Tackling Pseudo-Broad Ligament Fibroids During Laparoscopic Hysterectomy: Making a Bumpy Ride Smooth

Introduction

Broad ligament fibroid is a benign smooth muscle tumour that develops from either the broad ligament hormone- sensitive smooth muscle or the uterine smooth muscle. They often pose technical challenges during surgical management due to their potential to distort the pelvic anatomy [1]. Given sufficient operator skill, these fibroids can be safely managed laparoscopically.

Case Report

A 42 years old female P2L2A1 presented with heavy menstrual bleeding and heaviness in lower abdomen not controlled by medical management. Her general physical examination was unremarkable. On pelvic examination, the uterus was 6-8 wk gravid uterus size and another mass of around 5×5 cm was felt in the left fornix contiguous to uterus.

Laparoscopy was done with one supraumbilical 10 mm port and 2 ipsilateral & 1contralateral accessory ports. Intraoperatively, a 5 cm ×4 cm fibroid was seen in the left broad ligament arising from lateral wall of uterus. The tubo- ovarian pedicles were coagulated & cut.

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The left round ligament incised and the anterior leaf of broad ligament was dissected down to the base of the myoma. Capsule was incised after injecting vasopressin and myoma was removed by traction and countertraction with the help of myoma screw. The specimen was placed in the pouch of Douglas and the standard procedure for a total hysterectomy and bilateral salpingectomy was completed. The specimens were removed transvaginally and vaginal vault was closed using 2–0 delayed absorbable barbed suture. The patient was discharged uneventfully on 2nd post-operative day Figures 1-3.

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Discussion

The concept of performing myomectomy to facilitate easy hysterectomy has been insufficiently reported in literature. El-Agwany AS, et al. [2] reported a case of a large uterus with 20 cm broad ligament fibroid where they performed myomectomy first followed by open hysterectomy. The purpose of the initial myomectomy was to decompress the tumour for simple hysterectomy while carefully assessing the ureter to prevent damage [2].

Krishna BG, et al. [3] has reported successful total abdominal hysterectomy with bilateral salpingoophorectomy in a case of mammoth pseudo broad-ligament fibroid using the same technique [3]. Bahall V, et al. [4] reported a case of laparoscopic management of a true broad ligament leiomyoma in a patient with advanced endometriosis and a solitary kidney and used similar approach for broad ligament fibroid [4]. Similar technique has been reported by few other authors for ease of hysterectomy with both open as well as laparoscopic approach.

Conclusion

The authors conclude that myomectomy should be done before hysterectomy in cases of large broad ligament fibroids to facilitate laparoscopic surgery.