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Minimally Invasive Approaches to Myomectomy — 317
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LAPAROSCOPIC MYOMECTOMY
Laparoscopic myomectomy is an alternative to the abdominal
approach, with fewer complications, shortened hospital stay,
and less disability [8,9], but it is a difficult and tedious operation. Widespread acceptance of this procedure has been limited
because of the advanced skills required, but the advent of better
insufflators, light sources, and cameras as well as the electronic
morcellator has increased the use of this procedure. It is felt by
some authors that women with large intramural myomas who
want to bear children should not be managed laparoscopically
because meticulous repair of the uterus is difficult. Parker [10]
has established selection criteria for patients with symptomatic
myomas for laparoscopic myomectomy, which include uterine
size equal to or less than 14 weeks after a 3-month course of
GnRH agonist therapy, no individual myoma larger than 7 cm,
no myoma near theuterineartery ornearthe tubal ostiaiffertility
is desired, and at least 50% of the myoma subserosal, to be accessible and to allow adequate repair through the laparoscope.[11]
Certainly there are several highly skilled laparoscopists in the
world who are comfortable managing larger myomas, but the
vast majority ofpracticing gynecologists wouldresort to standard
laparotomy in these cases. Sinha et al. [11], in a study published
in 2003, removed 78 myomas in 51 patients. Three patients had
two myomas between5 cm and 9 cm (in addition to one ≥9 cm),
and one had three myomas between 5 cm and 9 cm (in addition
to one ≥9 cm). Mean number of myomas removed per patient
was 1.53 ± 1.17 (range, 1 to 6); 12 women (23.5%) had multiple myomectomy. The largest myoma removed was 21 cm. Mean
myoma weight was 698.47 ± 569.13 g (range, 210 to 3400 g).
Mean operating time was 136.67 ± 38.28 minutes (range, 80
to 270 minutes). Mean blood loss was 322.16 ± 328.2 mL
(range, 100to 2000 mL).One patient developeda broad ligament
hematoma, two developed postoperative fever, and one underwent open subtotal hysterectomy 9 hours after surgery for dilutional coagulopathy. Twenty women (39.2%) were given blood
transfusions postoperatively; 10 received a single unit, six were
given 2 U, three were given 3 U, and one was given 4 U.[12] This
study has a far higher incidence of blood transfusion than any
study in the literature and may be explained by different criteria for transfusion in India. Nezhat and associates [9] reported
on myomectomy in 137 women, from whom 196 leiomyomas
were removed. The fibroids ranged in size from 2 to 14 cm.
The operations lasted from 50 to 160 minutes (mean, 116 minutes). Estimated blood loss was between 10 mL and 600 mL,
and two women received transfusions because of intraoperative blood loss. The hospital stay ranged from 7 to 48 hours,
with a mean of 19.6 hours. In a retrospective multicenter study
comparing myomectomyby laparoscopyand laparotomy, Marret
et al. [12] found that compared with women undergoing
laparoscopic myomectomy, women undergoing open myomectomy had more myomas that were larger and that were generally interstitial and anterior. More of them received GnRH
analogues. Excised myomas weighed four times more, the
decrease in hemoglobin was greater (1 g/dL), fever was more frequent, and nine patients needed transfusions (compared to none
for laparoscopic myomectomy). There were 37 conversions to
laparotomy (29%) after laparoscopic myomectomy. The conversion rate was high for inexperienced surgeons. Length of hospital
stay was reduced by half for laparoscopic myomectomy (without
conversion). Recurrence rate at 2 years was 2.5% for laparoscopic
myomectomy versus 3.6% for open myomectomy (P = 0.506).
The authors concluded that preoperative evaluation by ultrasound was essential to establish myoma number, size, type, and
location to choose the most appropriate surgical procedure. The
ideal candidate for laparoscopic myomectomy is a patient with
fewer than three myomas, none larger than 8 to 9 cm. Those with
pedunculatedmyomasareideal fora minimallyinvasiveapproach
regardless of the size. Patients with multiple myomaswhose imaging studies report “fibroids too numerous to count” are not candidates for myomectomybecause the myometrial damage created
by excising them would belike doing a virtual hysterectomy. Certainly these patients should becounseledtoaccept hysterectomyif
future childbearing is not desired. If the patient strongly desires
keeping her uterus, she should be referred for uterine fibroid
embolization.
Surgical Technique
The patient is placed in the low lithotomy position using Allen
stirrups (Allen Medical Systems, Cleveland, OH). Ten milliliters
of a dilute vasopressin solution (2 U in 60 mL NaCl) is then
injected intracervically about 1 to 2 cm deep at both the 8 and
4 o’clock positions. Laparoscopic myomectomy is facilitated by
the use of auterine manipulator.Although manipulatorsthat use
a balloon for stabilization of the device within the uterus work
well for most laparoscopic procedures, these may be counterproductive in myomectomy. If the uterine cavity is entered, as occasionally occurs inadvertently or intentionally during the course
of myoma enucleation, the balloon may be ruptured, causing the
manipulator to fall out. We prefer the MHI uterine manipulator
(Medical Horizons, Fair Oaks, CA; Figure 12.1.1) or the Pelosi
manipulator (Apple Medical, Marlborough MA; Figure 12.1.2).
