腹腔鏡下筋腫核出術にて子宮マニピュレーター抜去後に核出部位より再出血を認めた症例から学ぶ―子宮マニピュレーターのバルーンによる圧迫止血能力―

抄録

　A uterine manipulator is frequently used as a complementary factor for operation during laparoscopic myomectomy in the field of gynecology. However, the influence of a balloon in the uterine manipulator has not been reported in the past and sufficient information on such influence has not been provided. This was a 41-year-old case with no pregnancy or childbirth, referred to by the previous doctor for the purpose of operation for a unilocular cyst of the left ovary and multiple uterine myoma. Laparoscopic myomectomy and laparoscopic extraction of a cyst of the left ovary were performed while using a uterine manipulator, and upon myoma enucleation, a measure to reduce bleeding was taken with 100-fold dilution of vasopressin. Sterile physiological saline was injected in the balloon at the distal end of the tip of the uterine manipulator until piezoresistance was felt. Occult bleeding occurred from the needle’s eye due to needle handling at the site of myoma enucleation on the bottom; therefore, resuture was performed, and tissue adhesion and closure sheets for biological tissues were also adhered. As a result, rebleeding was not confirmed after passing the time period when vasopressin efficacy was assumed to wear off. After removing the uterine manipulator, however, rebleeding was recognized from the muscular layer at the site of myoma enucleation on the bottom; therefore, suture by needle handling was added for arrest of bleeding. Complication of postoperative intraperitoneal hemorrhage was successfully avoided with the opportunity of hemostasis at this time. In consideration of operation history, however, the state of the fully inflated balloon in the uterine manipulator may be indicating stress on and closure of blood vessels within the uterine muscular wall, partially contributing to measures to suppress bleeding. When a balloon is depressurized, therefore, it is important to run a final check on the state of the site of myoma enucleation as it is, without immediately removing the uterine manipulator. While the issue of perioperative bleeding is often emphasized as a complication during laparoscopic myomectomy, a bleeding pattern that occurs due to its removal immediately prior to the end of surgery exists in the case of using a uterine manipulator. I would like to propose that sharing the astriction ability of a uterine manipulator could help avoiding a pitfall of complications.