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| OJHAS Vol. 16, Issue 1:
(January-March 2017) |
Case Report
Emergency Laparotomy in a Case of Large Anterior Wall Subserus Uterine Fibroid Causing Strangulated Umbilical Hernia in a Primary Infertile Woman.
Authors
Debmalya Maity, Assistant Professor, Department of Obstetrics & Gynaecology, NRS Medical College, Kolkata,
Arindam Saha, RMO, Department of Obstetrics & Gynaecology, NRS Medical College, Kolkata,
Utpal Ghosh, Senior Resident, Department of Obstetrics & Gynaecology, BSMCH, Bankura,
Dibyendu Mondal, 2nd Year PGT, Department of Obstetrics & Gynaecology, NRS Medical College, Kolkata,
Sudakhina Panja, 1st Year PGT, Department of Obstetrics & Gynaecology, NRS Medical College, Kolkata.
Address for Correspondence
Dr. Utpal Ghosh,
Senior Resident,
Department of Obstetrics& Gynaecology,
BSMCH, Bankura.
E-mail:
drghoshutpal@gmail.com
Citation
Maity D, Saha A, Ghosh U, Mondal D, Panja S. Emergency Laparotomy in a Case of Large Anterior Wall Subserus Uterine Fibroid Causing Strangulated Umbilical Hernia in a Primary Infertile Woman. Online J Health Allied Scs.
2017;16(1):12. Available at URL:
http://www.ojhas.org/issue61/2017-1-12.html
Submitted: Feb 22,
2017; Accepted: April 5, 2017; Published: May 15, 2017 |
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Abstract: Fibroid is the commonest benign tumour of uterus seen in women of reproductive age group. There have been case reports of pedunculated fibroid presenting as a content of hernial sac but herniation of intestinal loops through anterior abdominal wall due to pressure effect of a large fibroid resulting in strangulation and gangrene has rarely been reported. Here we report the case of a 32-year-old infertile woman, who underwent emergency Laparotomy and resection anastomosis of a strangulated small intestinal umbilical hernia which resulted due to pressure effect of a large subserous uterine fibroid.
Key Words:
Uterine fibroid; Small intestine; strangulated hernia; pressure effect; emergency laparotomy. |
Introduction:
Worldwide incidence of uterine fibroid is 20%-50% among women of reproductive age group[1] and it is one of the most common causes of hysterectomy in hospitalised women.[2,3] Although mostly asymptomatic, it has been seen to hamper the quality of life in 20-50% of patients due to various symptoms.[4] Severity of presentation varies according to the size, number and location of these tumours4. Apart from the common presenting symptoms i.e. menorrhagia, metrorrhagia, dysmenorrhea, infertility, recurrent miscarriage etc. these tumours can present with an array of uncommon symptomatology like compression-related symptoms, respiratory distress, cardiac symptoms, symptoms due to internal hemorrhage, vascular spread, symptoms simulating pelvic carcinomatosis, uterine inversion etc.[5] We report a case of subserous uterine fibroid presenting with abdominal herniation of intestinal loops due to pressure effect and subsequent strangulation and gangrene for which emergency Laparotomy had to be done.
Case Report
A 32-years-old infertile female, married for 5 years presented at general ER with signs and symptoms suggestive of acute intestinal obstruction. There is no previous history of conception or miscarriage. On detailed clinical examination it was found to be a strangulated sub umbilical hernia. Straight X ray abdomen in erect posture showed multiple air fluid levels indicating intestinal obstruction.
Patient’s clinical condition was deteriorating rapidly and it was impossible to go for any further investigation. The attending surgeons decided to go directly for Laparotomy and surgical exploration on an emergency basis.
After Laparotomy, dissection revealed strangulated gangrenous loops of small intestine within the hernial sac. On further exploration surgeons found a 15cmX15cm large pedunculated subserous fibroid of uterus with multiple seeding in the pelvic cavity compressing over the neck of the hernial sac. It was concluded that this large subserous fibroid was actually producing compression over anterior abdominal wall and therefore giving rise to the sub umbilical hernia with gut loops inside, which along with further enlargement of the fibroid got more compressed and ultimately, strangulated.
