Laparoscopic management of broad ligament fibroids.

Two cases of true broad ligament fibroids and thirty cases of false broad ligament fibroids were operated. All were removed through the laparoscopic route, with very minimal blood loss and without a need for blood transfusion. We traced the course of the ureters in all cases. No complications were met with.

INTRODUCTION

Broad ligament fibroids are divisible into two types:

True broad ligament fibroids: These spring from the muscle fibers normally found in the mesometrium. Such tumors may be found in at least three situations, (1) In the round ligament, (2) In the utero-ovarian ligament, and (3) In the connective tissue surrounding the ovarian and the uterine vessels.

As compared to the first two, the last one can attain a very big size and can distort the fallopian tubes. However, they are entirely separate from the uterus, hence can displace, but not distort the uterus.

False broad ligament fibroids: These originate mostly from the lateral walls of the uterus or cervix.

Indication of myomectomy

Myomectomy is generally indicated in symptomatic cases with menorrhagia, pelvic pain, pressure symptoms, and infertility.

If very large / adherent / vascular types, hysterectomy is preferred.

Preoperative preparation

The patient is investigated as for any other major surgery, with a complete hemogram, blood grouping, and cross matching, as also a pelvic ultrasound (both transabdominal (TAS) and transvaginal (TVS)) to figure out the exact number, size, and location of the fibroid. Intravenous urography is also necessary to look for any displacement or obstruction to the ureter.

Why the laparoscopic approach?

From multiple randomized controlled trials, it has now been concluded that with experienced hands, laparoscopy is the best route for broad ligament fibroid. Patients have a faster recovery, shorter hospital stay, and less morbidity.

Surgical technique

Preoperative Gonadotropin-releasing hormone (GnRH) analogs can be used to reduce the size and vascularity of the fibroid, but it causes loss of cleavage planes due to hydropic degeneration, hence we did not use it.

Site of the ports: We inserted a main 10 mm port at the supraumbilical fold and the accessory ports at the Palmer's point and the other one 2 cm above and medial to the ASIS, taking care to avoid the inferior epigastric artery. Sites of accessory ports can be chosen according the surgeon's convenience, as bilateral Palmer's points or one suprapubically.

Site of incision: We made an incision on the anterior aspect of the fibroid, incising the peritoneum. A myoma screw was used to give traction. With the help of traction and countertraction the myoma was removed [Figure 1, 2, 3 a and b]. The course of the ureter was traced at the beginning and at the end of the procedure [Figure 4, 5]. Complete hemostasis was achieved. The peritoneal incision was not sutured, to allow for drainage. An intraperitoneal drain was kept. The myoma taken out with the help of a morcellator.

Figure 1

True left broad ligament fibroid

Figure 2

Incision over anterior aspect

Figure 3 a and b

Myoma removal

Figure 4

Myoma bed

Figure 5

Course of ureter

Our experience

We have operated on two cases of true broad ligament fibroids and thirty cases of false broad ligament fibroids. All were removed through the laparoscopic route, with very minimal blood loss and without a need for blood transfusion. We traced the course of the ureters in all cases. No complications were met with.