Laparoscopic Approach to Fibroid Torsion Presenting as an Acute Abdomen in Pregnancy.

2013·0.05 MB·English

by  Currie, Andrew

C R
ASE EPORT
Laparoscopic Approach to Fibroid Torsion
Presenting as an Acute Abdomen in Pregnancy
Andrew Currie, MRCS, Elizabeth Bradley, MB, BS, Marcus McEwen, MB, BS,
Nawar Al-Shabibi, FRCOG, Peter D. Willson, FRCS (Gen Surg)
ABSTRACT INTRODUCTION
Uterine leiomyomas (fibroids) are seen in up to 4% of Uterine leiomyomas (fibroids) are common benign
pregnancies, and most commonly present with pain in growthsaffectingtheuterus.1Duringpregnancy,theycan
pregnancy, which can be due to red degeneration or become symptomatic by undergoing red degeneration,
torsion. Most cases previously have been managed with bleeding, or torsing around a stalk if they are peduncu-
open resection. We report the case of a 35-y-old prima- lated.2 Previous case reports have described open lapa-
gravida woman, presenting with acute lower abdominal rotomy for management of such cases in the first trimes-
painat11wkgestation.Ultrasounddemonstratedan8-cm ter.3,4 We describe the first case in the published surgical
fibroid only. She demonstrated features of lower abdom- literature of a successful laparoscopic management of
inal peritonitis and was scheduled for a diagnostic lapa- torsionofapedunculatedsubserosalfibroidpresentingas
roscopy. At operation, a torsed subserosal fibroid was an acute abdomen in the first trimester of pregnancy.
found.Shesuccessfullyunderwentlaparoscopicmyomec-
tomy with the endoGIA vascular stapler and subsequent
CASE DESCRIPTION
Pfannenstiel delivery. The patient was discharged 48 h
postoperatively to continue her pregnancy. This case
This27-y-oldprimagravidawomanhadanuncomplicated
demonstrates the safe application of laparoscopic exci-
first 11 wk of pregnancy. She was otherwise healthy and
sional myomectomy in the first trimester of pregnancy.
took no regular medications. She experienced lower ab-
Previouslyreportedcasesintheliteraturehavefocusedon
dominal pain that started suddenly and then progressed
openresectionorbipolardiathermyenucleationandmor-
over 24 h. She presented to her local obstetrics depart-
cellation. A high degree of suspicion should be main-
ment and ultrasound demonstrated an intrauterine preg-
tained for the diagnosis in patients presenting to the sur-
nancy and a large anterior fibroid. On comparison to a
gicalservicewithacutelowerabdominalperitonealsigns
previousultrasoundundertaken2yearlierforpelvicpain,
during pregnancy.
this had increased from 3 cm in size to its current 8 cm
Key Words: Leiomyoma, Pregnancy, laparoscopy, Acute diameter. Her pain did not resolve over the following
Abdomen. 24h.Laboratorystudiesdemonstratedrisinginflammatory
markers (CRP 100 g/dL and WBC 13g/dL) and so a surgi-
calopinionwassought.Arepeatultrasounddemonstrated
no free fluid and no other abnormal intraabdominal find-
ings. On clinical examination, the patient appeared
flushedandhadsignsoflowerabdominalperitonitis.She
was therefore scheduled for diagnostic laparoscopy.
With the patient under general anaesthetic, an open Has-
san approach was undertaken with a 10-mm infraumbili-
cal camera port, 5-mm suprapubic port, and 10-mm left
DepartmentofGeneralSurgery1KingstonHospital,Kingston-upon-Thames,Sur- iliacfossaport.Onlaparoscopy,theomentumwasfound
rey,UnitedKingdom(Drs.CurrieBradley,McEwen,Willson). to be densely adherent to the pelvis with some straw-
Department of Obstetrics and Gynaecology2 Kingston Hospital, Kingston-upon- colored fluid visible, but no frank pus. Blunt dissection
Thames,Surrey,UnitedKingdom(Dr.Al-Shabibi).
was undertaken to free the omentum and search for the
Addresscorrespondenceto:AndrewCurrie,MRCS,DepartmentofGeneralSur- appendix, which was normal. Examination of the small
gery,KingstonHospital,Kingston-upon-Thames,SurreyKT27QB,UnitedKing-
dom.Telephone:(cid:1)44(0)2085467711,E-mail:[email protected] andlargebowelwasalsoinconsequential.Furtherdissec-
tionofthepelvisdemonstratedalargefibroidarisingfrom
DOI:10.4293/108680813X13794522666400
theanteriorsurfaceoftheuterusthatwasadherenttothe
©2013byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. sigmoidandsmallbowel.Aftergentledissectionfromthe
JSLS(2013)17:665–667 665
LaparoscopicApproachtoFibroidTorsionPresentingasanAcuteAbdomeninPregnancy,CurrieAetal.
