**2. Case presentation**

A 40-year-old Malay nulliparous female (Height 161 cm, Weight 158.5 kg, BMI 60.1 kg/m2 ) presented with a history of severe menorrhagia for 6 months. She had been on medical treatment, an injection of Leuprolide acetate and progestin to control the bleeding symptoms; however, she opted for earlier surgical intervention due to intolerable side effects. She was morbidly obese with massive central adiposity on the chest, abdomen, and thigh. She also has bilateral lower limbs and chronic venous insufficiency evident by the varicose veins and leathery hyperpigmented skin of her lower extremities from mid-shin to the ankles bilaterally (**Figure 1**).

The patient's past medical and surgical history was unremarkable. Physical examination revealed a pelvic-abdominal mass with the upper border extending up

#### **Figure 1.**

*The patient's thick abdominal wall with bilateral lower limbs chronic venous insufficiency is evident by the varicose veins and leathery hyperpigmented skin of her lower extremities from mid-shin to the ankles.*

*3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese… DOI: http://dx.doi.org/10.5772/intechopen.113206*

**Figure 2.**

*The magnetic resonance imaging (MRI) examination showed features of left lower anterior lateral large uterine leiomyoma measuring 182 × 128 × 169 mm (ap x w x cc), FIGO grade 4-5 compressing the bladder inferiorly.*

to 4 cm above the umbilicus. An ultrasound was performed both abdominally and vaginally. It showed a vast uterine with a large single oval-shaped encapsulated mass likely to be a uterine fibroid, FIGO Grade 4, arising from the lower segment of the anterior-lateral aspect of the uterus, pushing the uterine fundus up, and deviating to the right. The magnetic resonance imaging (MRI) examination showed features of left lower anterior lateral large uterine leiomyoma measuring 182 × 128 × 169 mm (ap x w x cc), FIGO Grade 4-5 compressing the bladder inferiorly (**Figure 2**). There were no features suggestive of malignancy. Her pap smear and endometrial sampling results were both routine. Her preoperative hemoglobin was 11.9 g%. An option of bariatric surgery to manage her weight was discussed; however, she opted for a total laparoscopic hysterectomy.

The patient was counseled about the risks of morcellation of potential occult uterine leiomyosarcoma (LMS) or smooth muscle tumors of uncertain malignant potential. Written informed consent was obtained for the procedure and the publication of the case report and the accompanying images.
