Intramural vs Subserous Pedicled Uterine Fibroids

Today we had 2 surgeries, in both we removed large subserous fibroids while preserving the uterus, but we took the opportunity to explain the differences between a pedunculated subserous fibroid and an intramural subserous fibroid.

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About the First patient

What’s up good morning. I wanted to talk before the surgery, today we are going to have two fibroid surgeries, but this patient called me from Puerto Vallarta via Zoom, I made the consultation, she is a patient who already has a diagnosis from 3, 4 years ago. myomatosis of large elements and obviously because of fear of surgery, they had told her that they were going to remove her uterus, since she was postponing surgery.

It is very important to show you here in the ultrasound, see this tumor looks very well defined with a vaginal ultrasound. How do we know that the ultrasound is vaginal? Look at this small semicircle, it looks smaller than when it is done abdominally, right now I will show an abdominal one, but this tumor measures 5 x 64, that is, more or less 5 cm. to 6 and it is a tumor with large elements but it is accompanied by another one, which is this one here. This little tumor measures 72 by 76, that is, 7 cm. It is practically mounted on top of each other, it is a subserous tumor.

Remember that the subserous have a great advantage, that the subserous is a tumor that is outside the muscles as if it were a mushroom, but sometimes its base is very thick and the main problem with these fibroids is that if we let them pass they tend to to grow in very large dimensions because they do not have, let’s say, the compression of the muscles of the uterus and then they move towards the abdominal cavity, upwards, upwards and they are tumors like the ones we have shown weighing 2 kilos 3 or 4. Fortunately, Although they are two large tumors, they are outside the uterus, yet their main problem was hemorrhages. This patient has constant bleeding, she has mild anemia and so, that is why she came to us.

Today we are going to operate on her, we will show the video later but she wanted to show you in advance what fibroids initially look like, how we measure them. Look at the length, from the top to the bottom that already fits into the cavity, it has a length of 12 cm. Because? Because here I am covering the 2 subserosal fibroids, which are like little mushrooms but are very close to each other, you will see it more important in the surgery but I wanted to previously tell you about this patient: 37 years old, she has never been pregnant.

Obviously there is very little risk of removing the uterus but it is important to monitor bleeding during the operation.

Pedunculated subserous fibroid surgery

Good afternoon, we are going to operate on the first patient that we had a while ago that I mentioned, a 37-year-old from Puerto Vallarta, with 2 subserosal fibroids, right now we are going to show them to you so that you can see them and later when we do the resection. I wanted to show you, see, we already morcellated part of the fibroid because it was too big a fibroid, we morcellated it, we managed to remove what I told you is a pure pedicle, but it is one and the other was here like the son and this is the pedicle, look, it has been twisted, very easy because here we are going to give some points. Here is the uterus…

Left tube, right round ligament, ovary, here you have another subserous myomite and there you have another subserous myoma there at the bottom
It’s impressive, I’ll show you right now.

Left tube, left round ligament, right now we’re going to finish. Look, we already have the other pedunculated fibroid, on the posterior side it is, but there it has another subserous fibroid and then it has an intramural subserous fibroid down there almost in the region of the sacrum, intro-sacrum, so it is very important that we remove this patient those because it tends to make multiple fibroids and especially subserosal, the problem with subserosal, as I said, is that many times they do not cause problems and they begin to grow and since they have too large vascular pedicles, they are fibroids that sometimes grow to sizes like the ones we have operated from 2 kilos, 3 kilos.

So we are going to finish a relatively easy surgery because they are subserosal but they still take care of the vascular pedicle. We already removed the fibroid on the posterior surface but how beautiful its anatomy looks, the uterus is still of a regular, normal size, this is a normal uterus. We put the posterior face here, here is the posterior pedicle on the right side, but here is the right ovary, look at what a beautiful ovary it has, the patient is 37 years old, right ovary, left ovary, which is how they are normally placed leaning on the face posteriorly, here is the tube on the right side, the round ligament that supports it, here is the same round ligament, the tube, see the large uterine arms but we are done, here is the other pedunculate, the surgery lasted an hour with fibroids too large but this patient has a very good reproduction or reproductive future.

