Design: Stepwise demonstration using narrated video footage

Setting: Standard operating room with patient positioned in dorsal lithotomy

Patients or Participants: 32-year-old with history of heavy menstrual bleeding and pelvic pain of four months duration found to have a prolapsing fibroid filling the endocervical canal.

Interventions: The patient underwent myomectomy via a vaginal and hysteroscopic approach. Rectal misoprostol was administered preoperatively, dilute vasopressin was injected into the cervical stroma and the fibroid, and endo-loops were placed around the fibroid stalk. The fibroid was morcellated vaginally to diminish fibroid bulk until hysteroscopic approach was feasible. Because the cervix was excessively dilated, two purse string sutures were placed around the cervix prior to hysteroscopy to prevent leakage of hysteroscopic fluid. The remainder of the fibroid was excised hysteroscopically using a dense tissue resection device. The entire fibroid and stalk were noted to originate from the endocervical canal.

Measurements and Main Results: The patient underwent myomectomy via a vaginal and hysteroscopic approach without intraoperative complications. Her postoperative course was unremarkable. Postoperatively, her pelvic pain resolved and heavy menstrual bleeding improved. She had no further complaints at her four week postoperative visit.

Conclusion: Vaginal myomectomy is a commonly undertaken minimally invasive gynecologic procedure. Various techniques can be employed during vaginal myomectomy to diminish intraoperative blood loss. A combined or staged hysteroscopic approach may be necessary for complex cases of large prolapsing myomas. Furthermore, the placement of purse string cervical sutures may be advisable in cases of excessive cervical dilation.