Laparoscopic-Assisted Myomectomy During the Second Trimester of Pregnancy

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Video Description

Myomectomy has traditionally been avoided in pregnancy due to concern for maternal and fetal complications.

However, there are situations where this procedure is indicated, including refractory pain from degeneration or torsion, sepsis from necrosis and obstruction of organs. In this video we review a step-wise approach to a case of laparoscopic-assisted myomectomy at 15 weeks gestational age.

Presented By

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Dr. Meghan O’Leary
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Dr. Michael B. Secter
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Dr. Ari P. Sanders


University of Calgary

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What is Laparoscopic-Assisted Myomectomy During the Second Trimester of Pregnancy?

Laparoscopic-assisted myomectomy during the second trimester of pregnancy is a surgical technique used to remove fibroids from the uterus between 13 and 28 weeks of gestation. This minimally invasive procedure is typically considered when fibroids pose significant risks to the pregnancy or cause severe symptoms.

  • Minimally Invasive Approach: Uses small incisions and a laparoscope to guide fibroid removal, reducing recovery time and surgical risks.
  • Timing: Performed during the second trimester to minimize risks to both mother and fetus.
  • Indications: Recommended for severe pain, substantial bleeding, or fibroids that may interfere with fetal development or delivery.
  • Benefits: Aims to alleviate symptoms that threaten the health of the mother or fetus while preserving pregnancy.
  • Outcome Monitoring: Requires careful postoperative monitoring to ensure ongoing fetal health and maternal recovery.

What are the Risks of Laparoscopic-Assisted Myomectomy During the Second Trimester of Pregnancy?

Laparoscopic-assisted myomectomy during the second trimester of pregnancy, while beneficial for managing problematic fibroids, carries specific risks that must be carefully considered:

  • Preterm Labor: The surgical manipulation of the uterus can stimulate contractions, potentially leading to preterm labor or premature delivery.
  • Miscarriage: There is an inherent risk of miscarriage associated with any surgical procedure performed on the uterus during pregnancy.
  • Fetal Distress: The surgery, although minimally invasive, can cause fetal distress during the procedure due to alterations in uterine blood flow or mechanical impact.
  • Infection: As with any surgical procedure, there is a risk of infection, which can be more complicated to manage during pregnancy.
  • Bleeding: The highly vascular nature of the pregnant uterus increases the risk of significant intraoperative bleeding, which can be challenging to control and might necessitate further interventions.
  • Adhesions: Surgical intervention on the uterus can lead to the formation of scar tissue, which may cause complications in current and future pregnancies.

These risks underscore the importance of a thorough preoperative evaluation and detailed discussion between the patient and healthcare provider to carefully weigh the benefits against the potential complications.

Video Transcript: Laparoscopic-Assisted Myomectomy During the Second Trimester of Pregnancy

This video presents an approach to laparoscopic-assisted myomectomy during the second trimester of pregnancy. Our objectives are to summarise the literature on fibroids in pregnancy, discuss indications and considerations for laparoscopic myomectomy in pregnancy and present a step-wise approach to a case of laparoscopic myomectomy at 15 weeks gestation.

Up to 10% of pregnancies are affected by fibroids, though most are asymptomatic. The most common symptom is abdominal pain from degeneration or torsion, with possible necrosis. Compression of other organs may also occur.

Due to the risk of severe haemorrhage, uterine rupture, miscarriage or preterm labour, myomectomy during pregnancy has traditionally been avoided. However, there are instances which necessitate consideration of this procedure, such as refractory pain, peritonitis or sepsis secondary to necrosis or obstruction of other organs.

In a systematic review from 2020 of patients who underwent intrapartum myomectomy, the median gestational age was 16 weeks. Most had one fibroid removed, and 78% of cases were by laparotomy. Most fibroids were subserosal or pedunculated and fundal. Of 97 cases, only five miscarried and two delivered before 34 weeks.

Patient K.F. is a 26-year-old G1 woman who was admitted at 14 weeks and two days gestational age with severe pain. Eventually, she required PCA administration of narcotics. Examination showed a 40-week size multi-fibroid uterus, with focal pain and peritonitis over the right upper quadrant.

After ruling out other causes of pain, MRI was sought. And one can appreciate this view of the uterus, with ventricles of the foetal brain visible. Massive fibroids can be seen undergoing cystic degeneration. The sagittal view shows location of other degenerating fibroids, though she was mostly symptomatic from the large fundal fibroid.

