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Uterine FibroidsFrom: Garry E. Siegel (garrys@atl.mindspring.com)Tue Dec 3 21:56:56 1996
Some advice from the readers please: I have a 31 YO nulligravida who presented for a second opinion/MD change because of dyspareunia, as if her partner were "hitting something." 1.5 years ago she had an op hysteroscopy for a small submucous fibroid, 1 cm, in the area of the left ostium, which was removed, as well as a laser ablation for mild dysplasia (these from the op note-no pix or videos available to me). On exam, she had an enlarged uterus, with a 4 cm or so right fundal fibroid, essentially as large as her fundus. She desired assessment laparoscopically, and desires pregnancy eventually. Dx Hyst findings--indented right posterior uterine wall due to fibroid (better seen with lapscope) that did not allow viz of the right ostium; the left ostium was clear, and there was a slight indentation of the left posterior wall from an apparent intramural fibroid. At lap scope a 4 cm intramural fibroid was seen, as well as open tubes to Me blue, and one spot of endo excised and biopsy proven from the cul de sac. I did not do a laparoscopic myomectomy because I am working under the assumption (your opinions please) that open myomectomy is still the standard, and that laparoscopic myomectomy is not the equivalent. She is to have an open myomectomy on 12/5, and when she came in for her preop visit, she had some copied pages from a hysterectomy avoidance book (she didn't have the title page, author, date, etc.) that stressed using Dextran, Kenalog, and Intercede to lessen adhesion formation, as well as using heparized irrigation, and, of course, "sealing" all bleeding vessels. I am usually not in the habit of going into this type of detail with someone, and I am interested in the group's opinions about: 1. Is open myomectomy still the standard for nonpedunculated fibroids when pregnancy is desired? 2. I am working under the assumption that Dextran (I suppose this means High Molecular Weight, such as Hyskon) is passe, as is a steroid solution instilled in the pelvis, for adhesion prevention. Furthermore, I am assuming while hemostasis, fine suturing, minimal tissue handling, and irrigation are all the good things, I didn't really think the irrigant needed heparin. I also would usually use Intercede, but would not leave a bunch of LR because it would likely float the Intercede off. Opinions and Thoughts are welcome. Thanks, Garry
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