The triple-flap method for huge uterine adenomyosis with pelvic adhesions

We report surgery performed on a 44-year-old unmarried woman with the aim of preserving the uterus. Pelvic examination revealed a presumed uterus size of over 1000 g. Because of the size of the uterus and pelvic adhesions, we performed surgery using the triple-flap method described by Osada et al. (2011). During the operation, we could not remove the uterus from the pelvic cavity because of extensive adenomyosis, pelvic adhesions from rectosigmoid endometriosis and right ovarian endometriosis. After the uterus was extra-peritonealized, it was not possible to place a tourniquet around the cervix. Based on the description of the triple-flap method, the operator attempted to use a tourniquet on the lower part of the uterus and a vascular clamp on the ovarian vessel pedicle to decrease blood loss during the operation. However, these measures proved impossible because of the huge adenomyosis (over 1000 g) and cul-de-sac adhesion and the pelvic adhesion with endometriosis, which was hard to approach using the tourniquet and vascular clamp. It is difficult to predict pelvic adhesion and rectovaginal endometriosis before the operation. Without the tourniquet and vascular clamp, it is burdensome for the surgeon to perform an adenomyomectomy. We recommend two additional safety steps for preserving the uterus when using the triple-flap method. First