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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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GENERAL PRINCIPLES
Definition
A myomectomy is a surgical removal of uterine fibroids. This may be performed through an open laparotomy incision, using
only the hysteroscope for a fibroid with a submucous component, or exclusively with the laparoscope. A myomectomy is the
procedure of choice in patients wishing to retain the option of future conception. Other interventional therapies such as
uterine artery embolization, magnetic resonance–guided focused ultrasound (MRgFUS) or high-intensity focused ultrasound
(HIFU), and laparoscopic myolysis are associated with higher risks of pregnancy complications or have little data in support
of pregnancy posttreatment.
1
A laparoscopic approach, most commonly with robotic assistance, allows improved patient recovery with less morbidity,
outpatient treatment, equivalent results, decreased blood loss, and less pelvic adhesive disease as compared to conventional
open myomectomy.
2,3
In experienced hands, a robotic laparoscopic approach can successfully be used to treat fibroids
numbering up to twenty and very large uterine size (>20 weeks gestational age), limited by the ability to place intra-
abdominal trocars.
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Differential Diagnosis
Myomas are by far the most common uterine masses encountered in women of child-bearing age, but other masses such as
adenomyosis and leiomyosarcoma must be considered in the differential diagnosis.
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Nonoperative Management
Medical treatment with gonadotropin releasing hormone (GnRH)-agonists can lead to an approximate 30% reduction in
volume, but the effects are limited to the duration of use. Ulipristal acetate and mifepristone have also been used for the
treatment of fibroids. Studies on the long-term effectiveness of these medications is limited.
4
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IMAGING AND OTHER DIAGNOSTICS
Patients should initially be assessed with a pelvic ultrasound. If all fibroids can be clearly visualized and localized in relation
to the uterine cavity, this alone may suffice for surgical planning. In all other cases, a pelvic magnetic resonance imaging
(MRI) study should be performed and referred to intraoperatively to locate all fibroids. The goal of surgery should be to
remove as many fibroids as can be located. In complex cases with multiple fibroids, use of ultrasound or intraoperative
findings alone is inadequate and can lead to missing clinically significant fibroids.
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PREOPERATIVE PLANNING
Laparoscopic Approach
The first objective is to determine if a patient is a suitable candidate for a laparoscopic approach. This decision may be
surgeon dependent, but the primary limitation is a high order number of fibroids present (>10–20). In most cases, even very
large fibroids can be managed successfully with a laparoscopic approach. The limiting factor may be the amount of room
available for trocar and instrument placement within the patient’s abdomen.
If all fibroids cannot be clearly visualized and localized with a pelvic ultrasound, then an MRI should be performed. It is
important for the surgeon to become familiar with reviewing and reading the MRI in axial, sagittal, and coronal views to
determine feasibility of the laparoscopic approach and to use this intraoperatively to assist in locating and excising all
fibroids.
Preoperative screening for anemia should be performed. Ideally hemoglobin levels should be above 10 g/dL prior to surgery.
If below this, consideration should be given to medical management to improve levels, such as use of oral contraceptive
pills, iron supplementation, GnRH-agonist therapy, and/or tranexamic acid to limit menstrual blood loss.
Patients should be engaged in the discussion as to risks involved with the morcellation of fibroids. Inadvertent morcellation
of a leiomyosarcoma, though rarely encountered, could lead to a change in stage and possibly treatment outcomes. This
small risk must be weighed against the increased risk of patient morbidity, lengthened recovery, and adhesion formation due
to an open incision to remove the fibroids.
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Abdominal Myomectomy Technique
Preoperative ultrasound is usually sufficient in establishing an estimate of the overall uterine size and the size and number of
fibroids. At the time of surgery, most fibroids should be palpable, guiding excision.
Anticipation of blood loss should be discussed with the patient, including the possibility of requiring a blood transfusion.
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SURGICAL MANAGEMENT
Treatment should be aimed at removing all clinically significant fibroids and as many as feasible in order to lengthen the
amount of time before smaller fibroids become symptomatic in the future (Video 3.5.1 ).
