Parasitic leiomyoma in the trocar site after laparoscopic myomectomy:A case report

lNTRODUCTlON

Uterine myoma is the most common benign neoplasm of the female genitalia.However,most patients with uterine myoma are asymptomatic,despite the relatively high prevalence[1,2].A variety of treatment modalities,such as medical or surgical interventions have been used for symptomatic patients.As for surgical management,laparotomy or minimally invasive surgery may be preferred[3].

Since the introduction of laparoscopic hysterectomy in 1989,several laparoscopic surgical tools have been developed to broaden the scope of minimally invasive pelvic surgery and to facilitate surgeons[4].Several devices for laparoscopy are also used for the removal of large tumorssmall incisions,enabling laparoscopic hysterectomy and laparoscopic myomectomy.

The increased use of laparoscopic power morcellators has allowed the removal of large leiomyomas through small incisions with benefits,such as reduced bleeding,shorter hospital stays,and shorter recovery times[4,5].Fragmentation of myoma with a morcellator can result in peritoneal dissemination,which can develop into a parasitic leiomyoma if not identified during surgery[1].

It was my first day as newcomer to Miss Hargrove’s seventh grade. Past “newcomer” experiences had been difficult, so I was very anxious to fit in. After being introduced to the class, I bravely put on a smile and took my seat, expecting to be shunned1.

Parasitic myoma is defined as the ectopic implantation of uterine fibroids[6].They obtain their blood supply through new blood vessels coming from adjacent organs.Since the introduction of electromechanical tissue morcellator,many studies have reported the occurrence of parasitic myomas after morcellation.This is a rare late sequela of laparoscopic morcellation procedures[7].The prevalence of parasitic leiomyomas is estimated to be 0.07% after laparoscopically removing the uterine leiomyoma[8].As for parasitic leiomyomas,only a few studies have reported trocar-site implantation of parasitic leiomyomas[9-12].

Trocar-site implantation is defined as tumor recurrence at the abdominal wall within the trocar sites,following laparoscopic examination for malignant diseases[13].It is not metastasis but rather the occurrence of a residual tumor that has not been resected from a previous surgery.Since the pathophysiology is not clear,the disease is rare and difficult to manage.Herein,we present a case of trocar-site implantation of a parasitic myoma after laparoscopic myomectomy with power morcellation.

CASE PRESENTATlON

Chief complaints

A 50-year-old woman was referred to our outpatient clinic,owing to the presence of a mass on the left side of the lower abdominal wall.

In times past, women gained marriage offers and social standing through their domestic arts. Spinning was part of their domain and was later taken over by men and machinery. Bottigheimer contends that the tale was originally about a woman who was threatened because she could only spin gold, not the flax needed to clothe those who depended on her skills. She contends that Wilhelm Grimm changed the tale into one about boasting and greed instead of a young girl s ability to spin (Bottigheimer 1982, 149).

History of present illness

The patient had no recent history of trauma or abdominal injuries,and did not complain of any abdominal symptoms associated with the mass.

Here she resumed her own gigantic shape, tore up the trees by their roots, threw one of them over her back and clasped the other to her breast, carried them down to the shore and waded12 out with them to the ship

History of past illness

Yeah, he said, at thirty-two, I was beginning to wonder if any woman was going to have me. He pulled his wallet out of his pocket. Here, he said, suddenly serious, look at this.

The patient had undergone laparoscopic myomectomy for uterine myoma six years ago;however,she reported no past medical,psychological,or pharmacological history.

Personal and family history

The patient could not remember any remarkable medical history of her parents or siblings.

Physical examination

Physical examination revealed the presence of a palpable mass in the left lower quadrant,overlying the previous laparoscopic trocar site.There was no localized tenderness over the left lower quadrant.

Laboratory examinations

Initial laboratory tests were within normal limits as follows: white blood cell count,3900/μL;hemoglobin level,12.3 g/dL;and platelet count,217000/μL.Other routine blood chemistry tests,such as renal panel,hepatic panel,pancreatic enzymes,and coagulation test were also within the normal limits.

