Myomectomy With Rubber Tourniquet

Every uterus with fibroids is a latent challenge. You don't know exactly what you will find when you open the abdomen to perform a myomectomy. You could always do an MRI scan preoperatively to know the size and locations of the fibroids, but that is unnecessary use of costly technology, and there is no guarantee you can plan your operation accurately based on the results. It is best to be ready for whatever you may find inside, and modify your technique accordingly. That day we had this woman aged 40, single, with multiple fibroids. The uterus was 26 weeks’ size. Myomectomy would be possible, but difficult, we thought. We opened her abdomen. Was she lucky! She had a more than 20 cm diameter fibroid attached to the top of the uterus with a 2-3 diameter pedicle. She had 3 other fibroids measuring 2 cm in diameter in the front wall of the uterus and one in the left broad ligament. Curiously, she had four spots of endometriosis in the uterovesical fold on the left side but not anywhere else. I tried to deliver the large fibroid out of the abdomen, but it was too large. I did not divide the pedicle, because it would make it free to go anywhere in the abdomen, making its removal move even more difficult. There was no point in enlarging the abdominal incision. I thought for a minute and then I put an India rubber catheter around its pedicle and tied two knots. Then I put a clamp on the catheter beyond the knot so that it would not become loose. My residents were wondering what it was all about, I could see. They had not seen anything like that before. I did not blame them, because no one had done such a simple thing before. Then I proceeded to cut up the fibroid into a number of pieces until the mass became small enough to be delivered out. Thanks to the catheter tourniquet, it did not bleed a drop. Then it was back to conventional surgery to cut the pedicle and repair the defect in two layers. Then I removed the other four fibroids and cauterized the spots of endometriosis. Rubin had described placing a rubber catheter tourniquet around the uterine vessels instead of using a Bonney's myomectomy clamp to prevent bleeding during myomectomy. No one had put a tourniquet around the pedicle of a large single fibroid because such an occasion might not have come. Or perhaps such occasions might have come, but people must have either enlarged the incisions far beyond conventional length, or morcellated the fibroids accompanied by unnecessary blood loss. I must say what I did was a happy outcome for the patient and a satisfying experience for me as a surgeon.