Excision of Hemihematometra

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.

References

1.      Crosby WM, Hill EC. Embryology of the mullerian duct system. Review of present day theory. Obstet Gynecol 1962;20:507-15.

2.      Durain D. Primary dysmenorrhea: Assessment and management update. J Midwifery Womens Health 2004;49:520-28.

3.      Heinonen PK. Unicornuate uterus and rudimentary horn. Fertil Steril 1997;68:224-30.

4.      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.

6.      Spitzer, R.F., Kives, S. and Allen, L.M. (2009) Case series of laparoscopically resected noncommunicating functional uterine horns. Journal of Pediatric and Adolescent Gynecology. 2007;22:23-28.

7.      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