Imaging examinations

Surgeons must perform a meticulous examination to avoid tissue residue and abundant peritoneal lavage.Various alternatives have been suggested to reduce the risk of parasitic leiomyoma after laparoscopic power morcellation[21].One of them is performing morcellation using a containment bag.This method can reduce the spread of the morcellated fragments.However,the protected manual in-bag morcellation technique is still controversial for the spread that cannot be ignored at the microscopic level[22].Furthermore,small tissue of the myoma may be dispersed intraperitoneally during myomectomy or hysterectomy before bagging[23].Therefore,it is necessary to cautiously examine the peritoneal cavity after laparoscopic morcellation to ensure that no small tissue fragments remain,although this approach might be incomplete for removal of all myoma fragments.Although laparoscopic surgery established better patient outcomes,care must be taken to prevent the spread of occult sarcomas,which may be closely related to survival[24].

FlNAL DlAGNOSlS

The final diagnosis was a leiomyoma.Histopathological assessment after the surgery revealed that the fragment of brownish firm tissue measured 2.6 cm × 2.0 cm × 1.2 cm.Immunohistochemistry analysis for actin showed a positive result,and the final diagnosis was leiomyoma.

TREATMENT

After laparoscopic myomectomy for multiple myomas with power morcellation,the patient developed trocar-site implantation of a parasitic leiomyoma without recurrence of intraperitoneal parasitic leiomyoma.

OUTCOME AND FOLLOW-UP

The patient recovered from the surgery without complications,and no other complications were observed during follow-up.

DlSCUSSlON

We performed surgical excision of the mass.After the skin incision,we approached the mass,which was located between the rectus muscle and aponeurosis of the external oblique muscle.The surgery took approximately 27 min from the skin incision to wound closure without intraoperative complications.The patient was discharged on the operative day without any complications.

The authors declare that they have no conflict of interest.

The clinical feature of parasitic leiomyoma depends on the site of recurrence and is generally nonspecific.Parasitic leiomyomas are commonly seen in the abdominal cavity,such as small/large bowel,bladder,and vaginal stump[16,17].However,to date,few cases of trocar-site implantation of a parasitic myoma after laparoscopic morcellation have been reported[9-12].Most patients with trocar-site parasitic leiomyoma are asymptomatic,especially when parasitic leiomyomas are discovered incidentally during other investigations or procedures.On the other hand,in patients with symptoms,the most common symptoms are abdominal pain and a palpable mass.

Measurement of tumor markers was not considered since our patient had no radiologic pelvic ascites,and the lesion was improbable to be malignant given a history of laparoscopic myomectomy.CA-125 is occasionally elevated in large parasitic leiomyomas.However,the current use of CA-125 as a biomarker for the diagnosis,differentiation and surveillance of parasitic leiomyoma is controversial and not recommended.However,if a malignancy,such as a leiomyosarcoma is suspected,measurement of tumor markers could be helpful for treatment and follow-up,especially when the level of the marker is initially elevated[18].Treatment includes surgical resection of the parasitic leiomyoma.When the parasitic leiomyoma is in other organs,a multidisciplinary approach is recommended whenever possible.However,in this case,since the mass was located on the anterior abdominal wall of the previous trocar site,a multidisciplinary approach was not required.Thus,resection was performed by laparotomy.

4. Score-keeping. I’m a score-keeper, always calculating who has done what. “I cleaned up the kitchen, so you have to run to the store” -- that sort of thing. I’ve found two ways to try to deal with this tendency（，）. First, I remind myself of the phenomenon of unconscious over-claiming; i.e., we unconsciously overestimate8 our contributions or skills relative to other people’s. This makes sense, because of course we’re far more aware of what we do than what other people do. According to Jonathan Haidt’s The Happiness Hypothesis, “when husbands and wives estimate the percentage of housework each does, their estimates total more than 120 percent.” I complain about the time I spend organizing babysitting or paying bills, but I overlook the time my husband spends dealing9 with our car or food-shopping.

