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Adenomyosis, or endometriosis of the uterine musculature, is a very problematic condition,

which is usually treated by hysterectomy because its 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

the bleeding.

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

loss.

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 wont 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 its time to extrude this enormous adenomyomatous

uterus through the mini-lap incision onto the abdominal wall. You dont want to make

too big an incision, because that would make it difficult to provide a platform for the

uterus.

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 youre in the endometrial cavity, the rest of the incision becomes relatively

straightforward.

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

its relatively easy just to pluck the polyp out and continue with our surgery.

We use laparoscopic instruments copiously for irrigation, but we couldnt do this

operation through a laparoscope, as youll 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 dont occlude or compromise the uterine cornea. Were 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?] youve would have expected a huge amount of bleeding

from this resection, but you can see theres virtually no blood loss whatsoever. Now were

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

myometrial reconstruction.

The reconstruction must be secure with over 200 interruped 2-0 vicryl sutures so as to

be absolutely certain were 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 shell 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]

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The Description of The Treatment of Endometriosis with the Osada Procedure Performed by Dr. Silber