{"paper_id":"8e7ecb58-6eda-4377-bd2a-fa910fd99aa5","body_text":"~ 36 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2023; 7(4): 36-39 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2023; 7(4): 36-39 \nReceived: 08-05-2023 \nAccepted: 14-06-2023 \n \nDr. Satish Kumar KV  \nPediatric surgery, Consultant \nPediatric Surgeon, Department of \nPediatric Surgery, Bangalore \nBaptist Hospital, Rajiv Gandhi \nUniversity of Health Sciences \n(RGUHS), Bangalore, Karnataka, \nIndia  \n \nDr. Naveen Thomas \nPediatric surgery), M.Phil. \nConsultant Pediatric Surgeon \nDepartment of Pediatric Surgery \nBangalore Baptist Hospital, Rajiv \nGandhi University of Health \nSciences (RGUHS), Bangalore, \nKarnataka, India \n \nDr. Ravi Patil \nConsultant Obstetrician and \nGynecologist, Department of \nObstetrics and Gynecologist \nBangalore Baptist Hospital, Rajiv \nGandhi University of Health \nSciences (RGUHS), Bangalore, \nKarnataka, India \n \nDr. Sathyavani \nConsultant Obstetrician and \nGynecologist, Department of \nObstetrics and Gynecologist \nBangalore Baptist Hospital, \nUniversity, Rajiv Gandhi \nUniversity of Health Sciences \n(RGUHS), Bangalore, Karnataka, \nIndia \n \nDr. Nisha Girish \nGen. Surgery Resident \nDepartment of Surgery, Bangalore \nBaptist Hospital, Rajiv Gandhi \nUniversity of Health Sciences \n(RGUHS), Bangalore, Karnataka, \nIndia \n \n \n \n \nCorresponding Author: \nDr. Satish Kumar KV  \nPediatric surgery, Consultant \nPediatric Surgeon, Department of \nPediatric Surgery, Bangalore \nBaptist Hospital, Rajiv Gandhi \nUniversity of Health Sciences \n(RGUHS), Bangalore, Karnataka, \nIndia \n \nLaparoscopic excision of non-communicating accessory \nuterine horn in an adolescent girl with unicornuate \nuterus \n \nDr. Satish Kumar KV, Dr. Naveen Thomas, Dr. Ravi Patil, Dr. Sathyavani \nand Dr. Nisha Girish \n \nDOI: https://doi.org/10.33545/gynae.2023.v7.i4a.1368 \n \nAbstract \nDysmenorrhea in is seen in 41 -91.5% adolescent girls and is mostly due to primary dysmenorrhea. \nEndometriosis is the most common cause of secondary dysmenorrhea and very rarely is due to obstructive \nmullerian anomalies. \nAn adolescent girl with unrelenting dysmenorrhea with frequent hospital visits, had an obstructed \naccessory uterine horn on ultrasound and was confirmed on MRI scans. She underwent successful \nlaparoscopic excision and was relieved of her dysmenorrhea.  \nThese lesions are rare bu t can cause severe dysmenorrhea not responding to medical management and \nunrecognized lesions can lead to infertility, ectopic pregnancy in accessory horn with catastrophic \ncomplications and infertility. They are the most commonly detected during 3\nrd decade of life, with very few \ncases being diagnosed and successively treated in adolescent girls. Early recognition and laparoscopic \nexcision can relieve the dysmenorrhea and preserve fertility in these patients. \n \nKeywords: Secondary dysmenorrhea, Accessory communicating uterine malformation (ACUM), \nObstructive Mullerian anomalies, Unicornuate uterus, rudimentary uterine horn \n \nIntroduction  \nMullerian anomalies affect 5.5 -7% of women and are increasingly seen in women with \ninfertility and miscarriages.  Obstructive lesions can be symptomatic especially during \nadolescence. Completely obstructive lesions can present with amenorrhea and abdominal pain, \nwhile those with partial obstruction, present with cyclical pain and the diagnosis can get \ndelayed. In a large propor tion of patients with unicornuate uterus, the accessory horn may be \nfunctional and are non -communicating. These patients can present with cyclical pain and are \nusually diagnosed during 3 rd decade of life. Evaluation and management of an adolescent girl \nwith accessory blind ending uterine horn who presented with severe dysmenorrhea is presented \nhere. \n \nCase report \nA 13 year old girl, apparently well and healthy presented with worsening dysmenorrhea with \neach menstrual cycle. She had attained menarche 1 year a go and the cycles were regular but \nalways had some dysmenorrhea. In the current cycle she presented to emergency with severe \nabdominal pain and vomiting for 4 days.  