Author Information
Valvi D*, Parulekar SV**.
(* Assistant Professor, ** Professor
and Head, Department of Obstetrics and Gynecology, Seth
G. S.
Medical College
and KEM Hospital ,
Mumbai , India
Abstract
Uterine
leiomyomas are far more common than extrauterine leiomyomas. Of the latter, the
uteroovarian ligament is one of the least common sites of development of a
leiomyoma. We present an unusual case of uteroovarian ligament leiomyoma.
Introduction
Leiomyomas
are benign smooth muscle tumors of the uterus. They can arise from extra-uterine
structures attached to the uterus, such as the broad ligament, vagina, round
ligament, uteroovarian ligament etc. Extrauterine leiomyomas are far less
common than uterine leiomyomas. Of the extrauterine leiomyomas, are not as
common as uterine fibroids. They may arise in the broad ligament or at other
sites where smooth muscle exists. The uteroovarian ligament leiomyomas are
amongst the least common of the extrauterine leiomyomas. We present an unusual
case of a uteroovarian ligament leiomyoma and its surgical management.
Case
Report
A 33 years old woman came to our outpatient
clinic for treatment of primary
infertility and uterine leiomyoma. She was married and cohabiting since 12 years
but did not conceive. Her menstrual history was normal. She had been diagnosed
to have a leiomyoma of the uterus by another clinician elsewhere. Her medical
and surgical history was not contributory. General and systemic examination
revealed no abnormality. On gynecological examination; uterus was of 10 weeks'
size, retroverted, cochleate, displaced to forward and left side, and with a
nodular posterior surface. Approximately
7× 6 cm firm fibroid was felt on right lateral wall of uterus. A diagnostic hystero-laparoscopy
done 7 years ago showed normal findings. Her husband's semen analysis was
normal. Her hemogram, plasma sugar
levels, thyroid, liver and renal function tests, serological tests for HIV,
hepatitis B, and syphilis, and serum levels of FSH, LH, and prolactin were
normal. Her follicular study showed
follicular development and spontaneous rupture indicating ovulation. Ultrasonography of pelvis showed a leiomyoma
measuring 7.6× 7.1 cm in right lateral wall of the uterus. As per the patient's desire and clinical
findings, a decision to perform a myomectomy was made. On exploration, approximately 7× 8cm
degenerated leiomyoma with scattered calcification on the surface was seen
arising from right utero-ovarian ligament.
It was firmly adherent to the right half of the posterior wall of
uterus, anterior wall and floor of the pouch of Douglas ,
and the rectum. It had no
pseuadocapsule. There was no plane of dissection and hence it could not be
dissected off easily. It was first
separated from the ovary by division of the uteroovarian ligament between the
ovary and the leiomyoma. Then its anterior surface was dissected free from
above downwards. Then it was separated from the floor of the pouch of Douglas , passing backwards up to the rectum. This left
about 1-2 cm wide raw area in the area dissected. The serosal edges of the raw
portion on the back of the uterus could be approximated easily with a
continuous suture of No. 1-0 polyglactin, the adjacent part of the broad
ligament being used for that purpose.
The ovary was sutured to the upper part of this suture line for
suspension as well as for covering the scar to prevent adhesions. There was a
defect in rectal serosa 5 mm wide, whenre the leiomyoma had been dissected off.
Rectal injury was ruled out by injection of air through a tube passed in
through the anus, and filling the pouch of Douglas
with saline to see if any air bubbles escaped through a possible rent. The
defect in the peritoneum on floor of the pouch of Douglas
and upper 0.5 cm of the anterior surface of the rectum was not sutured, as that
would possibly kink the rectum. The abdomen was closed after leaving an
intraperitoneal drain in the pouch of Douglas .
The patient made an uneventful recovery. Histopathological examination of the
rectum confirmed the diagnosis of a leiomyoma with degeneration.
Figure
1. Operative findings. The uterus (U), the right fallopian tube (RFT) and ovary
(RO), and the leiomyoma (L) arising from the right uteroovarian ligament
(between arrows) are seen.
Figure
2. Leiomyoma.
Discussion
Uterine
leiomyomas are benign smooth muscle tumors, that usually arise within the
myometrium.[1] They may remain within the myometrium, or may grow towards its
external or internal surface to become subserous and submucous leiomyomas
respectively. Sometimes they arise from structures attached to the uterus, such
as the broad ligaments, round ligaments, vagina, and the uteroovarian
ligaments. Subserous pedunculated leiomyomas may become adherent to vascular
structures like bowel and omentum and derive their blood supply from them.[1]
When such leiomyomas lose their connection with the uterus, they become
wandering leiomyomas. This occurs when their blood supply from the uterus
diminishes and cannot sustain them. A similar occurrence is seen with
leiomyomas which arise from relatively avascular structures like the round
ligaments and uteroovarian ligaments.[2,3,4] The right uteroovarian ligament
leiomyoma in the case presented probably outgrew its blood supply through the
ligament. Hence it became adherent to the back of the uterus, the anterior wall
and the floor of the pouch of Douglas , and
rectum. A diagnosis of its origin could not be made preoperatively because it
was firmly adherent to the uterus and mimicked intramural leiomyoma. It was
considerably larger than the uterus, but was not responsible for the
infertility of the woman. Since it had not developed from the myometrium, it
did not have a pseudocapsule, and hence a plane could not be found to shell it
out. It had degenerated as a result of reduction in its blood supply, and hence
could not be dissected off easily. The first logical step was to separate it
from the ovary. Then its anterior surface could be accessed for dissection.
After its anterior surface was free, it could be separated from the floor of
the pouch of Douglas , passing backwards up to
the rectum. Thus the rectum could be protected during its separation from the
leiomyoma. The serosal edges of the raw portion on the back of the uterus could
be approximated easily. The ovary was sutured to the upper part of this suture
line, covering it so as to prevent postoperative adhesions.[5] The defect in
the peritoneum on floor of the pouch of Douglas
and upper 0.5 cm of the anterior surface of the rectum was not sutured, as that
would possibly kink the rectum. Placement of a drain locally ensured keeping
the area dry and allow serosal healing.
References
- Breech LL, Rock JA. Leiomyomata uteri and myomectomy. In Rock JA, Jones HW III, editors. Te Linde’s Operative Gynecology. 10th ed. New Delhi: Wolters Kluwer Health – Lippincott Williams & Wilkins 2008; pp. 687-726.
- Yoldemir T, Atasayan K, Eraslan A. A giant extra-uterine fibroma originating from an utero-ovarian ligament initially diagnosed as an ovarian tumour. Marmara Medical Journal 2014; 27: 132-3 DOI: 10.5472/MMJ.2014.03084.1
- Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36:433-45.
- Fasih N, Prasad Shanbhogue AK, Macdonald DB, et al. Leiomyomas beyond the uterus: Unusual locations, rare manifestations. RadioGraphics 2008; 28:1931-48.
- Parulekar SV. Practical Gynecology and Obstetrics. 5th ed. Mumbai: Vora Medical Publications; 2011.
Valvi D, Parulekar SV. Uteroovarian Ligament Leiomyoma. JPGO 2015. Volume 3 No. 1.
Available from: http://www.jpgo.org/2016/01/uteroovarian-ligament-leiomyoma.html