20Technical AspectsOnce the uterines are ligated, no reason why a fibroid of any size cannot be removed.Difficult in cases of large cervical fibroid.
21Technical AspectAfter the uterines are ligated and cut, suture and cut the broad ligament.Either reverse the uterusStart myomectomy or morcellationRestart suturing and cutting the broad ligament till the cornuals are reached.
22WarningHowever difficult and however big the uterus never dissect lateral to the uterine ligatures.If you start dissecting lateral to the uterines you are on the lateral pelvic wall with risk of injury to the ureter or uterines where it is difficult to ligate them
23AIM : To remove large fibroids but cause minimal damage to pelvis and vagina. Removal in toto-- myomectomyMorcellationLash techniqueBisection of the uterusCoring
24Morcellation Successive chunks of the fibroid are held and cut out Large wedges of tissue are removed.
25Lash techniqueCircumferential incisions given just below the serosa and parallel to it.Strong cervical tractionEnlarged fundus delivers as an elongated mass.
26Bisection Cut in the midline from below upwards. Try to reach upto the fundus by successively applying clamps.Offers more space to apply the clamps.Often combined with morcellation or myomectomy.
27Anterior FibroidIf low down and upto 7 cms, may reach it from anterior aspectBe careful of BladderBissect the uterus to reach the fibroidCut through the posterior wall
34Adjuncts Use of harmonic Use of Biclamp Laparoscopy pre vaginal or post vaginalUSGMRIUrographyUreteric catherization
35Drainage Use of Foley’s drain. Minimizes collection Helps monitor the patient.
36ContraindicationsExcept malignancy with large uteri, there should be no contraindication.Endometriosis, suspected adhesions may be tackled with Laparoscopy followed by vaginal hysterectomyLarge subserous fibroid may need to be confirmed with laparoscopy after hysterectomy.Previous scars relative contraindication