Above and below Hybrid Hysterectomy: Minimally Invasive Approach to a Prolapsed Uterus

Abstract

Study Objective

We present the surgical approach for a minimally invasive hysterectomy utilizing a hybrid above and below method in the setting of uterine inversion due to uterine embryonal rhabdomyosarcoma (ERS).

Design

Given the rare presentation of uterine ERS with prolapse and inversion, a minimally invasive hybrid approach was selected.

Setting

The patient was placed in dorsal lithotomy position with Allen stirrups. Equipment included a Rumi manipulator, ultrasonic dissection device, Hassan 10-mm trocar, two 5-mm ports, laparoscopic graspers, laparoscopic needle drivers, vascular clips, and 2-O VLOC suture.

Patients or Participants

This is a single-case report.

Interventions

Complete uterine inversion was seen where only the fallopian tubes and ovaries were appreciated. Attempt from below to relieve the inversion were unsuccessful. Attention was turned to retroperitoneal dissection. This was carried inferiorly all the way to the round ligament, bilaterally. A bilateral salpingectomy was performed. Attention then turned to the utero-ovarian ligaments where a peritoneal window was created under the IP ligament and stretched. The vessels were isolated, then sealed and divided bilaterally. The uterine artery was isolated at its origin and clipped with two 5 mm clips. This was repeated contralaterally. Vaginally, the uterine corpus was amputated with Jorgenson scissors. From above, residual lower uterine segment was able to be reduced. The bladder flap was created. The uterine vessels were then divided bilaterally. The colpotomy was performed and the vaginal cuff was closed using a 2-0 VLOC laparoscopically.

Measurements and Primary Results

Literature review revealed that non-puerperal uterine inversion is a rarity. A few case reports have documented successful management of benign inversion through minimally invasive approaches. Rodrigues et al. (2024) reported a case of uterine inversion associated with ERS, but management was performed via laparotomy. To our knowledge, there are no prior reports of minimally invasive management in this setting.

Conclusion

This case supports the feasibility of minimally invasive surgery even in complex presentations.