Intrauterine Morcellation at Laparoscopic Myomectomy

Table of Contents

• Procedure Summary
• Authors
• Youtube Video
• What is Intrauterine Morcellation at Laparoscopic Myomectomy?
• What are the Risks of Intrauterine Morcellation at Laparoscopic Myomectomy?
• Video Transcript

Video Description

In this video, we present an approach to previously described suprapubic laparoscopic-assisted myomectomy that we feel mitigates some of the disadvantages of traditional myomectomy – increased operative time, increased blood loss and surgical expertise in laparoscopic suturing.

Using footage from our own procedures of this kind, we propose a method by which a fibroid is just partially dissected free of the myometrium, is tagged with a unique suture and morcellated while still within the myometrium.

Presented By

Affiliations

University of Calgary

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What is Intrauterine Morcellation at Laparoscopic Myomectomy?

What are the Risks of Intrauterine Morcellation at Laparoscopic Myomectomy?

The risks of intrauterine morcellation at laparoscopic myomectomy are specific to the procedure and the use of morcellation technology to fragment and remove fibroids from the uterus. While this approach allows for minimally invasive surgery, it carries potential risks and complications, including:

• Spread of Undiagnosed Cancer: One of the most significant risks associated with morcellation is the potential for spreading undiagnosed malignancy, such as a rare type of cancer called leiomyosarcoma. Morcellating these tissues can disseminate cancerous cells within the abdominal cavity, complicating treatment and potentially worsening prognosis.
• Abdominal and Pelvic Organ Injury: The morcellator device can inadvertently damage surrounding tissues and organs, such as the intestines, bladder, and blood vessels, leading to serious complications.
• Infection: Surgical procedures, especially those involving internal organ manipulation, increase the risk of infections, which can range from localized at the surgical site to systemic.
• Bleeding: Although laparoscopic myomectomy aims to minimize blood loss, the morcellation process can lead to bleeding. In some cases, this may require additional interventions to control.
• Incomplete Removal of Fibroid Tissue: There’s a risk that morcellation may not completely remove all fibroid tissues, potentially leading to regrowth of fibroids and recurrence of symptoms.
• Adhesions: Surgical interventions in the abdominal cavity can lead to the formation of scar tissue (adhesions), which may cause pelvic pain, fertility issues, or intestinal obstruction.
• Port-site Metastasis: In cases where undiagnosed cancer is present, there’s a risk of cancer cells implanting in the incisions used for laparoscopic access, though this is rare.

Given these risks, the use of morcellation, particularly for removing uterine fibroids, has been subject to scrutiny and regulatory review. Patients are advised to discuss the risks and benefits of intrauterine morcellation with their healthcare provider, considering alternatives and the provider’s experience and precautions taken to mitigate these risks, such as the use of containment systems to minimize the spread of tissues during morcellation.

Video Transcript: Intrauterine Morcellation at Laparoscopic Myomectomy

This video describes intrauterine morcellation at laparoscopic myomectomy. A modified approach to suprapubic laparoscopic assisted myomectomy.

Laparoscopic myomectomy is indicated for FIGO type four to seven fibroids, causing bulk symptoms such as pain and pressure, with or without gastrointestinal or genital urinary symptoms. Though evidence is limited, laparoscopic myomectomy may be considered in select patients with type three fibroids, displacing or obscuring the cavity for the indication of fertility or preventing recurrent pregnancy loss.

Literature supports advantages for a minimally invasive approach over open, with a decrease in blood loss, post-op adhesions, and shorter recovery time. Disadvantages to laparoscopic myomectomy include increased blood loss, longer operative time, and a requirement of surgical expertise and ability to suture laparoscopically.

 We propose modifications to previously described suprapubic assisted laparoscopic myomectomy to address the disadvantages of a traditional laparoscopic myomectomy, and make this a more widely accepted approach. We propose that morcellating the fibroids while they remain partially within the uterus will decrease operative time and blood loss. This approach will also lead to an ability to tag and extract fibroids of various locations and sizes.

