Presented by:
Ashley Tshala
Affiliations:
University of Toronto – St. Michael’s
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What is Robotic-Assisted Myomectomy?
Robotic-assisted myomectomy is a minimally invasive, uterine-preserving surgery used to remove symptomatic uterine fibroids while leaving the uterus in place. Careful surgical planning is essential because the number, size, type, and location of fibroids can significantly affect the complexity of the procedure and whether a robotic approach is appropriate. Here’s what it involves:
- Patient Selection: Symptoms, reproductive goals, previous surgery, and overall health are considered when determining whether robotic myomectomy is appropriate.
- Fibroid Mapping: Preoperative imaging is used to determine the number, size, depth, and location of fibroids and their relationship to the uterine cavity and surrounding structures.
- Surgical Planning: Port placement, uterine incisions, fibroid removal strategy, and specimen extraction are planned according to the individual fibroid burden.
- Vasopressin Injection: Dilute vasopressin may be injected into the uterus around the fibroid to temporarily reduce blood flow and limit bleeding during removal.
- Fibroid Enucleation: An incision is made over the fibroid, which is carefully separated from the surrounding myometrium while preserving healthy uterine tissue.
- Uterine Reconstruction: The resulting defect is closed in layers, often using barbed sutures to facilitate secure closure and restore uterine integrity.
- Adhesion Prevention: An adhesion barrier may be placed over the repaired uterus to reduce postoperative scar tissue formation.
- Specimen Extraction: Removed fibroids are extracted using an appropriate containment and tissue-removal strategy.
- Final Inspection: The reconstructed uterus and surrounding structures are inspected for bleeding or injury before completing the procedure.
Strategic patient selection and careful reconstruction allow robotic myomectomy to provide a uterine-preserving option for appropriately selected patients with symptomatic fibroids.
What are the Risks of Robotic-Assisted Myomectomy?
The risks of robotic myomectomy depend partly on fibroid size, number, location, and the extent of uterine reconstruction required.
- Significant Bleeding: Fibroids can have a substantial blood supply, and myomectomy may result in considerable blood loss or, occasionally, require transfusion.
- Uterine Injury: Deep or numerous fibroids can require extensive incisions into the uterine muscle and make reconstruction more complex.
- Vasopressin-Related Complications: Although uncommon, vasopressin can cause significant cardiovascular effects, including changes in heart rate and blood pressure.
- Adhesion Formation: Scar tissue can develop around the uterus, ovaries, fallopian tubes, or other pelvic structures despite efforts to reduce adhesion formation.
- Injury to Surrounding Structures: The bladder, ureters, bowel, blood vessels, or other pelvic structures can be injured during dissection.
- Entry Into the Uterine Cavity: Removal of deep fibroids may open the endometrial cavity, potentially affecting postoperative management and future pregnancy counseling.
- Future Pregnancy Considerations: Uterine incisions and reconstruction create a uterine scar that may influence management of future pregnancies and delivery.
- Residual or Recurrent Fibroids: Small fibroids may remain after surgery, and new fibroids can develop over time.
- Specimen Extraction Complications: Tissue removal may require enlargement of an incision or other extraction techniques, with additional considerations if unexpected malignancy is identified.
- Conversion to Open Surgery: Extensive fibroid burden, difficult anatomy, uncontrolled bleeding, or other complications may require conversion to an open procedure.
- General Surgical Risks: Infection, blood clots, anesthesia-related complications, wound problems, and postoperative pain are possible.
Detailed fibroid mapping, appropriate patient selection, techniques to reduce blood loss, meticulous uterine reconstruction, and careful specimen extraction help minimize these risks while preserving the uterus.