The procedure is facilitated by the use of four ports, the sizes of
which are dependenton which suturing technique isemployedor
whether an electronicmorcellatoris used. Generally, one can perform most laparoscopic myomectomies with an 11-mm umbilical port, a high lateral port on each side placed 3 cm below
the umbilicus and 6 to 8 cm lateral to the midline. The lateral
ports may be placed above the umbilicus for larger uteri. Finally,
a suprapubic 11- to 12-mm port is placed, through which the
morcellator can be inserted after dilating the port site to 15 mm.
Alternatively, this port may be placed in the left lower quadrant.
Before proceeding with the insertion of multiple accessory ports,
the size andposition of themyomasare carefully assessed.If there
is any doubt about the safe performance of the myomectomy via
laparoscopy, such as the presence of large inaccessible posterior
or broad ligament myomas, a conventional laparotomy should
be performed.
A dilute vasopressin solution (2 U in 60 mL of normal saline)
is then injected into the serosa and myometrium overlying the
myomauntilthetissueblanches.This is easily accomplished using
a control-top syringe and a 4-inch 22-gauge spinal needle, which
is inserted percutaneously over theuterus. The tip of the needle is
then guided into the proper sites along the myoma with a 5-mm
grasper from a lateralport. The useof vasopressin for gynecologic
surgery has been controversialbutiswidelyacceptedintheUnited
States. In two prospective randomized studies, dilute vasopressin
318 — Mark H. Glasser
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Figure 12.1.1. The MHI uterine manipulator.
solution was found to decrease blood loss at time of myomectomy by laparotomy compared with placebo or a tourniquet.[13]
An alternative to the use of vasopressin is to inject 0.25% bupivacaine with epinephrine into the serosa and myometrium in
the same fashion. This also has a vasoconstrictive effect and has
been found in one randomized study to decrease the need for
postoperative pain medication in women undergoing laparoscopic myomectomy as well as to decrease blood loss.[14]
Pedunculatedmyomasaretheleastdifficulttomanage laparoscopically. After the dilutevasopressinsolutionis injected into the
stalk, the myoma is removed bycutting andcoagulating the stalk.
Care must be taken to stay close to the myoma and avoid thermal damage to the normal myometrium from which the stalk
arises. An alternative technique is to place one or two ties around
the pedicle (Endoloops [Ethicon] may be used) and to excise the
myoma by electrosurgically cutting through the serosa around
its base about 1 to 2 cm above the insertion of the pedicle. The
pedicle can then be oversewn to assure hemostasis. This technique minimizes the risk of later uterine rupture, which has been
reported during pregnancy following laparoscopic removal of a
pedunculated myoma.[15]
The removal of subserous myomas is less challenging than
the removal of deep intramural myomas. Dilute vasopressin is
injectedinmultiplesitesbetweenthe myometriumandthefibroid
capsule. An incision is made on the serosa overlying the leiomyoma, using the CO
laser (superpulse or ultrapulse mode), a
2
monopolar electrode, a fiber laser, or harmonic scalpel. The incision is extended until it reaches the capsule. The myometrium
retracts as the incision is made and the myoma bulges outward.
Two grasping, toothed forcepshold the edges of the myometrium,
and the suction–irrigator can be used as a blunt probe to shell
the leiomyoma from its capsule. A myoma screw is inserted into
the tumor to apply traction while the suction–irrigator is used as
a blunt dissector. An alternative is to insert a finger through the
12-mm suprapubic port site incision and manually dissect the
myoma free from the myometrium. Once this is accomplished,
the cannula is reinserted. Vessels are electrocoagulated before
being cut. After complete removal of the myoma, the uterine
defect is irrigated. Bleeding points are identified and controlled
with bipolaror monopolar electrocoagulation.Pointcoagulation
of identifiable vessels can be accomplished by using short bursts
of cutting current while the vessel is grasped with a Maryland
dissecting forceps, much as one would do in an open case with
a hemostat. The edges of the uterine defect are approximated by
superficial suturing.
Deep intramural or broad ligament intramural myomas are
the most difficult toproperlymanagelaparoscopicallyandshould
be done only by surgeons skilled in laparoscopic suturing. This
is especially true if the patient plans future childbearing. The
gold standardof myometrial closure afteropen myomectomy is a
three-layered closure beginning at the base of the defect to obliterate the dead space with figure-of-eight or horizontal mattress
sutures. A second layer of continuous suture is then placed to
further approximate the myometrium and finally ending with a
continuous imbricating “baseball” stitch on the serosa. Synthetic
absorbable polyglactin sutures (Vicryl, Ethicon, Somerville, NJ;
Polysorb, USSC, Norwalk, CT) are recommended because they
produce less inflammatory reaction than catgut.
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Figure 12.1.2. The Pelosi uterine manipulator.
Intraligamentousandbroadligamentmyomasrequire careful
observation of the course of the ureters and large blood vessels.
Depending on the location of the myoma, an incision is made on
the anterior orposterior leaf ofthe broad ligament.The myoma is
removed with the techniques described above for subserosal and
intramural tumors. Throughout the procedure, the location of
the ureters is noted. Hemostasis is obtained with thesutures,clips,
or bipolar forceps. None of the available lasers, despite the power
setting or focus of the beam, can adequately coagulate bleeding
myometrial vessels. A bipolar forceps, monopolar fine dissecting
forceps (Maryland), orargon beam coagulator isexcellent forthis
purpose. The broad ligament and peritoneum are not closed but
allowed to heal spontaneously. Drains are used infrequently.
