Navigating Adenomyosis: A Case Series on Uterus - Conserving Adenomyomectomy for Enhanced Clinical Insights

Diffuse adenomyosis poses a challenging clinical scenario due to its widespread infiltration within the uterine wall , often leading to symptomatic manifestations and impacting fertility . This

explores the efficacy and outcomes of conservative surgery , specifically adenomyomectomy , as a uterus - saving approach in managing diffuse adenomyosis . The study reviews a cohort of patients diagnosed with diffuse adenomyosis who underwent conservative surgery aimed at excising adenomyotic lesions while preserving the integrity of the uterus . Various surgical techniques and approaches are analyzed , considering their impact on symptom relief , reproductive outcomes , and postoperative complications . Preliminary findings suggest that conservative adenomyomectomy can be a viable option for patients seeking to retain their uterus while addressing the symptomatic burden of diffuse adenomyosis . The study emphasizes the importance of meticulous surgical planning , intraoperative precision , and patient selection for optimal outcomes . This

contributes valuable insights into the evolving landscape of adenomyosis management , highlighting the potential of conservative surgery as a uterus - preserving strategy for those facing the challenges of diffuse adenomyosis .

Adenomyosis , adenomyomectomy , conservative surgery , uterus preserving strategy 1.

Adenomyosis is uterine thickening that occurs when endometrial tissue , which normally lines the uterus , moves into the outer muscular walls of the uterus . The advised treatment for the severe forms of adenomyosis is hysterectomy [ 1] ( removal of the patient’s uterus ), but for the patient who wishes to preserve her uterus , a novel conservative surgery referred to as ‘adenomyomectomy’ ( removal of the abnormal tissues ) can be performed [ 2] . This technique must be developed for reduction of spontaneous uterine rupture , adhesions and recurrence rate [ 2] . This study aims to investigate the safety and therapeutic outcomes of adenomyomectomy . Because of the pathogenesis of adenomyosis , surgical treatment by adenomyomectomy must involve the resection of all the altered tissues , leave the thin healthy myometrium intact , reconstruct the uterus in a specific manner with the lowest degree of adhesion and ensure that the sutures allow for efficient blood supply for the repair . Decreasing ischaemia in the endometrium by removal of the fibrosis tissue is the major purpose of the surgical

. The aim of this study is to investigate the safety and therapeutic outcomes of a different adenomyomectomy technique with the above charactuteruseristics . The aim is to introduce this surgical technique as an alternative treatment option to hysterectomy for uterine adenomyosis , specifically for the patient who wishes to preserve her uterus and perhaps have a child in future . Case Series 1 A 33 years old female P1L1 complained of dysmenorrhoea and lower abdominal pain along with heavy menstrual bleeding since last 1 year was planned for myomectomy . Patient was given medical management prior to that for 3 months but symptoms did not get subsided . USG suggestive of myoma of size 6 .6 *7*6 .6 cm in posterior wall of uterus . Per vaginally uterus was 14 - 16 week size with firm to soft in consistency with no any separate mass feel in the adnexa and mobility of uterus was unrestricted . Intraoperatively , however there was no clear surgical plane or whitish whorled appearance of fibroid , posterior wall of uterus was symmetrically enlarged and diagnosis of adenomyosis is made . Case Series 2 A 34 yrs old female P1 L1 with huge adenomyoma of size 11 .4 * 9 .9 *10 .4 cm in posterior wall of uterus in USG was evaluated ivo lower abdominal pain and dysmenorrhoea since last 6 - 7 years . MRI confirmed diagnosis of adenomyoma . Patient was initially was treated with LNG IUS but symptoms did not subsided with medical management Per abdomen mass of size 14 - 16 weeks felt with side to side mobility but restricted from above downwards not separated from uterus . Per vaginally cervix was pulled up . Paper ID: SR24916211831 DOI: https://dx.doi.org/10.21275/SR24916211831 1324 International Journal of Science and Research (IJSR) ISSN: 2319 - 7064 SJIF (2022): 7.942 Volume 13 Issue 9, September 2024 Fully Refereed | Open Access | Double Blind Peer Reviewed Journal www.ijsr.net Patient was posted for adenomyomectomy and intraopeatively 7*6*7 cm adenomyotic tissue removed Case S eries 3 A 37 years old nulligravida with a history of primary infertility complained of heavy menstrual bleeding and dysmenorrhoea since last 6 - 7 months . Patient took medical management with antifibrinolytics and progesterone therapy for 3 - 4 months but symptoms didnot get subsided . MRI was suggestive of posterior wall adenomyoma of size 7 .2 *7*7 .1 cm . Per vaginally uterus was around 10 - 12 weeks size Patient posted for adenomyomectomy . Intraoperatively around 6*7*7 cm adenomyotic tissue removed . 2. Surgical Technique The surgical procedure consists of radical excision of adenomyosis ( leaving a 1 cm margin of tissue above the endometrium and a 1 cm margin of tissue below the serosal surface ), with subsequent triple - flap reconstruction of the uterus . In the uterus ,. inj vasopressin was injected . The enlarged uterus is bisected from the serosal surface of the fundus , in the midline and in the sagittal plane , all the way down through the adenomyosis until the uterine cavity is reached . In this way the entire extent of the adenomyosis is clearly visible , t he endometrial cavity is opened sufficiently to permit the

