Vaginal myomectomy: A new operative technique

I had a patient who had undergone a cesarean section in the past, and had developed a leiomyoma in the back wall of the uterus low down. Removing the tumor by opening the abdomen was risky in view of her past operation and the location of the leiomyoma. So I removed the tumor by the vaginal route, dividing the cervix and lower part of the uterus in midline on the back aspect, and then sutured the cervix and uterus back. This operative technique is not described in the literature, though I have written about it in my book, and also in the chapter that Wolter Kluwer have asked me to cotribute to their book: TeLinde's Operative Gynecology. For the technically minded readers, I am giving below my operation notes written on the patient's hospital paper. I must say it reduced the patient's operative morbidity quite a lot and was a satisfying experience for me as a surgeon too. _____________________________________________________________________________________ Vaginal myomectomy was done by Dr. S.V. Parulekar under spinal anesthesia. 1. Lithotomy position was given 2. Aseptic and antiseptic precautions were taken. 3. The cervix was exposed using a Sims’ speculum and held on its anterior lip with a vulsellum. The upper limit of the rectum was defined by per rectal examination, and was found to be posterior to the upper limit of the posterior wall leiomyoma in the supravaginal cervix. 4. 1:300000 adrenaline in saline was infiltrated under the vaginal mucosa above the portio vaginalis posteriorly in the midline. 5. The posterior lip of the cervix was held with two Allis’ forceps on either side of the midline and the cervix was divided upwards with No. 23 scalpel blade. 6. The incision was extended over the vagina and through it into the effaced posterior supravaginal cervix underneath the vagina. The incision was deepened until the pseudocapsule of the leiomyoma was divided and the myoma was exposed. It was held with a tenaculum and a bulldog vulsellum, and was enucleated by blunt dissection with an index finger and the closed blades of stout curved scissors. 7. Hemostasis was achieved by cauterization one bleeding vessel in the bed of the leiomyoma. The bed was occluded with a series of purse-string sutures of No. 1 polyglactin 910 from above downwards. Oxidized cellulose strip was placed in the highest part of the myoma bed which could not be reached with the suture needle. 8. Hemostasis was confirmed at systolic blood pressure of 115 mm Hg. The incision in the cervix was closed with interrupted sutures of polyglactin 910. Vaginal mucosal incision was closed with interrupted sutures of No. 1-0 chromic catgut. A vaginal mucosal tear was found in the right posterolateral part. It was sutured with a continuous stitch of No. 1-0 chromic catgut. Hemostasis was confirmed at systolic blood pressure of 115 mm Hg again. 9. Patency of the cervical canal was confirmed by passage of a uterine sound. Rectal examination was done with one finger to confirm absence of injury to the rectum. 10. 5% povidone iodine solution was applied to the cervix and vagina. A sterile pad was applied to the vulva.