Prelabor Uterine Rupture after Laparoscopic Repair of Uterine Perforation

Uterine rupture is an established risk of previous uterine trauma. Conventionally this has been considered most likely following prior classical or midline hysterotomies at cesarean section or subsequent to abdominal myomectomy in which the uterine cavity was breached. Although there are reports of such cases after laparoscopic procedures such as myomectomy the incidence is believed to be very small. We present an extreme case of uterine rupture at 27 weeks with a previous laparoscopically repaired uterine perforation.     

Uterine rupture after laparoscopic myomectomy

Myomectomy is performed frequently to preserve or increase fertility, although the risk of future uterine rupture is a major concern of any surgery of the uterus. A 36-year-old woman underwent laparoscopic removal of a pendunculated myoma, and 6 weeks later she conceived after IVF. At 35.5 weeks' gestation she was admitted to the hospital because of abdominal pain. Cesarean section revealed rupture of the uterine wall at the site of the myoma. This and similar case reports indicate that inadequate laparoscopic suturing is not the only factor involved in rupture of the uterine wall during pregnancy after laparoscopic myomectomy.     

Spontaneous uterine rupture in a patient with polyhydramnios as only risk factor. Case report, literature review and institutional experience

The uterine rupture is a catastrophic obstetric complication. The main risk factor is an antecedent of uterine surgery, usually caesarean. It is reported the case of a 39-years-old patient with 37 week-pregnancy and polyhydramnios, without surgical antecedents, whose was not in labor and developed complete rupture of the lateral face of the uterus, which was spontaneous, without previous uterine scar and with a unusual outcome.     

The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis

Fibroids may give rise to specific obstetrical complications such as pain due to degeneration, fetal malpresentation, or placenta previa. For all these reasons, surgical resection of the fibroid may be indicated before a pregnancy is pursued. The occurrence of a uterine rupture is a rare but severe complication of myomectomy. This study seeks to review the risk of uterine rupture during pregnancy and/or labor after laparoscopic myomectomy in comparison with laparotomic myomectomy. A systematic search of the literature through search strategies in MEDLINE (PubMed) and Embase (Embase.com) from January 1970 up to March 2013 was performed. We used the following MeSH terms and free text words: gynecologic surgical procedures, gynecologic surgery, leiomyoma, fibromyoma, fibroids, myoma, uterine tumors, and pregnancy complication. Our data show that the risk of uterine rupture during labor and delivery is low (0.75 %). Compared with traditional open myomectomy, the risk of uterine rupture during pregnancy is not significantly higher after a laparoscopic approach (P?=?0.119). More elective cesarean sections are performed after laparoscopic myomectomy compared with the conventional open technique (P?=?0.001). Our conclusions are supported by statistical pooling of observational studies of generally low methodological quality. The risk of uterine rupture after myomectomy is low (0.75 %). The available evidence in the literature does no allow discouraging attempts for childbirth per viam naturalem after previous myomectomy, regardless of the technique used. Randomized studies are needed before definitive evidence-based recommendations can be given.     

Rotura uterina. Diagnóstico y consecuencias en una gestante de 30 semanas

Uterine rupture is an infrequent obstetric complication with high morbidity and mortality for both the mother and fetus. Early diagnosis and treatment of this entity are important prognostic factors. We report the case of woman at 30 weeks of pregnancy with spontaneous uterine rupture in a previous scar from a laparoscopic myomectomy, giving rise to maternal hemoperitoneum and intrauterine fetal death. Emergency surgery was performed with subtotal abdominal hysterectomy.     

Spontaneous uterine rupture at thirty-three weeks subsequent to previous superficial laparoscopic myomectomy

Obstetric uterine rupture has previously been reported after the laparoscopic removal of deep intramural myomas, but never has it been reported to follow the removal of superficial myomas. A 39-year-old primigravid woman with a history of a superficial subserous laparoscopic myomectomy was seen for acute abdominal symptoms at 33 weeks of gestation. Emergency cesarean laparotomy confirmed a spontaneous rupture of the uterine fundus with extrusion of the intact fetal sac into the upper abdomen. This is the first reported case of obstetric uterine rupture subsequent to the removal of a superficial myoma by laparoscopic techniques.(Am J Obstet Gynecol 1997;177:1547-9.)     

