Laparotomy Management Of Multiple Subserossum Myoma in A 48 Years Old Woman

1
Cipta Pramana, 2Timotius, 3Johansen, 4Lifia Virginia, 5Kimberly Sarjono
1
Obstetrics and Gynecology Department of Medical Faculty Tarumanagara University Jakarta
Indonesia/K.R.M.T. Wongsonegoro Hospital Semarang, Indonesia
2,3,4,5
Medical Faculty Tarumanagara University Jakarta, Indonesia
Correspondence to: Cipta Pramana Email: pramanacipta@yahoo.com
Abstract
The case of Multiple Subserrosum myoma is seldomly described in the research and appeare with
different clinical manifestations. We report the case of a 48-year-old woman with a multiple
Subserrosum myoma, the form manifested as pedinculated and non pedinculated. The patient
underwent an exploratory laparotomy in which pedinculated subserossum myoma and subserossum
myoma was found with a solid lesion that the largest is 3x4 cm and the smallest 1x0.5 cm.
Laparotomy Myomectomy Was performed in this patient. There were no complications during or at
the end of the operation.
Keywords: Multiple Subserrosum Myoma, Pedincullated Subserrosum myoma, Laparotomy
Myomectomy
Introduction
Uterine fibroids, also known as myomas, are the most prevalent gynecologic neoplasms and can lead
to considerable morbidity, especially when located submucosally or when their size is sufficient to
elicit symptoms related to their mass. Accurate classification of fibroids is crucial for the purpose of
treatment strategizing and the mitigation of potential problems. Ultrasound is commonly employed as
the primary imaging modality for the characterization of myomas (Gomez et al., 2021). Uterine
fibroids can be categorized into three main types: submucosal, intramural, or subserosal fibroids.
Submucosal fibroids provide a particular concern for women desiring pregnancy, since they have the
potential to induce infertility or increase the risk of miscarriage (Palheta et al., 2023).
Uterine myomas account for around 20% of all benign tumors in women who are in the reproductive
age group. Some estimates suggest that these tumors can impact as many as 70-80% of women
(Monleón et al., 2018). Furthermore, it has been estimated that a significant proportion of myomas,
ranging from 25% to 40%, result in symptoms that have a detrimental effect on the quality of life and
daily functioning of affected women. In some cases, these symptoms become so severe that they
necessitate targeted interventions or treatments (Don et al., 2023).
Myomas have been found to be associated with several adverse effects, including to heavy menstrual
bleeding, anemia, (Fajardo et al., 2023) bowel and bladder dysfunction, urine incontinence, infertilty,
and recurrent miscarriage (Barjon & Mikhail, 2023). Several risk factors have been identified in
relation to the development of the condition. These include genetic predisposition, ethnic background,
advanced age, early onset of menstruation, use of caffeine and alcohol, as well as obesity
(Stewart et al., 2017)
.
Case Presentation
A 48-year-old P2A0 woman came to our outpatient clinic with a stomach complaint that lump since 3
months ago which was getting bigger and bigger this patient also complaints there are heavy
menstruation bleeding for 2 weeks. Physical examination showed that the general condition was good,
compos mental awareness, blood pressure was 138/88 mmHg, pulse 97 beats per minute, breathing 20
times per minute and a temperature of 36.0 C. Abdominal examination revealed a cystic mass with a
solid 2-finger height above the pubic symphysis, Flat mass surface, mobile, regular borders,
tenderness in the central and lower left quadrant.
Laboratory results showed Hb levels at 13.7 g/dL, hematocrit at 40.5%, leukocytes at 16.000/µl ,
thrombocyte at 234/µl, Eritrocyte at 4.37/µl, Activated Control Partial Tromboplastin Time at 26.6
second ,Activated Patien’s Partial Tromboplastin Time at 26.5 second , Control Prothrombin Time at
11.4s, Patient’s Prothrombin Time at 9.8 second, Sodium at 136.0 mmol/L, Potassium at 4.2 mmol/L.
All other laboratory tests are within the normal limit.
[Fig.1]. Ultrasonography of the abdomen showed a multi-lobulated cystic mass with a well defined
dan smooth border, with the biggest measured around 3.54x3.03 centimeters. The mass adhered
tightly with the uterus and not easily separated, while some calcification can also be found inside the
mass. A small amount of fluid collection also appeared in the douglass cavity. Exploratory abdomen
laparotomy found multiple mass with the sum of 12 individual masses in total, from which the biggest
one was around 4x3 centimeters and the smallest one around 1x0.5 centimeters. Several myomectomy
was then performed [Fig.2a]. Separation of the mass is done with the help of both sharp and blunt
instruments. The mass was successfully removed without any complications. There was no
complication during surgery or post-surgery. The uterus, both adnexa and other organs are now within
normal limits [Fig.2b].

