Surgical Considerations in Parasitic Fibroid Excision скачать в хорошем качестве

Surgical Considerations in Parasitic Fibroid Excision

This video presents a comprehensive review of parasitic fibroids and surgical considerations for excision. Objectives are to review the types of parasitic fibroids with a focus on pathophysiology and risk factors, summarise the literature, and present a surgical approach. Fibroids are typically classified using the FIGO system from zero to eight, based on the depth of the fibroid within the uterine layers. FIGO type eight includes parasitic fibroids, which are the focus here. Variants include parasitic, intravenous, disseminated peritoneal, and benign metastasising leiomyomas. These benign tumours resemble typical fibroids radiologically and histologically but grow in unusual locations and can be aggressive, creating diagnostic challenges. Parasitic fibroids are single or multiple pelvic tumours separate from the uterus. They behave like uterine fibroids in growth and regression. Their origin is unclear, but one theory suggests they arise from pedunculated fibroids that gain neovascularisation from another source and lose their original uterine stalk. Because of their pelvic location, parasitic fibroids can be mistaken for adnexal masses on imaging. Intravenous leiomyomatosis features intravascular proliferation of smooth muscle cells and can extend into distant venous or pulmonary sites, creating risk for thromboembolism. Disseminated peritoneal fibroids present as small benign nodules scattered over the peritoneum and can mimic peritoneal carcinomatosis. Benign metastasising fibroids are aggregates of smooth muscle cells that disseminate to distant locations, most often the lungs, but also pleura or abdominal cavity. Pathophysiology may include hormonal predisposition of peritoneal mesenchymal stem cells to undergo metaplasia under oestrogen influence. Genetic mutations on the X chromosome and chromosomes 8, 12, and 17 have been linked to myoma formation. Anatomical factors, such as neovascularisation of pedunculated fibroids, and iatrogenic factors, particularly post-myomectomy morcellation, contribute to risk. Asymptomatic patients may be managed expectantly. If imaging is inconclusive, histological diagnosis is recommended to exclude malignancy. Medical therapy may be considered when surgery is less feasible, such as intravenous or disseminated peritoneal leiomyomatosis. These tumours are hormonally responsive, and case reports describe reduction in fibroid size with goserelin or ulipristal acetate. Minimally invasive or open surgery remains the most common management. Imaging aids surgical planning and evaluation of proximity to visceral organs and vascular structures. We present a 34-year-old nulligravid patient with pelvic pain and bulk symptoms. Her history included hysteroscopic myomectomy and uterine artery embolisation. Pelvic ultrasound revealed a 6.1 cm fibroid with a pedunculated stalk. Because her pain was localised to the fibroid, she chose surgery. Step one is identification of relevant anatomy and vascular structures. Step two is vasopressin injection to reduce blood loss. Step three is opening the peritoneum over the fibroid. Step four is careful layer-by-layer dissection to remove the fibroid. Step five is ensuring haemostasis. Intraoperatively, the parasitic fibroid was visualised on the anterior abdominal wall. It was examined for adhesions and vascular proximity. After surveying the abdomen and pelvis, port placement was chosen for optimal access. Dilute vasopressin was injected into the myometrium and overlying serosa, causing blanching of superficial and deep vessels. Peritoneal incisions were planned with attention to surrounding structures and blood supply. A CO₂ laser was used to incise the peritoneum and adhesions, revealing the fibroid. Using blunt dissection and precise laser incisions, the peritoneum was grasped and the fibroid gently separated from surrounding tissue in a circumferential manner with counter traction. Meticulous haemostasis was maintained to achieve complete resection without damaging adjacent structures. Bipolar cautery was used to coagulate superficial vessels on the fibroid. Near the base, caution was taken because supplying vessels, including branches from the external iliac artery, are often present. The final stalk was well cauterised and divided with the laser. The round ligament was grasped and cauterised to ensure the remaining pedicle was haemostatic. Irrigation confirmed haemostasis at the fibroid bed. At the end of the case the fibroid and the remaining anterior abdominal wall were visualised.