Osada, H.
October 2010
Reproductive BioMedicine Online (Reproductive Healthcare Limited;Oct2010 S3 Supplemen, Vol. 20, pS14
Academic Journal
Introduction: Severe case of adenomyosis is not only a cause of infertility, but may include severe dysmenorrhea, thus may interfere with a woman's well-being. Routine conservative surgery for adenomyosis involves a wedge resection of the involved uterine tissue, followed by approximating the remaining myometrium and serosa. However, this method may retain unexcised affected tissue, and thus result in an unsatisfactory post surgical prognosis such as being incapable of sustaining a normal pregnancy. Our proposed treatment for severe cases of adenomyosis involves wide complete excision of affected tissues to reduce post surgical dysmenorrhea, followed by a triple-flap reconstruction of the uterine wall to prevent ruptures in subsequent pregnancies. Methods: 1. Resection and removal of all adenomyosis-affected myometrium: The affected tissue is vertically incised, to split the area to be excised in two, the incision is extended to the uterine cavity. The tissue to be excised is grasped and placed under tension with Martin forceps. The tissue is adequately dissected free with scissors, with care taken to retain a serosal flap with a layer of myometrium, as well as a medial flap containing both endometrium and myometrium. The tissue flaps, both medial and distal must be more than 5mm in thickness to assure adequate material for the reconstruction of the uterine wall. It is essential to introduce an index finger into the uterine cavity to assure maintenance of an adequate medial flap thickness. Special care must be taken to prevent damage to the Fallopian tubes. 2. Reconstruction of the uterine cavity: Care must be taken to retain sufficient endometrium to allow reconstruction of an adequate uterine cavity. In cases of an over abundance of endometrial tissue, excess amounts must be removed to secure a more physiological uterine cavity. 3. Reconstruction of the uterine wall: Reconstruction of the middle portion of the uterine wall involves approximation of the myometrial musculature to ablate the space created by the excision of diseased tissue. The serosa including adequate myometrium is dissected free with a scalpel to form the third flap. The serosal or distal and third flap is then approximated to finish the reconstruction. 4. Hemostasis and application of hemostatic barriers for prevention of adhesion: The last step of this method is to apply TachoComb®, a Fibrin adhesive in sheet form, to the uterine surface for the control of oozing. The applied TachoComb® is firmly anchored and works as physical barriers, thus contributing to the reduction of post surgical adhesions. Results: Clinical post surgical evaluation was performed using the Visual Analog Scale (VAS) to assess dysmenorrheal and hypermenorrhea at 3, 6, 12, 24 months after surgery. We performed the procedures on 104 patients during the period between June 1998 and August 2008. Of the 26 women desired to conceive, 16 (61.5%) subsequently conceived. Of these, 4 women conceived spontaneously and 12 women conceived by in vitro fertilization and embryo transfer (IVF-ET). Two women who had IVF-ET experienced a spontaneous abortion; 14 went to term and all were delivered by elective Caesarean section. There were no cases of uterine complications to the pregnancies. The triple-flap reconstruction of the uterine wall following wide adequate excision of adenomyosis tissue in women with hypermenorrhea and/or dysmenorrhea resulted in a dramatic reduction in both menstrual cramping and menstrual flow volume post surgically and gave women chances to become pregnant.


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