Approach to Minimizing Bleeding at Multiple Myomectomy

Summary

• Pre-operative measures involved administering iron therapy and selective progesterone receptor modulator courses to improve hemoglobin levels.
• Surgery preparations included preparation with the OR team and administration of IV tranexamic acid preoperatively.
• Initial surgical steps involved externalizing the uterus post-incision and securing the uterine blood supply using a pericervical tourniquet.
• Securing blood supply and fibroid removal involved securing utero-ovarian vessels with bulldog clamps, and removing fibroids starting with the largest, using dilute vasopressin and an ESU pen.
• Postoperative procedure and results involved detaching the tourniquet and clamps for uterine reperfusion, controlling bleeding with sutures, cleaning and closing the abdominal cavity. A total of 24 fibroids were removed, with an estimated blood loss of 100 cc and no transfusion required.

Presented By

• Dr. Fady Shehata
• Dr. Chandrew Rajakumar
• Dr. Sukhbir Sony Singh

Affiliations

University of Ottawa, The Ottawa Hospital

See Also

• All our gynecology education videos and articles.

Multiple Myomectomy Definition

• Multiple Myomectomy is a surgery to remove numerous uterine fibroids, noncancerous growths causing symptoms such as heavy periods, pelvic pain, and fertility problems.
• It’s preferred for women who want to maintain fertility. The surgical approach varies (open, laparoscopic, or hysteroscopic) based on fibroid size, number, and location.
• Risks include infection, bleeding, scar tissue, potential organ damage, and in rare cases, the need for a hysterectomy if complications arise.
• Regular follow-ups are needed post-surgery to monitor for fibroid recurrence, and pregnancy should be delayed for some months to allow proper uterine healing.

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Video Transcripts

The Ottawa Minimally Invasive Gynaecology Group, University of Ottawa, presents Approach to Minimising Bleeding at Multiple Myomectomy. The objective of this video is to present the perioperative and the intraoperative techniques used to minimise bleeding in a high-risk multiple myomectomy.

Patient Profile

In this case, we have a 37-year-old female diagnosed with multiple fibroids. The biggest was approximately 15 cm in diameter according to a recent MRI. The patient wished to pursue a fertility sparing procedure to help manage her heavy menstrual bleeding and resulting anaemia and pressure symptoms. Anaemia may be corrected using preoperative IRON and menstrual suppression using either gonadotropin-releasing hormone agonist or selective progesterone receptor modulator.

Preoperative Preparation

In our case, the patient received preoperative IRON and selective progesterone receptor modulator times two courses, each three months long, to control her bleeding and to help shrink the dominant fibroids. Her haemoglobin increased from 70 to 100 grams per litre at the time of her surgery. The day of the surgery requires planning with the OR team, including anaesthetists, nurses and surgeons.

Surgical Procedure

IV tranexamic acid was given prior to the surgery. Before skin incision, the patient was examined and the uterus was found to be about 22 weeks in size. Our initial step was to enter the abdomen and survey the fibroids in relation to the ovaries, fallopian tubes and adjacent structures. A midline incision was made with number ten blade, from the symphysis pubis, to 1.5-centimetre inferior to the umbilicus.

Abdominal Incision and Pericervical Tourniquet Placement

Using the ESU pen, the underlying adipose tissue and the facia was incised and cut and the abdomen was exposed. The uterus was then externalised through the laparotomy incision and the fibroids were surveyed in relation to the adjacent structures. The second step in our approach was to secure the uterine blood supply with a pericervical tourniquet. To this end, the visceral peritoneum was entered anteriorly and the bladder was dissected off the lower uterine segment inferiorly. Windows were created in the posterior leaf of the broad ligament on either side of the cervix, and a Penrose drain was passed around the cervix and tied tightly to act as a pericervical torniquet.

Securing Utero-Ovarian Vessels

In this procedure we used a Penrose tubing three-quarter inch, times half inch, times eighteen inch long. Next, we aim to secure the utero-ovarian vessels. Bulldog clamps were placed on the utero-ovarian ligaments bilaterally, thus minimising the blood flow to the uterus. Care should be taken to avoid clamping the fallopian tubes as the patient wishes fertility preservation.

Removal of Anterior Fibroids

The largest anterior fibroid was the first objective. Two units of dilute vasopressin was injected under the serosa along the planned incision line. Repeat dosing was done every 25 minutes as needed. Using the ESU pen and a number ten blade, an anterior sagittal incision was made just right of the midline. The fibroid was grasped with a tenaculum and shelled out bluntly and sharply with the help of the ESU pen.

This was repeated for neighbouring small fibroids using the same incision in the serosa. The endometrial cavity was not entered in these endeavours.

Closure of Anterior Incision

When no further fibroids could be approached through the incision, it was closed with a zero Polysorb in four running continuous layers, and a baseball stitch at the serosa with a 2-0 Maxon. The same process was prepared on the posterior surface of the uterus to remove all the fibroids that were palpated. A total of 24 fibroids were removed at this procedure.

Hemostasis and Cavity Wash

The tourniquet was then cut and the bulldog clamps were removed. The uterus quickly reperfused and there was some bleeding from the incision site that was controlled with interrupted zero Polysorb sutures. Upon achieving haemostasis, the abdominal cavity was washed thoroughly with warm saline and suctioned.

Abdominal Wall Closure

At the end, TAP blocks were given at the level of the iliohypogastric nerve on either side, and the abdominal wall was closed by mass closure, with 2-0 PDS sutures looped tied to each other. The skin was then reapproximated.

Conclusion

24 fibroids were removed and estimated blood loss was 100 cc. No blood transfusion was required. In summary, our approach to minimise bleeding at a high-risk multiple myomectomy starts pre-operatively with oral IRON therapy to correct anaemia, selective selective progesterone receptor modulator course to shrink the fibroids and IV tranexamic acid before the surgery. Intraoperatively, we use Penrose band and bulldog clamps to secure uterine blood supply and subserosal vasopressin injection to minimise bleeding.