Novel Technique for Hemostasis at Laparoscopic Myomectomy

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Video Description

This video demonstrates a novel in which a tourniquet is applied during laparoscopic myomectomy to achieve hemostasis.

Presented By

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Dr. Katie Phillips
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Dr. Caitlin Dunne
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Dr. Neeraj Mehra


University of British Columbia

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What is Novel Technique for Hemostasis at Laparoscopic Myomectomy?

A novel technique for achieving hemostasis during laparoscopic myomectomy, which is critical to minimize intraoperative blood loss and enhance patient safety, includes the use of barbed sutures. This approach has been gaining attention due to its efficacy and efficiency in sealing blood vessels and closing incisions without the need for extensive surgical knots.

  • Barbed sutures are a type of suture with tiny barbs on the surface that latch onto the tissue, providing continuous tension and closure without the need for traditional knots.
  • These sutures allow for quicker suturing, reduced operative time, and potentially lower blood loss compared to standard sutures. They facilitate the surgeon’s ability to close wounds with equal distribution of tension across the suture line, reducing the risk of tissue tearing or suture slippage.
  • In laparoscopic myomectomy, barbed sutures can be particularly effective for uterine wall closure after fibroid removal. They provide secure hemostasis and promote optimal wound healing, reducing the incidence of postoperative adhesions.

This technique enhances the overall safety and efficacy of the procedure by streamlining the surgical process and minimizing potential complications related to blood loss and wound closure.

What are the Risks of Novel Technique for Hemostasis at Laparoscopic Myomectomy?

While novel techniques for hemostasis, such as the use of barbed sutures during laparoscopic myomectomy, offer significant advantages, they also come with specific risks and considerations:

  • Tissue Trauma and Pain: The barbs on these sutures can cause more tissue trauma compared to smooth sutures. This can potentially lead to increased postoperative pain or heightened inflammatory response in the tissue.
  • Suture Migration: There is a risk of suture migration or extrusion, where the suture material may move from its original placement or even protrude through the skin or mucosal surfaces, which may require additional interventions.
  • Improper Wound Healing: If not applied correctly, barbed sutures may lead to uneven wound closure, which can result in poor cosmetic outcomes or complications in wound healing, such as dehiscence (wound reopening) or infection.
  • Learning Curve: The technique requires specific training and experience. Surgeons without adequate training in the use of barbed sutures might face challenges in achieving optimal results, leading to potential complications.
  • Increased Cost: Barbed sutures tend to be more expensive than traditional sutures. This cost factor needs to be considered, especially in settings where budget constraints are significant.
  • Adhesion Formation: Any surgical procedure on the uterus, including those using barbed sutures, carries a risk of adhesion formation. Although barbed sutures reduce the need for knots, which can decrease foreign body reactions, their specific impact on adhesion formation compared to traditional sutures is still under evaluation.

It’s important for medical teams to weigh these risks against the benefits when choosing to use novel hemostatic techniques in laparoscopic myomectomy, ensuring they are applied in appropriate circumstances and by experienced surgeons.

Video Transcript: Novel Technique for Hemostasis at Laparoscopic Myomectomy

Today, we’ll present a novel technique for haemostasis at laparoscopic myomectomy and demonstrate the steps to placement of a laparoscopic tourniquet using a Penrose drain.

Our case involves a 32-year-old nulliparous woman who had experienced ten years of increasing pelvic pressure, urgency, frequency and positional dyspareunia, with a normal menstrual cycle. Examination demonstrated a large mobile abdominal mass and negative beta HCG.

Investigations, including an MRI, revealed a multi-fibroid uterus, with the largest fibroid arising from the fundus and measuring 21 cm by 11 cm by 14 cm. It arose from a pedicle, which measured 5 cm in diameter. Another large fibroid arose from the posterior aspect of the cervix and measured 9 cm by 7 cm by 7 cm.

