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Ramdin and Wani: Save the uterus! Case of large fibroid with infertilityMOGS Chronicles | Volume 1 | Issue 1 | September 2024 29size 30%u201332 weeks extending from anterior wall down to cervix, with uterus pushed posterior.We faced different difficulties such as to consider myomectomy or hysterectomy, the approach of the procedure via laparoscopy or exploratory, risk of recurrence of the fibroid and prognosis with the aspect of future pregnanciesIn the pre-operative management detailed history of the patient was taken with proper counselling of the patient for the need of sos hysterectomy, optimization of hemoglobulin preoperatively and detailed pre-anaesthetic workup was done. Patient underwent an open myomectomy [Figures 2 and 3]. Intra operative management included use of Vasopressin to minimalize the blood loss, use of elliptical incision for proper dissection, use of hydro dissection, principles of myomectomy, use of hypotensive anaesthesia, surgical technique such as triple tourniquet technique and proper closure of dead space were used [Figures 4 and 5].DisscusionWith the correct method of dissection and steps of myomectomy, we managed to save the uterus in a case of secondar infertility. The patient required one pint of whole blood and was discharged on post operative day 4.Various techniques such as use of GnRh analogues preoperatively to reduce the blood loss,[4] pre-operatively use of interventions on uterine arteries such as laparoscopic uterine artery dissection, uterine artery embolization,[5]intraoperatively use of intra-fibroid infiltration of vasopressin, intravaginal misoprostol or dinoprostone, the use of pro-fibrin/thrombin agents, surgically we can use the single tourniquet technique which is generally used entails the application of the tourniquet around the cervix to occlude both uterine arteries or the triple technique which involves the occlusion of the ovarian vessels as well. Use of pharmacologic agents for manipulation of the coagulation cascade with antifibrinolytic agents such tranexamic acid, aprotinin, aminocaproic acid also helps in the management of such cases.ConclusionBy utilizing advanced surgical techniques and careful pre-operative planning, we effectively addressed the complications associated with the fibroid, including hydronephrosis. This approach not only alleviated the patient%u2019s symptoms but also maintained her reproductive potential, emphasizing the importance of individualized care in managing uterine myomas in reproductive age women.DeclarationConflict of interestNone.Figure 3: Uterus with myoma around 18%u201315 cm extending from anterior wall down to cervix, with uterus pushed posteriorlyFigure 4: Dissected myomaFigure 5: Reconstruction of uterus post myomectomy18.6 cm size subserosal fibroid with cystic degeneration with pressure effects on distal right ureter and resulting in right hydronephrosis and hydroureter. Single fibroid of