What’s up good morning. Here again with you, we are going to resume uploading some videos of fibroid surgeries. We are having more and more fibroid surgeries and both foreign and foreign patients. Today I’m going to show you a patient who wrote to us from Sacramento, California. She is 50 years old, due to a large tumor, myomatosis, she sent me an MRI and obviously we had the first consultation on June 13 and then from there we ordered the laboratories.

Her main symptoms were bloating, a little constipation and also constipation. So, she went to a consultation there, they told her about the fibroid but they wanted to remove her uterus. Even despite her age, she does not want her uterus to be removed, so we gave her a virtual consultation, she taught us the MRI, which helps us a lot. Remember that MRI is a more sophisticated study than an ultrasound where we make cuts and we can perfectly visualize the sizes and obviously see it from one side to the other, front to back or from top to bottom. So, this little patient saw the videos, she really liked the information we gave and now we are going to operate on her, we are going to undergo the entire surgery but we must remember that always… This is a tumor the size of a melon more or less So it has large elements, completely intramural and so it has to be resected very carefully due to the risk of bleeding although she is hemodynamically very well.

The other patient that we are also going to upload the video is a patient from León, Guanajuato. So, this patient is 36 years old, obviously her reason for consulting the videos was because she had a pregnancy and had an abortion and then during the abortion she had a little complication with the bleeding, they did 2 curettages because she had not removed all the residual chorionic remains but there they saw the fibroid and they even wanted to remove her uterus, she didn’t want to and then she consulted me, see it’s also an MRI. This is a slightly larger tumor than the one we are talking about about the patient from Sacramento but she has a little low hemoglobin, mild anemia of 11.8.

For her, the idea is obviously to preserve the uterus for the issue of reproduction, so unlike the other patient, what she had was more spotting, bleeding and obviously a gestational loss secondary to that fibroid with large elements. So it is very important that the consultations, if they are foreigners or foreigners who cannot come for a first visit, preferably have an MRI or a CT scan because there we can play a lot with the images and visualization, especially to explain to you where it is placed, This is also an intramural, it is a little bigger than a melon, this one is more or less between watermelon and papaya, so the surgery is a little more complicated. Both will therefore need to try to preserve and ensure that we do not have bleeding, but the most important thing is that in the consultation you can guide them on the size, location and surgical time or surgical risk.

We are going to start with the surgery, we have already placed the separator, now we will show you the ovaries are there all the way back. It is a completely intramural fibroid, it covers the entire body, we are going to give it an infiltration with vasopressin in the uterine fundus and from there we are going to move on to the dissection or resection of the tumor. With this wave clamp, remember it is a harmonic, the advantage is that it coagulates and cuts at the same time, you avoid having important or profuse bleeding and the idea of always doing surgeries with little bleeding is in favor of recovery and obviously avoiding, well, transfusion globular packages. Right now what we are doing is resecting or dissecting the capsule of the fibroid, see how there is still muscle tissue from the uterus obviously, these are the muscle fibers of the uterus, it is intramural and inside that muscle.

The idea is to resect and dissect it well so that we have more room for the fibroid to emerge… I don’t know if it will come out completely because we made a very small incision, so maybe we have to morcellate it. Right now we are doing a technique called splitting or removing the fibroid because that helps us to do a little hemostasis as well and the idea of this outside, it works much better, you abuse the uterine muscles much less. Obviously she no longer wants to get pregnant but the recovery is also much greater as long as we work less with the muscle. Yes, this fibroid already, for at least seven years with it, it grows, it grows, but in many cases if the fibroids do not give any symptoms, sometimes they do not notice. Because right now my fibroid is about eight or ten centimeters in size, but a five-centimeter fibroid, if it doesn’t cause bleeding or cramps, it’s difficult for them to find out if they don’t go for a checkup. The important thing there, as I always mention, is to do your gynecological check-ups annually with always a vaginal ultrasound to be able to evaluate the uterus and ovaries, that is the gold standard.

We put some transfictive stitches, in many cases the transfictive stitches are to create a bit of compartment and reduce the risk of post-surgical bleeding and obviously hemostasis. We are going to go with a myomite who has cornual here, the truth is that we could leave him but we are going to take advantage of the fact that we are already here. Look at the posterior surface, tube, ovary, ovary, tube, we gave the… We entered through the posterior surface because here is the horn and it is a very bleeding area but we are done, we are going to wash and the surgery is over.

See, this little patient is from León, Guanajuato. She is 36 years old but she obviously wrote to me a month ago because she had a pregnancy loss in the second trimester. The fibroid obviously hindered the development of that embryo and she had a loss around month 4, that is, week 16-18 and then she called me to see about the fibroid. Obviously fertility must be preserved, but if it is a fairly large fibroid and is somewhat fixed, it reaches the umbilical scar.