Stringer and associates [16] described a simplified way of
closing deep myometrial defects using the Endo Stitch automatic
suturing device(UnitedStates Surgical, Norwalk CT).[16]Multiple layers of continuous interlocking sutures are placed using this
device, whichcapturesthe 9-mm needle in the oppositejaw when
the handles are squeezed (Figure 12.1.3). The suture is held taut
by the assistant, and finally an intracorporeal knot is tied with the
device (Figure 12.1.4). The Endo Stitch must be used through a
10-mm port. Its limitations are a semi-straight needle that is relatively short. Once adept at using the device, one can often stitch
faster than by using conventional open suturing techniques.
Recently, the da Vinci surgical robot (Intuitive Surgical) has
been advocated as a suturing aid in performing laparoscopic
myomectomy. The initial published report done in a university
hospital setting showed a conversion rate of 8.6% to laparotomy
and an average operating time of 230.8 ± 83 minutes. The average length of stay was 1 day.[17] Although this technology is
certainly “space age,” it is very expensive in capital outlay, per
case cost, and annual service contract cost. This device performs
suturing precisely and because of its high cost, will be available
only in a very few centers. The average operating time of close
to 4 hours as reported above is unacceptable and far longer than
the average operating time for laparoscopic myomectomy in the
published literature. The degree of precision the system affords is
hardly necessary or appropriate for myomectomy, which can be
accomplished safely by many of the techniques discussed in this
chapter. Until good data are presented clearly demonstrating the
superiority of this instrument, gynecologists should approach it
with a critical eye.
320 — Mark H. Glasser
https://t.me/med1917
Figure 12.1.3. The Endo Stitch automatic suturing device.
Specimen Removal Techniques
Other than laparoscopic suturing, the greatest challenge and
often the most frustrating step in laparoscopic myomectomy is
specimen removal. For multiple small myomas, the enucleated
specimens can be placed in a specimen retrieval bag, brought up
to the largest port site, and morcellated in the bag at the skin line
using a#11 scalpel blade. Another techniquefor intra-abdominal
morcellation of larger myomas is to grasp opposite sides of the
myoma with strong toothed graspers from each lateral port and
to suspend it in the lower abdominal airspace near the anterior
peritoneum. A narrow scalpel with a #11 blade is then passed
Figure 12.1.4. The Endo Stitch is used to tie an intracorporeal knot
after a line of continuous suture.
through the suprapubic 12-mm port, and the myoma is cut into
small segments, placed in a specimen retrieval bag, and removed
through the umbilical or suprapubic port site after the cannula
is removed. The port site incision can be made larger to facilitate
this. If the cannula needs to be reinserted, a disposable coneshaped adaptor or a Hasson cannula can be used.
The laparoscopic morcellator has been a significant advance
for specimen removal during laparoscopic myomectomy and has
saved many patients from major laparotomies. The most widely
used device in the United States is made by Gynecare (Johnson
& Johnson, Somerville, NJ). Other excellent electronic morcellators are made by Karl Storz, WISAP, and Richard Wolf. Because
the morcellator blade is very sharp and turns at a high rate of
speed, it is most important that the cutting edge of the blade be
kept in view at all times. The morcellator is best inserted through
the lateral or suprapubic port and held parallel to the abdominal
wall. Afull pneumoperitoneum mustbe maintained to maximize
the airspace and minimize the risk of a loop of bowel or other
structure being injured by coming into contact with the active
blade. The myoma should be grasped with a heavy claw forceps
or laparoscopic tenaculum and drawn into the morcellator blade
without changing position of the morcellator. Slow, gentle pressure will withdraw the morcellated myoma in a single strip from
the end of the morcellator. Excess traction should be avoided
because it will sever the strip and necessitate regrasping. The surgeon should work from the periphery of the myoma and around
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it, almost like peeling afruit. It is not advisabletodrill through the
center of the myoma because this technique takes much longer
and increases the risk of injury to organs hidden from view by
the myoma. It is also important to not lose sight of any fragments of myoma that have been morcellated and dropped into
the abdomen or any small myomas that have been enucleated.
Transfixing these small myomas with a single suture and suspending them from the anterior abdominal wall is a good way to
prevent their loss in the abdomen. One study reported the loss of
a 6-cm myoma during alaparoscopicsupracervical hysterectomy.
The specimen becameentangled and fixed to themesentery of the
small bowel in the upper abdomen and caused a bowel obstruction, resulting in the need for an exploratory laparotomy.[18]
Seeding of port sites with malignant cells or endometriosis is a
well-known sequela of laparoscopic procedures. This may also
occur with morcellated myoma tissue, as was shown in a case
report by Ostrzenski.[19]
In a randomizedtrial, Sinha and associates [20] evaluatedtwo
groups of patients undergoing laparoscopic myomectomy with
at least one myoma 7 cm in diameter to assess the feasibility of
enucleation of myomas by morcellation while the myoma is still
attached to the uterus compared with standard enucleation and
morcellation as described above. The meanweightof the myomas
removedin each groupwas about 600g. Blood loss,length of stay,
and complication rates were similar in both groups, but operating time was significantly decreased in the group employing the
technique of morcellation of the myomas while still attached to
the uterus. The authors speculate that this technique may allow
larger myomas to be managed laparoscopically. In situ morcellation of large myomas is the technique employed in minilap
myomectomy, which is discussed at length later in this chapter.
