Case Report

Retained Uterine Fundus after Vaginal Hysterectomy

Rakesh Sinha, MD*, Smita Lakhotia, MD, Meenakshi Sundaram, MD, DNB,Gayatri Manaktala, DGO, DNB, Parul Shah, MD, and Chaitali Mahajan, MDFrom the Department of Endoscopic Surgery, Beams Hospital, Mumbai, India (all authors).

ABSTRACT We report a case of retained uterine fundus after vaginal hysterectomy that was subsequently removed at laparoscopy. The

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Khar Pali, Khar (

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patient had undergone vaginal hysterectomy 8 years previously and came to our hospital with abdominal pain. Examination

revealed a supravesical mass. Laparoscopy was performed and showed the uterine fundus with its cornual attachments. The

mass was excised and sent for histopathologic analysis, which confirmed that it was uterine tissue. Retained uterine tissue

or myoma tissue has been reported, usually after morcellation. However, to our knowledge, our case is only the second reported

case of retained fundus after complete vaginal hysterectomy. Because of adhesions, it is possible that the uterus was not com-

pletely removed. In such cases, laparoscopic assistance is extremely useful. Journal of Minimally Invasive Gynecology (2010)

17, 94–96 � 2010 AAGL. All rights reserved.

Retained tissue fragments after surgery have been

reported, usually after morcellation of the tissue during

retrieval. These tissue fragments may later cause abdominal

pain or an abdominal mass abdomen depending on whether

they undergo necrosis or become parasitic [1]. Retained

tissue after vaginal hysterectomy is rare. In cases in which

the uterus is large, the organ is retrieved by morcellating it

into pieces. We report a case in which the entire uterine

fundus was retained after vaginal hysterectomy.

Case Report

A 42-year-old woman had pelvic pain for 2 years, which

was previously periodic but became continuous over a few

months. Her surgical history was significant for 2 deliveries

via cesarean section, and a vaginal hysterectomy with right

adnexectomy because of symptomatic myomas 8 years previ-

ous to the present pain. The operative notes suggested the

presence of a posterior lateral wall myoma, 8 ! 6 cm in

greatest diameter, and that the uterus was adherent to the

no commercial, proprietary, or financial interest in the

anies described in this article.

uthor: Rakesh Sinha, MD, Department of Endoscopic

Hospital, 674, 16th Cross Rd, behind Khar Gymkhana,

W), Mumbai 400052, India.

k@yahoo.co.in

, 2009. Accepted for publication September 3, 2009.

.sciencedirect.com and www.jmig.org

front matter � 2010 AAGL. All rights reserved.

.2009.09.004

abdominal wall. Histopathologic analysis did not demon-

strate any evidence of malignancy. At clinical examination,

the mass was palpable in the suprapubic region in relation

to the anterior abdominal wall.

Pelvic ultrasonography revealed a well-defined hypo-

echoic lesion, 4.2 ! 3.8 ! 3.4 cm, in the right iliac fossa,

suggestive of a postoperative collection or a suspected

neoplasm. The left ovary measured 3.0 ! 1.7 cm with small

peripheral follicles. Color Doppler ultrasonography demon-

strated a hypoechoic solid-appearing mass, 4.5 ! 3.4 cm,

in the midline above the bladder, with negligible vascularity.

Findings at computed tomography suggested a well-defined

homogeneously enhancing midline mass just superior to the

bladder dome and near the right rectus muscle, suggestive

of a fibrotic mass or an old hematoma. Tumor markers

were within normal limits.

Laparoscopy was performed with the patient in a modified

lithotomy position. A Veress needle was inserted at the

Palmer point. A 10-mm supraumbilical port was inserted

under vision, as well as 2 accessory 5-mm ports, 1 each in

the right and left lumbar regions. A supravesical mass was

identified as uterine fundus adherent to the anterior abdominal

wall with attachment on the left side, with fallopian tube,

round ligament, and ovarian ligament, and on the right side

to the partially amputated round ligament (Figs. 1 and 2).

