2.86 kilo fibroid [over 6 pounds]
“I had never seen a fibroid like this 🧐🥔☝ it pushed the uterus up to the sternum”
Today in #KnowledgeIsSuccess Dr. Arturo Valdés illustrates the diagnosis, surgery and prognosis of this patient. Caution #GraphicContent this surgery required a large incision.
Remember that the symptoms of fibroids worsen over time, if you have fibroids do not let time pass and go to the experts, preserving the uterus is possible.
This is a little patient who came just two weeks ago, 45 years old, who obviously had previously seen some videos of us and then came for a fourth opinion. They had told her that they definitely had to remove that uterus but the reality is that it was not. easy, the case was a fairly large tumor, approximately 30 centimeters in length, but anatomically, that’s why I want to present it to you and explain a little here on the blackboard so that we can first have an idea of how normal surgeries are and how it happened we did this surgery.
What is important about this patient? She had a tumor, she was almost seven times pregnant, that is, she had a very pronounced abdomen. She already felt her tumor in any movement because she felt something that weighed on her, something that moved, but most importantly, she came due to fatigue and headache. Due to the same compression of that tumor, it was compressing the bladder on some occasions and during those three or four years that she planned to have surgery, she had urinary retention twice. I had thought with the tumor that the uterus was obviously compromised but not really, the tumor was very large and then compressed the bladder.
Remember that we have the vagina and it is above the vagina we have the ureteral meatus of the woman through which she pees, that is compressed by the fibroid and then there was no tube or the tube was squeezed and then the pipe did not come out and that It was what made her come with us because there came a time when she got very scared and said now this is something very delicate. In addition, the laboratory studies that we did, unlike almost all patients that one thinks that with fatigue and headache or headache had anemia, this patient had polycythemia or polyglobulia, that is, an exaggerated increase in red blood cells, in erythrocytes and then his hemoglobin instead of being low had almost double the hemoglobin. This seems to be beneficial, because it was beneficial for the surgery, but this also conditions the patient with important risks, such as respiratory problems, strokes or even pulmonary or cerebral thrombosis, which fortunately she did not present, but it also has a lot of risk having too much excess blood.
Four doctors had told her that she was not going to be able to save her uterus and that she was going to have to remove the fibroid, plus a total hysterectomy. So, the only thing we did on the first visit was an abdominal ultrasound because nothing could be seen from the vagina, obviously due to the size of the tumor, and we couldn’t cover the entire tumor, let alone locate where the uterus was. That was the reason why I requested the axial tomography, because honestly when doing the ultrasound, I could not visualize with that tumor where the uterus was located and that was very important to see the obviously approach of the incision and more or less see the surgery prognosis.
To give you an idea, what the tomography does, I want to point out a bit, is that it makes millimeter sagittal cuts, let’s say that it makes small slices of the entire anatomy, both of the uterus… But it starts from above, it starts from the upper abdomen to see how the kidneys are, how the ureters are, how the uterus is, how the fibroid is, how the ovaries are and then we can visualize these cuts perfectly well in the sagittal cut how is the huge tumor and all the way up see the small uterus that is drawn, that’s where we realized that the fibroid moved upwards from the uterus.
So, this patient in a normal condition or in a normal surgery, we have always talked about making an incision above the pubis, an incision called fanestil or horizontal, but on this occasion, since the tumor is too large, we made a median incision that goes from the supra-umbilical pubis, this is the navel and we extended almost to the sternum because this tumor is too big, you will see it in the video and then it is impossible to work with cosmetic incisions, we must remember that we are not always going to do cosmetic surgery because The first indication of a cosmetic surgery is that the tumor is accessible and obviously that we can work in the surgical field without complicating or causing any discomfort or complication to the patient. The uterus is supported, imagine that this is a ship and it is supported by two ligaments on the right and left sides, which are called the round ligaments and down here it is by the cardinal ligaments.
This fibroid, to give you an idea, was so large that it displaced the uterus to such a degree that it was felt almost up to the sternum, which means that the displacement also elongates these bras or round ligaments, they are like big leagues, which did is that with the passage of growth were elongating, elongating to such a degree that the round ligament to give you an idea in this drawing, the fibroid was sitting on the vaginal vault and the uterus moved until it reached the sternum, but the ligaments are still there, they do not break , then the ligaments were approximately 35 centimeters in length.
What’s left of anatomy, this is the round ligament on the right side, this is where it comes from, but you’ll see here how the fallopian tube is, all the blood vessels, see the large amount of vascularity that it has here due to the kidnapping obviously and the growth. This is the utero-ovarian ligament on the right side and the same on the left side, round ligament here, the uterine tube and the utero-ovarian ligament. We are going to start from the posterior face but honestly we do not know where the cervix is, so surely this uterus I do not know if we can save it because the tumor is below, that is, the fibroid grew I think cervical and began to displace the uterus towards above and then the tumor is below where all the vascular vehicles are.
All the vascular vehicles, the great vessels are anatomically enormous, so we are going to do everything possible to start to dissect and morcellate, but we will see it as the surgery progresses, we already gave it 2 vasopressins in 250cc but the fibroid is so big that it cannot It has obviously turned white.
Very important to know: Almost all the steps lead to open; obviously make the incision, then infiltrate the fibroid, then incise the fibroid to extract it with digito-digital pressure, a resection, but in this specific case, this patient will be seen in surgery, when we will show everything at the end We removed the tumor divided.
We practically removed approximately 10 fragments, 10 centimeters each fragment, they are huge, they are very large. She weighed 2 kilos 860 g the tumor. We’re just done, but just look at the number of resections we’ve done, this tray weighs approximately two and a half kilos. We still have about 200 grams of tumor left but the difficult part comes, see how ugly it grew, it really grew in the lower part, we can’t identify the cervix right now. Everything elongated, here is the uterus but we are going to finish it, the problem is that it is already in all the vascular pedicles, we are going to see if we can finish and preserve the uterus.
The last flap is done, I practically think we’re done, however we have to perform the hemostasis and review why anatomically… I can tell you that I had never seen this, all the tissues are super elongated, the uterus is practically stretched it was side. Down here it looks like it was born from the cervix, but to be honest, I can’t find the real anatomy of where the neck really is, I think it’s all the way down, if it is, look at this is the neck, it looks like it was born from the neck.
This appears to be neck. You see? That seems to be the cervical neck, so we are practically in the region of what is the vaginal vault, this is the uterine. We’re done, look, there was a large hole left on the entire posterior face of the visceral peritoneum that goes to the cardinals and in fact almost reached the rectus sigmoid, however, look at the elongation of the tissue, I don’t know how this uterus will turn out, because honestly it is the first time that we have a fibroid that is below the uterus, apparently here is the cervix, this is a fibroid, this is another fibroid, but I don’t want to touch it anymore because if not the uterus we have mistreated a little with this of the surgery. It is too elongated, later when the tissues shrink we will assess if it is necessary to have surgery or if we can get her pregnant or leave it like that.
The important thing is: Three of the doctors who are specialists here at Creafam entered, because we could not be only two due to the size and dimensions of that tumor, to save time and obviously in favor of surgical time, but above all to reduce the risks of bleeding and complications.
It is very important if you are going to do a consultation via Zoom or Skype if we do not have these studies, that maybe we do them or at the time of the first visit they were requested, but then I need to visualize those images well and then do a physical examination of the patient.
This little patient was discharged today, she is doing very well, but it is important to do a timely follow-up to see how the size of the uterus is and how it is anatomically restructured and see if she can later perform fertility. Call us come to us. “Knowledge is power” and we can solve your fibroids without the need to remove the uterus.