Another variation of laparoscopic myomectomy used as an
alternative to the morcellator is specimen removal through a
colpotomy incision. The colpotomy incision can be done vaginally below the cervix between the uterosacral ligaments. This is
facilitatedbytransfixingthemyomawithatumor screwand pushing it into the cul-de-sac laparoscopically. This allows the vaginal
surgeon to make the colpotomy incision directly over the myoma
without fear of injury to intra-abdominal structures. Once the
peritoneum is opened, the myoma is grasped vaginally with a
tenaculum or Leahy clamp and removed intact or progressively
morcellated using a coring technique. Alternatively, the vagina
can be identified laparoscopically by the uterine manipulator,
vaginal probe, or a sponge stick placed in the posterior fornix
vaginally. An incision is then made laparoscopically using an
electrosurgical needle or scissors, harmonic scalpel, or CO
laser.
2
The disadvantage of this approach is the pneumoperitoneum is
rapidly lost, making it difficult to bring the myoma into the culde-sac. A wet lap pad may be placed in the vagina to facilitate
restoring the pneumoperitoneum to view the pelvis. Multiple
small myomas can be removed with a specimen retrieval bag
placed through the colpotomy incision. The colpotomy incision
can be sutured laparoscopically, but it is far quicker and easier to
close the colpotomy vaginally.
In a retrospective cohort study, Ou and associates [21] compared two groups of patients undergoing laparoscopic myomectomy with specimen removal by colpotomy versus morcellation.
They found that multiple myomas can be removed more quickly
via posterior colpotomy than by morcellation. The incisions were
closed vaginally and then inspected laparoscopically to ensure
hemostasis. Certainly, avoiding the use ofelectronic morcellators
and the high cost of disposable morcellator blades is an economical way of performing laparoscopic myomectomy.
VAGINAL MYOMECTOMY AND
LAPAROSCOPICALLY ASSISTED VAGINAL
MYOMECTOMY
Several authors have reported on vaginal myomectomy and
laparoscopically assisted vaginal myomectomy (LAVM), a version of laparoscopicmyomectomy in which the dominant myoma
is incised and partially enucleated by the techniques described
above and the enucleation is completed through a transverse
colpotomyincision. Smaller myomas are then incised andenucleated vaginally. The fundus is then delivered through the colpotomy and the defects repaired.[22,23] This technique is possible only if there is adequate room vaginally and the cul-de-sac
can be reached easily. For large dominant posterior myomas, the
use of the laparoscope may not be necessary. In a small pilot
study, Birsan and associates [24] compared two similar groups
of women undergoing laparoscopic myomectomy versus vaginal
myomectomy for large posterior myomas. There was no difference in parity or myoma size between the two groups. Vaginal
myomectomywasfoundtobe feasible and safe andwasassociated
with a shorter operating time and lower morphine consumption than laparoscopic myomectomy.[24] LAVM through an
anterior approach was reported by Chin and associates.[25] Seven
women with symptomatic fundal andanterior wall myomas were
treated by laparoscopically placing a suture through the myoma
and bringing it down through the anterior cul-de-sac into the
vagina via an anterior colpotomy. Resection and suturing were
performed transvaginally.Therewereno complications,although
four patients developed transient hematuria.
LAPAROSCOPICALLY ASSISTED
MYOMECTOMY/MINILAP MYONECTOMY
First reported by Nezhat et al. [26] in 1994, laparoscopically
assisted myomectomy (LAM) is a safe alternative to laparoscopic
myomectomy. It is less difficult and requires less time to complete than other modes of myomectomy. These considerations
are summarized in Table 12.1.1. The decision to do LAM usually
is made in the operating room after the diagnostic laparoscopy
and treatment of other pelvic abnormalities are completed. The
criteria for LAM are a myoma greater than 8 cm, many myomas
requiring extensive morcellation, and a deep, large, intramural
myoma that requires uterine repair in multiple layers.
A combination of laparoscopy with a 2- to 4-cm abdominal
incision may enable more gynecologists to apply this technique.
The conventional uterine suturing in two or three layers reduces
the potentialforuterinedehiscence,fistulas, andadhesions.Better
pelvic exposure during the laparoscopy allows the gynecologist
to diagnose and treat associated endometriosis or adhesions.
Three major objectives of LAM are reduction of blood
loss, prevention of postoperative adhesions, and maintenance of
myometrial integrity. LAM with morcellation and conventional
suturing reduces the duration of the operation and the need for
more extensive laparoscopic experience.
322 — Mark H. Glasser
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Table 12.1.1: Results of Types of Myomectomy
P(LM)*
Studied Parameter LAM (57 patients), mean ± SEM LM (64), mean ± SEM Lap (22), mean ± SEM
Leiomyoma weight, g 247 ± 30.1 58 ± 7.16 337 ± 77.4 P(LM) ≤ 0.00001
Uterine size, weeks 12 ± 26 8 ± 14 10 ± 24
Operative time, minutes 127 ± 7.62 136 ± 9.6 134 ± 9.95 P(LM) = 0.36
Blood loss, mL 267 ± 54.4 143 ± 35.6 245 ± 56.1 P(LM) = 0.0068
Postoperative hospital stay, days 1.28 0.91 3.3 ± 0.39 P(LM) = .0141
Days to resume normal activity 12.2 11.2 39.2 P(LM) = 0.43
Days for complete “100%” recovery 23.1 20.9 70.0 P(LM) = 0.41
LAM, laparoscopically assisted myomectomy; Lap, laparotomy; LM, laparoscopic myectomy; SEM, standard error of the mean.
