Surgical Techniques

Ins and outs of straight-stick laparoscopic myomectomy

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Once fibroid enucleation is complete, perform a multilayer closure of the defect using an absorbable, unidirectional barbed suture (V-Loc, Covidien). Eliminate all dead space in the closure. The last two throws of each barbed suture should be in the direction of the prior two throws to secure the suture. Finally, cut the suture at the tissue edge without leaving any trailing tail or knot.

Why use a barbed suture? The advantages of using absorbable barbed suture include:

  • elimination of knot tying
  • shorter closure time
  • better tension distribution throughout the wound.

Close the seromuscularis layer in a hemostatic baseball stitch fashion to minimize suture exposure and subsequent adhesions (FIGURE). Use of the suprapubic port for the needle retrieval device facilitates placement of the alternating “inside-out” baseball stitch (see VIDEO 3).


FIGURE Use of a hemostatic baseball stitch (with absorbable, unidirectional barbed suture) to close the seromuscularis layer of the uterus, thereby minimizing suture exposure and subsequent adhesions.

Morcellation

Mechanically morcellate the fibroids through the suprapubic port site. We use an electrical morcellator (Karl Storz Endoscopy). In cases of massive fibroids (>15 cm) we utilize cold- knife morcellation with a # 10 scalpel through an extended 3-cm suprapubic incision with a vertical fascial incision protected by a self-retaining wound retractor. It is important to be vigilant to remove all fibroid pieces as postoperative disseminated leiomyomatosis is well described.

Adhesion prevention

Myomectomy is notorious for creating dense and challenging postoperative adhesions. Given the high rate of repeat surgery for patients undergoing the procedure, anything you can do to limit the adhesion load will be appreciated by both your patient and her next surgeon. Without exception, the most important adhesion-prevention strategy is meticulous attention to tissue handling and hemostasis. In general, laparoscopy leads to fewer adhesions than laparotomy, but a bloody field and raw uterine serosa will create an environment ripe for adhesions regardless of surgical approach. If the operative field is dry, use commercial adhesion prevention aids according to manufacturers’ recommendations.

Laparoscopic myomectomy: Key takeaways
  • Use preoperative MRI to tailor your surgical approach
  • When menorrhagia is a presenting symptom, assess the endometrial cavity preoperatively and consider combining the laparoscopic myomectomy with hysteroscopic myomectomy
  • Minimize blood loss with vasopressin or a laparoscopic tourniquet
  • Utilize a transverse uterine incision and a lateral suturing technique
  • Use delayed absorbable barbed suture to close the myometrial defect
  • Bury the seromuscular closure suture by utilizing an “inside-out” baseball stitch
  • If the risk for postoperative cavitary adhesions is high, consider postoperative balloon placement with close postoperative follow-up
  • Advise patients to wait 6 months prior to attempting to conceive and have a low threshold for scheduled cesarean delivery to minimize the risk of uterine rupture

Concluding thoughts, from experience

Laparoscopic myomectomy is a challenging yet rewarding procedure. For essential points to our approach, see “Laparoscopic myomectomy: Key takeaways” on this page.

Other important things to keep in mind:

  • Fibroid presentation is as varied as the women who have them—meticulous preoperative preparation is an absolute must.
  • Utilize well-established approaches to preventing blood loss, removing fibroids, and repairing the uterine defects. The accomplished gynecologic laparoscopist will be successful in the majority of cases.
  • Practice suturing in a box-trainer setting before taking on initial cases. Early cases should focus on straightforward subserosal fibroids and, as skills progress, more and more difficult cases will become reasonable.
  • Do not place any hard and fast limit on either the number or size of fibroids you are willing to remove laparoscopically. Rather, rely on sound surgical judgment, an honest assessment of your limitations, and a healthy dose of caution as you approach every new patient. Never sacrifice the quality of your repair for a less invasive approach to surgery.
HAVE YOU READ THESE RELATED ARTICLES?

Laparoscopic myomectomy: 8 pearls
Jon I. Einarsson, MD, MPH (March 2010)

Give vasopressin to reduce bleeding in gynecologic surgery
Robert L. Barbieri, MD (Editorial, March 2010)

Barbed suture, now in the toolbox of minimally invasive gyn surgery
Jon I. Einarsson, MD, MPH; James A. Greenberg, MD (September 2009)

When necessity calls for treating uterine fibroids
William H. Parker, MD (Surgical Techniques, June 2008)

Advising your patients–Uterine fibroids: Childbearing, cancer, and hormone effects
William H. Parker, MD (May 2008)

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