Fig. 1: Ultrasonography of the abdomen showed multi-lobulated cystic mass with well defined
borders. The biggest mass measured at 3.54x3.03 cm shown with crosshair markings.
Fig.2: a. Mass of the cyst is removed from the uterus. b: After removal, the macroscopic
myomas consisting of smooth muscle cell with the biggest mass measured 4x3 cm and the
smallest at 1x0.5 cm

Discussion
Uterine myoma or by another name uterine fibroid or leiomyoma is the most common benign tumor
in gynaecology with a prevalence of 70% to 80% in women who have reached the age of 50 years
(Allaire et al., 2015). Based on the results of research conducted at Manado Hospital, the prevalence
of uterine myoma most often occurs in the 41-50 year age group or the fourth decade of age (Pasinggi
et al., 2015). Risk factors for the development of uterine myoma include nulliparity, early menarche,
family history of uterine myoma, obesity, and age (peak incidence age 40 to 50 years). Clinical
conditions that may increase the risk of myoma are hypertension and diabetes (Allaire et al., 2015). In
this case, the patient is 48 years old, in the fourth decade of life, many women experience uterine
myoma due to the influence of exposure to the oestrogen hormone based on the incidence of uterine
myoma which will develop as age increases.
Uterine myoma can cause various signs and symptoms so that this will affect the patient's
quality of life. Therefore, this condition needs to be identified immediately through the signs and
symptoms presented by the patient as well as other examinations that can provide a definite diagnosis
of the patient's illness. The most common sign of uterine myoma is abnormal uterine bleeding and is
usually presented with very heavy menstrual bleeding. Other symptoms that may be experienced are
pelvic pain, low back pain, constipation, dyspareunia, bowel movement disorders or increased
frequency of urination. Based on bimanual examination, the uterus was enlarged, mobile (correlated
with a weight of 300 g or the same as 12 weeks of gestation) with iregular contours. Transabdominal,
transvaginal ultrasound examination is the most chosen examination in diagnosing uterine myoma
because it has a sensitivity of 90-99% in detecting uterine myoma. In addition, ultrasound can observe
the growth of myoma and adnexa if the myoma cannot be palpated. Another examination that can be
chosen is Sono hysterography or hysteroscopy which provides better sensitivity in detecting
submucosal myoma (Allaire et al., 2015; de la Cruz & Buchanan, 2017). In this case, the patient
complained some lower abdominal pain with a lump that had been continuing to grow since 3 months
ago. Another complaint that the patient felt her prolonged menstrual bleeding, in total for 2 weeks.
These signs and symptoms support the previously mentioned diagnosis of uterine myoma. Based on
physical examination of the abdomen, a mass was palpable located 2 fingers above the pubic
symphysis, flat surface, mobile, regular edges, and there was pain in the middle of the abdomen and
lower left quadrant. Uterine myoma in this patient was determined as a definite diagnosis through
abdominal ultrasound examination.
Uterine myomas can be single or multiple. This tumour vary in size, location and perfusion
and can generally be divided into 3 subgroups depending on location, namely: subserosa (protruding
outside the uterus), intramural (in the myometrium) and/or submucosal (protruding into the uterine
cavity) (Allaire et al., 2015). Based on all the examinations that have been carried out on the patient in
this case, the treatment option chosen is laparotomy myomectomy because the patient is
premenopausal so she can maintain her fertility, has less risk of bleeding as a hysterectomy operation,
and healing time is faster. Apart from that, based on a study conducted by Kotani et al, laparoscopic
myomectomy has a higher risk of recurrence compared to laparotomy myomectomy because manual
removal of myomas during laparotomy is a more detailed extraction of smaller myoma masses than
performed in Laparoscopic, hence laparotomy myoma contribute to a lower postoperative recurrence
rate (de la Cruz & Buchanan, 2017; Kotani et al., 2017).

Conclusion :
Myomas are one of the most common gynaecologic neoplasm and if not treated well, can lead to
considerable morbidity depending on the location of the mass and it’s size. Diagnosis of myomas are
usually established with the help of ultrasonography, which makes it faster to diagnose thereby
treating the problems quicker before any complications arise. The surgery of myomas can be done
especially on subserous myomas as a treatment without severe consequences while also improving the
patient’s quality of life.

Source of funds: None

Conflict of interest: The author declares no conflict on interest
Ethical clearance: The authors have obtained written consent from the patient to publish this case
report.
Acknowledgement: None
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