Intraoperative blood loss can be lessened by the injection of a dilute vasopressin solution. A typical solution is made by
diluting 20 units of vasopressin in 80 to 100 mL of saline. This can be injected into the myometrium either by using a
laparoscopic cyst aspiration needle through a trocar, or by inserting a long spinal needle transabdominally into the uterus.
The total dose of vasopressin should be limited to 5 units (approximately 20 to 25 mL of above solution). Complications of
vasopressin use include bradycardia, hypertension, and cardiac ischemia and arrest.
5
Uterine incisions should be planned so as to allow removal of multiple fibroids if possible, thus limiting the number of
incisions that will decrease the overall total surgical time.
Uterine incisions should be closed in multiple layers with absorbable suture. Preferred suture is an absorbable barbed suture
(2–0 V-Loc™ 90 [Covidien, Medtronic Minimally Invasive Therapies, Minneapolis, MN]). Care should be taken to
approximate the cut tissues carefully, eliminate dead space, and obtain full hemostasis.
Care should be taken to keep a tally of the number of fibroids removed and to ensure that all are completely removed from
the abdomen at the end of the case. Retention of even small fibroids/fragments have been associated with parasitic growth,
adhesions, and even bowel obstruction.
6
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Positioning
The patient is placed in the standard dorsal lithotomy position. An intrauterine manipulator is used to allow for
chromotubation with indigo carmine or methylene blue. This will also stain the endometrial cavity, allowing better
visualization of the cavity when addressing submucosal fibroids or entry into the uterine cavity when resecting an intramural
leiomyoma.
Discuss with anesthesiology providers the anticipation of having the patient in Trendelenburg position for an extended period
of time. Often the maximum Trendelenburg position is required, but if possible the least angle of Trendelenburg positioning
needed to maintain the intestines out of the pelvis should be used.
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Approach
Laparoscopic trocars must be placed high in the abdomen in order to allow room to work, taking into account that often the
uterus/fibroids will be retracted in a cranial direction closer to the camera/ports.
For procedures using robotic assistance, the use of three arms in addition to the camera port allows for better uterine
manipulation. With the da Vinci Si
®
robot (Fig. 3.5.1A), Arm 1 is placed on the patient’s right, while Arms 2 and 3 are
placed on the patient’s left, for a right-handed surgeon. An assistant port is placed midway between the camera and Arm 1.
With the da Vinci Xi
®
robot (Fig. 3.5.1B), the camera and three accessory ports are placed in the upper abdomen in a
straight line since the camera can be placed in any of the ports. The assistant port is place in right lower quadrant. With
both systems, the camera port can be placed intraumbilical for uteri of 16 weeks gestational size or smaller, or moved to a
supraumbilical location for larger uteri.
Fundal fibroids should be approached first, followed by anterior, and lastly posterior fibroids. This provides the most mobility
to the uterus that will aid in anteflexion to reach posterior fibroids.
Figu re 3 .5.1. A: Typical laparoscopic port placement using the da Vinci Si
®
robot. Arm 1 is placed on the pat ient’s right (yellow dot), while Arms 2 (green dot)
and 3 (red dot) are placed on the patient ’s left, for a right-handed surgeon. An assistant port (white do t) is placed midway between the camera (blue d ot) and
Arm 1. B: Typical laparoscopic port placement using the da Vinci Xi
®
robot. T he camera (b lue dot) and three accessory ports (gray dots) are placed in the
upper abdomen in a straight line since the camera can be placed in any of the four port s. T he assistant port (white d ot) is place in right lower quadrant.
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Laparoscopic Approach
Injection of vasopressin
Insert the injection needle into the myometrium and into the body of the fibroid. Slowly withdraw the needle while attempting
to inject the solution. Generally this will allow the vasopressin to infiltrate around the fibroid as the needle is slowly
withdrawn (Te ch Fig. 3.5.1). For subserosal/pedunculated fibroids, injection should be on the lower aspect of the fibroid
and not into the uterus itself.
Te ch Fig ure 3.5.1. Injection of dilute vasopressin solution into myometrium overlying t he fibroid.
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