Surgical Approach to a Large Cervical Fibroid

Video Objective The objective of this video is to outline a unique approach to removal of a large intracervical fibroid during hysterectomy. Setting The patient is a 49 year-old para 3 who presented with pelvic pain, pressure and increased abdominal girth. She was found to have a 20 week size uterus with a large intracervical fibroid on exam. Her cervix was dilated to 4 cm and effaced on exam and the fibroid was palpable. MRI demonstrated a large multi-fibroid uterus, with a dominant 10 centimeter cervical fibroid and a dominant 9 centimeter broad ligament fibroid. She desired definitive management of her symptoms. Interventions After extensive surgical planning, a hysterectomy was performed in a three-staged approach. Stage one included dissection of the broad ligament fibroid and ligation of the uterine arteries. Stage 2 of the procedure involved a vaginal myomectomy, in which the cervical fibroid was dissected after use of Duhrssen's incisions on the cervix. The uterine manipulator was then secured using 0 prolene suture. In the last stage of the procedure, the hysterectomy was completed laparoscopically and the entire specimen removed vaginally. The patient had an uncomplicated postoperative course and surgical pathology was consistent with benign leiomyoma. Conclusion In this video we outline one unique and feasible approach to hysterectomy when there is a large cervical fibroid. When considering surgical approaches, it is important to remember that there may be distortion of the usual anatomy due to fibroids. Through use of Duhrssen's incisions, we were able to use an obstetrical surgical technique to aide in the removal of a large intracervical fibroid.