∗
P(LM) compares LAM and LM.
†
P(Lap) compares LAM and myomectomy by laparotomy.
Source: Nezhat [9] p206, 715-2.
†
P(Lap)
P(Lap) = 0.27
P(Lap) = 0.59
P(Lap) = 0.78
P(Lap) = .00004
P(Lap) ≤ 0.0001
P(Lap) = 0.0002
The useof minilaparotomy in surgery forbenign gynecologic
disease hasbeen well established.[27]In a randomizedcontrolled
trial, Benassi and associates [28] evaluated the efficacy and applicability of the minilaparotomy technique inabdominal myomectomies and compared it with traditional laparotomy. They found
duration of surgery and days of postoperative hospital stay were
significantly lower inthe minilaparotomy group, aswell as higher
treatment satisfaction reported by the patients (P ≤ 0.05). More-
over, each minilaparotomy operation ended up saving 620 euros.
Based on a review of 139 cases, Glasser [29] found that
myomectomy performed through a 3- to 6-cm minilaparotomy
incision affords the advantageofsame-daydischarge as well as the
ability to palpate the uterus and close the defect using a standard
three-layered suturing technique. Of the original 139 patients,
66 had LAM, during which the laparoscope was used to identify
and mark the incision site or to perform adhesiolysis. The vast
majority of those procedures were done during our early experience. For the last 4 years, virtually all myomectomies were done
without the use of the laparoscope. All patients with leiomyomas
complaining of “bulk” symptoms and desiring intervention were
offered minilap myomectomy as one of their treatment options.
Those who had completed childbearing were also offered vaginal
or minilap supracervical hysterectomy, uterine artery embolization, or medical therapy if they were perimenopausal.
Laparoscopic myolysis was also offered asa treatment option.
Laparoscopic myolysis was our first choice for the management
of large symptomatic myomas in the mid-1990s. We did perform
102 myolysis procedures from 1994 to 2001 but have not done
any in the past 4 years. The procedure is technically much easier
to perform than myomectomy, blood loss is less, and operating
time is shorter. Over time, however, both patients and physicians
found this procedure to be distasteful. Patients, in particular,were
unhappy with leaving “dead fibroids” in their uterus. We did see
some regrowth, and subsequent hysterectomies done onmyolysis
patients were difficult secondary to adhesions. As our skill level
with minilap myomectomy improved, more of our physicians
encouraged this procedure as a first option – even when fertility
was not anissue.Certainly, myomectomyisalwaysthe first option
in patients desiring future childbearing.
All patients underwent pelvic ultrasonography to assess uterine size, individual myoma size, and number and location of
myomas. Those with equivocal sonography and those with multiple myomas desiring future fertility underwent MRI studies to
“map” the uterus more accurately. Those with abnormal uterine bleeding underwent diagnostic office hysteroscopy and hysteroscopic resection at the time of myomectomy if submucous
myomas were present. Myomas larger than 2 cm were removed
transmyometrially. Patients with more than five measurable
myomas on imaging studies and not desiring future fertility
were strongly urged to undergo hysterectomy or uterine artery
embolization. The “ideal” patient for this procedure is thin, with
a single large anterior fundal myoma. We have, however, performed this procedure on patients weighing as much as 280 lb
and on those with multiple or posterior myomas.
Pretreatment with GnRH analogues was used in all patients
in the early part of the study, but this practice has largely been
abandoned. GnRH analogues are given only to reduce massive
bulk in uteri greater than 20 weeks’ gestational size or to patients
who are anemic (Hgb <10 GMS.) to create amenorrhea and
increase hemoglobin levels. An 8-week course is generally sufficient to achieve these results. The results of this series are summarized in Table 12.1.2. The average age of the patients was 38.9
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Table 12.1.2: Minilap Myomectomy in 139 Patients
Patient Characteristic Median Range
Age, years 30 23–56 8
Myoma weight, g 275 30–975 270
Estimate blood loss, mL 300 50–2000 200
Operating room time, minutes 110 44–260 61
Length of stay, hours 6 2–48 9
Additional procedures Three hysterectomies: one due to
emergency hemorrhage and two
due to recurrent fibroids
∗
Performed at Kaiser San Rafael January 1, 1995, [29], to December
31, 2003.
∗
Interquartile
Range
years, with a range of 23 to 56 years. There were also a few
perimenopausal patients who were poor candidates for either
vaginal hysterectomy (nulliparous, no uterine decensus and huge
fibroids) or laparoscopic supracervical hysterectomy (LSH) and
wanted a minimally invasiveapproach rather thana conventional
abdominal hysterectomy. Those patients are now offeredminilap
supracervical hysterectomy as an alternative.
