A 33-year-old nulliparous woman presented to the gynaecology clinic with a 2-year history of heavy and painful periods. On pelvic examination, the uterus was thought to be 12-weeksize and irregular, suggesting fibroids. On ultrasound scan, the uterus was 12 · 7.7 · 7.8 cm. There was an area of mixed echogenicity on the anterior uterine wall measuring 8.4 · 7.4 · 7.8 cm, consistent with a fibroid. She was initially managed with tranexamic acid and mefenamic acid, but her periods continued to be heavy, and she developed symptoms of urinary urgency and frequency.Five months later, laparoscopy and hysteroscopy revealed a 16-week-size uterus with a large anterior wall fibroid and two small, right-sided subserosal fibroids. There was no evidence of endometriosis, and both tubes and ovaries were normal. The uterine cavity measured 14 cm and was distorted due to the presence of the large fibroid. She was offered myomectomy and made aware of the possible risk of hysterectomy.At laparotomy, she had a 10-cm left anterolateral myometrial fibroid, 3-cm right-sided subserosal fibroid and a 1-cm posterior subserosal fibroid. These were excised by Coblation (Figure 1). After adequate exposure of the uterus, the coblator was used to incise over the greater curvature of the myoma through the myometrium to the pseudocapsule of the lesion. The edges were grasped and retracted to enable tissue lysis between lesion and uterine muscle until sufficient tumour was exposed to allow insertion of a myoma screw. This allowed maximum distraction and exposure of the surgical plane. Most small vessels were coagulated without bleeding. Any larger, actively bleeding vessels were coagulated using the coagulation-only pedal, with simultaneous irrigation and suction delivered by the plasma wand, making identification of vessels easy and their coagulation accurate. This process was carried out in all directions, progressively freeing the tumour until total removal was achieved. The uterine wall was then reconstituted with interrupted sutures and the abdomen closed in layers with suction drainage. No haemostatic clamps were used and the endometrial cavity was not opened. Blood loss was recorded as 300 ml.Postoperatively, the suction drained 50 ml, but her haemoglobin dropped from 11.8 preoperatively to 9
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