A Huge Parasitic Fibroid Causing Hernia

Abstract

Leiomyoma is the most common estrogen dependent benign tumour of the uterus occurring in the reproductive age. It is composed of smooth muscle and fibrous tissue. Asymptomatic myomas can be present in 50% of cases. It causes mainly menstrual problems like menorrhagia, metorrhagia, dysmenorrhoea and also infertility. Nowadays it is very rare to get huge myomas because most of the patients for any vague, trivial complaints undergoes scan, which picks up even very small myomas. We are presenting a very huge fibroid causing hernia in a patient 48years old P3L3 who developed hernia, following puerperal sterilization done. She had a hernia repair done 20 years ago. Now she developed recurrent hernia due to the huge abdominal mass 22×22cms of a parasitic fibroid. She was taken up for laporotomy. The mass was removed in addition total hysterectomy with bilateral salpingo oophorectomy was done. This case is presented here because of its rarity and its management was quite tough-a Herculean task of course. KEYWORDS: Hernia, parasitic fibroid, Subserous fibroid, total abdominal hysterectomy with salpingo-oophorectomy. CASE REPORT:A 48years old lady P3L3 got admitted with the history of menorrhagia, abdominal pain and breathlessness since 6months. On examination she was found to be anemic. Uterus was palpable up to 24 weeks size and she had a separate huge mass 22×22cms size extending up to the umbilicus and the right lumbar region. She had a scar in the infra umbilical region with incisional hernia. Cervix was healthy.No significant medical history present. She was transfused with two units of blood. Other blood investigations were normal. X-Ray chest showed cardiomegaly with left ventricular hypertrophy. Intra venous pyelogram showed bilateral hydroureter. Ultrasound showed umbilical hernia, uterus had multiple fibroids-sizes: 20×17×10cms and a huge fundal fibroid of size 22×22cms. The right ovary was cystic. Computed tomography showed large heterogeneous multi loculated abdomino pelvic mass of size 22×20cms with internal degeneration and calcifications from the pelvis. MANAGEMENT:Patient was taken up for laporotomy. There were plenty of adhesions which were released. A huge subserous fundal fibroid, 24×24cms with a twisted pedicle almost getting detached was attached to the Fundus of the uterus on the right side. There were plenty of vessels from the omentum feeding the fibroid. The whole omentum was attached to the surface of the fibroid. It was very vascular. The clamps were applied on the twisted pedicle of the subserous fibroid as well as on the huge vessels which were feeding it.Thanks to the general surgeon, the task was made easy. Part of the omentum had to be sacrificed because it was adherent to the surface of the subserous fibroid. The uterus was enlarged to 24 weeks size which had intramural fibroids. Total abdominal hysterectomy with bilateral salpingo oophorectomy was done. Hernia repair was done meticulously with mesh.