Uterine rupture in pregnancy subsequent to previous laparoscopic electromyolysis

Reports about uterine rupture in pregnancy subsequent to previous laparoscopic surgery are not frequent. This may be due to the lack of long term follow up of patients who had undergone this surgery rather than the rarity of this complication. A case of uterine rupture subsequent to laparoscopic myomectomy is reported. An increasing rate of the occurrence of this complication is reviewed in current literature, thus reiterating the need for more stringent selection criteria for patients who benefit from this surgical technique.     

Uterine Vein Rupture at Delivery as a Delayed Consequence of Laparoscopic Surgery for Endometriosis: A Case Report

Laparoscopic resection of deep infiltrating endometriosis (DIE) has been reported to be an effective method for reduction of endometriosis-associated pain. As its complications, bowel perforation, urinary tract injury and neurogenic bladder are well known; however, uterine vein rupture during pregnancy has not been reported previously. We encountered a case of hemoperitoneum resulting from uterine vein rupture at a delivery as a delayed consequence of laparoscopic resection of DIE. A 31-year-old, para 2 woman underwent laparoscopic resection of lateral pelvic peritoneum, uterosacral ligaments, and bilateral endometriomas, exposing uterine vessels, which we covered with fibrin glue. Endometriosis-associated pain disappeared, and then the patient conceived 4 months later. The course of pregnancy and induction of labor with controlled oxytocin infusion was uneventful, and the patient delivered a female baby without asphyxia. Immediately after delivery, low abdominal pain with hypotension occurred despite absence of abnormal vaginal bleeding. Ultrasonography and the blood hemoglobin value suggested hemorrhagic shock owing to hemoperitoneum; therefore emergency exploratory laparotomy was performed. Active bleeding was found at the right uterine vein, which was then sutured for hemostasis. The patient received a blood transfusion and recovered without any problems. The bleeding lesion was located at the vein on which the peritoneum had been removed at the first laparoscopy, which suggested that the operation for DIE included a risk of uterine vessel rupture during pregnancy.     

Uterine rupture during pregnancy soon after a laparoscopic adenomyomectomy

Although laparoscopic adenomyomectomy may be a possible risk factor for uterine rupture in subsequent pregnancy, few reports have described it. A 35-year-old woman became pregnant 1 month after laparoscopic adenomyomectomy. At the 28th week, uterine contraction occurred, leading to intravenous ritodrine infusion. Severe abdominal pain and a non-reassuring fetal heart rate occurred abruptly and an emergency cesarean section was carried out. The uterus ruptured at the site of previous surgery of the uterine body, which was reconstructed. The mother and the infant did well postoperatively. We report the second case of uterine rupture during pregnancy subsequent to laparoscopic adenomyomectomy. A history of adenomyomectomy and a short interval to subsequent pregnancy may be risk factors for uterine rupture. (Reprod Med Biol 2007; 6 : 175–177)     

Laparoscopic Mesh Sacrohysteropexy With Concurrent Laparoscopic Myomectomy for Treatment of Multiple Myomas: Case Report and Literature Review

Conservative surgical management of uterine prolapse with uterine conservation has become an alternative treatment in women who wish to maintain their uterus. Vaginal and abdominal approaches for uterine suspension have been described and reported. Certain concomitant pathologic conditions of the uterus such as uterine myomas have been considered in some patients to be a contraindication to conservative surgery. Herein we report the case of a 55-year-old woman with symptomatic uterine prolapse with multiple myomas who desired uterine preservation and was successfully treated via laparoscopic myomectomy and laparoscopic mesh sacrohysteropexy.     

Augmented Reality with Diffusion Tensor Imaging and Tractography during Laparoscopic Myomectomies

