(Professor and Head, Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)
Myomectomy is operative removal of uterine leiomyoma(s) and reconstructing the uterus. Conventionally a posterior wall leiomyoma is removed by Bonney’s hood operation. In this operation the incision is made transversely through the posterior wall of the uterus, but the flap raised is sutured over the uterine corpus such that the final scar is on the anterior uterine wall. This prevents a posterior wall scar and related adhesions to rectum, bowel and/or omentum. A novel approach of combining half of Bonney’s hood with a lateral incision is presented, to minimize the possible complications associated with Bonney’s hood operation. A review of the world literature reveals that this is the first time this approach has been described.
The bulk of the myometrium is in the anterior and posterior walls of the uterus, and leiomyomas develop there more often. Conventionally uterine incision is placed such that the scar will be on the anterior uterine wall.[2,3,4] This is achieved by making an anterior wall incision for removal of anterior wall leiomyomas, and using Bonney’s hood operation for removal of upper posterior wall leiomyomas. Another approach to avoid a scar on the peritoneum covered surface of the uterus is to use a lateral approach through the broad ligament. The uterine scar gets covered by the broad ligament which is sutured back after the myomectomy. Bonney’s hood operation and lateral myomectomy prevent adhesions which can lead to infertility, retroverted fixed uterus, chronic abdominal and pelvic pain and intestinal obstruction.[6,7] Bonney’s hood operation places the final scar on the anterior surface of the uterus. But the edges of the hood often pass over the fundus of the uterus and close to the cornua, which can cause adhesions in that area. A lateral approach is not suitable if a posterior wall leiomyoma is in the center rather than on one side. A half hood and a lateral incision combined would reduce the risk of adhesions associated with Bonney’s hood operation and make a lateral approach feasible in such cases.
The abdomen is opened through infraumbilical vertical or transverse incision. The bowel and omentum are packed away into the upper abdominal cavity. The uterus and pelvic structures are examined. If the leiomyoma is large and posterior-central in location, it is checked if it is exactly in the center or a little more on one side than the other. In case of the former, the lateral incision can be made on the side on which the operating surgeon stands. In case of the latter, the lateral incision is made on the side on which greater part of the leiomyoma lies. Any technique used for reducing blood loss during myomectomy can be used, such as use of Bonney’s myomectomy clamp, Rubin’s technique of rubber tourniquet, and injection of diluted vasopressin around the uterine vessels and their anastomoses with the ovarian vessels. The lateral incision is made vertically downwards, behind the attachment of the uteroovarian ligament. It is started just behind the attachment of the ligament, close to the broad ligament, and extended downwards to a level not lower than 2 cm above the entry of the uterine vessels into the uterus, well posterior to them. The upper end of the incision is continued transversely across half or less of the posterior wall of the uterus parallel to the coronal plane, just posterior to the junction of the contour of the leiomyoma and the uterine fundus. The incision is deepened until the pseudocapsule is cut. Then the leiomyoma is held with a tenaculum, Allis’ forceps or vulsellum, and enucleated by making traction while it is dissected bluntly as well as sharply from inside the pseudocapsule. If the uterine incision is found to be inadequate for removal of the leiomyoma, it is removed by morcellation rather than by enlarging the incision. Any other leiomyomas present in the posterior uterine wall are removed through tunnelling incisions as have been described conventionally. Hemostasis is achieved in the bed(s) of the leiomyoma(s) by ligatures, sutures and electrocauterization as appropriate. The cavities formed by removal of the leeiomyomas are occluded, the deepest one first and the most superficial one last. The width of the half hood is reduced such that the lateral edge will approximate with the anterior edge of the lateral incision. The medial cut edge is trimmed such that the half hood will not cross the midline. Extra part of the pseudocapsule is excised to reduce the bulk of the reconstructed uterus. The inner surface of the half hood is sutured over the fundus and the anterior wall of the uterus with rows of interrupted sutures of No. 1 polyglactin, starting posteriorly and progressing anteriorly. The anterior edge of the half hood is sutured to the lower part of the anterior wall of the uterine corpus. The round ligaments are plicated with zig-zag sutures of black silk or linen. The abdomen is closed in layers.