Important steps in this modified procedure include, preoperative optimisation and correction of anaemia. Laparoscopic survey and mapping of fibroid anatomy. Administration of tranexamic acid and vasopressin to prevent excess blood loss. Serosal incision and enucleation of approximately 50% of the fibroid.

Suture tagging of fibroid for later retrieval using various suture types and clamps for multiple fibroids. Creation of a mini laparotomy, with a traverse skin incision and vertical fascial incision, and O-ring retractor for optimal visualisation. Complete enucleation of fibroid and closure of myometrial layers through mini laparotomy. Laparoscopic confirmation of ongoing haemostasis and photo documentation.

It is imperative to assess haemoglobin at least 30 days before surgery to allow time for correction of anaemia with menstrual suppression, oral iron, or IV iron if not tolerated. This pre-operative optimisation step is of critical importance as a haemoglobin less than 120 g/l has been associated with an increased risk of morbidity and 30-day post-op mortality.

Step two, laparoscopic survey and mapping of fibroid anatomy. Careful inspection and photo documentation is performed correlated to imaging to ensure the number, size, location, and relation of fibroids to the cavity are understood. In this case, one large anterior fundal fibroid is seen, and the uterus and cornual insertion bilaterally are noted.

Step three, tranexamic acid is given IV by our anaesthesia colleague, while a dilute solution of vasopressin is prepared. This is injected between the serosa and fibroid capsule to proactively decrease blood loss. The vasopressin is injected through a spinal needle guided into the correct plane by a Maryland grasper.

Step four, serosal incision and enucleation of approximately 50% of the fibroid. Monopolar energy is used to create an incision on the uterus overlying the fibroid. The incision is continued in layers until a plane can be identified over the fibroid capsule. In the correct plane, blunt dissection is used to partially enucleate the fibroid from the myometrium. We stop shelling the fibroid out of the myometrium at approximately 50%, as this will be completed later in the intrauterine morcellation.

Step five, the fibroid mapping from earlier comes into play, as each fibroid that has been partially shelled out is tagged with a different suture and clamp outside of the abdomen. Suture tagging becomes particularly important when there are multiple fibroids, especially those that may be posterior and are unable to be accessed until anterior or fundal fibroids are removed, and the uterus is flipped.

Step six, mini laparotomy. A transverse skin incision approximately 4 cm long is planned. To maximise space and exposure for the next steps, the fascial incision is created in a vertical direction. Insertion of an O-ring retractor further improves visualisation.

Step seven, complete enucleation of fibroids and closure of myometrial layers through mini laparotomy. By tagging the fibroids with different sutures through lateral ports, we are able to use the O-ring retractor to sweep the sutures up through and begin morcellating the fibroid while still within the myometrium. Providing traction with a tagged suture, the fibroid is morcellated while still within the uterus with a C-cut. The plane between the fibroid capsule and myometrium is gradually dissected bluntly and sharply as it becomes visible.

The edges of the uterus surrounding the defect are brought up through the retractor and splayed for better visualisation. The apex is identified. The defect is closed in layers, careful to reapproximate the entire space. In this particular case, because of the fibroid size, three layers were used to close the myometrium. Using Monocryl on a fine needle, a baseball stitch is placed to close the serosa.

Step eight, laparoscopic confirmation of ongoing haemostasis. Post-procedure photo documentation is taken at this time.

This approach to laparoscopic myomectomy involves intrauterine morcellation, multi-fibroid tagging, and uterine closure through optimised mini laparotomy. Though a traditional myomectomy may be appropriate for some patients, there are others who would benefit from a shorter procedure with less blood loss and a stronger myometrial closure.

It is beneficial to partially shell out multiple fibroids, tag them with identifiable suture, and bring them to the incision one by one. Even posterior fibroids may be reached if anterior bulk is removed first, and the uterus is tipped forward. This is an excellent option in a surgeon’s toolbox of methods to remove fibroids efficiently.