(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)
Location of a leiomyoma may be clinically evident when it is submucous or subserous pedunculated. It is more difficult to locate it clinically as well as during a myomectomy operation when it is intramural. A new technique is described here to help locate the leiomyoma when the uterus is enlarged uniformly and symmetrically.
An intramural leiomyoma enlarges the uterus. It may be an asymmetrical enlargement if it is on one side, anterior or posterior, right or left.[1,2] Usually it can be located easily during a myomectomy operation when it alters the contour of the uterus asymmetrically, and is firm in consistency. However it may not be possible to locate it if it is deep seated and causes uniform and symmetrical enlargement of the uterus. It is even more difficult to locate it if it is soft in consistency. A new method to help locate such a leiomyoma during myomectomy.
The part of the uterus suspected to have the intramural leiomyoma is held between two fingers of each hand on either side, making pressure towards each other and also below the leiomyoma, so that it tends to get displaced towards the surface of the uterus. The color of the uterine surface is observed prior to making the pressure, during maintenance of the pressure, and after relieving the pressure. If there is no blanching of the surface at any time, there is no leiomyoma underneath the uterine surface at that site. If there is blanching with pressure, and restoration of original color after the pressure is removed, there is an intramural leiomyoma deep to the surface of the uterus under study.
Figure 1. Intraoperative view of the uterus. The uterus seems to be uniformly and bilaterally symmetrically enlarged. There is no blanching of any part of the uterine serosa.
Figure 2. Pressure on the posterior wall of the corpus to demonstrate a leiomyoma on the right side, if any. There is no blanching of uterine serosa.
Figure 3. Pressure on the posterior wall of the corpus to demonstrate a leiomyoma on the left side, if any. There is blanching of uterine serosa.
Figure 4. Presence of a leiomyoma at the site suggested by the blanching test is confirmed by extrusion of the leiomyoma through an incision in the uterine wall and pseudocapsule of the leioyoma.
Usually a leiomyoma is of a consistency different from that of the myometrium. It is a rounded structure. It is firmer and can be palpated through the myometrium lying over it.[1,2] When it lies deeper and is softer due to degenerative changes, it does not offer greater resistance to palpation than the overlying myometrium. A softer consistency may be due to degeneration, cellular nature of a leiomyoma, or a sarcoma. A leiomyoma is best located by an ultrasonography preoperatively. When in doubt, a coputed tomography or a magnetic resonance imaging scan help.[4-8] But even with that knowledge, it is important to locate it intraoperatively so that the incision on the uterus can be made at a site best suited for removal of the leiomyoma.[9,10] An incision placed away from such a site will involve having to make bigger incisions, greater degree of cutting into the myometrium, greater amount of intraoperative blood loss and use of more suture material for closing the incision.
The method described here depends on blanching of the overlying myometrium by the pressure of an underlying leiomyoma. When the leiomyoma is made prominent by compressing the myometrium on its sides, it rises towards the surface of the uterus and presses on the myometrium lying over it. Since it is already less vascular due to the pressure of the underlying leiomyoma before the test is performed, the surface does not blanch. But when the test is done in an area of the uterus that does not have an underlying leiomyoma, the surface of the uterus blanches and goes back to the original color when the pressure on the leiomyoma from two sides is removed.
This is a simple, noninvasive test that can be performed during both a laparotomy and laparoscopy. In case of the former, fingers of two hands are used, while in case of the latter terminal portions of two grasping forceps are used. This test should prove a useful adjunct to conventional methods like palpating directly over the leiomyoma and observing the contour of the uterus for distortion.
I thank Dr Durga Valvi for taking the intraoperative photographs.
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Parulekar SV. Blanching Test To Locate An Intramural Leiomyoma. JPGO 2017. Volume 4 No. 11. Available from: http://www.jpgo.org/2017/11/unusual-broad-ligament-leiomyoma.html