HYSTEROSCOPIC MYOMECTOMY Kristine Herrmann MD, presents the hysteroscopic myomectomy of a 34 year old female, G2P2 who presented with menometrorrhagia unresponsive to hormone therapy. A pelvic ultrasound identified the pedunculated, mobile intrauterine mass consistent with either a leiomyoma or a polyp. Subsequent histologic examination identified the mass as a leiomyoma. A leiomyoma is the result of the benign growth of a smooth muscle cell in the muscle of the uterus. The leiomyoma is visualized inside the uterus which is distended with 32% dextran 70. Because it has grown on a pedicle, it is essentially floating in the distention media suspended by its stalk. The stalk contains the blood supply of the tumor. The loop of the resectoscope can be seen in the foreground at the internal os of the cervix and the myoma in the background. The endometrium appears atrophic because the patient was treated preoperatively with a GnRH agonist to diminish the size of the myoma and, as a result, decrease the operating time. Long term GnRh agonist therapy is not recomended because of the hypoestrogenic side effect of bone loss with long term treatment. If bleeding occurs despite the electocoagulation technique and GnRH agonist pretreatment, a balloon catheter can be inserted into the endometrial cavity postoperatively to tamponade the bleeding sites. It can be deflated several hours after surgery, and removed if the bleeding has ceased. The myoma is released by progressive shaving of the stalk. The loop of the resectoscope is placed at the most distant portion, and current is applied as the resectoscope is drawn toward the surgeon. Current should never be applied when the direction of the resectocope is moving away from the surgeon to avoid perforating the uterus with the risk of damage to the organs adjascent to the uterus. The stalk of the myoma is all that remains, and it is shaved with the cautery only as the instrument is withdrawn toward the surgeon. The Chester forceps were used to remove the myoma from the cavity. Hemostasis is assured, and the operation is complete. Possible complications of myomectomy can include blood loss, fever, ileus, anemia, pain, late intestinal ostruction, infertility, recurrence, possible need for hysterectomy, cesarean section, and subsequent surgery.