Laparoscopic myomectomy: tips 'n tricks

Surgery is the treatment of choice for myomas. Myomectomy has undergone a dramatic evolution over the years. Laparoscopic myomectomy provides a preferable alternative to abdominal myomectomy for women with symptomatic fibroids who desire uterine preservation. It is also an excellent method for women who have infertility primarily related to fibroids. A lot of patients prefer myomectomy over hysterectomy even if they do not desire pregnancy. However, laparoscopic myomectomy is not easy and needs some practice. Together with the basic steps, some tips and tricks are provided to make this technique even more safe and feasible for surgeons. For good results, the use of a few technical tricks provides an optimal solution for all issues.

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Laparoscopic myomectomy: tips 'n tricks

Authors

A Wattiez, P Trompoukis, AM Furtado Lima, J Nassif, B Gabriel

Abstract

Surgery is the treatment of choice for myomas. Myomectomy has undergone a dramatic evolution over the years. Laparoscopic myomectomy provides a preferable alternative to abdominal myomectomy for women with symptomatic fibroids who desire uterine preservation. It is also an excellent method for women who have infertility primarily related to fibroids. A lot of patients prefer myomectomy over hysterectomy even if they do not desire pregnancy. However, laparoscopic myomectomy is not easy and needs some practice. Together with the basic steps, some tips and tricks are provided to make this technique even more safe and feasible for surgeons. For good results, the use of a few technical tricks provides an optimal solution for all issues.

Classification

tips and tricks

Keywords

laparoscopy, myomectomy, tips and tricks, fibroids

Media type

Surgical video

Duration

08'05''

Publication

2010-12

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E-publication

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3131.htm

Laparoscopic myomectomy: tips 'n tricks

1. View 00'19''

The procedure is started with an appropriate view. Sometimes, in case of big fibroids, the position of the camera may be changed to a higher supraumbilical position for a better view and approach.

2. Exposure 00'38''

The adnexa and/or the bowel are suspended to the abdominal wall. This improves view and movements and, more importantly, it gives your assistant an enhanced freedom of movement.

3. Blood loss minimization 01'04''

Several techniques may be used in order to minimize blood loss: GnRH agonists, intramyometrial vasopressin, intravenous oxytocin 40 mIU/min intraoperatively, use of a tourniquet or Penrose drain at the lower part of the uterus. Clipping of the uterine arteries and infundibulopelvic ligaments is another very efficient method. According to studies published in the literature, clipping of the uterine arteries is associated with less blood loss during this operation and a decreased recurrence rate. The technique consists in opening the parietal peritoneum of the pelvic side wall in order to detect the uterine artery between the ureter and the umbilical artery and to clip it temporarily.

4. Incision 02'25''

There is no guideline for the orientation. The serosal incision is determined by the size, number and location of leiomyomas and by their proximity to the uterine vessels and uterine tubes. A good incision is one that gives the best results and makes the suturing more easy and efficient.

5. Dissection 02'46''

The myoma is grasped for better manipulation with a 5mm instrument like a myoma screw or a “Pozzi” or “Manhes” grasper. The cleavage plane between the leiomyoma and the surrounding myometrium is determined. The leiomyoma is enucleated using traction and counter-traction.

6. Control of endometrial integrity 03'53''

Attempts are made not to breach the endometrial cavity. The integrity of the cavity is controlled using methylene blue. However, it is by no means a disaster if the cavity is opened in case of a big fibroid. In this case, the mucosa is not sutured; however, in case of a big rupture, the mucosa has to be repaired with fine interrupted extramural sutures.

7. Closure 04'21''

The debate is on whether one or multiple layers must be used for closure. The dead space has to be adequately closed to minimize the risk of hematoma formation. Interrupted figure-of-eight sutures are usually sufficient; monocryl or Vicryl, 1 or 0, with extracorporeal knots may be used for extra strength. The serosa can be approximated with interrupted 2/0 sutures if need be.

8. Extraction 06'17''

The specimen can be directly extracted into a bag if the fibroid measures less than 3cm. The electrical morcellator is another very useful instrument. However, if electrical morcellation is not available, a Chardonnens cold knife can be used for morcellation and the fibroid can be extracted through a posterior culdotomy. Monopolar current should never be used for morcellation.

9. End of procedure 07'50''

Hemostasis is thoroughly controlled. Clips are removed. The suspension of the ovaries and/or the bowel is removed afterwards, if necessary. The peritoneal cavity is lavaged with warm water to wash out any remaining collection of blood and/or fluids. Anti-adhesion agents can be used, although controversial.