Close to 15 weeks, pain was worsening. There was concern for degeneration causing necrosis and sepsis, which may carry a risk of miscarriage and loss of the pregnancy with conservative management. The patient declined termination and interval myomectomy and opted for surgical management with myomectomy in pregnancy.

The first step in an approach to laparoscopic myomectomy in pregnancy is a thorough pre-operative workup. In massively enlarged uteri, ultrasound is of limited value and MR is essential for surgical planning. Mapping of fibroids, FIGO typing and understanding the impact and relationship of a fibroid on the cavity is paramount. Proximity of the placenta to the fibroid to be removed is also important.

In this case, the symptomatic fundal right fibroid was a FIGO type six. Canadian guidelines suggest that MRI is safe in the second and third trimester of pregnancy and may be used with gadolinium in all trimesters when the indication outweighs the risks.

It is critical that time is taken to discuss the risks of the procedure and help the patient weigh these risks against those that may occur if pregnancy continues in the current state. Optimisation of haemoglobin, if time permits, is extremely important, as methods such as vascular occlusion or vasopressin, typically employed during myomectomy, cannot be used.

Consideration of laparoscopic entry is the next step. Due to cephalad displacement of organs, landmarking in the left upper quadrant for Palmer’s point entry was performed after placement of an orogastric tube. A 5 mm optical trocar was used for direct entry, given the compression of small bowel in the left upper quadrant. Accessory trocars were then placed.

Survey laparoscopically showed ascitic fluid surrounding the massively enlarged uterus. The fundal fibroid was confirmed to be FIGO type six, in close proximity to the liver and gall bladder. Fibrinous adhesions, a consequence of inflammation from degeneration and necrosis, were lysed. This was accomplished very carefully with traction-countertraction. Adhesions from the omentum and small bowel to the posterior aspect of the fibroid were also documented.

Serosal incision and partial fibroid enucleation. An incision was planned through the serosa overlying the fibroid, away from the uterus. Vasopressin was not used due to theoretical decreasing of perfusion to the pregnant uterus. Monopolar energy was also avoided due to increased tissue impedance. In its place, bipolar energy was used to coagulate the serosal surface to score the planned incision site.

An ultrasonic electrosurgical instrument was used to extend the incision, coagulating small vessels along the way. As neither vascular occlusion to the uterus nor tranexamic acid were used, meticulous surgical technique was employed to prevent bleeding. The dissection was carried down to the fibroid capsule and a plane in the fibroid myometrial interface exploited. With a carefully placed laparoscopic tenaculum, the plane was developed with traction-countertraction and the fibroid enucleated.

Because of the significant adhesions of bowel to the fibroid posteriorly and little room to safely release them, the decision was made to enucleate the fibroid only partially. It was debulked and a ridge created for easy transition to remove by mini-laparotomy.

Mini-laparotomy and fibroid morcellation. Directly above the partially enucleated fibroid, a vertical mini-laparotomy was created approximately 4 cm in length. With the help of an O-ring retractor, the fibroid was grasped, brought up to the incision and debulked with the C-cut morcellation technique.

The remaining fibroid was enucleated through the mini-laparotomy and haemostasis of the bed achieved. From the pathological analysis, the fibroid specimen weighed 980 g. The leiomyoma showed degenerative and infarct changes as well as necrosis.

Closure of myometrium. Because exposure happened to be excellent, the myometrium was closed through the mini-laparotomy. Three layers were placed, two deep, with a barbed suture, and a third running serosal layer with delayed absorbable suture. Haemostasis was ensured after returning laparoscopically. An adhesion barrier was placed over the incision.

The patient had significant improvement of her pain and was discharged home on post-op day number two. She was readmitted briefly for an ileus, which resolved with conservative management. She is currently doing well in pregnancy at 26 weeks, with no pain and normal bowel function.

Plan for delivery will be caesarean section with pre-operative fibroid mapping and consideration of caesarean myomectomy. A post-op MR was performed during her readmission. Before and after images demonstrate the drastic reduction in bulk.

In summary, we have reviewed the indications and considerations for laparoscopic myomectomy in pregnancy. We have presented a case illustrating a step-wise approach to performing this procedure safely.