Author Information
Parulekar SV.
(Professor and Head, Department of Obstetrics and
Gynecology, Seth G.S.
Medical College
& K.E.M. Hospital,
Mumbai, India)
Abstract
A unicornuate uterus with a rudimentary horn which has
noncommunicating endometrial cavity is a rare uterine malformation.[1]
It belongs to Class IIIB-5a1a of the American Fertility Society classification
of uterovaginal anomalies. In such a case the woman develops a hematometra of
the noncommunicating horn, which causes intense dysmenorrhea and may lead to
development of pelvic endometriosis.[2] It needs to be excised
because an opening cannot be created successfully between the horn and the
cervix. Excision is easy if that horn is widely separated from the communicating
horn and has a narrow pedicle. It is difficult when the two are close by. A new
operative technique is presented for excision of such a horn.
Introduction
A combination of lateral and vertical fusion defects of the
mullerian ducts can result in a number of unusual malformations of the uterus.[1]
A unicornuate uterus with a rudimentary horn which has noncommunicating
endometrial cavity is one such malformation. A high degree of suspicion is
required to make the diagnosis early, because the functioning horn continues to
menstruate through the open cervix and vagina, and collection of menstrual
blood in the noncommunicating horn is not suspected.[3,4] It is
diagnosed when an ultrasonographic scan is performed to evaluate severe
dysmenorrhea. The diagnosis can be confirmed by computed tomography or magnetic
resonance imaging.[5] The resultant hemihematometra has to be
excised because an opening cannot be created successfully between the horn and
the cervix. Excision is easy if that horn is widely separated from the
communicating horn and has a narrow pedicle.[6] It is difficult when
the two are close by, and the uterine contour is smooth, with a longitudinal
depression between the two horns. Laparoscopic surgery does not yield
satisfactory results in such cases because there is a risk of injury to the
functioning horn during dissection, and a wide raw area is left on the uterine
surface, from where the noncommunicating horn has been excised. A new operative
technique is presented for excision of such a horn.
Operative Technique
Figure 1. The left cornual structures are clamped. HS:
hematosalpinx on left side; HM: left hematometra.
Figure 2. The left
cornual structures are divided.
Figure 3. The left cornual structures are ligated. Contents
of hematometra are seen beginning to escape from the cornual opening (arrow).
Figure 4. The uterovesical peritoneum is cut and the urinary
bladder is dissected downwards.
Figure 5. The hematometra is opened.
Figure 6. Left uterine artery is ligated just below the lower
limit of the hematometra to prevent blood loss during excision of the
hematometra.
Figure 7. Inner half of the walls of the hematometra are
excised by cutting through middle of the walls.
Figure 8. Excision in progress.
Figure 9. Excision in progress.
Figure 10. Excision in progress.
Figure 11. Outer half of myometrium is left behind after the
endometrium and the inner half of myometrium if the left hematometra have been
excised.
Figure 12. Redundant part of the myometrium is excised.
Figure 13. The opposite flaps are sutured to each other with
interrupted sutures of No. 1 polyglactin.
Figure 14. End result of closure of the flaps.
Figure 15. The left hematosalpinx is excised.
Figure 16. The uterine scar is covered by suturing the left
ovarian pedicle over it.
Discussion
Excision of hemihematometra is essential because it causes
severe dysmenorrhea and it can lead to the development of pelvic endometriosis
by retrograde menstruation.[4] Timely intervention would help
preserve the woman’s fertility. When the two horns of the uterus are not widely
separated, laparoscopic excision of the hemihematometra does not yield
satisfactory results because deep myometrial dissection becomes difficult, risk
of residual endometrium and recurrence of hematometra is increased, and too
deep a dissection may result in injury to the endometrium of the normally
functioning horn. If the endometrium is injured, the risk of rupture of that
horn in a future pregnancy is increased.[7] A laparotomy is a better
option in these cases.
The technique described here involves opening the
hemihetamometra in the coronal plane starting at the cornual opening, so that
the endometrium and the inner half of the myometrium can be excised with
precision, avoiding injury to the other horn, and also avoiding leaving behind any
endometrium. The residual flaps of the myometrium are sutured to each other
over the raw area created by excision of the inner half of the horn. The serosa
of the flaps used to prevents development of adhesions postoperatively. They
also strengthen the adjacent wall of the other horn. This is not possible in
laparoscopic surgery. The linear scar is further covered with the stump of the
ovary after excision of the hematosalpinx. That minimizes the risk of
development of adhesions to the uterus.
Conclusion
The new technique of excision of hemihematometra is an
innovative technique that effectively removes all endometrium, strengthens the
adjacent wall of the other horn, and prevents pelvic adhesions by covering all
raw areas with peritoneum lined surface.
Acknowledgement
I thank Dr P. Y. Samant for the operative photographs.
Acknowledgement
I thank Dr P. Y. Samant for the operative photographs.
References
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Crosby WM, Hill EC. Embryology of
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Heinonen PK. Unicornuate uterus
and rudimentary horn. Fertil Steril 1997;68:224-30.
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Jeffcoate, N. Malformation and
maldevelopments of the genital tract: In principles of gynaecology. The 4th
Edition, Butterworth & Co Ltd, London,2006.
p. 138.
5.
Tsuda H, Fujinov, Umesaki N et al.
Preoperative diagnosis of a rudimentary uterine horn. Eur J
obstet Gynecol Reprod Bio 1994; 56:143-5.
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Allen, L.M. (2009) Case series of laparoscopically resected noncommunicating functional
uterine horns. Journal of Pediatric and Adolescent Gynecology. 2007;22:23-28.
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Raga F, Bauset C, Remohi J,
Bonilla-Musoles F, Simón C, Pellicer A. Reproductive impact of congenital
mullerian anomalies. Hum Reprod 1997;12:2277-81.
Citation
Parulekar SV. Excision of Hemihematometra. JPGO 2014 Volume 1
Number 3 Available from: http://www.jpgo.org/2014/03/excision-of-hemihematometra.html