Surgical Techniques

Ins and outs of straight-stick laparoscopic myomectomy

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The multiple advantages a laparoscopic approach to myomectomy can offer over laparotomy hinge on surgical technique—from preoperative evaluation to uterine repair. Here, pointers and steps to success.


 

References


Watch 3 videos illustrating laparoscopic myomectomy

These videos were provided by Gaby Moawad, MD, and James Robinson, MD, MS.

By age 50, almost 70% of white women and more than 80% of black women will have a uterine leiomyoma.1 These benign, hormone-sensitive neoplasms1 are asymptomatic in the majority of women, but they can cause infertility, abnormal uterine bleeding, and bulk symptoms.2

When symptomatic, fibroids are amenable to multiple management options, ranging from expectant management to medical therapy to uterine artery embolization to myomectomy to hysterectomy. Myomectomy remains the surgical option of choice for women with symptomatic fibroids who wish to retain their fertility. It is also an option for some women who may not desire fertility retention but who do wish to maintain their uterus.

Compared with traditional myomectomy by laparotomy, laparoscopic myomectomy offers the advantages of:

  • less blood loss
  • less postoperative pain
  • less postoperative adhesions formation
  • faster recovery
  • better cosmesis.3,4

Current technology makes performing laparoscopic myomectomy by either “straight-stick” or robotic assistance a viable option for most women.

In this article, we describe our technique in performing straight-stick laparoscopic myomectomy.

Preoperative evaluation: The first key to success

Laparoscopic myomectomy is an advanced, delicate, and challenging surgery. Preoperative evaluation is integral to its planning and a successful outcome.

Imaging

We recommend magnetic resonance imaging (MRI) as a standard order whenever a laparoscopic approach to myomectomy is being considered, for several reasons. First, MRI of the abdomen and pelvis with contrast allows for a precise map of the location of fibroids in relation to the myometrium and the uterine cavity. Reviewing the MRI results with the patient preoperatively gives both you and the patient a clearer picture of the challenges ahead. Patients tell us they appreciate these easier-to-understand images of their anatomy and, in cases when the decision is made to proceed abdominally, it is more clear to the patient why the decision is being made.

Surgically, the MRI helps compensate for the lack of tactile feedback when faced with deep intramural fibroids laparoscopically. The MRI also helps avoid operative surprises. Experience teaches us that, when relying on transvaginal ultrasound alone, adenomyotic regions can be identified mistakenly as fibroids. Preoperative MRI can help you avoid this discovery at the time of surgery.

A flexible office hysteroscopy serves as an adjunct to MRI for precise preoperative cavitary evaluation, especially when fibroids are present in close proximity to the endometrial cavity or the patient reports menorrhagia as a component of her symptomatology. When small submucosal fibroids exist in addition to larger fibroids, we frequently perform a combined hysteroscopic and laparoscopic approach to myomectomy.

Although bowel preparation does not diminish complications from bowel surgery or improve outcome,5 we generally use laxative suppositories the night prior to surgery to improve access to the posterior cul-de-sac and reduce bulk resulting from a sigmoid full of feces.

Preoperative laboratory evaluation should always include complete blood count, beta hCG, blood type testing, and antibody screen. In patients with known anemia or large intramural fibroids, we typically match the patient for 2 units of packed red blood cells. Additionally, if significant blood loss is anticipated, cell saver technology can be modified to accommodate a laparoscopic suction tip, allowing the patient’s own blood to be collected and readministered.

Counseling your patients on the risks of laparoscopic myomectomy

Aside from the standard risks of surgery, including bleeding, transfusion, infection, and injury to adjacent organs, myomectomy has its own unique risks that need to be made clear to patients preoperatively.

Surgery timing. Initially, women with symptomatic fibroids are at significant risk for developing more fibroids in the future. In fact, 25% of women who undergo myomectomy will require a second surgery at some point in their lives to address recurrent symptoms.1 If women are young, not yet ready to conceive, and are still relatively asymptomatic, waiting to perform myomectomy may be the most prudent course.

Future uterine rupture. There are no good myomectomy data to guide us with respect to the risk of uterine rupture at future pregnancy. When we perform deep intramural myomectomy (regardless of endometrial disruption), we extrapolate from classical cesarean section data and counsel our patients to have planned cesarean sections for all future pregnancies. Patients are also counseled that uterine rupture has been well described after laparoscopic myomectomy prior to the onset of labor so any sudden onset of pain or bleeding during the late second or third trimester of pregnancy has to be regarded as a medical emergency.

Pregnancy. Again, no good data exist to guide us with respect to postoperative timing of future pregnancy. We typically suggest patients refrain from conceiving following myomectomy for at least 6 months. We are aware that other well-respected surgeons have different thresholds.

Reference

1. Andiani GB, Fedele L, Parazzini F, Villa L. Risk of recurrence after myomectomy. Br J Obstet Gynaecol. 1991;98(4):385-389.

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