 As the patient wished to maintain her future fertility and avoid aggressive surgery on any intramural fibroids, she was booked for a laparoscopic myomectomy of the dominant pedunculated fibroid.

Since blood loss at myomectomy can be substantial, numerous techniques have been developed to reduce haemorrhage. These include pre- and intraoperative pharmacological and mechanical approaches.

Focusing on mechanical approaches, a 2014 Cochrane review found a significant reduction in blood loss at myomectomy when a Foley catheter was tied around the base of the uterus, when a polyglactin suture was tied around the cervix, with polythene catheter tied around the IP ligaments, the so-called triple tourniquet technique, and with loop ligation of the myoma pseudocapsule. A significant reduction in the need for blood transfusion was seen with the Foley catheter and triple tourniquet techniques.

Use of a tourniquet to reduce blood loss at abdominal myomectomy has been well described. By contrast, few descriptions of tourniquet use at laparoscopic myomectomy exist. These include looping and 0-PDS through the broad ligament to compress the uterine vessels at the level of the uterine isthmus, occlusion of the uterine and ovarian vessels with polyglactin suture and use of an endoscopic loop under progressive tension.

In our group’s experience, applying significant tension to a suture tourniquet can cut into tissues and cause further bleeding. Thus, we set out to develop a laparoscopic tourniquet capable of maintaining high tension, using a less harmful material.

Our patient was brought to the operating room. Examination under anaesthesia confirmed an extremely bulky but mobile uterus. We entered the abdomen in the left upper quadrant, where we placed a 5 mm port. A 10 mm port was placed in the umbilicus, and two additional 5 mm ports were placed in the right and left lower quadrants.

 There was normal upper abdominal anatomy, and the multi-fibroid uterus filled most of the abdomen. The adnexa were normal, although the left ovary and fallopian tube were hidden behind the large posterior cervical fibroid that filled the cul-de-sac.

We set forth to create a tourniquet, using a Penrose drain. The drain was introduced through the 10 mm umbilical port. It was then wrapped around the base of the large pedunculated fibroid that arose from the uterine fundus. The ends were overlapped, tightened and held in place with vascular clips. The clips looked like they were holding, but unfortunately, the tension was too much and the clips couldn’t hold.

We then took a different approach by tying a knot in the Penrose drain. We tried several different methods of tightening it, but we couldn’t achieve the desired tension. Finally, we returned to the technique of overlapping the ends of the Penrose drain, as this did achieve optimal tension.

A 10 mm suprapubic port was placed, and a right-angled dissection forceps was introduced into the abdomen to hold the Penrose drain on tension. We secured the ratcheted forceps in place from above and proceeded with the surgery in the usual fashion.

Dilute vasopressin was injected at the incision site for additional haemostasis. A harmonic scalpel was used to circumferentially work around the serosa and myometrium to free the pedunculated fibroid from the uterine fundus. The defect was closed in layers with a V-loc suture, and the serosa was reapproximated using a baseball stitch. Inspection of the incision site revealed good haemostasis. The fibroid was morcellated through the umbilical incision using a scalpel and small self-retaining retractor.

The final specimen weight was 2,050 g, the estimated blood loss was less than 200 ccs, and there were no complications. The patient’s postoperative day one haemoglobin was 116 compared to 127 preoperatively. Pathology confirmed a benign leiomyoma, and we started her on ulipristal acetate for the treatment of the remaining fibroids.

In summary, the laparoscopic tourniquet is a great adjunct to vasopressin for reducing blood loss at laparoscopic myomectomy and is quick and easy to apply. 5 mm vascular clips and tightening the Penrose drain with a knot in place failed to hold optimal tension.

However, a right-angled dissecting forceps, introduced through a suprapubic port, maintained excellent tension throughout the procedure, without causing interference. Consideration can also be made for placement of a laparoscopic tourniquet around the cervix at the level of the internal os for occlusion of the uterine vessels.