The average weight of the myomas removed was 285.6 g,
with a range of 30 to 925 g. The patient with a 30-g myoma
was an infertility patient with a 5-cm type 2 myoma penetrating the entire myometrium. Two patients had 15 separate
myomas removed that were not evident on preoperative imaging
studies. Seventy of 139 patients had pretreatment with GnRH
analogues.
The average length of stay was 13.6 hours, with a range of
4 to 48 hours. One of the two patients who spent 48 hours in
the hospital developed a fever, probably secondary to atelectasis,
and was kept for observation. The other patient had nausea and
vomiting, which resolved with antiemetics. Twenty-four of 139
patients were discharged within 4 hours of surgery and 61 within
8 hours. Of the 51 patients discharged between 8 and 23 hours
post surgery, 27 lived more than 50 miles from the hospital and
chose to spend the night rather than drive home.
Average operating time for this procedure was 110 minutes,
with a range of 55 to 260 minutes. The operating time was, to some
degree, related to the skill and experience of the surgeon. There
was a direct relationship between operating time and number
of myomas, rather than size, although individual myomas larger
than 10 cm took longer to morcellate.
The average blood loss was 330 mL, with a range of 50 to
2000 mL. The patient with the 2000-mL blood loss had a large
broad ligament myoma that was avulsed by too vigorous upward
traction before being completely morcellated. She had uncontrolled bleeding at the myoma bed and underwent emergency
hysterectomy after efforts at uterine artery ligation failed. She
was the only patient to undergo a blood transfusion in our series.
This complication occurred early in our series in a procedure
performed by a relatively inexperienced surgeon.
The two other hysterectomies performed in this group were
for recurrent myomas. Both these patients had multiple myomas
at the time of initial myomectomy. One had a hematometra
following surgery and gradual uterine growth over a 6-month
period. Her bulk symptoms recurred, and she elected to have
an abdominal hysterectomy at that time. The second patient had
multiple myomas removed at age 38 andhad recurrence of symptoms 5 years later. She underwent a supracervical hysterectomy
for a uterus that weighed 900 g and contained multiple myomas.
Surgical Technique
If LAM is being performed, the following technique is used. In
patients with multiple myomas, the most prominent myoma is
injected at itsbase with 3to7 mL ofdilutedvasopressin.A vertical
incision is made over the uterine serosa onto the surface of the
tumor andextendeduntilthecapsuleoftheleiomyomaisreached.
A corkscrew manipulator is insertedintothe leiomyoma and used
to elevate the uterus toward the midline suprapubic puncture.
With the trocar and manipulator attached to the myoma, this
midline 5-mm puncture is enlarged to a 4-cm transverse skin
incision. After the incision of the fascia transversely, the rectus
muscle is divided using a monopolar electrode. If the inferior
epigastric vessels are found, they are coagulated. This approach
provides excellent access to the abdominal cavity.
The peritoneum is entered transversely, and the leiomyoma
is observed. It is brought to the laparotomy incision by using the
corkscrew manipulator to raise the uterus. A corkscrew manipulator is replaced with two Lahey tenacula. The tumor is shelled
and morcellated sequentially, and after its complete removal, the
uterine wall defect shows through the incision. If uterine size
allows, the uterus is exteriorized to complete the repair. When
multiple leiomyomas are found, as many as possible are removed
through one uterine incision if it can be accomplished without
excessive tunneling. When other myomas are located that cannot
be removed through theinitial uterine incision,the 4-cm abdominal opening is approximated temporarily with two or three Allis
clamps or an inflated latex glove. The laparoscope is reintroduced,
and the remainingmyomasare identified andbrought to thelevel
of the abdominal incision. They are removed under laparoscopic
control. The uterus is exteriorized through the 4-cm abdominal
incision. Themyometrium is closed inlayerswith 2-0and 0 polydioxanone sutures. The serosa is closed microsurgically with 5-0
sutures. The uterus is palpated to ensure that no small intramural leiomyomas remain. It is returned to the peritoneal cavity.
The fascia is closed with a 1-0 polyglactin suture, and the skin
is closed in a subcuticular manner. The laparoscope is used to
evaluate hemostasis. The pelvis is observed to detect and treat
endometriosis and adhesions that may have been obscured previously by myomas. Copious irrigation is used, blood clots are
removed, and Interceed (Gynecare, Somerville, NJ) is applied
over the uterus to help prevent adhesions.
Intraoperatively, injections of dilute vasopressin into the
myoma help reduce blood loss. Vertical uterine incisions bleed
less than do transverse incisions [4], and pneumoperitoneum
seems to decrease intraoperative bleeding.
A recent innovation in LAM is the use of the LAP DISK
abdominal wallsealing device (Ethicon Endosurgery, Somerville,
NJ), which allows the surgeon to place a hand in the abdomen
during laparoscopic surgery, facilitatingexposure and dissection.
In a retrospective study of43 patients who underwent LAMusing
the LAP DISK, Tanaguchi and associates [30] in Japan removed
myomas that ranged in weight from 40to 700 g(mean, 208 g) and
324 — Mark H. Glasser
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diameter from 2 to 10 cm (mean, 5.4 cm). Mean blood loss was
42.3 mL. Half of the 18 patients who had been diagnosed with
primary infertility for 2 years or longer became pregnant without postoperative assisted reproductive techniques. The authors
concluded that the LAP DISK abdominal wall sealing device was
useful for LAM, allowing surgeons to remove myomas safely and
repair uterine defects effectively while minimizing blood loss and
trauma.
