Uterine leiomyoma is a common benign tumor in women of childbearing age. The incidence increases with age, especially between 30 and 40 years old [2]. With the increase of childbearing age, the incidence of uterine leiomyoma in pregnancy increases accordingly, and complications such as early abortion, early pregnancy bleeding, premature delivery, premature rupture of membranes and placental abruption may occur, but in most cases, patients do not have any clinical symptoms, and even many women are found to suffer from uterine leiomyoma during obstetrical ultrasound examination after pregnancy [3]. Pregnancy with uterine leiomyoma, if there is no obstruction of the birth canal, trial delivery without contraindications, most pregnant women can still be encouraged to try vaginal delivery. However, if it is a myoma located in the lower segment of the uterus, it will often lead to obstruction of the birth canal and abnormal fetal position, which will become one of the indications of cesarean section.
Whether to remove uterine fibroids at the same time during cesarean section is still controversial. According to the traditional view, uterine hyperemia during pregnancy is obvious [4], and myoma is generally enlarged under the influence of progesterone. Uterine myomectomy may have perioperative complications such as massive bleeding, prolonged operation time, postoperative infection and so on. In severe cases, there is even the risk of hysterectomy. Therefore, except for subserous myoma with pedicle, hysteromyomectomy at the same time after cesarean section is not recommended [4–9]. However, in recent years, with the development of hemostatic technology of cesarean section, more and more studies have shown that hysteromyoma enucleation at the same time of cesarean section is safe and feasible[5, 10]. In this study, the innovative application of the method of removing myoma from the anterior wall of the uterus through the edge of the uterine incision is a safe and feasible method compared with the traditional method. There was no significant difference in preoperative and postoperative hemoglobin, incidence of perioperative bleeding, frequency of blood transfusion, incidence of postoperative fever and complications between the study group and the control group.
Uterine myoma evisceration is performed at the same time during cesarean section, especially for large fibroids, according to the traditional subserous myomectomy method, it often increases the wound on the surface of the uterus, thus increasing the risk of pelvic adhesion in the future. In order to solve this problem, Hatirnaz et al proposed a method to remove uterine leiomyoma from the endometrium [4, 11]. They believed that the endometrium, myometrium and serosal layer can be healed smoothly through endometrium incision to enucleate uterine fibroids, and directly merge to reduce the risk of pelvic adhesion in the future [11]. Although endometrial myomectomy helps to avoid the formation of adhesions between the serosa and the surrounding organs, adhesions may occur in the uterine cavity [4]. To solve this problem, our team innovatively adopted the method of enucleation of uterine fibroids from the edge of the uterine incision. This method is suitable for the myoma of the anterior wall of the middle and lower segment of the uterus. Without adding a new uterine incision, the myoma of the uterus can be removed, which can preserve the integrity of the uterine tissue as much as possible and reduce the possibility of uterine and pelvic adhesion in the future. In this study, 90 cases of cesarean section with myomectomy of anterior uterine wall were selected, 40 cases of uterine myoma were eviscerated through the edge of uterine incision as the study group, and the other 50 cases were treated with traditional serous layer enucleation of uterine leiomyoma as the control group. The results showed that the operation time and average hospitalization time of the study group were slightly longer, which may be related to the higher proportion of major myoma (diameter ≥ 5cm) in the study group than that in the control group. Compared with small leiomyoma, large myoma takes more time to eviscerate and repair, and it takes more time to recover after operation.
The method of cutting into the edge of the uterine incision and enucleating the uterine leiomyoma is more suitable for the myoma of the anterior wall of the middle and lower segment of the uterus, especially the large leiomyoma, and the intermuscular leiomyoma has an advantage. For obstetricians, there is one more option to remove uterine fibroids at the same time during cesarean section, especially for young patients with reproductive requirements, reducing the incision on the uterine surface and uterine cavity, which is conducive to postoperative recovery. In this study, the proportion of III-V type in FIGO classification of leiomyoma in the study group was high, and the proportion of lower edge of leiomyoma to uterine incision edge ≤ 2cm was high, which reflected the applicability of this method.
Make good use of the uterine incision of the lower uterine segment of cesarean section, successfully remove the myoma of the anterior wall of the middle and lower segment of the uterus, and minimize uterine injury, so as to facilitate the recovery of the uterus after operation and reduce the risk of long-term pelvic adhesion. Myomectomy at the same time after cesarean section has its own advantages and disadvantages [4, 8, 12, 13]. It is very important to make a good evaluation and countermeasures before operation. All the operations in this study were performed by the same medical team, and the chief surgeon had 15–25 years of surgical experience, and the patient's tolerance and willingness were fully evaluated before operation. In this study, there were 3 cases of blood transfusion, of which 1 case in the study group was postpartum hemorrhage caused by multiple myoma evisceration, and 2 cases in the control group were complicated with severe anemia before operation, so they were treated with blood transfusion before operation.
In short, pregnancy with uterine leiomyoma will increase the difficulty of obstetrical management. Pregnancy with large myoma in the lower segment of the uterus often has to choose cesarean section to terminate pregnancy because the myoma blocks the birth canal. It is the aspiration of many pregnant women to eviscerate the myoma of the lower part of the uterus at the same time during cesarean section, which can reduce the possibility of postpartum hemorrhage and secondary operation caused by uterine weakness caused by myoma. In this study, we make full use of the transverse incision of the lower segment of the uterus to remove the myoma of the intermuscular type of the anterior wall of the middle and lower segment of the uterus, which can not increase the wound surface of the uterus and reduce the risk of pelvic adhesion and uterine adhesion in the future. This method is easy to master and is a choice for hysteromyoma evisceration during cesarean section. Because the number of cases in this study is limited, and the follow-up time is not long enough, the long-term impact on the long-term needs to be further prospective case-control studies.