Postoperative Rectal Necrosis after Laparoscopic Multibipolar Radiofrequency Myoma Ablation.

A 40-year-old nulliparous woman underwent an outpatient laparoscopic ultrasound-guided multibipolar radiofrequency ablation of 2 myomas measuring 4 × 7 cm (anterior International Federation of Gynecology and Obstetrics type IV) and 6 × 7 cm (posterior International Federation of Gynecology and Obstetrics type V) using the Celon device (Olympus, Inc.). Three applicators were used to treat the anterior myoma during 35 minutes with a total energy delivered of 119 KJ. The posterior myoma was treated using the same 3 applicators (placed to treat the right then the left half of this myoma, to allow a better visualization and distancing of the rectum) during 40 minutes with a total energy delivered of 159 KJ. Fifteen days postoperatively, the woman presented with pelvic pain and clinical bowel obstruction. Clinical examination revealed an acute abdominal syndrome and tachycardia with serology reporting a C-reactive protein of 380 mg/L. Pelvic ultrasound reported that the myomas were necrotic (Fig. 1). Abdominal/pelvic computed tomography reported that the posterior myoma was indistinguishable from the rectal wall, with a loss of rectal wall continuity (Fig. 2). A laparotomy revealed a 7 cm rectal perforation and fecal peritonitis (Fig. 3). Multiple myomectomy and Hartmann's procedure with partial sigmoid resection and terminal colostomy were performed. Fig. 2(A) CT scan of the pelvis, sagittal view, demonstrating a rectal fistula in communication with posterior uterine myoma. No distinction possible between the rectum and the necrotic myoma (green arrow). (B) CT scan of the pelvis, transverse view, demonstrating a rectal fistula with the presence of a few foci of gas (pneumoperitoneum bubbles) in contact with myoma (green arrow). Probable stercoral matter in myoma. CT = computed tomography. View Large Image Figure Viewer Download Hi-res image Fig. 3Intraoperative photo of the uterus in vivo with a large fistula communicating between the posterior uterine wall and the anterior wall of the rectum. (A) Uterus. (B) Anterior myoma. (C) Opened and impacted rectum. (D) Pseudomembrane. View Large Image Figure Viewer Download Hi-res image