Hospitalization No. *73534 First course record
Case characteristics.
(1) Medical history: She was admitted to the hospital because “a mass in the right adnexal area was found on physical examination for 1 month. The patient used to have regular menstruation, 5/30 days, heavy, with blood clots, no dysmenorrhea, LMP2021-02-15. 1 month ago, a mass in the right adnexal area was found on physical examination, but no attention was paid to it. In the past 3 days, she had lower back pain and occasional lower abdominal vague pain, now 3 days after menstruation, now she came to the hospital and asked for surgical treatment and was admitted to our department. Since the onset of the disease, she has no weakness, no abdominal pain or diarrhea, no fever, and no abnormal vaginal discharge. She is eating and sleeping well, her bowel movements are normal, and her weight is not significantly abnormal.
(2) The patient, 45 years old, female, underwent lower uterine cesarean section in 2007 in a foreign hospital.
(3) Physical examination: T36.4℃ P63 times/min R18 times/min BP138/87mmHg W62 kg, no cardiopulmonary abnormalities, abdominal tenderness, liver and spleen not palpable, no mobile turbid sounds. Gynecological examination: vulva has been delivered style, vagina is smooth, little discharge, no odor, smooth cervix, no lifting pain. The uterus was as large as 2+ months of pregnancy, with irregular surface, good mobility and no pressure pain. A 7*6 cm mass was found in the right adnexal area with average mobility, and no obvious abnormality was found in the left adnexa.
(4) Auxiliary examination: 2021-02-21 (Xuzhou Medical University), ultrasound: transabdominal ultrasound: uterine body enlargement, myometrial echogenicity is not uniform, multiple hypoechoic nodules are detected, the largest is located in the posterior wall, about 4.0*3.0*3.7cm, clear boundary, blood flow signal, endometrial thickening of about 0.6cm, intracavity does not show obvious mass sound image. The intrauterine device was in normal position. The left ovary was visible, while the right ovary was not clearly visible. The left adnexal area did not show a significant mass, while the right adnexal area showed a cystic mass with an extent of about 7.3*4.4*5.1 cm, with poorly defined boundaries and a solid portion showing blood flow signal. The pelvic cavity did not show any significant fluid accumulation. Ultrasound suggests: uterine multiple myoma sound image, right adnexal area cystic solid mass.Admission diagnosis: 1. right adnexal mass 2. uterine multiple myoma 3. scarred uterus
After completing relevant auxiliary examinations:Pelvic CT: lower abdominal structures showed clear, good bladder filling, bladder wall was not thick and more uniform. The uterus is enlarged, and the posterior edge of the uterus shows an ovoid low-density shadow, size about 3.8cm*5.4cm, the right adnexal area shows a class of round low-density shadow, diameter about 3cm, the pelvic wall does not show enlarged lymph nodes, the pelvic cavity does not show effusion. ,
Ultrasound: transvaginal examination: uterus size is about 6.5cmx5.0cmx4.4cm, muscle layer echogenicity is not homogeneous, posterior wall detects hypoechoic mass of about 3.2cmx3.6cm, the boundary is still clear, colorful blood flow is detected in the periphery, endometrial thickness is about 0.6cm, intrauterine cavity sees normal position of birth control device. The ovaries were normal in size bilaterally. A cystic mass of approximately 4.2cmx3.4cm in size was detected in the right adnexal area with clear borders and colored blood flow in the periphery. A 7.5cmx6.8cm heterogeneous hypoechoic mass with clear borders was detected in the right adnexal area, and colored blood flow was detected in the periphery and inside. The pelvis did not show any significant fluid accumulation.
The patient insisted on minimally invasive surgery and refused to undergo hysterectomy. After completing the relevant auxiliary tests, she was subjected to “laparoscopic exploration” under general anesthesia. The anterior wall of the uterus was separated from the peritoneal adhesions of the anterior abdominal wall, the anterior wall of the uterus was exposed, and the base and posterior wall of the uterus were explored for dense adhesions with the greater omentum and intestinal canal, and the rectal recess could not be exposed. The adhesions were gradually separated and the posterior wall of the uterus was exposed. Two myomas were seen, one measuring about 443 cm and the other about 765 cm, which were peeled off and the trauma was closed with 2-0 barbed sutures continuously. The uterine rectal sink remained incompletely exposed. The adhesions in the adnexal region were gradually separated and it was seen that the left fallopian tube was still normal in shape, the left ovary was 432cm in size, the right fallopian tube was still normal in shape and the right ovary was adherent to the posterior wall of the uterus and broad ligament, 421cm in size. blood oozing from the peeled surface was examined and electrocoagulation was given to stop the bleeding and saline was used to flush the pelvic cavity. The wound was covered with hemostatic gauze to stop bleeding and prevent adhesions, and a pelvic drain was left in place. The CO2 gas was exhausted and the abdominal wall incision was closed with a No. 1 silk suture.
The specific video is as follows.
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Reflections: 1. Patients with surgical history basically have pelvic adhesions 2. Simple adhesions of the greater omentum to the abdominal wall are easier to separate , 3. If adhesions after myomectomy of the posterior uterine wall are removed, they are usually adhesions of the greater omentum, small intestine, and colon together, and there may be collateral damage during the separation of adhesions, and even if there is no collateral damage, later thermal damage may not be avoided. 4. In cases of severe adhesions, the operation takes a long Time and is prone to infection, and the medical insurance requires antibiotic application for Class II surgery only to prevent infection for 24-48 hours. 5. Ancillary examination of pelvic masses, fibroids sometimes cannot be clearly identified with adnexal masses. 6. The case ——— separated the adhesions before gradually exposing the lesion as a fibroid. The patient also adamantly requested minimally invasive preoperatively and refused to remove the uterus. So the surgery was very difficult.
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