Laparoscopic Myomectomy

LAPAROSCOPIC MYOMECTOMY

Key Points

First described by Kurt Semm in 1979 and reported for both subserous and intramural fibroids in 1991 by Dubuisson et al, laparoscopic myomectomy (LM) is a minimally invasive surgical alternative to laparotomic/open abdominal myomectomy (AM).
The size or the number of fibroids that is amenable to laparoscopally-directed technique depends on the experience and training of the surgeon.
Prior to the procedure, following appropriate informed consent, carefully selected patients should undergo preoperative thrombo- and antibiotic prophylaxis.
Anemia should be corrected, and in cases of large fibroids, pretreatment with gonadotropin-releasing hormone (GnRH) modulators may be instituted, to reduce the size of the fibroid and possibly reduce intraoperative blood loss.
To reduce intraoperative bleeding, prior to uterine incision, a dilute solution of vasopressin can be injected between the myometrium and the fibroid pseudocapsule. Preoperative vaginal misoprostol, infiltration of the myometrium overlying the fibroid with bupivacaine plus epinephrine, oxytocin infusion, intravenous tranexamic acid, uterine artery embolization and pretreatment with GnRH agonists are also effective in reducing intraoperative blood loss during LM.
Large fibroids can be cut into smaller pieces for easy retrieval by electromechanical (power) or manual morcellation. Compared to uncontained morcellation, in-bag morcellation reduces the risk of unintentionally upstaging/spreading undiagnosed leiomyosarcoma malignant cells throughout the abdominal cavity, as well as risk of morcellation injury to contiguous structures.
Laparoscopically assisted minilaparotomy (LAM) is useful for removing larger and/or multiple fibroids with minimal blood loss and less complications via a much smaller abdominal incision compared with standard sized laparotomy incisions.
LAM obviates the need for morcellation and its attendant risks, as fibroids can be removed intact through the minilaparotomy incision.

Tool Box

Bedside Laparoscopy

DaVinci Assisted Laparoscopy

-Surgeon console

-InSite Vision System

-Patient side cart with telerobotic arms and EndoWrist instruments Paragraph

Patient Preparation

Prior to the procedure, carefully selected patients should be counselled on the procedure and appropriate informed consent obtained. The following should be emphasized during counselling and obtaining informed consent:

Procedure steps
Intended benefits of procedure: removal of fibroid and improvement of symptoms, fibroid tissue for histology
Alternatives: open abdominal myomectomy, radiological treatment, medical treatment, expectant management
Possible risks and complications
Possible additional procedures: conversion to laparotomy, repair of iatrogenic injury to contiguous structures, blood transfusion
Having counselled the patient and obtained an informed consent, the patient should be administered preoperative thrombo- and antibiotic prophylaxis. Anaemia, if present, should be corrected before surgery, and in cases of large fibroids, pretreatment with GnRH analogues may be instituted, to reduce the size of the fibroid and possibly reduce intraoperative blood loss.

Operating Room Setup

Patient is placed on the operating table in dorso-lithotomy position with the buttocks at or slightly over the table's edge to allow placement and use of a uterine manipulator, with the legs supported by stirrups
Generally, a right handed surgeon stands on the patient's left side with the surgical assistant on the patient's right. Some surgeons however prefer the patient's right side
If only one video monitor is available, this is usually placed between the patient's legs. If two monitors, these are usually placed over the patient's lower legs, opposite the surgeon and assistant respectively. Newer surgical suites have ceiling-mounted, movable flat screens
The insufflator monitor is usually placed across from the surgeon so intraabdominal pressure can be viewed
If using the DaVinci telerobotic system, the surgeon controls the robotic system remotely from the surgeon console. A stereoscopic viewer as well as hand and foot controls are contained in this unit. With the robotic trocars inserted, the surgical cart is brought between the patient's legs and docked

Procedure Steps

Laparoscopic myomectomy and RLM are performed under general anaesthesia with endotracheal intubation, with the patient in dorsolithotomy position and the legs supported by stirrups. Abdominal entry and initial trocar insertion is completed in the manner preferred by the surgeon (i.e., open versus closed entry), with the laparoscopic access location depending on the fibroid location and size, previous abdominal surgery and the patient’s body habitus. For very large fibroids, the laparoscope may be inserted supraumbilically or in the Palmer’s point to gain optimal panoramic view and room for surgical manipulation. Accessory trocars are inserted for the introduction of the surgical instruments. Location and size are tailored to surgeon preference and fibroid location (i.e., ipsilateral port configuration). For RLM, three to four robotic trocars are utilized with an additional accessory port for the bedside assistant. The accessory port is utilized for the introduction of suture, tenaculum for myoma traction, and suction/irrigation instruments.

A uterine manipulator introduced into the uterine cavity can be controlled by a second assistant and is useful for obtaining optimal exposure of fibroids. Full manipulation of the uterus into anteversion allows for exposure of the posterior cul de sac and is especially useful in completing myomectomy for posteriorly located myomas. The uterine manipulation also allows a central position of the fibroid to be maintained in the operating field and strong counter traction to be provided during enucleation of the fibroid and suturing. The tip balloon of the uterine manipulator may be inflated with methylene blue solution to assist in easily identifying if and when the uterine endometrium is breached.

