Surgical Management of a Necrotic Fibroid in a Patient With Venous Thromboembolism

INTRODUCTION: Venous thromboembolism (VTE) is a serious, yet rare, complication of uterine fibroids. Anticoagulation is typically required, making management of vaginal bleeding more challenging. In most cases, surgery should be delayed; however, when medical management fails, and delaying surgery is not possible, appropriate surgical preparation and technique are critical. OBJECTIVE: The objectives of this video are to review the management of patients with fibroids and concurrent VTE, and to demonstrate uterine-sparing surgical management of a complex patient with a large necrotic fibroid with concurrent VTE. METHODS: Educational video highlighting management and surgical techniques. RESULTS: We highlight recommendations for the management of patients with a VTE in the setting of a large uterine fibroid, including delaying surgery 1–3 months after VTE diagnosis, IVC filter placement in severe cases, the need for anticoagulation, and management of vaginal bleeding while on anticoagulation. We present a case of a complex patient with a large necrotic fibroid with concurrent VTE who underwent uterine-sparing surgical management. We then demonstrate specific surgical techniques used in laparoscopic myomectomy of a large necrotic fibroid, including use of vasopressin and ligation of the distal internal iliac arteries for hemostasis, and repeated retrograding filling of the bladder and ureterolysis to prevent urologic injury. CONCLUSIONS: We have demonstrated appropriate medical and surgical management of a complex patient with a large necrotic fibroid with concurrent VTE.