Hello, how are you? Look, we already have a scale model of what the pelvis and uterus would look like, primarily the internal genitalia, which are what we’re responsible for showing you about fibroids and other pathologies. Remember, come to Creafam, knowledge is power.

I’m going to show you right now. This would be a patient if she were lying supine. It’s called the abdomen. Then the incisions we normally make, which people refer to as “on the bikini line,” are called the pfannestiel. It’s above the pubic line, at the level of the bikini line. But look, anatomically, the bladder will be inside. I’m going to untie it… If I take out the bladder, the uterus will remain in front, and here’s the vagina. Is that okay?

So why am I showing this to you? Because when I remove the uterus, when we have anterior fibroids, the bladder is there, and often we have to move the bladder to access the space between the bladder and the uterus, which is called the isthmus. There are also cervical fibroids, like the 9 kg one we removed, and there are fibroids that develop on the posterior aspect. So, understand that when I have the uterus, the patient is lying down.

How do I know if it’s anatomically posterior? Well, because this uterus moves posteriorly, the fibroid, and posteriorly, we have the descent of the rectosigmoid, which enters toward the anus. So, it’s very important to know anatomically where it is, because the degree of difficulty of this surgery depends more or less on the anatomy. The most important thing here is to know if they are intramural or when they come in. Here is the cavity. Look how beautiful the uterus is, the uterine cavity. These are called submucous fibroids, and obviously, polyps can also appear.

In many cases, we can do it vaginally, entering to perform a hysteroscopy, but when the patient’s size is very large, we enter from above and remove it by opening the uterine musculature. In fact, the surgery we performed was extremely interesting because she had a polyp, and so we entered vaginally into the endometrial cavity with a camera called a hysteroscope and removed the polyp. You’ll see it. And then she had a very pretty subserous myoma, which is also very clearly visible in surgery.

What we want with this is for patients to understand: the fibroid we removed right now in this surgery is this size and was a pedunculated fibroid. You’ll see it very clearly in the surgery. It was attached to the right uterine horn, and so this is very easy because the muscles are there, but we only remove the pedicle and resect the entire fibroid.

A 39-year-old patient wants to get pregnant but has an endometrial polyp. Look how beautiful the polyp looks! It’s in the uterine fundus. If I go over here, we have the tubal ostium on the right side, which looks very beautiful. The cavity is a little swollen. Here’s the ostium on the left side, and there’s a little bleeding there. The cavity looks beautiful, so it should be pinkish white, but we’re going to remove the polyp, and then she has a fibroid that needs to be removed abdominally. This surgery is a hysteroscopy first, then an upper approach.

Look, we’re done. Here was the base of the polyp. If it was a large polyp, the polyp can stay here. Look, the polyp can generally stay in the cavity, and we’ll eventually expel it, or we’ll detach it, as we did before.

Look, the right ovary is already deep inside, so I can’t externalize it because it has a bit of endometriosis, so it’s attached to the posterior aspect of the broad ligament, but it’s fine. The one on the left side that looks very nice. Look, here it is, for 39 years, the surgery is over. I’m going to remove this little polyp. Look, they also had a pedunculated fibroid here! The one on the right side is already there. Look how nice the pedicle looks there.

Look, we’ve already entered the cavity. It’s really very deep, but it’s a pedunculated fibroid in the right horn—this would be the right horn. As soon as we’ve finished resecting the pedicle, I’ll show you the uterus and the ovaries. Look, we’re done with the surgery. The truth is, it was a relatively short surgery.

The fibroid was pedunculated, a bit large, and the other one was also pedunculated, but look at the scar, it’s practically four fingers wide, and it’s a 7.8 cm incision. So, remember, this fibroid was subserous, meaning on the outside, they look like mushrooms, only the stem is attached to one part. In this case, it could be in one of the horns, but it could be in the uterine fundus. It could be on the posterior surface, which generally extends upward, or it could be on the anterior surface, or it could be intraligamentary, where I mentioned, it’s between the bladder and the vagina.

It’s very important to see the size of this fibroid compared to the uterus because the uterus is actually at a normal scale; this is a regular uterus, 7.8 cm long. It’s roughly 4 or 5 cm wide, about 4 cm anteroposterior, and its tubes, so when fibroids are subserous, we don’t struggle much. But remember that these fibroids are the ones that have also grown in size from 4, 5, or even 9 kg. The important thing here is not to let the fibroids go over 5 or 6 cm. The moment you have a diagnosis, whether it’s a submucous fibroid or, as I just saw a patient in the consultation with a polyp inside the uterus, the ideal is to remove them, and the smaller the better.

For small fibroids, obviously, those under 6 or 7 cm are better than 4, 5, or 6 cm than waiting for 9 or 10 cm. Patients often write to us saying, “Hey, doctor, you told me I have fibroids, but I’m not bleeding and I’m not having any discomfort.” And then they let it go, and 4 or 5 years go by, and by the time they come to us, they already have many fibroids larger than 8 or 10 cm. So, fibroids aren’t necessarily going to cause hemorrhages or bleeding, but if they’re larger than 5 cm, the ideal is to remove them as soon as you get that diagnosis. Please come to Creafam, call us, remember that #KnowledgeIsSuccess