In minilap myomectomy without the use of laparoscopy,
the patient is placed in the low lithotomy position using Allen
stirrups (Allen Medical Systems, Cleveland, OH). Ten milliliters
of a dilute vasopressin solution (6 U in 60 mL NaCl) is then
injected intracervically about 1 to 2 cm deep at both the 8 and
4 o’clock positions according to the technique described by
Phillips et al. [31], and we have noticed a marked blanching of
the entire uterus when this is done before making the abdominal incision. A firm uterine manipulator with a 5-mm obturator
(Medical Horizons, Fair Oaks, CA) is then placed in the cervix
(Figure 12.1.1). A Pelosi (Figure 12.1.2) or Valtchev manipulator
also works well. It is important not to use a uterine manipulator with an inflatable balloon because it may be mistaken for a
myoma on palpation. The midline is identified on the abdomen
and a3- to 5-cm horizontal line is drawn on the skinabout two to
three finger breaths above the top of the symphysis. The incision
should be madeslightly higher ifthemyomais posterior.Also,the
incision should be made slightly longer for patients with central
obesity.For patients whoare massively obese with a largepannus,
this can be raised and taped to the top of the table with 6-inch
cloth tape secured with tincture of benzoin. The incision then is
made at the skin fold above the pubic bone, which is often the
thinnest part of the abdomen.
The operation is performed using a cruciate incision. The
cruciate incision, as described by Pelosi [32] for minilaparotomy, affords excellent exposure. By dissecting the fascia vertically rather than horizontally, the abdominal opening is round
rather than ovoid, giving an increased working area. Before making the skin incision, 10 mL of 0.25% bupivacaine (Marcaine,
AstraZeneca) with epinephrine solution is injected superficially,
extending laterally beyond the limitsof the incision. The skinand
subcutaneous tissue are opened horizontally to the level of the
fascia, and a finger is used to bluntly tunnel under the subcutaneous fat close to the fascia in the midline both cephalad toward
the umbilicus and caudad to the pubic bone. The fascia is then
opened in the midline for a total length of about 6 cm. The rectus muscle is then separated in the midline and the peritoneum
grasped, nicked, and entered longitudinally. Care must be taken
not to injure the bladder when extending the peritoneal incision
downward. Once the peritoneum is opened, the surgeon’s finger
is swept circumferentially, to make sure there are no adhesions to
the anterior abdominal wall. A Mobius elastic retractor (Apple
Medical, Marlborough, MA) is then inserted (Figure 12.1.5). The
bottom blue ring of the retractor is first inserted under the peritoneum, andthe polyethylene membrane is then rolled up on the
top yellow ring. This is facilitated by the surgeon grasping the top
ring at the 10and 2 o’clock positions and twisting it down toward
the abdominal wall. The assistant then completes the twist while
the surgeon holds the top ring firmly. Usually two or three twists
are sufficient to create a nice round opening in the abdominal
wall with a diameter equal to the length of the skin incision. The
Mobius elastic self-retaining retractor [33] enhances this expo-
Figure 12.1.5. The Mobius retractor.
sure, and the incision can be moved to the areas of dissection
using small Deaver or Lorenz vein retractors. A 4-cm incision
results in a working areaof 12.5 cm
increase this working area to 28 cm
2
, whereas a6-cm incision will
2
.Theretractorgentlycompresses the layers of the abdominal wall and allows the specimen
to be elevatedto the skinline. Also, the retractorallows the skinto
stretch so thatmuch larger specimens can be removed. Thisis not
possible using a fixed metal self-retaining retractor. There is also
minimal trauma to the rectus muscles. The vast majority of our
patients require only oral analgesics in the immediate postoperative period and manage well on nonsteroidal anti-inflammatory
drugs or acetaminophen at home. The retractor is soft and very
atraumatic to the tissues of the abdominal wall while it keeps
subcutaneous fat, muscle, and peritoneum out of the operative
field. We have found that a 4- to 5-cm incision gives us adequate
room to remove myomas by morcellation and repair the uterine
defect by conventional suturing techniques.
Before proceeding with the myomectomy, the size and position of the myomas are carefully assessed. If there is any doubt
about the safe performance of the procedure via minilap, such
as the presence of large inaccessible posterior or broad ligament myomas, a conventional laparotomy should be performed.
This can easily be accomplished by removing the Mobius retractor, extending the skin and fascial incisions, and reinserting the
Mobius to its full 6-inch diameter. Conversion to laparotomy
when the myoma is partially dissected results in increased blood
loss secondary to the delay, so this decision should be made early.
Assessment as to where the uterine incision should be placed is
the next step. We prefer anterior midlinefundalincisions for large
solitary intramural myomas. If multiple myomas are present, a
strategic incision site through which most of the myomas can
be removed is attempted, but it is sometimes preferable to make
separate incisions for each myoma. Posterior myomas can usually
be approached through a transverse incision well below the tubal
insertions. For large subserosal myomas, it is important to make
the initial incision high on the myoma, usually 2 to 3 cm distal to
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the junction between the myoma and the uterus. This allows for
easier closure of the defect. Also, pedunculated myomas should
be incised above where the pedicle inserts on the myoma toavoid
cautery damage to the fundal myometrium. Attempts should be
made toavoid the cornualregion, thusminimizing trauma to the
tubal ostia.
