A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage

A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage is safe and feasible with good anatomical results
A stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage
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VOLUME 118, ISSUE 5, P987-989

Authors:

Marco Aurelio Pinho Oliveira, M.D., Ph.D., Thiers Soares Raymundo, M.D., Gaby Moawad, M.D., Thiago Dantas Pereira, M.D., M.Sc., Juliana Coelho Alves, M.D., Alice Brandão, M.D.

Abstract:

Objective

To propose a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.


Design

A narrated video footage of the surgical approach of a clinical case with extensive adenomyosis and recurrent abortions. Institutional review board approval was obtained (No 3.725.458).


Setting

A university center.


Patient(s)

We present a case of a 37-year-old patient, gravida 4 para 0 with a history of 3 first trimester miscarriages after spontaneous pregnancies, and a 20-week spontaneous abortion after an in vitro fertilization pregnancy. She underwent 2 laparoscopic excisions of deeply infiltrative endometriosis and was treated with gonadotropin-releasing hormone for 6 months and dienogest for a year with no improvement of her adenomyosis. Currently, she experiences moderate dysmenorrhea and desires future fertility.


Intervention(s)

For 3 months, gonadotropin-releasing hormone analogues were used before performing the robotic surgery for adenomyosis resection and abdominal cerclage. (Step 1) Control the blood supply with a tourniquet placed lateral to the uterine arteries at the level of the internal cervical os, and a diluted solution of vasopressin 20% is administered at the area to be excised. (Step 2) Uterine incision: we use a vertical uterine incision with monopolar scissors, extended anteriorly and posteriorly. (Step 3) Resection of adenomyosis: carried with monopolar scissors using pure cut current. It is recommended that 0.5–1 cm of the myometrium is maintained around the uterine cavity as well as the serosa. (Step 4) Flap 1: interrupted sutures with vicryl 2.0 are used to approximate the inner myometrium close to the endometrial cavity, and a 2.0 barbed suture is used to approximate the inner myometrium of the contralateral side of the incision to the ipsilateral outer myometrium. (Step 5) Flap 2: another 2.0 barbed suture is used to approximate the outer myometrium of the contralateral side to the base of the repaired inner myometrial layer. (Step 6) Serosal closure: the serosa is approximated with a barbed suture in a baseball fashion before the tourniquet is released and hemostasis is ensured. (Step 7) Abdominal cerclage: a mersilene tape is placed medial to the uterine arteries at the level of the internal cervical os and a tape is tied anteriorly.


Main Outcome Measure(s)

Description of a stepwise approach to robotic diffuse adenomyosis resection with double flap and concomitant abdominal cerclage.


Result(s)

The operating time was 255 min with minimal estimated blood loss (250ml). She was discharged with no complaints. Three months postoperatively, dysmenorrhea significantly improved, and the magnetic resonance imaging showed a good anatomic result. An embryo transfer is planned at 6 months postoperatively.


Conclusion(s)

A minimally invasive approach to fertility-sparing management of diffuse adenomyosis is safe and feasible with good anatomical results. However, it should be noted that after the removal of uterine adenomyosis, the patient should be advised on the high risk of uterine rupture during pregnancy. Robotic cerclage may also be performed concomitantly in cases of 2nd-trimester recurrent abortions.

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