How are you? I want to tell you about a patient who came to us from Chiapas. She saw us on YouTube about a large-element intramural fibroid and also a medium-element submucosal fibroid, and everything was done in a single surgery. Remember, knowledge is success.

I’m going to show you a little schematically. This patient has already had two pregnancies, but they wanted to remove her uterus because she had a large intramural fibroid measuring 10 to 12 cm. Let’s see anatomically, she has her uterus, and one of the fibroids is inside here, that is, this is the submucosal fibroid, which would be this one. Anatomically, this is the size of a uterus, which is approximately 7 cm, and this one measured 5 cm. Imagine that half of this fibroid was inside her uterus, causing her excessive discomfort, bleeding, and pain, but they wanted to remove her uterus, and she refused.

This intramural fibroid was in the uterine muscle, and she actually felt the tumor above the pubis, and it literally looked like a 4- or 5-month pregnancy. So what we did was enter with a Pfannenstiel incision. We have two or three tricks that we’ve learned over our 20 years of experience. We made a Pfannenstiel incision, but in the midline, where the muscles are, we made a medial cut. With this, what we do is: The abdominal cavity loses a little resistance, we make a triangular incision, and we can enter with the Alexis. That’s really why we were able to exteriorize the tumor, because with that rhombus incision, it gives us a larger surgical field, and with the Alexis, we remove the fibroid and morcellate it.

The idea of ​​morcellation, as I always tell you, is to try to remove such large fibroids through a smaller incision, and also because the recovery is much faster. Why? Well, because we’re not making the traditional Pfannenstiel incision with the medial cut or the horizontal cut in the uterine muscle, and that causes a little more pain.

If you can watch our first videos of fibroid surgeries, we also performed morcellation and it involved making triangular slices, actually removing little pieces and removing them, and then removing the tumor. This often meant, when we filmed, we had no idea how big these fibroids were… For these very large intramural fibroids, what we’re doing now is: We start with an incision and practically make it look like a spiral. This makes it look like a little screw, and when we externalize it, it looks like a flower, a bud, or sometimes a cabbage. But the idea behind this is to try to reduce surgical time, be able to externalize the tumor into the cavity, and work on the outside to prevent bleeding.

This type of fibroid, which is a submucous fibroid, generally if the patient comes to us with a desire to conceive and is obviously bleeding or spotting, we insert it vaginally, which is called the surgical hysteroscopy approach. As we’ve taught some, the advantage of surgical hysteroscopy is that it’s an outpatient surgery because we don’t open it. We can slowly resect the tumor with a curved loop, slicing it into small pieces. But the disadvantage is that since it’s inside the cavity, it’s very large, and then it starts to bleed and obstructs the fiber optic cable. To such an extent that in this type of tumor larger than 2.5 to 3 cm, we often have to perform two hysteroscopies.

The patient was a foreigner, coming from Chiapas, so we wanted to save surgical time and decided to enter from above. As you can see in the video, at the end of the… myomectomy, what we performed was on the posterior aspect. I pushed the uterus from below to feel the fibroid where it was. We incised internally over the sac of the cavity and thus were able to exteriorize this myoma. We cut it at its base with Wave scissors or Wave forceps, which transmit heat. Then we were able to close the cavity and the musculature, and everything was done in a single operation.

What’s the advantage of this surgery? We were able to remove two tumors in a single operation for this patient. The surgical time was also very fast, less than 2 hours, and the bleeding was only 300 ml. It is very important, as we mentioned: Location, size, desire or not to reproduce, age of the patient and whether we have anemia or not and whether we have bleeding or not, because from there we often decide if it is really worth doing one surgery above and another below as we have done in some videos that we have uploaded.

A 46-year-old patient from San Cristóbal de las Casas, Chiapas. She has a 10 to 11 cm intramural fibroid. They told her they were going to remove her entire uterus, and she also has a submucosal fibroid, which we’re also going to remove through an upper incision to avoid two surgeries. We’ll show you that now.

Look, we’ve already managed to exteriorize the fibroid. Yesterday, we received questions on YouTube about whether a large fibroid could be removed through an incision other than a medium one. This is a Pfannenstiel aesthetic incision, as we were talking about. The idea is to morcellate the fibroid a bit so it can emerge, and here outside, we work with the Wave forceps to burn it so it doesn’t bleed.

We’ve already finished the surgery. Look how nice the right vario is for a 46-year-old. Here’s the hemorrhagic corpus, where she ovulated. This is how it’s normally done, like a small volcano. Her right tube, here’s the healing process, see how it turned out. Obviously, it’s very large on the entire anterior uterine surface, and here’s the posterior surface of the uterus, which is still a medium-sized uterus because she’s pregnant with multiples, has two children, and look at what good ovaries she has for 46 years old. But she doesn’t want to get pregnant anymore. She simply wanted to preserve the uterus, and we were able to do it with a cosmetic incision.

Look, we’ve already removed the intramural fibroid. The fibroid is very large, but this fibroid, remember what I was saying, has a submucosal fibroid. We’ve already entered the cavity. Sometimes they bleed a little, but it’s better for her because performing surgery above and below sometimes requires two procedures to remove a submucosal fibroid. So, ideally, with this surgery, we remove both fibroids and then check how the cavity looks.

Remember, patients often write to us, and we mentioned it in the YouTube interview we had a few days ago. Patients often ask us if it’s necessary to do a virtual consultation and take an MRI… It’s all relative. Why? Because if I have an intramural fibroid, with a vaginal or abdominal ultrasound and I can clearly define where this tumor is, sometimes it’s not necessary to do an MRI.

Then they ask us, “Hey, do I absolutely have to go see if they do an MRI?” Not necessarily, but I do prefer to review them myself because if I can identify this intramural tumor and it’s submucosal, sometimes you can save the MRI, which costs… Around $6,000 to $7,000 pesos.

So we only order the MRI for patients who come from outside, and we do an interview via Zoom, but I can’t identify the images very well.

Remember what I was telling you: An interpretation is not enough for me, I normally prefer to see ultrasound images, but sometimes ultrasounds do not give me a real idea of ​​​​where the tumors are, especially when they are multiple, MRI is perfect because there, via Zoom, we can manage and manipulate all the images in 3D to get a better idea of ​​​​what anatomy they are in and I can tell you what the approach will be, the surgical time and the risk of bleeding.