Laparoscopic ACUM Surgery in Müllerian Anomaly скачать в хорошем качестве

Laparoscopic ACUM Surgery in Müllerian Anomaly

This video presents a case of Accessory and Cavitated Uterine Mass (ACUM), a rare Müllerian anomaly. ACUM is defined as a cavitated lesion surrounded by a myometrial mantle in continuity with the anterior-lateral uterine wall, usually beneath the insertion of the round ligament and the interstitial portion of the fallopian tube. The endometrial cavity, tubes, and ovaries are otherwise normal, and there is no adenomyosis. Prevalence is unknown. The leading pathophysiologic theory is a developmental defect of the gubernaculum, consistent with the frequent location of ACUM near the round ligament attachment. Symptoms include dysmenorrhoea, menorrhagia, and infertility, often refractory to medical therapy. A recent scoping review reported an 85.7% failure rate with medical management alone, whereas laparoscopic excision achieves complete symptom resolution in about 80% of cases and partial resolution in the remainder. Our patient was a 28-year-old gravida 0 with moderate dysmenorrhoea and dyspareunia who initially presented with infertility. She reported normal cycles and no use of oral contraceptives. Community ultrasound suggested a V-shaped uterus consistent with a bicornuate uterus, with a well-developed left horn and a presumed right rudimentary horn. A 5 mm echogenic focus in the right horn contained likely blood products, and a hypoechoic solid structure suggested a subserosal fibroid. MRI was performed for further characterisation. In transverse and coronal views, a thick fibromuscular uterine septum was identified without cervical involvement. A 2.1 cm noncommunicating cystic focus within the right upper uterine body contained haemorrhagic contents and was favoured to be an ACUM. An additional extrauterine cyst had features suggestive of an endometrioma. At laparoscopy, a cystic structure with chocolate-coloured contents was visualised protruding from the right uterine fundus. Vasopressin was injected into the base of the mass to reduce bleeding. Monopolar cautery was used to incise the serosa at the base, and traction was applied while dissecting the mass from the underlying myometrium. Tactile feedback helped define the inferior border. The first mass was completely excised. Because MRI had shown two cystic structures, intraoperative vaginal ultrasound was performed. A second cystic mass was identified in the right uterine body. Under ultrasound guidance, suction was used to localise the area of fluctuance, and monopolar cautery was again used to incise the myometrium. Traction and counter-traction facilitated dissection until the cyst was entered and chocolate fluid drained. The second mass was then completely removed without entering the endometrial cavity. The uterine defect was closed in four layers with V-Loc sutures, and the serosa was closed in a running baseball stitch. Vaginal ultrasound confirmed no residual cystic mass. Concurrent superficial endometriosis was excised. Hysteroscopy confirmed an intact endometrium and visualised a uterine septum, which was resected with bipolar cautery to normalise the cavity. Histology of the ACUM was negative for endometrial stroma, consistent with ACUM containing denuded lining. Pelvic sidewall specimens were positive for endometriosis. At follow-up the patient reported complete resolution of dysmenorrhoea, though she had persistent vaginismus and was referred to a multidisciplinary pelvic pain programme. Müllerian anomalies, both obstructive and non-obstructive, are variably associated with endometriosis. Proposed mechanisms include retrograde menstruation, persistence of embryonic Müllerian remnants, and metaplasia. This case highlights the importance of imaging and intraoperative ultrasound for diagnosis and localisation, and demonstrates that laparoscopic excision provides effective treatment when medical management fails.