There were bowel and omental adhesions to the mass and to

the anterior abdominal wall. Omental and bowel adhesiolysis

was performed (Fig. 3). Ten percent vasopressin was injected

Fig. 1. Retained uterine fundus with adhesions. Fig. 3. After adhesiolysis.

Sinha et al. Retained Uterine Fundus 95

into the mass, and a myoma spiral was inserted for manipula-

tion. Anteriorly, the mass was dissected free from the anterior

abdominal wall. The right round ligament stump was desic-

cated and cut (Fig. 4), as were the left round ligament, left fal-

lopian tube, and left ovarian ligament. After freeing the mass

from all of its attachments, it was morcellated and retrieved

from the abdominal cavity. Hemostasis was confirmed. The

weight of the specimen was 40 g. The histopathology report

was consistent with a portion of uterine fundus.

The postoperative period was uneventful, and the patient

was discharged 2 days after surgery. She is being followed

up regularly.

Discussion

Hysterectomy via the vaginal route has become increas-

ingly popular. However, careful selection and proper

reexamination of the patient are essential to avert complica-

tions. There are few reports in the gynecologic literature of

small retained fragments or myomas after vaginal hysterec-

tomy with the various techniques available to remove a large

Fig. 2. Left fallopian tube and ovary.

uterus [2]. Retained fragments have been reported after total

laparoscopic hysterectomy [3] and laparoscopic supracervical

hysterectomy [4].

Although vaginal hysterectomy is associated with less mor-

bidity and faster recovery, there are limitations to what can be

accomplished via the vaginal route. These limitations are

related to the size of uterus, adhesions from previous surgery,

lack of uterine descent, and simultaneous adnexectomy.

Various morcellation techniques have been described, includ-

ing bisection of the uterus, coring, and wedge resection [5],

which can help remove a large uterus vaginally; however, post-

operative complications are well known and have been

reported.

In retrospect, several factors may have contributed to our

patient’s symptoms. At the time of vaginal hysterectomy, she

had an enlarged uterus with a 8 ! 6-cm myoma that would

have required morcellation to deliver the uterus vaginally.

Also, because of 2 previous lower segment cesarean section

deliveries, there were dense uterine adhesions to the bladder

and probably to the anterior abdominal wall that would have

Fig. 4. Right round ligament stump released.

96 Journal of Minimally Invasive Gynecology, Vol 17, No 1, January/February 2010

prevented the fundus to be delivered at the time of morcella-

tion of the uterus vaginally.

Retained myoma after vaginal hysterectomy is rare. This

is an unusual case of laparoscopic removal of retained uterine

fundus after vaginal hysterectomy manifesting as a supraves-

ical mass 8 years after surgery.

In conclusion, morcellation techniques for tissue retrieval

are useful in the presence of a large uterus or myomas; how-

ever, utmost care must be taken to remove every single piece

of the specimen. Careful preoperative assessment, meticu-

lous surgical techniques, and proper postoperative care can

reduce complications.

References

1. Sinha R, Hegde A, Mahajan C. Parasitic myoma under the diaphragm.

J Minim Invasive Gynecol. 2007;14:1.

2. Brown ME, Lin EC, McGonigle KF. Retained uterine fundus after

vaginal hysterectomy. Eur J Radiol Extra. 2008;66:e33–e34.

3. LaCoursiere DY, Kennedy J, Hoffman CP. Retained fragments after

total laparoscopic hysterectomy. J Minim Invasive Gynecol. 2005;12:

67–69.

4. Hutchins FL, Reinoehl EM. Retained myoma after laparoscopic supracer-

vical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc.

1998;5:293–295.

5. Lash AF. A method for reducing size of the uterus in vaginal hysterectomies.

Am J Obstet Gynecol. 1941;42:452–459.