgical morbidity.
- Preoperative Planning: Uses imaging such as MRI to confirm the diagnosis, assess severity, and identify contributing factors like leiomyomas.
- Vascular Control Strategy: Involves temporary occlusion of pelvic blood supply (e.g., with clamps) to reduce hemorrhage risk during manipulation and surgery.
- Combined Surgical Technique: Integrates laparoscopic visualization with vaginal procedures to improve access, allow fibroid removal, and attempt uterine repositioning.
- Stepwise Surgical Decision-Making: Includes attempts at uterine correction (Johnson, Huntington, Haultain techniques), with readiness to proceed to hysterectomy if unsuccessful.
What are the Risks of a Minimally Invasive Approach to Chronic Uterine Inversion?
While minimally invasive techniques improve visualization and recovery, this approach still carries important risks due to the complexity of the condition:
- Significant Hemorrhage: Chronic uterine inversion is highly vascular, and manipulation can trigger severe bleeding without proper vascular control.
- Injury to Surrounding Structures: Distorted anatomy increases the risk of damage to the ureters, bladder, bowel, and major pelvic vessels.
- Failure of Uterine Repositioning: Long-standing inversions may not be reversible, requiring conversion to hysterectomy.
- Anesthesia and Operative Risks: Prolonged surgical time and potential blood loss increase anesthesia-related risks.
- Postoperative Complications: Includes infection, delayed healing, and the need for transfusion or extended recovery.
- Technical Complexity: Requires advanced laparoscopic and vaginal surgical expertise, as well as precise intraoperative decision-making.
Careful planning, strong anatomical knowledge, and a flexible surgical strategy are essential to minimizing complications and achieving optimal outcomes.
Video Transcript: Minimally Invasive Approach to Chronic Uterine Inversion: A Case Report
Uterine inversion is described as the collapse of the fundus into the uterine cavity. It can range in severity and is most commonly associated after obstetrical events. Non-obstetrical related uterine inversions are rare, with case reports describing leiomyomas as the most common etiology. Associated risks can include significant hemorrhage, shock and death.
Management can include the Johnson maneuver (which involves manually repositioning the fundus through the constriction ring, the Huntington procedure (which involves cranial traction on the round ligaments), the Haultain procedure (which involves an incision in the posterior uterus to bisect the constriction ring), or proceeding to a hysterectomy, which occurs in 87% of cases. There is a paucity of educational videos that describe this process, especially one involving a laparoscopic perspective.
We present the case of a 39 year old female, G0, who was a refugee to Canada and presented to the emergency department four days after arrival. She reported a history of heavy vaginal bleeding for at least 6 months, and new-onset obstructive urinary symptoms. She was otherwise healthy with no prior surgeries. Pelvic exam revealed a tennis-ball sized mass in the vagina that was significantly friable to touch and at risk of profuse bleeding. The cervical os could not be appreciated.
Pre-op MRI showed a completely inverted and prolapsed uterus into the vaginal cavity through the internal os, with an 8 x 6 x 7 cm (7.5 x 6.2 x 7.3 cm) fibroid arising from the posterior fundal cavity, almost to the level of the introitus, consistent with a 3rd degree uterine inversion.
She was admitted for pre-op optimization including 2 units of blood transfusion for a starting hemoglobin of 67 g/L, as well as a thorough consent including possibility of a hysterectomy.
After bilateral ureteric stents were placed by urology, the following port placements (umb, LLQ, LUQ, RLQ, midline suprapubic 10mm) were chosen to allow adequate manipulation of the tissue. Upon entry into the peritoneal cavity, we visualized bilateral round ligaments, fallopian tubes and ovaries, pulled into the constriction ring where the uterus was collapsed through the cervix, consistent with the “flowerpot” appearance.
We aimed to first obtain temporary occlusion of the pelvic blood supply to allow for subsequent vaginal manipulation, as there had been significant bleeding from a pelvic examination alone. Beginning on the ___left __ hand side, the para rectal space was entered. The ureteric stents were palpable.
The internal iliac artery was identified and confirmed with the pulling technique of the medial umbilical ligament. The same steps were repeated on the right hand side. Bulldog clamps were placed 1cm proximal to the origin of the uterine artery to ensure all accessory vessels were secured.
Additional bulldog clamps were placed on bilateral IP ligaments at a 90 degree angle. The utero-ovarian ligaments were not accessible.
Once the major blood supply to the pelvis was secured, we began prepping the vagina and examining the structures vaginally.
Minimal bleeding was noted vaginally due to the prophylactic hemostatic measures. The fibroid was noted to be intramural, with the endometrial cavity as shown. Thus a myomectomy was completed.
Several attempts were made to manually re-invert the uterus, both laparoscopically and vaginally, including the use of the Johnson maneuver – consisting of pushing the inverted fundus cranially through the constriction ring – and the Huntington procedure, whereby cranial traction is placed on the round ligaments.
The Haultain procedure was also utilized, involving an incision in the posterior uterus to bisect the constriction ring. As we had secured hemostasis, rigorous attemps were made by multiple providers. The inversion persisted. Thus, we decided to proceed with a hysterectomy. The round and broad ligaments were dessicated laparoscopically.
The left uterine artery was isolated, which branches off at a 45 degree angle from the medial aspect of the internal iliac artery, commonly known as the V sign [insert overlay]. The uterine vessels were dessciated. The same steps were repeated on the right hand side. The bladder edge was clearly visualized. The remaining hysterectomy was completed vaginally.
This is the serosal surface of the uterus. [insert overlay]
The cervix and vaginal tissue were signficantly edematous from the chronic nature of the inversion.
Bulldog clamps were removed. The remnants of the cervical tissue was excised and the cuff was closed laparoscopically. Hemostasis was confirmed and ureteric stents removed.
Estimated blood loss was 50cc.
Postoperative recovery was uneventful.
Pathology revealed leiomyoma with focal areas of hemorrhage.
In conclusion, Non-obstetrical uterine inversion can result in significant anatomical distortion. Effective management often necessitates a combination of vaginal and laparoscopic approaches. Therefore, a thorough knowledge of pelvic anatomy, and well-developed vaginal surgical skills are essential for safe gynecologic surgery. Implementing prophylactic hemostatic measures, such as Bulldog clamps for temporary occlusion of the pelvic blood supply, is a valuable skillset for gynecologic surgeons