About the Second patient

Right now we are going to talk about the second patient, this patient is from Querétaro, in fact she contacted me more or less last year in November or December, it was the first consultation via Zoom, she is a patient who has a lot of work. She was 39 years old, now she is 40 years old, she has not gotten pregnant either but she still had a problem of starting to have an abdominal tumor, it was beginning to be noticed, in fact you will see it in the surgery, she has an abdomen as if it were a pregnancy 24 weeks it is quite noticeable, very close to the umbilical scar.

She has a single intramural fibroid, unlike the first one, this is a large fibroid. She measures 87 by 100, that is, she measures 8 cm. a little more than 8 and a half. Longitudinal measures 10 cm. and also ovarian pathology. Remember that we are talking about benign endometriotic cyst tumors in the left ovary measuring 38 by 33, that is, 3.5 cm, a little larger than a lemon perhaps. This causes a lot of pain with menstrual cycles and in the intermediate stage when she is ovulating because endometriosis creates multiple adhesions, so what we are going to do with this patient is that first we are going to remove the fibroid and then we will have to go to the ovary to also resect but only the cyst, remember that endometriotic cysts are benign, there is no or very low probability of malignancy and then you have to remove, just resect that tumor and leave what you can of that ovary because it is already 40 years old. patient and I wanted to show you, see in cross section it measures 118, that is almost 12 cm. It is a very large intramural tumor, where her main risk is obviously bleeding and the idea is not to remove the uterus because she has not had one, neither of the two patients has been able to get pregnant.

Intramural fibroid and endometriotic cyst surgery

We are going to start the second surgery, this patient comes from Querétaro, I wanted to show you before we start, see how far the scar is. It is a tumor more or less the size of a melon, unique intramural, we talked about it, she also has no children, she is 40 years old and she also has an endometriotic cyst, remember the talk about benign ovarian tumors, right now we are going to show it, the Endometriotic cyst is one of the main ones… That, the teratoma and the simple cyst are the three benign tumors or ovarian cysts that sometimes do not need to remove the ovary, just do a resection or excision of the cyst, let’s start.

This is a small subserous fibroid but all we see back here is the fibroid really, it is too big a fibroid, let’s start infiltrating it. Obviously it has to be morcellated because we made an incision that was too aesthetic and small, but we are going to show you the surgery later. Look a little, this is the musculature of the uterus, all this is the fibroid, obviously we morcellate it, there is the other piece, right now I will show you but we are already in the final part which is where the blood vessels are, you have to be very careful .

This is the tube on the right side, remember that we said that he apparently had an endometriotic cyst, but look at this piece of tube. What she has is an episalpinx or pyosalpinx. It looks completely swollen…

We took a puncture of her ovary because the ovary is completely adhered to the colon, we are not going to go there but look, it is an abscess, this is pus, we have to send it for analysis, but she had… She had told them that she was encouraged to operate when it started with a lot of abdominal pain, so there is an adhesion there at the level of the tube with the ovary, it is buried in the posterior surface and here is the intestine. We are not going to go there because remember that the first thing is not to damage, obviously we are going to remove that trunk because she is no longer functional and she is 40 years old.


We are having a very good response to consultations via Skype or Zoom online, without them having to come, remember that many times we ask for a CT scan and then the surgery can be scheduled very easily.

The most important thing is to see that we do not have anemia, the size of those fibroids, the location, but later I will show you a video of how to outline why a medium-sized or large tumor is important and not let time pass, it is better Go to the doctor, to the specialist and assess if it is important to do the surgery or visualize during the short period of time of a year or two if that fibroid did not grow.

“Pedicles grow much more because they are not enclosed in the muscles of the uterus, and for this reason they are sometimes easier to operate, but you have to be careful with the pedicle, which can bleed a lot”

Dr. Arturo Valdés
Dr. Arturo Valdés
Reproductive Medicine and Gynecological Endocrinology
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