of the index finger to protect and help guide during excision of the adenomyotic tissues . The adenomyotic tissues are excised from surrounding myometrium leaving a myometrial thickness , from the serosa above and the endometrium below , of 1 cm . Care is also taken to avoid damage to the Fallopian tubes . The endometrial lining is then approximated with interrupted sutures of 3 – 0 Vicryl . Thereafter , the myometrial defect closed with the triple - flap overlap

[ 1] , with care being taken to avoid overlapping suture lines . The uterus is reconstructed in the following manner . On one side of the bisected uterus the myometrium and serosa are approximated in the antero - posterior plane with many interrupted sutures of 2 – 0 Vicryl . Then the contralateral side of the uterine wall ( composed also of serosa and myometrium ) is brought over the reconstructed first side in such a way as to cover the seromuscular suture line . Suture lines must not overlap ; only myometrial tissue flaps overlap . The myometrium of the underlying flap must be denuded of serosa . Remarkably , there is no significant bleeding because of the tissue pressure created by the reconstruction . Figure 1 : S tepwise procedure of adenomyomectomy with triple flap overlap

Paper ID: SR24916211831 DOI: https://dx.doi.org/10.21275/SR24916211831 1325 International Journal of Science and Research (IJSR) ISSN: 2319 - 7064 SJIF (2022): 7.942 Volume 13 Issue 9, September 2024 Fully Refereed | Open Access | Double Blind Peer Reviewed Journal www.ijsr.net Post - operative course Post - operative period was uneventful . The removed tissues were confirmed by histopathological assay . Symptoms of dysmenorrhoea and heavy menstrual bleeding significantly reduced on visual analogue scale score of 1 - 10 . Post - operatively , after discharge from the hospital , the patients were initially followed monthly for 6 months and subsequently every 2 – 3 months . For the first 6 months , the uterine blood flow was checked monthly with endovaginal ultrasonography with colour Doppler imaging and with contrast - enhanced MRI every 3 months . Uterine blood flow in the operated area generally returned to normal within 6 months and post - operative MRI appeared remarkably normal . Figure 2 : USG showing pre and post - operative case of adenomyomectomy 3.

This study shows that adenomyomectomy can be a conservative and effective option to treat adenomyosis , especially in women who seek uterine and fertility preservation . Severe adenomyosis causes infertility , severe dysmenorrhea and hypermenorrhoea [ 1] [ 4] . Uncertainty in defining the site and extent owing to a lack of surgical plane makes it difficult to determine the extent of complete excision [ 3] . One constantly needs to balance between inadequate removal of the adenomyoma versus excessive healthy myometrial excision that is detrimental to wound integrity [ 3] . The rationale for adenomyomectomy includes that of cytoreduction , debulking to relieve the mechanical disturbances , and correcting physiological disturbances that may impair sperm transport [ 3] . The procedure described in this study can be an efficient procedure to treat severe adenomyosis . This

can be further modified for better outcomes and this study centre is attempting to develop safer and less invasive

to promote the management of adenomyosis .

[1] Surgical procedure to conserve the uterus for future pregnancy in patients suffering from massive adenomyosis Hisao Osada et al . Published : October 06 , 2010DOI : https : // doi . org/10 .1 016/j . rbmo .2 010 .0 9 .0 14 [2] Treatment of adenomyomectomy in women with severe uterine adenomyosis using a novel technique AboTaleb Saremi et al Published : March 06 , 2014DOI : https : // doi . org/10 .1 016/j . rbmo .2 014 .0 2 .0 08 [3] Approaches to adenomyomectom Serene Thain et al https : // doi . org/10 .1 016/j . gmit .2 014 .0 8 .0 06 [4] Medical and surgical management of adenomyosis Cynthia Farquhar MBChB , MD , FRANZCOG , CREI , MPH ( Postgraduate Professor of Obstetrics and Gynaecology ), et al https : //doi . org/10 .1 016/j . bpobgyn .2 006 .0 1 .0 12 Paper ID: SR24916211831 DOI: https://dx.doi.org/10.21275/SR24916211831 1326