Performing laparoscopic adenomyomectomy with the four-petal method

Abstract

Objective: To demonstrate an innovative idea for a four-petal method for performing laparoscopic adenomyomectomy on a patient with focal-type adenomyosis. Design: A step-by-step explanation of the technique with narrated video footage. Setting: University hospital. Patient(s): A 38-year-old female with a 7 Â 4 cm adenomyoma at the anterior uterine wall. Intervention(s): Laparoscopic adenomyomectomy began with a cruciate incision to turn the adenomyoma into the shape of a blooming four-petal flower to fully expose the tumor and maximize the removal of adenomyotic tissue. During excision of the lesion, around a 1 cm thickness of the myometrium was preserved at the subendometrial region and around a 0.5 cm thickness of the serosa flap was also left in each ''petal.'' Suture repair in the method introduced is different from closing the wound by approximation of myometrium to myometrium as in traditional myomectomy; instead, herein we repaired the adenomyomectomy wound by anchoring the serosal flap to the subendometrial tissue, with care taken to avoid dead space. Main Outcome Measure(s): Subjective clinical symptoms as well as serial ultrasonographic measurement of the uterine size, shape, and wall thickness. Result(s): The specimen removed was 92 g in weight. The symptoms have dramatically decreased since the procedure and dysmenorrhea improved from visual analog scale 8 to 1 postoperatively. Besides achieving satisfactory symptomatic relief, the ultrasonographic measurement of the myometrium was of adequate thickness (2.3 cm) after the operation and did not increase in a serial follow-up of 33 months. Conclusion(s):The four-petal method of adenomyomectomy with cruciate incision offers full exposure to the localized adenomyosis. It greatly facilitates a balance between the maximized resection of the lesions and tailored reserves of myometrium. Subsequent repair by anchoring the serosal flap to the subendometrial tissue ensures adequate thickness of the uterine wall after the operation. (Fertil Steril Ò 2020;114:1352-4. Ó2020 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo.

Modern approaches to performing organ-preserving operations in adenomyosis

“…Эти разрезы проводят на глубину до полости матки, но не вскрывая ее. Глубину разреза планируют заранее, основываясь на данных ультразвукового исследования или магнитно-резонансной томографии малого таза, и контролируют визуально во время операции [7]. Далее выделенный лоскут захватывают жестким зажимом за наружную часть стенки и серозную оболочку, а пораженный миометрий иссекают с серозной оболочки матки с оставлением гладкомышечной ткани на серозе толщиной около 5 мм.…”

The Era of 4K Three-dimensional Imaging is Coming

“…[ 1 ] Currently, the laparoscopic technique is increasingly being utilized in performing simple and complex gynecologic procedures for various benign and malignant gynecologic conditions. [ 2 3 4 5 6 7 8 ]…”

Comparison of Clinical and Reproductive Outcomes between Adenomyomectomy and Myomectomy

“…Another cytoreductive procedure for adenomyosis is the double-flap method, which uses a serosal side flap for the reconstruction of the uterine wall [11]. The newly described method, published in 2020, used for performing laparoscopic adenomyomectomy in a patient with focal-type adenomyosis, is called the four-petal method [12]. The definitive radical solutions (laparoscopic, vaginal or abdominal hysterectomy) should be reserved for women showing failure of conservative therapy and/or willingness to forgo fertility.…”