Fibroids
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Laparoscopic Myomectomy

Laparoscopic Myomectomy
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Video Description

This video outlines technical tips for performing laparoscopic myomectomy.

Presented By

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Dr. Nicholas Leyland
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Dr. Ally Murji
 
 

Affiliations

McMaster University

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What is Laparoscopic Myomectomy?

Laparoscopic Myomectomy is a minimally invasive surgical procedure used to remove fibroids (myomas) from the uterus while preserving the uterus itself. Here’s an overview:

  • Procedure: Performed through small incisions in the abdomen using a laparoscope (a thin, lighted tube with a camera) and specialized surgical instruments. This approach allows the surgeon to visualize and remove fibroids with precision.
  • Benefits: Includes reduced recovery time, less postoperative pain, and minimal scarring compared to traditional open surgery (laparotomy). The procedure generally allows for a quicker return to normal activities and less disruption to daily life.
  • Indications: Recommended for women with symptomatic fibroids causing heavy menstrual bleeding, pelvic pain, or other issues, particularly if they wish to preserve their fertility.
  • Recovery: Patients typically experience a shorter hospital stay and faster recovery compared to open surgery, although individual recovery times can vary based on the complexity of the fibroid removal and overall health.

What are the Risks of Laparoscopic Myomectomy?

Laparoscopic myomectomy, while generally considered safe and minimally invasive, carries certain risks:

  1. Infection: There is a risk of infection at the incision sites or within the pelvic cavity.
  2. Bleeding: Potential for intraoperative bleeding, which may require blood transfusion or conversion to open surgery.
  3. Injury to Surrounding Organs: Risk of accidental injury to nearby organs, such as the bladder, intestines, or blood vessels.
  4. Adhesions: Formation of scar tissue (adhesions) can occur, which may cause pelvic pain or complications in future surgeries.
  5. Incomplete Fibroid Removal: Potential for residual fibroid tissue, which might cause symptoms to persist or recur.
  6. Anesthesia Risks: Complications related to general anesthesia, such as allergic reactions or respiratory issues.
  7. Infertility or Pregnancy Complications: Rarely, the procedure may impact future fertility or lead to complications in subsequent pregnancies.

Video Transcript: Laparoscopic Myomectomy

Technical tips for performing laparoscopic myomectomy. Pre-operative planning is extremely important, and sonohysterography is an important tool for mapping fibroids and determining which fibroids have for the submucosal component. Port placement is also important, as the bigger the pathology, the higher the ports should be placed.
Here we’re infiltrating the uterus with dilute vasopressin. Planning the uterine incision is an important step, as you want to remove as many fibroids in the smallest and the fewest uterine incisions possible. A horizontal incision in the uterus also facilitates laparoscopic suturing, which can sometimes be challenging. Here, monopolar cautery is used to make a horizontal incision in the uterus. And this is taken down all the way until the capsule of the fibroid is visualised.
Blunt dissection is used to shell out the fibroid, as it would in an open myomectomy. Dissecting the fibroid can be facilitated by a laparoscopic tenaculum. A 5mm tenaculum is used here. Putting traction on the fibroid allows us to visualise strands and fibres, which are then cut using monopolar cautery. It is essential that the fibres are cut on the fibroid, so as to avoid damaging myometrium.

This patient was pre-treated with Lupron for a few months prior to the surgery, and hence the fibroid has degenerated. This can make it further challenging to remove the fibroid intact. Care is taken not to enter the uterine cavity. And this is facilitated by the liberal use of traction with the tenaculum. Furthermore, the dissection is kept on the fibroid capsule, so as the myometrium can fall away. It is important for the surgeon to know if the cavity has been entered. And for this reason, prior to starting the procedure, we hysteroscopically evaluated the cavity, and then stained the uterine cavity and the endometrium with methylene blue.
Because the fibroid is degenerated, care is taken to ensure that all fibroid tissue is removed, so as to decrease the chance of recurrence. Here the cavity of the uterus has not been entered, and the bluish hue of the endometrium that has been stained with methylene blue can be seen in the centre. Care is going to be taken when we place our sutures not to go through the endometrial cavity. We use a V-Loc barbed suture, and introduce it through a lateral 12mm port.
Laparoscopic suturing is done, and the defect is closed in layers. We make sure that we take deep bites to close the myometrium and not to leave any gaps. Doing so can cause dead space and haemorrhage in the myometrial wall. The V-Loc suture has a loop at the end of it, which means that you don’t have to tie a knot on the first pass. It is important with the V-Loc suture that with each pass, the suture is pulled tight so that the barbs can actually hold on the tissue. This can be done by pulling the suture, and at the same time, pushing the tissue down.

The whole defect is repaired in three layers. The second layer is closed, using the same suture, but going back, taking bites of more superficial myometrium. To end a line in suturing with the V-Loc stitch, we place the last stitch, and then pull the suture taught and then cut the suture right close to the tissue. The final layer is closed using a baseball stitch, this time with a 2-0 V-Loc suture. Wide bites are taken out of the [unclear] to ensure haemostasis.
When cutting the suture material, we make sure that we cut it flush with the tissue, so as to prevent an end that can cause bowel obstruction. And this has been reported in the literature with the barbed suture. Once haemostasis has been assured, prior to ending the case, an adhesion barrier material can be placed on the incision line. The fibroid is then removed using a morcellator. We take care to make sure that all small pieces of this degenerated fibroid are removed from the abdomen.
The final step is to ensure that there’s been no injury to the uterine cavity and a hysteroscopy is performed. We make sure that there are no stitches through the endometrium. If there are any concerns, a paediatric Foley balloon catheter can be placed into the uterine cavity and left for one week.