To reduce intraoperative bleeding, prior to uterine incision, a dilute solution of vasopressin can be injected between the myometrium and the fibroid pseudocapsule until blanching occurs. Injection of vasopressin into blood vessels should be avoided by obtaining a negative aspiration prior to local injection. Systemic injection can be complicated by pulmonary edema, severe hypotension, bradycardia and cardiac arrest (17–19). To reduce the risk of adverse effects, vasopressin should be diluted to a concentration of 0.05-0.3 units/ml and a dose of 5-6 IU is considered safe (17,20,21). Preoperative vaginal misoprostol, infiltration of the myometrium overlying the fibroid with bupivacaine plus epinephrine, oxytocin infusion, intravenous tranexamic acid, uterine artery embolization and pretreatment with GnRH agonists are also effective in reducing intraoperative blood loss during LM (20–25), Apart from reduction in blood loss, less use of electrocoagulation for haemostasis with vasoconstrictors preserves adjacent myometrium.

Depending on the fibroid location, size, and proximity to critical structures, such as the bladder or fallopian tubes, a vertical or horizontal incision is made over the most distended part of the myometrium. This is carried down to the fibroid pseudocapsule using a monopolar electrosurgery or ultrasonic cutting device. Blunt dissection is used to enucleate the fibroid from its pseudocapsule. Traction on the fibroid applied with a myoma corkscrew or tenaculum and counter traction exerted by the uterine manipulator facilitate dissection. Minimal use of monopolar or bipolar electrosurgery is used to secure haemostasis of the fibroid bed after enucleation of the fibroid.

The uterine defect is closed with 1 to 3 layers of interrupted or continuous suturing with a delayed absorbable suture. Barbed sutures have the advantage of equally distributing tension along the whole length of the suture and tissue rather than concentrating it at the site of knotting (21). As surgical knots are not required with barbed sutures, they reduce the risk of uterine tissue damage from tears or lacerations that might occur in the tissue area surrounding the knot (26). Less suturing difficulty reduces suturing and total operating time with barbed sutures, and this combined with the more effective tension distribution, reduces intra- and postoperative blood loss, hematoma formation, as well as perioperative infection rates (21,26). Barbed sutures however carry a risk of bowel obstruction and volvulus. If the free/exposed end of these sutures are kept too long, the barbs may adhere to intestinal wall, predisposing to intestinal obstruction or volvulus. Cutting the suture flushed with the tissue obviates this risk (27).

Large fibroids can be cut into smaller pieces for easy retrieval by power (electromechanical) or manual morcellation using a ring forceps, scalpel or scissors (28). In-bag morcellation reduces the risk of unintentionally upstaging/spreading undiagnosed leiomyosarcoma malignant cells throughout the abdominal cavity or secondary implantation of benign leiomyoma tissue; risks that are associated with uncontained morcellation. The risk of morcellation injury to contiguous structures is also reduced with in-bag morcellation.

Laparoscopically assisted minilaparotomy (LAM) is useful for removing larger fibroids with minimal blood loss and less complications via a much smaller abdominal incision compared with open AM (29). With LAM, the uterus and fibroids can be palpated, allowing for the removal of smaller or deep intramural as well as submucosal fibroids compared with LM. Laparoscopically assisted minilaparotomy also facilitates suturing of the uterine incision and obviates the need for power morcellation (and its already highlighted attendant risks), as fibroids can be removed intact through the minilaparotomy incision (30).

Video 1. Laparoscopic myomectomy of a FIGO 2-5 Leiomyoma

Video 2. da Vinci assisted remote laparoscopic myomectomy.

Video 3. Laparoscopic-ultrasound assisted myomectomy of a deep FIGO Type 2 leiomyoma with surrounding adenomyosis.

Post Procedure Care

Immediate diet as tolerated
Postoperative pain management; minimize opiates
Generally can be discharged in 4-6 hours provided tolerating oral fluids, return of bladder function, and adequate pain management
If performed in an in-patient environment, discharge home 1-2 days after surgery to see with histology report of fibroid specimen at gynaecologic clinic
Subsequent pregnancy rate of between 33.3%-68% following LM or RLM: age of the patient, duration of infertility, diameter of the largest fibroid and number of enucleated fibroids affect fertility after LM
Successful vaginal delivery rate of up to 93% in subsequent pregnancy

Adverse Events

Intraoperative:

Hemorrhage
Myometrial haematoma
Morcellation accidents/injuries to contiguous structures
Bladder, bowel and ureteral injuries
Subcutaneous emphysema
Cardiocirculatory problems

Postoperative:

Wound complications
Thrombosis
Uterine fistula
Peritonitis and abscess collection
Port site haematoma
Port site hernia which may be complicated by bowel obstruction
Intra-abdominal and intrauterine adhesions
Uterine rupture in subsequent pregnancy: Uterine rupture in pregnancy following LM is seen in 1% of cases, and is comparable to the occurrence of uterine rupture after AM

References

Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy 1979;11(02):85-93.

Dubuisson JB, Lecuru F, Foulot H, Mandelbrot L, Aubriot FX, Mouly M. Myomectomy by laparoscopy: A preliminary report of 43 cases. Fertil Steril 1991;56(5):827–30.

American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol 2008;112(2 Pt 1):387-400.

Bedient CE, Magrina JF, Noble BN, Kho RM. Comparison of robotic and laparoscopic myomectomy. Am J Obstet Gynecol. 2009;201(6):566.e1-566.e5.

Pundir J, Pundir V, Walavalkar R, Omanwa K, Lancaster G, Kayani S. Robotic-Assisted Laparoscopic vs Abdominal and Laparoscopic Myomectomy: Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2013;20:335–45.

Advincula AP, Song A, Burke W, Reynolds RK. Preliminary experience with robot-assisted laparoscopic myomectomy. The Journal of the American Association of Gynecologic Laparoscopists. 2004;11(4):511-8.

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