Keeping the fertility status of the patient in mind only myomectomy was done and repair of hernial orifice with mesh placement was performed and abdomen was closed in layers with placement of a drain. After 48 hours the drain was removed.
Histopathological examination confirmed the mass to be leiomyoma.
The patient recovered well and was discharged after 10 days without any significant post-operative complication. The patient is currently in regular follow up at the infertility clinic of our hospital and doing well.
Discussion
Fibroid is the most common estrogen dependent benign neoplasm of uterus of women of reproductive age group. According to the site of origin it is of three types - sub-mucous, intramural and subserous.[6] Though there is no clear cut definition available at present usually when >50% of a fibroid protrudes out of serosal surface of uterus, it is called as subserous fibroid.[7] Pedunculated fibroids are categorised as type 7 in FIGO fibroid classification system and it is rarest among three types discussed above.[8] During the review of literature available, we found a few cases where fibroids were the content of hernia.[9] Reports, regarding fibroid causing intestinal obstruction in pregnant women were also available [10] but in our case, it was the large pedunculated uterine fibroid in a non pregnant woman which was according to our opinion the reason behind the umbilical hernia (by causing increased intra abdominal pressure) which became complicated to intestinal obstruction and strangulation due to further pressure effect of the growing fibroid. Another interesting finding in our case was multiple seeding of fibroid in the peritoneal cavity, which is also a rare finding. According to Wen-Hsiang Su et al, this finding is called as Leiomyomatosis Peritonalis Disseminata (LPD). Though it is believed that, this condition is associated with recent pregnancy or previous myomectomy using morcellator.[11] In our case there was no such history in the patient.
Conclusion: Familiarity with the rare symptoms of leiomyoma helps surgeons to reach correct diagnosis. Before final choice of treatment is made, surgeons are encouraged to bear this rare event in their mind for the differential diagnosis of intestinal obstruction, particularly in the backdrop of primary infertility with large fibroid.
References
- Gupta S, Jose J, Manyonda I, Clinical presentation of fibroids, Best Pract Res Clin Obstet Gynaecol 2008;22;615-26.
- Zhao SZ, Wong JM, Arguelles LM. Hospitalisation cost associated with leiomyoma, Clin Ther. 1999;21:563-75.
- Cheng MH, Chao Ht, Wang Ph. Medical treatment for uterine myomas. Taiwan J Obstet Gynaecol. 2012;51:7-11.
- Lasmer RB, Xinmeio Z, Indman PD,Celeste Rk, Spiezio Sardo A. Feasibility of a new system of classification of submucous myomas: a multicentre study. Fertil Steril 2011;95:2073-7.
- Wen-Hsiang Su, Wen-ling Lee, Ming-Huei Cheng, Ming-Shyen Yen, Kaun-Chong Chao, Peng-Hui Wang. Typical and atypical clinical presentation of uterine myomas. Journal of Chinese Medical Association 2012;75:487-493.
- Lotterman S. Massive hemoperitonium resulting from spontaneous rupture of uterine leiomyoma. Am J Emerg Med. 2008 Oct;26(8):974 e1-2. Doi: 10.1016/j.ajem.2008.02.029
- Bajekal N,
Li TC. Fibroids, infertility and pregnancy wastage.
Hum Reprod Update 2000;6(6):614-620.
- Munro MG, Critchley HOD, Broder MSet al. FIGO classification system(PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology and Obstetrics 2011;113:3-13.
- Akhator A. Uterine Myoma as a Content of a Strangulated Indirect Inguinal Hernia. JCR 2015;5:304-306. Available at http://www.casereports.in/articles/5/2/Uterine-Myoma-as-a-Content-of-a-Strangulated-Indirect-Inguinal-Hernia.html
- Seims AD, Lube MW. Incarcedration of a sessile uterine fibroid in an umbilical hernia during pregnancy. 2009 Jun;13(3):309-11. doi: 1007/s10029-008-0444-3
- Karasahin KE, Gezginc K, Ulubay M, Baser I. Disseminated peritoneal Leiomayomatosis. Taiwan J Obstet Gynaecol 2008;47:123-5.
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