bowel, the fibroid was investigated jointly by the surgical Myomectomyduringpregnancyhastraditionallybeenre-
and gynecology teams, and found to be a torsed pedun- served for cases of severe, intractable pain late in preg-
culated subserosal variant. This was detorsed with gentle nancy.Risksofgravidmyomectomyincludehysterectomy
mobilization. In view of the risk of myomectomy during secondary to severe hemorrhage, pregnancy injury, and
pregnancy, a decision was made to proceed via the lapa- pregnancy loss.12 Select case reports have provided evi-
roscopic approach, and a 5-mm laparoscopic vascular denceofsatisfactoryoutcomeforopenmyomectomydur-
stapler was introduced through the 10-mm umbilical port ing pregnancy.3,4,13 Ardovino et al.14 report a case of
and the camera switched to the left iliac fossa port. Suc- myomectomy of a painful adhered pedunculated fibroid
cessfulmyomectomywasundertakenbythisapproach.A at 14 wk gestation. They enucleated and morcellated the
small Pfannenstiel incision was undertaken to deliver the fibroidpriortoexcision.Pneumoperitoneumwascreated
fibroid. A small drain was left in the pelvis and was using the Veress technique in their case. Our case dem-
removed24hpostoperatively.Thepatientwasdischarged onstrates the safe use of the open Hasson method in the
48 h later to continue with her pregnancy. firsttrimester.Thekeytechnicalmessageistoadjustport
site to gravidity and fundal height for safety to be as-
DISCUSSION sured.15 Most previous cases undertaken laparoscopically
have enucleated the fibroid using bipolar diathermy.16–19
Uterineleiomyomasareseeninupto4%ofpregnancies,
We have demonstrated the successful application of a
and with the increasing age of obstetric patients they are
laparoscopic vascular stapling device to achieve safe ex-
increasingly common.1 Fibroids predispose to pregnancy
cisional myomectomy. Although morcellation has been
complications including early miscarriage, antepartum
reported effectively elsewhere, this approach can risk in-
bleeding, and preterm labor.5 Most remain asymptomatic
traabdominal injury, prevents histological analysis, and is
for the duration of pregnancy; however, symptomatic fi-
comparatively expensive.20 We detorsed the fibroid prior
broidspresentinamannerdependentontheiranatomical
toexcision,acontentiousapproachinovariantorsiondue
location and size.2 Fibroids may be intramural, submuco-
to the theoretical risks of venous thromboembolism from
sal (where 50% of the mass may be in the myometrium),
the ovarian vein, although recent studies suggest this risk
cervical,extrauterine,orsubserosal,asinourcase.Painis
mayhavebeenoverestimated.21However,theserisksare
the most common complication of fibroids during preg-
less likely in fibroid torsion.
nancy (occurring in up to 15% of cases),6 which can be
severe if the fibroid undergoes “red degeneration” or
CONCLUSION
torsion. As our case demonstrates, the painful presenta-
tion can be sufficiently acute to give signs of lower ab-
Torsion of uterine fibroids is an uncommon condition
dominal peritonitis. Pedunculated subserosal fibroids are
during pregnancy, but carries significant risk if left un-
especiallyatriskoftorsion,andthisriskwillincreaseifthe
treated. A high index of suspicion is required, as despite
fibroidenlarges.Somestudieshavesuggestedthatsmaller
useful assistance of imaging modalities such as ultra-
fibroids are more likely to increase in the first half of
sound,thediagnosisremainsessentiallyclinical.Ourcase
pregnancy.7 Our patient was noted to have a small
demonstrates the safe and successful laparoscopic man-
prepregnancyfibroid,whichhadsignificantlyenlargedby
agement of a torsed subserosal fibroid using the endo-
presentation.
scopicvascularstaplingdevice.Surgicalawarenessofthe
Ultrasound is the mainstay of abdominal imaging assess- entity and its management is vital, because it can present
ment in pregnancy.2 Fibroid complications that can be as acute lower abdominal peritoneal signs during preg-
seen include red degeneration, in which there is signifi- nancy, which will mandate surgical referral.
cant internal echogenic change.8 Torsion can be defined
usingDopplerassessmentofvesselsespeciallyforpedun- References:
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