Author Information
Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Abstract
Myomectomy is
operative removal of uterine leiomyoma(s) and reconstructing the uterus.
Conventionally a posterior wall
leiomyoma is removed by Bonney’s hood operation. In this operation the incision is made
transversely through the posterior wall of the uterus, but the flap raised is sutured over the uterine
corpus such that the final scar is on the anterior uterine wall. This prevents
a posterior wall scar and related adhesions to rectum, bowel and/or omentum. A novel approach of combining
half of Bonney’s hood with a lateral incision is presented, to minimize the
possible complications associated with Bonney’s hood operation. A review of the world literature reveals that this is the first time
this approach has been described.
Introduction
The bulk of the myometrium is in the
anterior and posterior walls of the uterus, and leiomyomas develop there more
often.[1] Conventionally uterine
incision is placed such that the scar will be on the anterior uterine wall.[2,3,4] This is achieved by making an anterior wall incision for removal of
anterior wall leiomyomas, and using Bonney’s hood operation for removal of
upper posterior wall leiomyomas. Another approach to avoid a scar on the
peritoneum covered surface of the uterus is to use a lateral approach through
the broad ligament.[5] The uterine scar
gets covered by the broad ligament which is sutured back after the myomectomy. Bonney’s
hood operation and lateral myomectomy prevent adhesions which can lead to
infertility, retroverted fixed uterus, chronic abdominal and pelvic pain and
intestinal obstruction.[6,7] Bonney’s hood operation places the final scar on the anterior surface of
the uterus. But the edges of the hood often pass over the fundus of the uterus
and close to the cornua, which can cause adhesions in that area. A lateral
approach is not suitable if a posterior wall leiomyoma is in the center rather
than on one side. A half hood and a lateral incision combined would reduce the risk of
adhesions associated with Bonney’s hood operation and make a lateral approach
feasible in such cases.
Operative Technique
The abdomen is opened through
infraumbilical vertical or transverse incision. The bowel and omentum
are packed away into the upper abdominal cavity. The uterus and pelvic
structures are examined. If the
leiomyoma is large and posterior-central in location, it is checked if it is
exactly in the center or a little more on one side than the other. In case of
the former, the lateral incision can be made on the side on which the operating
surgeon stands. In case of the latter, the lateral incision is made on the side
on which greater part of the leiomyoma lies. Any
technique used for reducing blood loss during myomectomy can be used, such as
use of Bonney’s myomectomy clamp, Rubin’s technique of rubber tourniquet, and
injection of diluted vasopressin around the uterine vessels and their anastomoses with the ovarian
vessels.[8] The lateral incision is made vertically
downwards, behind the attachment of the uteroovarian ligament. It is started
just behind the attachment of the ligament, close to the broad ligament, and
extended downwards to a level not lower than 2 cm above the entry of the
uterine vessels into the uterus, well posterior to them. The upper end of the
incision is continued transversely across half or less of the posterior wall of
the uterus parallel to the coronal plane, just posterior to the junction of the
contour of the leiomyoma and the uterine fundus. The incision is deepened until
the pseudocapsule is cut. Then the leiomyoma is held with a tenaculum, Allis’
forceps or vulsellum, and enucleated by making traction while it is dissected
bluntly as well as sharply from inside the pseudocapsule. If the uterine incision is found to be inadequate for removal of the leiomyoma, it
is removed by morcellation rather
than by enlarging the incision. Any other leiomyomas
present in the posterior uterine
wall are removed through tunnelling incisions as have
been described conventionally.
Hemostasis is achieved in the bed(s) of the
leiomyoma(s) by ligatures, sutures and electrocauterization as appropriate. The cavities formed by removal of the
leeiomyomas are occluded, the deepest one first and the most superficial one
last. The width of the half hood is reduced such that the lateral edge will
approximate with the anterior edge of the lateral incision. The medial cut edge
is trimmed such that the half hood will not cross the midline. Extra part of
the pseudocapsule is excised to reduce the bulk of the reconstructed uterus.
The inner surface of the half hood is sutured over the fundus and the anterior wall
of the uterus with rows of interrupted sutures of No. 1 polyglactin, starting
posteriorly and progressing anteriorly. The anterior edge of the half hood is sutured to the lower part of the
anterior wall of the uterine corpus. The round ligaments are plicated with
zig-zag sutures of black silk or linen. The abdomen is
closed in layers.
Figure 1. Right lateral view of the uterus with a large central leiomyoma
in the posterior
uterine wall
(M). Arrow: left ovary.
Figure 2. Vertical incision is made in the
uterine wall and pseudocapsule of the leiomyoma posterior to the right
uteroovarian ligament (arrow). The right fallopian tube (hollow arrow) is seen
anterior to the ligament.
Figure 3. The uterine incision is extended
transversely over the posterior uterine wall in continuity with the upper end
of the first incision.
Figure 4. The leiomyoma is being dissected
bluntly from its pseudocapsule.