Using the uterine manipulator, the uterus is elevated to
the abdominal incision. The serosa and myometrium along the
course of the proposed incision is then injected with the same
dilute vasopressin solution used intracervically to a depth of
1 to 2 cm. This is easily accomplished with the use of a standard 22-gauge1.5-inch needle. Additional vasopressin isinjected
deeply into the myoma. Subserous myomas should be injected
at the base, directing the needle both into the myoma and into
the uterus. A distinct blanching of the myoma becomes readily apparent. Usually, 10 to 15 mL of vasopressin is sufficient to
achieve hemostasis. A 4- to 6-cm incision is then made through
the serosa and myometrium and carried down through the pseudocapsule of the myoma. The myoma usually bulges out at this
point. Small “army–navy,” Jarit “S,” or Lorenz vein retractors are
then inserted between the myoma and the myometrium inside
the pseudocapsule (Figure 12.1.6). The myoma is grasped with
Lahey thyroid clamps and strong upward traction applied. This
tamponades the uterine incision against the upper abdominal
wall and markedly reduces blood loss. The myoma is then progressively morcellated, much as one would do in a vaginal hysterectomy using a #10 scalpel blade on a long handle (Figure
12.1.7). This is more ergonomic and thus less tiring than using a
short-handled scalpel. It is most important to regrasp a remaining edge of the myoma before the morcellated core of tissue is
removed so that upward traction andtamponade aremaintained
(Figure 12.1.8). Attempts to enucleate the large myoma should
be avoided because this tears blood vessels both in the periphery and at the base of the myoma. Careful dissection around the
capsule of the myoma with coagulation of blood vessels as they
are encountered significantly reduces blood loss. The large blood
vessels at the base are easily identified and desiccated when the
remains of the myoma are brought through the incision (Figure
Minimally Invasive Approaches to Myomectomy — 325
Figure 12.1.7. Morcellation of the myoma using a #10 scalpel.
12.1.9). Carefulpalpation atthis point allows additional myomas
to be identified and, if possible, removed through this incision by
a combination of morcellation and enucleation. Also, palpation
of the obturator of the manipulator identifies the uterine cavity. If additional myomas are identified in other areas, it is more
prudent to first close the original uterine incision and approach
the others through separate incisions using the same technique
described above.
The uterine elevator is helpful in bringing the uterus up to
the anterior abdominal wall, where the edges of the uterine incision are then grasped with Pennington clamps. The Pennington
clamps are placed as deep as possible into the myometrial defect
and an attempt is made to evert the edges. The entire uterine
defect can often be exteriorized completely for easy repair on the
abdomen (Figure 12.1.10). This allows placement of deep figureof-eight or horizontal mattress sutures. We use #1 Polysorb on an
HGS 21 needle (USSC, Norwalk, CT) and take deep myometrial
bites to close off the base of the incision and approximate the
Figure 12.1.6. Lorenz vein retractors are placed between the myoma
and the myometrium before morcellation.
Figure 12.1.8. Upward traction on the myoma is maintained with an
additional Leahy clamp before the morcellated core is removed.
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Figure 12.1.9. The dominant vessels are clamped and coagulated after
the morcellated myoma is delivered through the minilap incision.
myometrium. A second layer of continuous 0 Polysorb or interrupted horizontal mattress sutures are placed to further approximate the myometrium. The serosa is then closed with a continuous “baseball” imbricating layer using 3-0 Polysorb on a V20
(vascular) needle for minimal trauma and adhesion prevention
(Figure 12.1.11). All anterior and pedunculated myomas should
be removed first so that the uterus can be sharply anteflexed by
the uterine manipulator to approach posterior lower-segment
myomas. We have been surprised that even posterior cervical
myomas can be removed by this technique.
Large pedunculated fundal myomas are most easily managed
by minilap because extensive deep suturing usually is not necessary. Usually, a 3-cm incision suffices. Once the myoma pedicle
is identified, it is injected with the dilute vasopressin solution
as described above. A large, blunt right-angled vascular clamp
(Grover or Satinsky) is placed under the myoma pedicle and a
Figure 12.1.11. The serosa is closed with an imbricating baseball closure using fine suture on a vascular needle.
0.5-inch Penrose drain is drawn under and tightly tied around
the myoma pedicle (Figure 12.1.12). Using the electrosurgical
pencil, a circumferential mark is made at the myoma base about
1 to 2 cm above the tourniquet. The top of the myoma is then
brought to the incision (Figure 12.1.13) and progressively morcellated with ascalpel until themark at thebase is reached (Figure
12.1.14). It is then carefully dissected free from the pedicle (Figure 12.1.15). A horizontal mattress suture is then placed in the
fundus of the uterus incorporating the base of the pedicle and
Figure 12.1.10. The uterinedefectisdeliveredthroughtheincisionand
the edges grasped with Pennington clamps. The defect is closed with
multiple layers to eliminate any myometrial “dead space.”
Figure 12.1.12. A 0.5-inch Penrose drain is placed under thepedicle of
a 7-cm pedunculated myoma, which has been grasped by a tenaculum.
The drain is tied tightly to form a tourniquet. The uterus is visible
below the Penrose drain.
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