Adenomyosis, or endometriosis of the uterine musculature, is a very problematic condition,
which is usually treated by hysterectomy because it’s generally been considered inoperable.
But when we have patients that want to have children, as you see is this huge adenomyoma
on this MRI, then you have to find a way of preserving the uterus and yet removing adenomyosis
tissue so they can get pregnant.
The lower abdomen is opened through a mini-lap incision. Then a tourniquet is placed around
the uterine, cervix and the adnexa so that we can have complete hemostasis. This would
otherwise be a very bloody operation and protresan[phonetic] alone would not be adequate to controlling
So the tourniquet is placed around the uterine cervix to block off the blood flow to the
uterine artery and another clamp can be put on the ovarian artery so that the uterus has
absolutely no bleeding during the entire operation, which would otherwise result in massive blood
We use a piece of rubber tubing for the tourniquet and first put it around the adnexa on one
side and then the other side so we can then tighten it around the cervix. After tightening
the rubber tourniquet using a series of clamps, we then tie off the lowest clamp with a piece
of zero silk suture so that the clamps won’t be in the way, and we have complete blockage
of the uterine artery as well as the ovarian artery.
We have the clamps applied now so that the tourniquet is very tight, and then we tie
the suture around it and take the clamps off. Now it’s time to extrude this enormous adenomyomatous
uterus through the mini-lap incision onto the abdominal wall. You don’t want to make
too big an incision, because that would make it difficult to provide a platform for the
But you want to be able to just extrude it so that it sits with the tourniquet in place
right on top of the uterine wall in preparation now for this massive incision of adenomyoma
and subsequent reconstruction.
We check the ovaries and the fallopian tubes to make sure nothing that we do is going to
interfere with their integrity. You can see the tourniquet well around the cervix. We
start to make the incision and tearing it down very briskly down right to the endometrium.
The whole operation is made easier by making a median incision all the way to the endometrial
cavity. Once you’re in the endometrial cavity, the rest of the incision becomes relatively
The finger is inserted into the endometrium so that we always have control, and in this
case we find an enormous polyp complicating her problem of adenomyosis. With this incision
it’s relatively easy just to pluck the polyp out and continue with our surgery.
We use laparoscopic instruments copiously for irrigation, but we couldn’t do this
operation through a laparoscope, as you’ll be able to see as we begin to make the incision
one centimeter from the serosal surface. Then one centimeter from the endometrial surface,
planning to remove all of the adenomyomatous tissue in between these two incisions so that
we have one centimeter or serosal surface and one centimeter of endometrial surface
remaining to reconstruct.
First we attack the right side of this midline incision and resect all of the adenomyoma,
checking with the finger always to make sure that we are not entering the endometrial cavity
or any place other than that initial incision.
And making sure also we don’t occlude or compromise the uterine cornea. We’re almost
about to completely resect now all the adenomyoma, just on the right side. But remember this
was a huge circumferential adenomyoma requiring us going to both sides one at a time.
Normally even with protressan [sp?] you’ve would have expected a huge amount of bleeding
from this resection, but you can see there’s virtually no blood loss whatsoever. Now we’re
trimming off extra adenomyomatous tissue so that we can thin out and soften up the remaining
uterine musculature on the serosal surface.
This is done with just a scaling procedure with a sharp knife blade. Then we go to the
other side. Again, an incision one centimeter from the serosal surface and one centimeter
from the endometrial surface using the finger to protect the endometrial canal. Once again
we resect all of the intervening huge amount of adenomyomatous tissue with scissors dissection
and protecting the endometrial cavity with the finger in place.
Again, observe that there is virtually no bleeding despite what otherwise would have
resulted in massive hemorrhage, because of control of the tourniquet.
Now again, we clean off residual adenomatous tissue so that we will have a soft, muscular
surface just next to the serosa. We have to do this almost in a sculpting fashion bit
by bit so as to preserve the integrity of the uterine musculature, but on the other
hand get rid of all the indurated tissue.
Once we are complete with that, then we have to do the reconstruction. First we use 2-0
vicryl-interrupted sutures for the endometrial cavity. Once the endometrial cavity is properly
closed in securely and tight, then we will turn our attention to what will be a massive
The reconstruction must be secure with over 200 interruped 2-0 vicryl sutures so as to
be absolutely certain we’re taking no risk of uterine rupture with the subsequent pregnancy.
So this is performed by closing in layers, pants over vest, with no one suture line directly
overlapping another suture line. We have to basically make multi-layer flaps one over
another with 2-0 vicryl-interrupted sutures never overlapping each other. And making certain
we have complete closure of all dead space so as to minimize the risk of entry uterine
or intro myometrial hematoma formation.
All of this suturing of multiple layers may seem at first to be tedious, but it is necessary
to assure that when the patient gets pregnant we are minimizing the chance of either uterine
ruption or hematoma formation post-operatively.
In fact, all the sutures are interrupted, and every single layer is made in a pants
over vest flap fashion. After the final fashioning of these different layers we close the uterus
and make sure the serosal surface if completely approximated.
Post-operatively this patient, who had had two-week long painful, miserable periods for
the previous five years, had absolutely normal periods, minimal pain, and felt incredible
symptomatic relief. She had a very minor post-operative course. She was home from the hospital in
two days with minimal pain. And immediately felt relief of menorrhagia and metrorrhagia.
In fact she is now ready to have her frozen embryos transferred so that she’ll be able
to carry a baby.
When the tourniquet is removed you can see that there is no bleeding and the uterus is
just placed back in the abdomen. The closure is very simple and quick.
And her one-week post-operative ultrasounds show basically a normal looking uterus with
multiple suture lines. In six months her ultrasound and MRI looked completely normal. [music]