Laparoscopic myomectomy: Tips for patient selection and technique
Surgical technique
After injecting vasopressin, I use a high-frequency mechanical vibration scalpel to incise the myometrium directly over a prominent fibroid and carry the incision deeply until fibroid tissue is definite. Alternatively, a monopolar laparoscopic needle can be used in cut mode—which also limits damage to the myometrium.
Tip. The course of vessels over a fibroid is unpredictable, and we cannot be certain that any uterine incision will avoid bleeding. Therefore, I make transverse incisions, which allow more ergonomic laparoscopic suturing.
It is important to incise completely through the myometrium and through the pink-red pseudocapsule containing the vascular network surrounding the fibroid. This plane is often deeper than usually recognized and can be identified just over the white fibroid.
The fibroid is grasped with a tenaculum for traction, and countertraction is applied with a grasper on the myometrial edges. Once the fibroid is reached, graspers and the mechanical vibration scalpel are used to tease the pseudocapsule away from the fibroid (VIDEO).
Tip. Staying under the pseudocapsule reduces bleeding and may preserve the tissue’s growth factors and neurotransmitters, which are thought to promote wound healing.6
Dissection with the mechanical vibration scalpel (or monopolar needle) should be performed under visual control to identify the tissue adhering to the fibroid, which is desiccated and then divided. The fibroid is dissected until free of the myometrium and is placed in the right lower abdomen. Small fibroids can be strung together on a long suture so none will be lost. Using bipolar paddles, desiccate large bleeding vessels in the myometrial defect sparingly, with care taken to avoid devascularizing the myometrium, which might compromise wound healing. Myometrial repair should be performed in accordance with the accepted surgical technique used in laparotomy.
Place delayed absorbable sutures in 2 or 3 layers, as needed, to reapproximate the myometrium and secure hemostasis.
Tip: I use 0 polydioxanone interrupted figure-of-8 sutures, but continuous running sutures with or without barbs also can be used. For the serosa, I use a continuous barbed suture in a baseball stitch, which buries both the raw edges of the serosa and the barbs for smooth closure (FIGURE 3). These closure methods have not been compared to see which provides superior wound healing or subsequent wound strength.
The fibroid can be morcellated with an electromechanical morcellator or a scalpel (hand morcellation). Either instrument can be used in contained or uncontained fashion. I insert an electromechanical morcellator through the right lower quadrant incision and morcellate tissue in the anterior midpelvis. Safety requires careful control of the rotating blade and scrutiny of the bowel, bladder, and major vessels. Our operating room has 4 rules for morcellator use:
- The blade is activated only under direct visualization.
- Both the surgeon and the assistant must say “ready” before the blade is activated.
- The hand holding the morcellator must remain still while tissue is being drawn into the device.
- Any undue resistance from the tissue is cause to stop the blade. This precaution is taken because there is a tendency to drop the blade in an attempt to overcome the resistance.
Tip: I limit rotational forces and scattering of tissue by “pulsing” the blade on and off when morcellating softer tissue.
Various methods of contained morcellation (morcellation in a containment bag) have been described.7 In one method, tissue is placed in a bag, the neck of the bag is brought through an enlarged umbilical incision, and the tissue is cut into small pieces until it is entirely removed. Another method is to use an electromechanical morcellator with a specially designed containment bag inside the abdomen. The bag is introduced through a 12-mm port and unfurled inside the abdomen; the specimen is placed in the bag; the neck of the bag is brought out through the port; the bag is insufflated with carbon dioxide; the laparoscope, a 5-mm grasper, and the morcellator tip are passed into the bag; and morcellation is performed. Early studies of contained morcellation reported longer operating times, leaking bags, and visceral injuries. In 2016, the US Food and Drug Administration (FDA) cleared the PneumoLiner containment system but required that its manufacturer (Advanced Surgical Concepts) warn patients and health care providers that its bag has not been proved to reduce the risk of spreading cancer during morcellation procedures.8
During laparoscopic myomectomy, fibroid removal by myometrial dissection disperses tissue fragments, and the unprotected fibroid is usually stored in the abdomen until hemostasis is secured and suturing completed. Limiting the rotational forces that lead to further dispersement and irrigating copiously to remove tissue fragments help eliminate residual tissue.