Let’s start doctor, we’re going to put 30 here, I think. Will it come out? I’m going to go very slowly, it’s easy, easy, easy, easy, easy. Well, see, we are already focusing a little on the serosa, remember, this patient only had the loss of the previous month but she already wanted to, because of course with the pregnancy she began to have more symptoms, more symptoms of bleeding, distension, pain and obviously the abortion that it got. So, the ideal right now is to go in and remove it because she started with anemia and also had bleeding during curettage, so the intention right now is to remove the tumor so that she no longer has hemorrhages.

We are going to start morcellating because it is very large and the truth is that although we made a medium incision to have a better surgical field, the fibroid is too large, we cannot mobilize the uterus well. So see what degeneration the fibroid has, it looks kind of unpleasant because it looks like muscle, remember that fibroids are made of muscle, so you have to morcellate it a little to be able to part.

– Yes… This is very degenerated, I mean in theory this is how they should look because it comes from the muscle, right? But it does give an unpleasant impression, because for example, when you do practice in the amphitheater that’s how the dead man’s muscle can be seen.

– So it’s almost like necrotic?

– No, mind you, no. You simply never see fibroids… You open a fibroid and everything is white as if it were calcified but it is not calcified, right? This one does look muscular.

See, we are doing morcellation but this is not very common, see that this is a fibroid that is generally seen in all the videos we upload, that is, pearly white but here is the interface between the capsule, that is, the fibroid externally but internally see… It is like a muscle because the fibroid is a degeneration of the muscle but this one is watery, totally a uterine muscle, they are unpleasant to look at but well it is not bleeding at all, you have to morcellate it to be able to remove it and Later you will see how it looks compared to other fibroids.

Look, this little patient has been ten years since she learned that she had a 3-centimeter fibroid! Now to give you the idea, in 10 years this fibroid measures more than 20 centimeters, that is, it grew more than one centimeter per year. That’s why I always tell you in the videos the importance of a fibroid smaller than five centimeters, to monitor it annually, the moment that fibroid exceeds five centimeters, please have surgery, come to Creafam, it’s easier, it’s less surgical risk, it’s very It is quick to remove a five centimeter fibroid and obviously, surgically and economically, it is much cheaper. The main problem here is that when many patients go to the doctor, the vast majority of gynecologists tell them: “No, it’s a very big fibroid, I’m going to remove your uterus” and that discourages, discourages and obviously the patient is absent. from the doctors and that is when they go to a consultation for some discomfort, some problem, because they are already very large fibroids. So, always ask for a second opinion, always see who has experience and obviously who is more dedicated to performing myomectomy surgeries.

Many of the questions from patients are: But what can happen to me if I don’t have surgery? The first complication that fibroids have is hemorrhages, even if there are no hemorrhages there may be anemia and a patient with anemia is in a constant inflammatory state that can even put her life at risk, but the main risk is that the tumors continue to advance and then become poorly resectable and then a surgery that is too complicated or with hemorrhage that puts life at risk during the surgery. We have here, we have already managed to split or externalize the uterus, see here her right ovary looks very beautiful, she is 36 years old. The right tube, elongated and hidden here, has the other ovary. Oh! This one is up to here, see, it’s just that you turn it around, it’s a little crooked, the ovary should be here but right now we’re going to remove it… Not the ovary, the fibroid.

In it we use regional anesthesia, it is controlled a little better, we administer adjuvant medications to control the pain after surgery and now keep it as hemodynamically stable in terms of volume and if necessary, until now it has not presented bleeding, so we are going to maintain hemodynamics.

I was anemic, well 11 hemoglobin is being anemic, the ideal is that they have 14 to 16. 11 is anemia, however, going into surgery with 11 hemoglobin does not mean that we have to transfuse it, it is important to see how much it tolerates us. her bleeding and how it evolves… The advantage is that she is a young patient and does not have adjacent diseases such as high blood pressure, diabetes or any other alteration, that will always help us a lot in the evolution and in remaining hemodynamically more stable during the surgery.

Many times patients always ask us, that is one of their main doubts: How long do I have for recovery? And if I need to pass blood? Remember that blood transfusion has to look at certain parameters first: Before surgery, if the hemoglobin is below 10.5, the ideal is to transfuse at least one packet, but if it is below nine, maybe you should give 2 packets and obviously During the transoperative or postoperative period everything has to do with how much we bleed during surgery.

Generally the average is: If there is bleeding less than 500 ml, we do not put globular packets. The recovery is very fast, a patient you do a surgery of one and a half or two hours of surgical time and obviously you did not give her blood, believe me, the next day, we get the patient up, we make her walk and generally we discharge her. However, the patients who are from Puebla go home, but the patients who are foreigners, let’s say two or three hours away from here in Puebla, generally leave them for two more nights in a hotel, that’s what we call tourism. doctor and then they can go home on the third or fourth day and the patients who are foreigners, like this 50-year-old patient from Sacramento. Well, obviously she arrived yesterday, I checked her, today he operated on her which is Tuesday and she returns on Saturday or Sunday, that is, generally four nights or five nights that they stay here in Puebla so to see that everything is well, the evolution, that he tolerates food, that he can walk and above all see his basic functions such as: Uresis, evacuations and that he begins to tolerate oral intake.