Hysteroscopic Myomectomy

Hysteroscopic Myomectomy

Key Points


  • Hysteroscopic is the least invasive of all of the surgical approaches to myomectomy and should be the procedure of choice when feasible and performed by those with appropriate training and skill.
  • Most Type O and 1 and many Type 2 tumors can be removed hysteroscopically, with some limits on leiomyoma number and volume
  • It is critically important to distinguish Type 2 tumors from Type 2-5 lesions, or others with a narrow outer free margin (OFM) of myometrium to minimize the risks of perforation
  • Appropriate technique for deep Type 1 and Type 2 tumors involves dissection in the pseudocapsule.

ToolBox

Generic

  • -Operating room table with padded stirrups

Specific Technique 1

Specific Technique 2

Specific Technique 3

Tool Box

Outline


Contributors: 

Sarah

Phillipe 

Edgar

 

 

a.    Rationale - a one phrase detailing the reason for this material

b.    Content details – what will this contribution cover

c.     Patient selection, counselling and consent 

(who should be advised to have hysteroscopic myomectomy, what we discuss)

d. Uterine preparation 

 (use GnRH analogues or not?, other endometrial or myoma suppression options)

e. Surgery preparation 

(devices - hysteroscope (outpatient), resectoscope (GA), energy sources, haemostatic tools, visuals, morcellators, electric loop, laser vaporisation, electromechanical)

f. Fluid management 

 (in outpatient, inpatient, mono or bipolar)

g. Surgical techniques 

(cervical dilatation, planning the resection, access to fibroid, fluid management, when to stop, repeat procedures, specimen)

h. Visual materials to include

a.    Drawings, photos

b.    White Board illustrations

c.     Video recordings (theory or surgical demonstrations)

i.      Adverse events, management and minimising risk

j.      Case presentations (description; thought process, intervention, outcome)

k.    Summary and conclusions

l.      Infographic or algorithm

Everything below the line is material inserted for demonstration purposes.

Hysteroscopic myomectomy can be performed when leiomyomas are submucous, and generally less than 5 cm in mean diameter. The FIGO type is also important as while it is relatively easy to remove most Type 0 and 1 tumors, this that are Type 2, particularly if deep, and Type 3 lesions are far more challenging. Prior to any decision regarding the performance of hysteroscopic myomectomy, and especially when considering Type 2 or Type 3 lesions, it is imperative to perform detailed evaluation of the uterus, in particular to determine the presence and thickness of the outer free margin (OFM) using sonohysterography or MRI. This is important to avoid operating on Type 2- or 3-5 tumors that would result in myometrial perforation.

The Pseudocapsule (This is a draft video)

Understanding the anatomy and tissue dynamics associated with the leiomyoma pseudocapsule is essential to the performance of hysteroscopic myomectomy, particularly for deep Type 1 and Type 2 lesiions. The video demonstrates how the leiomyoma essentially is under pressure, the result of its expansion and the counterforce provided by the compressed and muscular myometrium. By identifying and entering the pseudocapsule circumferentially, the myometrium assists in the extrusion of the leiomyoma. Traditional blunt and sharp dissection further facilitates the process. This not only allows for total removal of the tumor, there is an absence of injury to the myometrium allowing it to expand to its original thickness. Prior to using electrosurgery or electromechanical instruments to morcellate and remove the tumor, it should be left with a small attachment - otherwise the tumor will float free impairing the process.

Type 0 Leiomyoma: Electromechanical Technique

This video demonstrates the use of a hysteroscopic electromechanical morcellating and aspirating device. The tissue is transected and the fragments are caught in a fabric filter near the suction generating console situated near to the patient.

Type 2 Leiomyoma: Dissection and Electromechanical Technique

This video demonstrates dissection into the pseudocapsule using a combination of a bipolar RF needle, mechanical scissors, and the blunt tip of the suction aspiration instrument, followed by electromechanical morcellation and aspiration.

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