Compared to myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified, as the organs that have to be considered differ depending on the location of the myoma. Surgical difficulties associated with these cases are, poor access to the operative field, difficulty in suturing the repairs, increased blood loss, and distortion of the anatomy of the vital neighboring structures in the pelvic cavity.
An additional difficulty may be the introduction of conventional manipulators during total Laparoscopic Hysterectomy, where a myoma screw with additional port may be utilized, to manipulate the uterus.
A reasonable option is to perform myomectomy and correct the distortion of the anatomy before proceeding to the hysterectomy, in selected cases.
When performing hysterectomy with myoma in situ, approach the broad ligament on the side with less distortion first and try to tackle the uterine simultaneously on that side. After release of the uterosacrals on the less affected side, normally, reasonable mobility of the uterus is gained so as to be at a safe distance from the vital pelvic organs on the contralateral side (where myoma is projecting) when performing the dissection and coagulation.
Prior identification of the ureters with either retroperitoneal dissection or pre-procedure cystoscopic ureteric stenting may be of help in selected cases of very large cervical myomas with lateral projection. In cases of anterior myomas, prior bladder dissection helps in reaching the uterines. Thus, after considering the location of the myoma, cervical myomectomy or hysterectomy can be performed safely by developing a uniform strategy that uses a fixed operative procedure, if sufficient attention is paid to the following points.
- Reducing the size of the myoma with preoperative GnRH
- Determining the positional relationship between the myoma and the surrounding organs
- Optional blocking of the uterine artery blood flow temporarily
- Suppressing bleeding during myomectomy with the use of vasopressin
- Minimizing the risk of damaging the surrounding organs by properly positioning the incision in the myometrium
- Suturing the bottom of the wound after grasping with the forceps, to avoid making a dead space
- Prior myomectomy before attempting definitive steps for hysterectomy