Here I like to share some of the practical issues in case of Myomectomy.

Pt aged 24 yrs admitted with a married life of 7 months,one abortion at 8 to 10 Weeks and a solitary intramural posterior wall fibroid for myomectomy.
Fibroid of 20 weeks in the posterior wall ,vertical incision is more comfortable,incision can be extended to explore and to do comfortable surgery. Length of the vertical incision depends on the skill of the surgeon by partial myomectomy in situ one can reduce the length of the incision but length of the incision doesn’t matter unless one can attempt the resultful steps.
Here attempt of hydrodisection was tried but failed to get the appropriate plane informing that may be that either fibroid adherent to the capsule or breached.
Inspite of the Incision beyond the capsule ,fibroid not popping out also suggest that it is adherent to capsule may requires sharp dissection and removal of its adherent remnants . Fibroid was removed enmass by a sharp dissection. Remnants were searched and removed . Uterus was closed in three layers with appropriately trimming hyper plastic myometrium reducing its size to 8 - 10 weeks after confirming that there is no either endometrial polyp or sub mucosal fibroid by the bimanual digital exploration. Bilateral ovarian cysts were punctured to a depth of 2 - 3 mm. Bilateral plication of round ligaments were done to keep the uterus anteverted and prevent posterior adhesion. Lap hydrotubation was atempted in the begening and in the end by occluding the cervical canal but not yielded satisfactory results. See the back pressure even though the needle is inside the endometrial cavity. May be endometrial capacity is more after myomectomy,quantity
of fluid taken is less ,enough pressure not built up to over come the cornual spasm and mucosal oedema. Benifit of dought I dropped further attentemt since she had a miscarriage 3 months back. If one really wants to test the tubal patency can do bilateral retrograde canulation with epidural catheter or flushing from the fibrial end feeling or see the distension of endometrial cavity. This may damage oedematous epithelial lining and tubal cilia. Here,main intention is complete myomectomy . During myomectomy if endometrial cavity opened one can try bilateral osteal cannulation or flushing. Since Many a times Sonologist may not give the correct picture of the degenerative changes in the fibroid , it may may be difficult to do the Myomectomy during laparotomy or marcelation during laparoscopic procedure. Seniors can share their views and the experiences in this regard for the benifit of juniors. This is the specimen of the cystic degeneration of the fibroid and the trimmed hyper plastic myometrium. One can try the TUBAL PATENCY if needed during laparotomy by utilising some of the easily available simple things or as per one’s ideas in the interest of patient.
Shirodkers cervical occluding clamp.
Tubal plushing cannulae with cannulation devise.
Infant feeding tubes ( less than size of 5 ). No 1 vicril, No 2 chromic cat gut or nylon thread.
Foleys cathetor
One can utilise the Foleys catheter transe cervicaly to distend the endometrial cavity just before laparotomy. This will help to delineating the plane between the myoma and the endometrium avoids one’s to open the endometrial cavity and helps to test the tubal patency.
HSG cannula
Epidural cathetor with flushing syringe.
All these procedures may damage the oedematous tubal epithelium and the tubal cilia should be done meticulously otherwise one can resolt later HSG or laparoscopic chomopertubation or Sonohydrotubation if the pregnancy not achieved even after 4 - 6 cycles.
Here tubes were apears of normal luster.