Augmented reality is a technology that allows a surgeon to see key hidden subsurface structures in an endoscopic video in real-time. This works by overlaying information obtained from preoperative imaging and fusing it in real-time with the endoscopic image. Magnetic resonance diffusion tensor imaging (DTI) and fiber tractography are known to provide additional information to that obtained from standard structural magnetic resonance imaging (MRI). Here, we report the first 2 cases of the use of real-time augmented reality during laparoscopic myomectomies with visualization of uterine muscle fibers after DTI tractography–MRI to help the surgeon decide the starting point incision.In the first case, a 31-year-old patient was undergoing laparoscopic surgery for a 6-cm FIGO type V myoma. In the second case, a 38-year-old patient was undergoing a laparoscopic myomectomy for a unique 6-cm FIGO type VI myoma. Signed consent forms were obtained from both patients, which included clauses of no modification of the surgery. Before surgery, MRI was performed. The external surface of the uterus, the uterine cavity, and the surface of the myomas were delimited on the basis of the findings of preoperative MRI. A fiber tracking algorithm was used to extrapolate the uterine muscle fibers’ architecture.The aligned models were blended with each video frame to give the impression that the uterus is almost transparent, enabling the surgeon to localize the myomas and uterine cavity exactly. The uterine muscle fibers were also displayed, and their visualization helped us decide the starting incision point for the myomectomies. Then, myomectomies were performed using a classic laparoscopic technique.These case reports show that augmented reality and DTI fiber tracking in a uterus with myomas are possible, providing fiber direction and helping the surgeon visualize and decide the starting incision point for laparoscopic myomectomy. Respecting the fibers’ orientation could improve the quality of the scar and decrease the architectural disorganization of the uterus.     

Laparoscopic devascularization of uterine myomata followed by enucleation of the myomas by direct morcellation

Most intraoperative conversions of laparoscopic myomectomy to laparotomy reported in the literature occur because of intraoperative bleeding. Devascularization of a uterine myoma at the start of myomectomy would help reduce the blood supply to the uterus and hence to the myoma. Another advantage of the procedure is that the need to separate the myoma from the uterus completely before morcellation, as in conventional laparoscopic myomectomy, is obviated. The tumor can be enucleated only up to about half its circumference by standard enucleation before morcellation is begun. Traction accorded by the 15-mm traumatic serrated-edge claw forceps of the morcellator during morcellation causes progressive separation of the myoma from the uterine wall, thus completing enucleation. In two patients, myomas were devascularized at the outset of myomectomy, in one by intracorporeal suturing of uterine vessels and in the other by laparoscopic bipolar coagulation of uterine vessels.     

Laparoscopic management of pregnancy in a patient with uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis

Pregnancy in a rudimentary uterine horn is a rare and potentially lethal condition. The highest risk of rupture is reported to be during the late first and second trimester. The risk of rupture correlates with the thickness of the myometrium surrounding the fetal pole. In 2005, a 20-year-old woman was incompletely diagnosed by imaging studies and laparoscopy to have an absent right kidney, a bicornate uterus with a right rudimentary uterine horn and a single cervix, a transverse vaginal septum with hematocolpos, and endometriosis caused by reflux menstruation. The transverse vaginal septum was excised, and the surgeon observed a single cervix. Oral contraceptives were prescribed as complementary treatment for the endometriosis and associated dysmenorrhea. In 2009, magnetic resonance imaging confirmed resolution of hematocolpos and revealed a right cervix connected to the right horn of a uterus didelphys and covered by a partial longitudinal vaginal septum. The patient had a contraception failure and presented in 2010 at 9(6/7) weeks' gestation. By ultrasonography and subsequent magnetic resonance imaging, the pregnancy was in the right uterus and the corpus luteum was on the left ovary. The myometrium was thinned to 2 to 3 mm atop the gestational sac. Using the Harmonic ACE, laparoscopic excision of the right fallopian tube and a supracervical right hysterectomy with an intact pregnancy was performed. This case supports the Acién hypothesis that the vagina forms from both Müllerian and Wolffian duct elements, and it illustrates the risk for uterine rupture when pregnancy forms in a rudimentary structure; presumed transperitoneal migration of an ovum that was captured by the opposite fallopian tube; and?surgical management of the in situ pregnancy by laparoscopic supracervical excision of the rudimentary uterine body.     

子宫肌瘤剔除术后子宫破裂危险因素分析

子宫肌瘤是妇科最常见的盆腔良性肿瘤,常影响女性月经周期和月经量,有时影响育龄妇女的妊娠,子宫肌瘤剔除术是保留生育功能最常用的治疗方法。但子宫肌瘤剔除术后妊娠存在子宫破裂的风险,是威胁母儿生命安全最严重的产科并发症之一。近年来随着妇科内镜技术的广泛应用,子宫肌瘤剔除术后子宫破裂时有报道,但其危险因素及预防措施尚未达成共识,因此有必要总结分析子宫肌瘤剔除术后子宫破裂的相关研究及可能的危险因素,从而规范手术技术。术中应减少电热器械的过度使用,尽量避免进入宫腔破坏子宫内膜完整性,仔细缝合子宫肌层,术后合理的避孕时间及个体化选择终止妊娠方式,以降低术后妊娠子宫破裂的风险。     