The pelvis and the abdomen are irrigated with normal saline (approximately 3 L) and suctioned multiple times.
Tip. Alternating between the Trendelenburg and reverse Trendelenburg positions allows fluid to wash tissue down to the pelvis, where it is more easily seen and removed.
Careful inspection for tissue fragments and copious irrigation and suctioning are important in reducing the risk that tissue fragments will remain in the peritoneal cavity and parasitic fibroids will develop. In cases of occult leiomyosarcoma (LMS), this step may be particularly important.
I place a knitted fabric of modified cellulose over the hysterotomy suture lines to reduce the incidence of adhesion formation. Once the procedure is complete, the local anesthetic bupivicaine is injected deep into the incision sites. Injecting anesthetic before making the incisions does not provide better pain relief; injecting after the procedure provides pain relief for 6 hours.9
Related article:
Robot-assisted laparoscopic myomectomy
Morcellation and risk of leiomyosarcoma
Given the need to prevent laparoscopic morcellators from inadvertently spreading tissue within the peritoneal cavity of women with occult LMS, the FDA issued a safety communication in 2014 warning against their use in the majority of women who undergo myomectomy or hysterectomy for fibroids.10 However, Pritts and colleagues estimated the prevalence of LMS in women who had surgery for presumed uterine fibroids at about 1 in 2,000 (0.05%), significantly lower than the FDA’s estimate of 1 in 350.10,11 In 2015, a large population-based prospective registry study found 2 cases of occult LMS in 8,720 fibroid surgery patients (0.02%).12
Related article:
The FDA’s review of the data on open power morcellation was “inadequate, irresponsible” and a “disservice to women”
Since LMS metastasizes through the bloodstream, there is no reliable evidence that morcellation influences survival or that electromechanical morcellation is inferior to vaginal or mini-laparotomy morcellation with a scalpel. According to recent publications, compared with MIS, open abdominal surgery is associated with more morbidity and mortality in women.13 Since the FDA advisory was issued, the number of abdominal surgeries has increased, as has the number of related complications.13
I use electromechanical morcellation techniques for women who want MIS. All surgical procedures have potential risks, and patients’ and physicians’ understanding of risks forms the foundation of medical decision making. The possibility of occult LMS should be considered by women and their gynecologists, and proper informed consent, noting both the LMS risk and the increased risks of abdominal surgery, should be obtained.
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Risk of uterine rupture after laparoscopic myomectomy
After abdominal myomectomy, uterine rupture during pregnancy or delivery is rare, according to reviews of delivery records of many thousands of women.14 Operative techniques, instruments, and energy sources used during laparoscopic or robot-assisted myomectomy may differ from those used during laparotomy, and anecdotal communications suggest that uterine rupture may be more common after laparoscopic or robot-assisted myomectomy. A meta-analysis of 56 articles (3,685 pregnancies) published between 1970 and 2013 found 29 cases of uterine rupture after myomectomy, with no statistical difference in rupture risk between laparoscopic and abdominal myomectomy.15 As most reports are case studies or small case series, the incidence of rupture cannot be reliably calculated.
There is no consensus regarding the factors that may increase the risk of uterine rupture after laparoscopic myomectomy. Three factors are postulated to interfere with myometrial wound healing and increase uterine rupture risk: failure to adequately suture myometrial defects, excessive use of monopolar or bipolar electrosurgery with devascularization of the myometrium, and lack of hemostasis with subsequent hematoma formation.16 It seems prudent that surgeons should adhere to time-tested techniques for abdominal myomectomy. Even with use of ideal surgical techniques, however, individual wound-healing characteristics may predispose to uterine rupture.
CASE Resolved
After giving proper informed consent, the patient underwent laparoscopic myomectomy and electromechanical morcellation. Her 2 fibroids were removed, with a blood loss of 200 mL, and that afternoon she was discharged from the surgery center with written postoperative instructions and oral pain medication. A telephone call the next day found her comfortable, with no nausea or vomiting, and happy to be fibroid free. Pathologic inspection of the morcellated tissue confirmed that the fibroids were benign. At 2-week follow-up, the patient was no longer taking pain medication and was ready to return to work and normal activity. Her fatigue persisted, though, and she arranged to take time to rest during the day.
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