Figure 5. The leiomyoma is seen being
delivered from its bed.
Figure 6. The leiomyoma is enucleated almost
completely.
Figure 7. Excess of the pseudocapsule is
being excised from the anterior wall.
Figure 8. Excess of the pseudocapsule is
being excised from the posterior wall.
Figure 9. The bed of the leiomyoma and the hood
(held by a hand) are seen.
Figure 10. The bed of the leiomyoma is
occluded by interrupted sutures of No. 1 polyglactin.
Figure 11. The hood is being sutured over
the bed of the leiomyoma and the fundus of the uterus.
Figure 12. The hood has been sutured over
the fundus and the anterior wall of the uterus. Note the right fallopian tube
is not compressed by the hood, while the left half of the fundus is without any
scar.
Discussion
Making an incision in the posterior wall of
the uterus is considered the worst option because the postoperative scar would
be exposed to the general peritoneal cavity and would invite adhesions with
bowel and/or omentum.[ 6,7] Unless the uterus is anteverted by
plication of the round ligaments, it would get retroverted and perhaps get
adherent to the rectum. An upper segment posterior uterine incision is usually
managed by Bonney’s hood operation.[8] This operation involves
making a transverse incision near the anterior limit of the leiomyoma over the
posterior wall of the uterus, and the flap of the pseudocapsule, myometrium and
uterine serosa left behind after the myomectomy is sutured over the bed of the
leiomyoma and uterine wall so that the anterior edge of the flap (Bonney’s
hood) lies on the anterior wall of the uterus. The back and top of the uterus is
devoid of any scar and hence adhesions do not develop. However the right and
left edges of the hood pass forward close to the cornua. Adhesions may develop
to the edges and they may cause obstruction of the fallopian tubes. The new
technique described here combines the advantages of the lateral approach and
Bonney’s hood operation. A lateral incision just posterior to the uteroovarian
ligament results in a scar which is not directly exposed to the peritoneal
cavity, and to which bowel and omentum may get adherent. Since that incision
would not be sufficient to get out a leiomyoma extending on both the sides of
the midline, it is extended across the back of the fundus transversely. A half
or less than a half of the width of the uterine top gets cut, and the resultant
flap has one edge close to the side of the uterus and the other near the
midline. Even if any adhesion develops to it, it would not be close to the
fallopian tube. It needs to be noted that this edge would have invited
adhesions had it been a result of a full hood too. A half hood just minimizes
the risk of obstruction of one fallopian tube, over and above the other
advantages of Bonney’s hood operation. The edges of the hood can be covered
with oxidized regenerated cellulose barrier, polytetrafluoroethylene membrane,
or bioresorbable membrane (sodium hyaluronate and carboxymethylcellulose),
preventing adhesions further.[9]
Conclusion
Modified Bonney’s hood operation is a
technique that is easy, satisfactory and associated with absence of complications
of adhesions of the intraperitoneal structures to the scar seen with posterior
uterine wall incisions. It reduces risk of adhesions to one edge of the hood
near a fallopian tube, thereby reducing the risk of its obstruction as could
occur with Bonney’s hood operation.
References
1.
Standring S:
Gray’s Anatomy, 39th ed. Philadelphia
2.
Breech LL, Rock
JA. Leiomyomata uteri and myomectomy. In Rock JA, Jones HW III, editors. Te
Linde’s Operative Gynecology. 10th ed. New Delhi
3.
Guarnaccia MM,
Rein MS. Traditional surgical approaches to uterine fibroids: abdominal
myomectomy and hysterectomy. Clin Obstet Gynecol 2001;44:385-400.
4.
Parulekar SV.
Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical
Publications; 2011, pp345-8.
5.
Parulekar SV. Myomectomy: lateral extraperitoneal Approach. JPGO 2014
Volume 1 Number 2 Available from:
http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
6.
LaMorte AI, Lalwani S, Diamond MP. Morbidity
associated with abdominal myomectomy. Obstet Gynecol 1993;82:897-900.
7.
Iverson RE,
Chelmow D, Strohbehn
K, Waldman L, Evantash ED.
Relative morbidity of abdominal
hysterectomy and myomectomy
for management of uterine leiomyomas. Obstet Gynecol
1996;88:415–419.
8.
Tito Lopes T, Spirtos NM, Naik R, Monaghan JM. Bonney’s
Gynaecological Surgery. 11th ed. Wiley Blackwell:2011; Pp 121-124.
9.
Diamond MP.
Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F):
a blinded, prospective, randomized, multicenter clinical study. Fertil Steril
1996;66:904-911.
Acknowledgement
I thank Dr Durga Valvi, Dr Vibhav Manjrekar and Dr Digvijay Raut for taking pictures of the operative steps.
Citation
Parulekar SV. Myomectomy - Modified Bonney’s Hood Operation. JPGO 2014 Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/myomectomy-modified-bonneys-hood.html