Spontaneous uterine rupture of a twin pregnancy after a laparoscopic adenomyomectomy: a case report

Adenomyomectomy is a treatment option to preserve fertility and reduce symptoms associated with adenomyosis. Although this procedure is reasonably expected to increase the risk of uterine rupture during pregnancy, reports on this issue are scarce. We recently encountered a 33-year-old nulliparous woman with a twin pregnancy who experienced a spontaneous uterine rupture at 30 weeks' gestation. This patient was the first to conceive after undergoing laparoscopic adenomyomectomy at our institution. Her pregnancy was established with in vitro fertilization-embryo transfer 12 months after laparoscopic adenomyomectomy. The uterine rupture was heralded by a sudden onset of severe abdominal pain while she was receiving intravenous ritodrine. This case reinforces that pregnancy after adenomyomectomy should be closely monitored with respect to uterine rupture.     

Early spontaneous rupture of the post myomectomy gravid uterus

Rupture of a pregnant uterus is a serious threat to the mother's life and her fetus. Most of these cases have predisposing factors of which a post myomectomy scar is rare. Rupture of a post myomectomy gravid uterus usually occurs in the third trimester of pregnancy or during labor. We present a case of a very early spontaneous rupture which occurred at the 20th week of gestation in a post myomectomy uterus. To the best of our knowledge no previous report of a ruptured myomectomy scarred uterus has been described at such an early stage.     

Fertility outcome: long-term results after laparoscopic myomectomy.

From 1991 to 1998, 29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 +/- 3.6 cm (mean +/- SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas, three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors, seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity, nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice), four (26.6%) had spontaneous vaginal delivery, one patient had a serious placental failure at the 28th week, and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies, the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover, our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Fertility outcome: long-term results after laparoscopic myomectomy

From 1991 to 1998 ,29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 ± 3.6 cm (mean ± SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas ,three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors ,seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity ,nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice) ,four (26.6%) had spontaneous vaginal delivery ,one patient had a serious placental failure at the 28th week ,and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies ,the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover ,our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Patency of uterine wall in pregnancies following assisted and spontaneous conception with antecedent laparoscopic and abdominal myomectomies – a difficult case and systematic review

A case of uterine rupture at 24 weeks in a pregnancy succeeding myomectomy and triple embryo transfer is described and literature is reviewed systematically to evaluate the importance of uterine rupture in pregnancies after myomectomy in general and some important sub-populations. Systematic search identified 179 papers and following a strategical selection process 45 studies were analyzed in detail, including 6 cohort and 19 observational studies, 3 case series and 17 case reports. Comparison of risk of uterine rupture after abdominal and laparoscopic myomectomy is made. In pregnancies after IVF number of embryos transferred are determined. Optimal contraceptive intervals and surgical techniques are discussed. The consequences of these observations are analyzed and conclusions are made which can assist individualizing treatment options and improve patient selection.     

Stepwise Laparoscopic Myomectomy and the Baseball Closure

Study ObjectiveTo demonstrate the importance of planning all the steps of laparoscopic myomectomy, including incision, techniques to reduce blood loss, and suturing.DesignStep-by-step video demonstration of the technique, with narration in the background. The video was approved by the local institutional review board.SettingLive surgery at Hospital PIO XII, Institute for Research into Cancer of the Digestive System and American Institute of Telesurgery, Barretos.InterventionsWe describe a case of a 33-year-old woman with no pregnancy and diagnosed with endometriosis and chronic pelvic pain associated with a 5-cm posterior transmural myoma. We performed a laparoscopic myomectomy, with temporary clipping of the uterine arteries associated with the treatment of endometriosis lesions. Specimen extraction was performed inside a bag [1]. The patient was discharged the next day with no complications. Ten months after the procedure, the patient reported that there was no pain, and that her menses were normal.ConclusionThe laparoscopic approach remains the gold standard for myomectomy [2]. Planning the steps before execution is fundamentally important to ensure the security of the procedure. A seromuscularis baseball suture associated with figure-of-8 knotting with an H3H2 sequence at the internal layers seems to be an adequate technique for myometrium closure [3]. Choosing the correct angle for the incision, clipping the uterine artery, and developing the suture in 2 layers results in less bleeding, reduced operating time, decrease in hospital length of stay, and fewer complications.