The patient, a 40yo nullipara, was symptomatic with pain, heavy menstrual bleeding and gastrointestinal side effects thought to be due to rapidly enlarging fibroids. The patient’s uterus was grossly enlarged to a 34-week gestation size. Ultrasound showed a 1521cc uterus with at least 4 fibroids, the largest 17cm then 6.5cm, 3.5cm and 2.4cm, exact location difficult to confirm but all thought to be in the posterior wall.
The patient was very keen to preserve her uterus and optimise future fertility. She was also keen to avoid a midline laparotomy. Laparoscopic approach was deemed unsuitable due to limited access. And so, after extensive discussion and evaluation of the benefits and disadvantages of the routes of surgery, tissue extraction methods and risk of hysterectomy, the patient chose the robotic approach.
While the total procedure time was significant, the operation was completed successfully with an acceptable blood loss (Hb dropped from 12.2g/dL to 10.4g/dL) and no transfusion was required. She was discharged home day 2 and had an uneventful recovery. The fibroids weighed 1700g.
In this video we highlight several critical learning points which made it possible to successfully remove such huge fibroids:
- primary port entry at xiphisternum
- high placement of working ports below the rib cage
- full utilisation of the dexterity and manoeuvrability of the endowristed instruments
- the benefit of robotic assisted single-tooth retraction
- the importance of maintaining orientation throughout the case
- the comfort and benefits of endowristed needles in uterine wall reconstruction