On admission she was mildly dehydrated, in severe \npain and had a diffusely tender abdomen. After adequate resuscitation and analgesia, she \nunderwent further evaluation. Her blood investigations were essentially normal. Ultrasound was \nsuspicious of non- communicating left rudimentary horn filled with blood, which was then \nconfirmed on MRI Scan. (F igure 1). She was electively planned for laparoscopy with a plan to \nresect the accessory horn. After bladder catheterization a 3 -port laparoscopy was performed \nusing 10mm Umbilical camera port and 2 infraumbilical 5 mm lateral ports. On laparoscopy, \nthere was no blood in the peritoneal cavity and the uterus appeared bulky with deviation to right. \nA large accessory horn was evident on the left side with a deep notch on the superior aspect of \nuterus (Figure 2a). Bilateral tubes were present with normal lookin g ovaries and fimbria.  \nMarking with hook diathermy delineated the accessory horn with care being taken to avoid entry \ninto the main uterine cavity (Figure 2 b).  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 37 ~ \nUsing ligature and hook diathermy the accessory horn was \nseparated from the uterine wall and  broad ligament and \ncompletely resected  laparoscopically (Figure 2 C) . The \nmyometrium was repaired with interlocking 2 -0 vicryl sutures. \nThe specimen was delivered out through small suprapubic \nincision (Fig 3). She recovered uneventfully; urinary catheter \nwas removed next day, and she was discharged on full orals after \n2 days. The biopsy confirmed rudimentary uterine horn. In the \nlast follow up one year from the procedure, her menstrual cycles \nare painless and regular. \n \nDiscussion \nUterine malformations are known to occur in 4% of infertile \nwomen and in 15% of those women, who have experienced \nrecurrent miscarriage, can harbor Mullerian malformation. \nObstructive Mullerian anomalies (Uterus didelphys with \nimperforate hemivagina, a noncommunicating cavitated ut erine \nhorn in unicornuate uterus; an accessory cavitated uterine mass \n(ACUM); a micro perforate transverse vaginal septum) can also \npresent with severe dysmenorrhea \n[1]. The unicornuate uterus \nwith rudimentary horn is one of the rarest of uterine anomalies  \naffecting 1in 100,000 fertile female population [2]. Seventy five \npercent of unicornuate uterus cases present with a rudimentary \nhorn, and in 80 -90% of cases, there is no communication with \nthe primary uterine cavity [3]. \nThe basis of the defect lies in n ormal development of one \nMullerian duct coupled with failure of the contralateral \nmullerian duct to elongate or to reach the urogenital sinus \n(which forms the lower third of the vagina) dur ing the ninth \nweek of gestation \n[4]. The most common presentation of these \nanomalies is severe dysmenorrhea dating back to menarche, but \nmean age at diagnosis is usually in 3 rd decade of life. Our index \npatient presented with dysmenorrhea since menarche and had \nmultiple outpatient consultations for the same, which was \ninitially diagnosed as primary dysmenorrhea. \nIf dysmenorrhea is not responding to 3 cycles of medical \ntherapy, detailed pelvic imaging and laparoscopy may be \nindicated to exclude mullerian anomalies, endometriosis, or \nother pathologies [1]. These rudimentary horns are predominantly \nright-sided (62%) and in our case it was found on the left side.  \nThe clinical presentation is based on the configuration of horn, \nwhether blind or communicating and presence of endometrium. \nUnilateral renal agenesis are associated w ith mullerian \nanomalies in up to 30% of cases  \n[4]. In our patient the imaging \nmodalities showed presence of normal appearing kidneys \nbilaterally with no other renal tract anomalies. \nThough the mean age of presentation is usually in 3\nrd decade of \nlife when patients are symptomatic, detection before clinical \nsymptoms have also been reported in 14 % of cases [5] and in our \npatient persistent dysmenorrhea and imaging led to diagnosis, \nearly in her adolescence. The criteria used for the diagnosis are: \nPresence of an accessory intramyometrial cavitated mass, \nnormal appearance of the uterus, fallopian tubes and ovaries, and \nthe cavity must not communicate with the normal endometrial \ncavity. More th an 90 % of these rudimentary horns are non -\ncommunicating. There are o ther modalities ( hysteroscopy) \ndescribed to ensure blind nature of the r udimentary horn in \nparous women \n[1, 6]. In our index patient, on laparoscopy the horn \nwas well above the confines of pelvic peritoneal reflection and \nwith the findings on imaging, it was non-communicating variant. \nThe primary objective of surgery is to alleviate symptoms, \nprevent complications and preserve future pregnancy. \nLaparoscopic excision is an established technique in alleviating \nsymptoms and also preve nts future complications \n[7]. Ectopic \npregnancy occurring in a communicating uterine horn is a \npossibility and can lead to serious complications if \nunrecognized. Successful pregnancy following excision of \naccessory uterine horns have been reported \n[8]. The aryl \nrecognisition, especially in adolescent period as in our case, may \nprevent future complications such as endometriosis, infertility \nand ectopic pregnany in future.  Our index patient is now 14 year \nold and needs close meticulous follow up by obstetricians during \nadult hood to go through safe pregnancy. \n \n \n \nFig 1: MRI Scan-large left accessory horn. \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 38 ~ \n \n  \n \nFig 2 a: Laproscopic appearance of accessary uterine horn. A deep \nnotch (Arrow) demarcates  the main uterine body and the horm \nFig 2 b: Laparoscopic excision using diathermy and ligasure, \navoiding entry into main uterine cavity \n \n \n \nFig 2c: Resected specimen \n \n \n \nFig 3: Port sites closed after completion. Suprapubic incision was used to extract the specimen\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 39 ~ \nConclusions \nSignificant dysmenorrhea in young adolescent girls can \noccasionally be due to obstructive mullerian anomalies. Severe \ndysmerrhoea not responding to repeat cycles of medical \nmanagement, may need imaging to exclude obstructive uterine \nlesions. Lpaparoscopy is the most useful tool in evaluating \npelvic pathology in unex plained dysmenorrhea. Laparoscopic \nresection of obstructed accessory uterine horns is feasible in \nyoung adults and this will prevent complications and can \nfacilitate successful pregnancy in future.  \n \nConflict of Interest \nNot available \n \nFinancial Support \nNot available \n \nReferences \n1. Fontana E, Parma M, Fedele F, Girardelli S, Parazzini F, \nCandiani M. Forty-two norm menstruating adolescents with \nMüllerian obstructive anomalies: Presentation, pitfalls in the \ndagnosis and surgical management. Acta Obstet Gynecol \nScand. 2023 Jan;102(1):92-98. \n2. Acién P, Acién M. The presentation and management of \ncomplex female genital malformations. Human \nReproduction Update. 2016;22(1):48-69. \n3. Gaied F, Calmolu EQ, Emil S. Laparoscopic excision of a \nrudimentary uterine horn in a child . our nal of Pediatric \nSurgery. 2011;46(2):411-414. \n4. Jayasinghe Y, Rane A, Stalewski H, Grover S. The \npresentation and early diagnosis of the rudimentary uterine \nhorn. Obstet Gynecol. 2005 Jun;105(6):1456-67. \n5. Takahashi T, Shiojima S, Hamano T , et al.  Laparoscopic \nresection of a non -communicating uterine rudimentary horn \nusing intra-operative indigocarmine injection: A case report. \nInternational Journal of  Surgery Case Reports. \n2021;81:105743 \n6. Strawbridge LC, Crouch NS , Cutner AS, et al. Obstructive \nMullerian A nomalies and Modern Laparoscopic \nManagement. Journal of Pediatric and Ado lescent \nGynecology. 2007;20(3):195-200. \n7. Ueda M, Ota K, Takahashi T, et al.  Successful pregnancy \nand term delivery after treatment of unicornuate uterus with \nnon-communicating rudimentary horn pregnancy with local \nmethotrexate injection followed by laparoscopic resection: a \ncase report and literature revi ew. BMC Pregnancy. \nChildbirth; c2021. p. 26. \n \n \nHow to Cite This Article \nKumar SKV, Thomas  N, Patil  R, Sathyavani, Girish N. Laparoscopic \nexcision of non-communicating accessory uterine horn in an adolescent girl \nwith unicornuate uterus . International Journal of Clinical Obstetrics and \nGynaecology. 2023;7(4):36-39. \n \n \nCreative Commons (CC) License \nThis is an open -access journal, and arti cles are distributed under the terms \nof the Creative Commons Attribution -Non Commercial-Share Alike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}