Figure 1. Right lateral view of the uterus with a large central leiomyoma in the posterior uterine wall (M). Arrow: left ovary.
Figure 2. Vertical incision is made in the uterine wall and pseudocapsule of the leiomyoma posterior to the right uteroovarian ligament (arrow). The right fallopian tube (hollow arrow) is seen anterior to the ligament.
Figure 3. The uterine incision is extended transversely over the posterior uterine wall in continuity with the upper end of the first incision.
Figure 4. The leiomyoma is being dissected bluntly from its pseudocapsule.
Figure 5. The leiomyoma is seen being delivered from its bed.
Figure 6. The leiomyoma is enucleated almost completely.
Figure 7. Excess of the pseudocapsule is being excised from the anterior wall.
Figure 8. Excess of the pseudocapsule is being excised from the posterior wall.
Figure 9. The bed of the leiomyoma and the hood (held by a hand) are seen.
Figure 10. The bed of the leiomyoma is occluded by interrupted sutures of No. 1 polyglactin.
Figure 11. The hood is being sutured over the bed of the leiomyoma and the fundus of the uterus.
Figure 12. The hood has been sutured over the fundus and the anterior wall of the uterus. Note the right fallopian tube is not compressed by the hood, while the left half of the fundus is without any scar.
Making an incision in the posterior wall of the uterus is considered the worst option because the postoperative scar would be exposed to the general peritoneal cavity and would invite adhesions with bowel and/or omentum.[ 6,7] Unless the uterus is anteverted by plication of the round ligaments, it would get retroverted and perhaps get adherent to the rectum. An upper segment posterior uterine incision is usually managed by Bonney’s hood operation. This operation involves making a transverse incision near the anterior limit of the leiomyoma over the posterior wall of the uterus, and the flap of the pseudocapsule, myometrium and uterine serosa left behind after the myomectomy is sutured over the bed of the leiomyoma and uterine wall so that the anterior edge of the flap (Bonney’s hood) lies on the anterior wall of the uterus. The back and top of the uterus is devoid of any scar and hence adhesions do not develop. However the right and left edges of the hood pass forward close to the cornua. Adhesions may develop to the edges and they may cause obstruction of the fallopian tubes. The new technique described here combines the advantages of the lateral approach and Bonney’s hood operation. A lateral incision just posterior to the uteroovarian ligament results in a scar which is not directly exposed to the peritoneal cavity, and to which bowel and omentum may get adherent. Since that incision would not be sufficient to get out a leiomyoma extending on both the sides of the midline, it is extended across the back of the fundus transversely. A half or less than a half of the width of the uterine top gets cut, and the resultant flap has one edge close to the side of the uterus and the other near the midline. Even if any adhesion develops to it, it would not be close to the fallopian tube. It needs to be noted that this edge would have invited adhesions had it been a result of a full hood too. A half hood just minimizes the risk of obstruction of one fallopian tube, over and above the other advantages of Bonney’s hood operation. The edges of the hood can be covered with oxidized regenerated cellulose barrier, polytetrafluoroethylene membrane, or bioresorbable membrane (sodium hyaluronate and carboxymethylcellulose), preventing adhesions further.
Modified Bonney’s hood operation is a technique that is easy, satisfactory and associated with absence of complications of adhesions of the intraperitoneal structures to the scar seen with posterior uterine wall incisions. It reduces risk of adhesions to one edge of the hood near a fallopian tube, thereby reducing the risk of its obstruction as could occur with Bonney’s hood operation.
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5. Parulekar SV. Myomectomy: lateral extraperitoneal Approach. JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
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I thank Dr Durga Valvi, Dr Vibhav Manjrekar and Dr Digvijay Raut for taking pictures of the operative steps.
Parulekar SV. Myomectomy - Modified Bonney’s Hood Operation. JPGO 2014 Volume 1 Number 11. Available from: http://www.jpgo.org/2014/11/myomectomy-modified-bonneys-hood.html