CASE: IS OPEN MYOMECTOMY THE BEST OPTION FOR THIS PATIENT?
In her only pregnancy, a 34-year-old patient experienced a spontaneous first-trimester loss and underwent dilation and curettage. She had noted an increase in her abdominal girth, as well as pelvic pressure, but had attributed both to the pregnancy. Three months after the pregnancy loss, however, neither had resolved. Because she hopes to conceive again and deliver a healthy infant, the patient consulted a gynecologist. After ultrasonography revealed multiple fibroids, that physician recommended open myomectomy. The patient, a Jehovah’s Witness, comes to your office for a second opinion.
On physical examination, she has a 16-weeks’ sized irregular uterus with the cervix displaced behind the pubic symphysis. T2 weighted scans from magnetic resonance imaging (MRI) of the pelvis in the sagittal view reveal multiple subserosal and intramural fibroids that displace, but do not involve, the uterine cavity (FIGURE 2). The MRI results confirm that the uterus extends beyond the pelvis above the sacral promontory, the fundus lies a few centimeters below the umbilicus, and there is no evidence of adenomyosis. The patient’s hemoglobin level is normal (12.2 g/dL).
What surgical approach would you recommend?
Endometrial ablation, uterine artery embolization, MRI-guided focused ultrasound, hysterectomy, and myomectomy are all treatments for symptomatic uterine fibroids. For women desiring uterine preservation and future fertility, however, myomectomy is the preferred option of many experts.
Myomectomy traditionally has been performed via an open laparotomy approach. With the rise of minimally invasive surgery in gynecology, safe endoscopic surgical approaches and techniques have evolved.
The EndoWrist technology from the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California) provides increased instrument range of motion, enabling the surgeon to mimic open surgical technique, thereby simplifying the technical challenges of conventional laparoscopic suturing and knot-tying. However, this technology does not minimize or simplify the challenges that leiomyomas can pose, including enucleation (FIGURE 1). Although it has facilitated the progression and adoption of endoscopic myomectomy, the da Vinci system requires an experienced gynecologic endoscopic surgeon.
In this article, we outline the essential steps and offer some clinical surgical pearls to make robot-assisted laparoscopic myomectomy a systematic, safe, and efficient procedure.
Benefits of the robotic approach
Compared with open abdominal myomectomy, the robot-assisted laparoscopic approach is associated with less blood loss, lower complication rates, and shorter hospitalization.1 A retrospective case study from the Cleveland Clinic confirmed these findings when investigators compared surgical outcomes between the robot-assisted laparoscopic approach, standard laparoscopy, and open myomectomy.2 In an assessment of 575 cases (393 open, 93 laparoscopic, and 89 robot-assisted laparoscopic), they found the robot-assisted laparoscopic approach to be associated with the removal of significantly larger myomas (vs standard laparoscopy), as well as lower blood loss and shorter hospitalization (vs open myomectomy).2
Comprehensive preoperative assessment is critical
Careful patient selection and thorough preoperative assessment are the cornerstones of successful robot-assisted laparoscopic myomectomy. Among the variables that should be considered in selecting patients are uterine size, the patient’s body habitus, and the quantity, size, consistency, type, and location of fibroids.
Size of the uterus, body habitus, and laxity of the abdominal wall all influence the surgeon’s ability to create the necessary operating space. Intraperitoneal space is required during myomectomy because of the need to apply traction and countertraction during enucleation of fibroids. If the necessary space cannot be obtained, a minilaparotomy technique is one alternative. This technique, described by Glasser, limits the skin incision to 3 to 6 cm in myomectomies for large fibroids that can be accessed easily anteriorly.3
Number and location of fibroids. Women with a solitary fibroid, a few dominant fibroids, or multiple pedunculated fibroids are excellent candidates for an endoscopic approach. Although there are no limits on the number of fibroids that can be removed, women with what we have termed “miliary fibroids,” or multiple fibroids disseminated throughout the entire myometrium, with very little normal myometrium, are poor surgical candidates. Not only does the presence of these fibroids leave some concern about the functional ability of the remaining myometrium in pregnancy, but it may be technically difficult to adequately resect all of the critical fibroids and reapproximate the myometrial defects.
The consistency of fibroids also affects the ease of the enucleation process during myomectomy. Due to the soft, spongy nature of degenerating fibroids and their tendency to fragment and shred when manipulated, these cases are more challenging and should not be attempted without a solid foundation of surgical experience.