What is a Laparoscopic Hysterectomy with a Prolapsed Cervical Fibroid?
A laparoscopic hysterectomy with a prolapsed cervical fibroid is a minimally invasive surgical procedure to remove the uterus when a fibroid has descended into or through the cervix. Key details include:
Definition: A hysterectomy is the surgical removal of the uterus. In this case, the surgery is performed laparoscopically (through small abdominal incisions using a camera) and addresses a fibroid that has prolapsed through the cervix into the vagina.
Fibroid Characteristics: Cervical fibroids arise from the cervix and can grow large enough to protrude into the vaginal canal, causing heavy bleeding, pelvic pressure, or difficulty with standard surgical techniques.
Indications: Surgery is considered when medical therapy fails to control bleeding, when the fibroid causes significant symptoms, or when the patient desires definitive treatment.
Technique: The procedure typically involves laparoscopic ligation of uterine vessels, careful dissection around the bladder and ureters, and circumferential incision of the vaginal cuff to remove the uterus. When a large prolapsed fibroid obstructs the cervical canal, a uterine manipulator may not be usable, requiring alternative methods of uterine traction and identification of key anatomical landmarks.
What are the Risks of a Laparoscopic Hysterectomy with a Prolapsed Cervical Fibroid?
The risks are similar to those of a standard laparoscopic hysterectomy but may be heightened by the size and location of the fibroid. Potential risks include:
Hemorrhage: Cervical fibroids are highly vascular and can increase intraoperative blood loss.
Bladder or Ureter Injury: Distorted anatomy and proximity of the fibroid to the bladder and ureters raise the risk of injury during dissection.
Infection: As with any hysterectomy, there is a risk of postoperative pelvic or urinary tract infection.
Conversion to Open Surgery: Extensive adhesions, uncontrolled bleeding, or poor visualization may necessitate conversion to an open abdominal hysterectomy.
General Surgical Risks: These include anesthesia-related complications, thromboembolism, delayed healing, or formation of pelvic adhesions.
Careful preoperative planning, clear identification of pelvic structures, and meticulous surgical technique help reduce these risks and improve patient outcomes.
Video Transcript:
This video demonstrates a technique for laparoscopic hysterectomy with a prolapsed cervical fibroid. The case is of an otherwise healthy 46-year-old nulliparous patient with no prior surgical history, who presented with acute vaginal bleeding and a haemoglobin of 66. Her only medication was an iron supplement.
Pelvic ultrasound revealed an 8 cm mass near the cervix, which was found to be a prolapsed cervical fibroid on examination. This was also confirmed with biopsy. She was admitted to hospital and her bleeding settled with tranexamic acid. She was also given Depo-Provera and IV iron.
Myomectomy and hysterectomy were discussed as surgical options. She was undecided on how she wanted to proceed, so she was discharged home with a plan to discuss surgery at her out-patient follow-up.
She represented to hospital with bleeding and a haemoglobin of 80. She was admitted and stabilised again on tranexamic acid. She opted for hysterectomy. She was transfused with one unit of packed red blood cells to a haemoglobin of 95 prior to surgery.
The purpose of this video is to demonstrate an approach to simple hysterectomy without the use of a manipulator colpotomy cup or any specialised equipment. We think this approach can be accomplished by any gynaecologist with laparoscopy training.
As shown in this video, the success of this approach is accomplished through the dynamic use of instruments to provide uterine manipulation, the awareness of key anatomical landmarks, and the use of the second assist to provide delineation of the vaginal fornices. Ports for this case were placed ipsilaterally with the operating surgeon on the patient’s left.
On vaginal examination a large fibroid is seen prolapsed through the cervix precluding the use of a uterine manipulator. Dilute vasopressin was injected into the fibroid.
At laparoscopy, the anterior cul-de-sac is free. The uterus is approximately eight weeks size, and there is evidence of endometriosis with peritoneal retraction pockets and powder burn lesions. The patient did not have any dysmenorrhea, so we opted not to perform excision of endometriosis.
The ureters are clearly visualised transperitoneally. Sigmoid adhesions were taken down first to restore normal anatomy. Beginning on the right-hand side, salpingectomy was performed with cephalad and medial traction placed on the fallopian tube with the operator’s left hand. Similar cephalad and medial traction is applied to facilitate the division of the utero-ovarian ligament. The same is applied to the round ligament.
The assistant at the bottom end introduces a sponge and ring forcep into the right vaginal fornix to assist with cephalad traction and to guide the trajectory of dissection. Similar to a colpotomy cup, the sponge can be palpated to direct dissection.
The uterine vessels are ligated with the ureter in clear view. Note the importance of cephalad and medial traction by the operator’s left hand to mimic the movement of a uterine manipulator.
The same is performed on the left-hand side. The cephalad and medial traction is now provided by the assistant’s grasper from the right. Moving the grasper further down the body of the uterus as dissection progresses allows for better retraction while reducing twisting of the uterine corpus, which can obscure dissection planes.
The uterine vessels on the left side are skeletonised and the ureter is clearly visualised transperitoneally while the uterine vessels are ligated.
The sponge stick in the vagina was moved to the left vaginal fornix to facilitate dissection and assist with cephalad pressure. The primary assistant now grasps the uterine fundus with cephalad traction to facilitate dissection of the vesicocervical space.
The vaginal sponge is moved to the anterior fornix to facilitate dissection. The sponge is palpated to confirm the colpotomy site. The colpotomy is started anteriorly with a monopolar L-hook. The sponge can be seen with entry into the vagina. Soaking the sponge in methylene blue can help with visualisation. Working clockwise, the right round ligament is grasped with the operator’s left hand to provide cephalad and medial traction. The sponge is moved to the right vaginal fornix and the colpotomy is continued.
The same is continued on the other side. The vaginal sponge is dynamic, moving around the fibroid into the fornices to guide dissection.
Therefore, communication between the surgeon and the bottom assistant is important to confirm specimen movement and surgical trajectory.
The uterus is moved again to the left to finish the colpotomy. The specimen is removed through the vagina. It is then carefully inspected, and a portion of cervix is noted to be missing. It is identified at the ten o’clock position of the cuff. It is grasped removed with monopolar energy and placed in the vagina for later retrieval.
The vault is then closed with an 0 barbed suture in a running non-lock fashion from left to right. Haemostasis of the pelvis and all pedicles was adequate. Cystoscopy was then performed and was normal with both ureteric jets visualised.
Estimated blood loss was 300ml, mainly from vaginal examination and from vaginal prep at the start of the case. The patient was discharged home on postoperative day one in stable condition with a haemoglobin of 93.
This video showcased a technique for laparoscopic hysterectomy with a prolapsed cervical fibroid with no specialised equipment, by demonstrating the dynamic use of instruments to provide uterine manipulation, the awareness of key anatomical landmarks, and the use of the second assist to provide delineation of the vaginal fornices. To see another approach on the topic, see this video in the CanSAGE video library. Thank you.