Abdominal computed tomography demonstrated a 2.2-cm well-defined contrast-enhancing mass on the left side of the abdominal wall beside the rectus muscle.There were no remarkable findings in the upper abdominal solid organ.The radiological diagnosis was a desmoid tumor,and the differential diagnosis included endometriosis and neurogenic tumors,such as neurofibroma(Figure 1).

CONCLUSlON

Trocar-site implantation of a parasitic leiomyoma is a rare late complication after laparoscopic myomectomy or hysterectomy using power morcellation.Clinicians should explain to the patient the benefits and risks of the laparoscopic approach using morcellation.Moreover,efforts should be made to examine the abdominal cavity to retrieve all myoma fragments.Power morcellation during laparoscopic myomectomy should always be performed in a containment bag whenever possible to prevent excessive tissue fragmentation.

FOOTNOTES

Kwon HJ and Roh CK drafted the paper;Roh CK and Jung MJ revised the manuscript;Kwon HJ and Roh CK collected patient’s information;Roh CK performed the treatment for this patient.

This case report was approved by our institutional review board(Approval No.AJIRBMED-EXP-21-424),who waived the requirement for informed consent because of full anonymization of patient information.However,written informed consent was obtained from the patient.

The Prince was so overwhelmed with grief that he could think of nothing but his father, and exclaimed: Yes, yes, dear father, whatever you desire shall be done

Laparoscopic myomectomy and hysterectomy are increasingly used to treat gynecological tumors[4].Power morcellators are often used to fragment bulky lesions,such as uterine myomas.Some of the small fragments may unintentionally settle in the peritoneal cavity and be implanted[14].They receive vascular supply from the adjacent structures and develop into a parasitic leiomyoma[15].Parasitic leiomyoma is a rare late sequala after laparoscopic myomectomy using power morcellation;the reported incidence is 0.2% to 1.25%,and diagnosis interval is four years(median)[8].It is unclear why parasitic leiomyomas develop in only a few patients who undergo laparoscopic myomectomy or hysterectomy.A large-scale prospective study is warranted to determine the incidence and risk factors for parasitic leiomyomas after laparoscopic myomectomy or hysterectomy using power morcellation.

Power morcellation during laparoscopic myomectomy is considered a factor in the pathogenesis of iatrogenic parasitic leiomyoma[19].In this case,parasitic leiomyoma of the abdominal wall supports this hypothesis,as the parietal peritoneum anatomically attaches to and protects the abdominal wall.During unconfined morcellation,small myoma fragments may inadvertently disperse into the abdominal cavity and regrow as parasitic leiomyomas.Morcellation should be avoided when malignancy is suspected.In 2014,the United States Food and Drug Administration(U.S.FDA)released the safety statement for laparoscopic power morcellation as follows: U.S.FDA recommended avoiding laparoscopic power morcellation for hysterectomies or myomectomies because of the risk of occult uterine sarcomas spreading[20].Likewise,this warning should be taken seriously for benign uterine tumor removal during laparoscopic surgery.

The woman was still raging, and did not seem likely to stop, when her husband, who by this time had forgotten all about her, drew out the chest from under his cloak, and opened it

At this the witch became so furious that she danced about and knocked everything to pieces that she could lay her hands upon, so that the splinters flew about the ears of the prince and princess, who now stood there in her own beautiful shape

The authors have read the CARE Checklist(2016),and the manuscript was prepared and revised according to the CARE Checklist(2016).

This had gone on so long that now there were no men left, and he had been obliged to send his own daughter instead, and the poor girl was waiting till the monster got hungry and felt inclined to eat her

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers.It is distributed in accordance with the Creative Commons Attribution NonCommercial(CC BYNC 4.0)license,which permits others to distribute,remix,adapt,build upon this work non-commercially,and license their derivative works on different terms,provided the original work is properly cited and the use is noncommercial.See: https://creativecommons.org/Licenses/by-nc/4.0/

South Korea

Chul Kyu Roh 0000-0003-2254-6146;Hyuk-Jae Kwon 0000-0003-1821-6515;Min Jung Jung 0000-0001-8870-5475.

Gao CC

A

Gao CC