A Minimally Invasive Approach for a Large True Broad Ligament Fibroid

Kavita Khoiwal https://orcid.org/0000-0002-3156-7486

Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Corresponding Author: Kavita Khoiwal, Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India, Phone: +91 9013436908, e-mail: kavita.kh27@gmail.com

How to cite this article: Khoiwal K. A Minimally Invasive Approach for a Large True Broad Ligament Fibroid. World J Lap Surg 2023;16(3):175–176.

Source of support: Nil

Conflict of interest: None

Received on: 19 November 2022; Accepted on: 20 February 2023; Published on: 11 January 2024

Keywords: Broad ligament, Fibroid, Laparoscopic, Myomectomy.

Fibroid is the most common uterine tumor. The occurrence of fibroid at extrauterine sites is very rare. If this occurs, the broad ligament is the most common site followed by round ligament, ovarian ligament, and ovaries. The reported incidence of broad ligament fibroid is <1%.¹ Broad ligament fibroids are usually asymptomatic but patients may present with pelvic pain, heaviness, and pressure symptoms to the ureter, bladder, or bowel depending upon the size as these fibroids have the capacity to grow to an enormous size. Rarely menstrual abnormalities can occur if intrauterine myoma coexists. Differential diagnosis includes pedunculated subserosal fibroid or ovarian tumor. There are reports where large broad ligament fibroids mimic ovarian malignancy.^2,3 Exact preoperative diagnosis is difficult still imaging modalities (transvaginal ultrasound, CT and MRI) have been found helpful. Management is purely surgical and is challenging due to its large size and location as surrounded by the ureter, urinary bladder, and iliac vessels. Identification of the course of the ureter is crucial.⁴

We report a case of a large true broad ligament fibroid due to its rare occurrence and demonstrate the surgical technique of laparoscopic myomectomy in such a case. A 33-year-old parous lady presented with a complaint of heaviness in her lower abdomen for 5 months. Ultrasound sonography’s (USG) pelvis was suggestive of a large solid right adnexal mass. Contrast enhanced computerized tomography (CECT) abdomen and pelvis revealed a 15 × 15 cm large fibroid either pedunculated subserosal fibroid or broad ligament fibroid. A plan of myomectomy by minimally invasive approach was made after discussion with the patient. Written and informed consent was taken for laparoscopic myomectomy. General anesthesia was administered. The patient was placed in the lithotomy position. Pneumoperitoneum created. A 10 mm supra umbilical port was put for laparoscope. Three accessory 5 mm ports were placed. Intraoperative findings revealed a normal-sized uterus deviated to the left lateral pelvic wall due to a large 15 × 15 cm right-sided broad ligament fibroid (Fig. 1). Bilateral tubes and ovaries were healthy. The right round ligament as well as the infundibulopelvic ligament was stretched over the fibroid. The right ureter was traced and found medial to the fibroid (Fig. 2) which makes it a true broad ligament fibroid. To minimize intraoperative blood loss, diluted vasopressin (20 units of vasopressin in 200 mL of normal saline) was injected at the junction and in the substance of fibroid. The right round ligament was dissected in order to get entry into the fibroid. A combination of sharp and blunt dissection was used to enucleate the fibroid. Myoma screw was used to provide counter traction. Continuous traction and counter traction are essential. The base of the myoma was broad and deeply seated, so it was dissected with a harmonic ace in order to minimize blood loss. The ureter on the side of the surgery was traced again. The bed of fibroid was stitched with a delayed absorbable suture. The round ligament was reapproximated to maintain the ligamentous support of the uterus and to restore pelvis anatomy. Cut edges of the peritoneum were also sutured to avoid adhesion formation and bowel entanglement (Fig. 3). The fibroid was then removed using electronic morcellation. The patient recovered well in the postoperative period and was discharged on the next postoperative day.

Fig. 1: Laparoscopic image showing a large true broad ligament fibroid

Fig. 2: Laparoscopic image showing ureter medial to the fibroid

Fig. 3: Peritonization after suturing of myoma bed

Probable surgical complications in large true broad ligament fibroid are excessive intraoperative blood loss, injury of ureter and major blood vessels.

Tips and tricks for laparoscopic myomectomy:
- Deep knowledge of pelvic anatomy
- Measures to decrease intraoperative blood loss (e.g., injection vasopressin, uterine or internal iliac artery ligation)
- Keep an eye on the ipsilateral ureter during surgery
- Always operate inside the capsule of fibroid

ORCID

Kavita Khoiwal https://orcid.org/0000-0002-3156-7486

REFERENCES

1. Parker WH. Uterine myomas: An overview of development, clinical features, and management. Obstet Gynecol 2005;105(1):216–217. DOI: 10.1097/01.AOG.0000150453.10906.b6.

2. Jagtap SV, Gupta A, Kshirsaga NS. Broad ligament myoma mimicking as ovarian tumour. Sch J Appl Med Sci 2014;2(1C):258–260. DOI: 10.36347/sjams.2014.v02i01.0056.

3. Bansal P, Garg D. A case of massive broad ligament leiomyoma imitating an ovarian tumour. J Clin Diagn Res 2014;8(3):136–137. DOI: 10.7860/JCDR/2014/7642.4136.

4. Rajput DA, Gedam JK. Broad ligament fibroid: A case series. IJSS Case Rep Rev 2015;1(11):8–11. DOI: 10.17354/cr/2015/58.

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