Are there any limits for laparoscopic myomectomy?-tips & tricks

Uterine leiomyomas, also known as fibroids or myoma uteri, are the most common benign pelvic tumor in women. Although different theories have been proposed to explain the development of uterine leiomyomas, estrogen hormone plays the most important role. Several factors such as age, race, early menstruation, genetic factors, and life style contribute to the development of uterine leiomyomas ( 1 ). Uterine leiomyomas are usually diagnosed in reproductive-aged women. Although women having uterine leiomyomas may suffer from abnormal uterine bleeding, pelvic pain, pelvic mass, infertility, and obstetric complications, others remain asymptomatic ( 2 ). Women with uterine leiomyomas demand treatment depending on the severity of their symptoms. There are different approaches ranging from non-invasive to surgical options to manage uterine leiomyomas. The choice of treatments should be individualized according to demographic and clinical characteristics of the patients. Myomectomy is considered as the most appropriate treatment option rather than hysterectomy in order to preserve fertility since uterine leiomyomas are often required to be treated during the reproductive age ( 3 ). Recently, with minimally invasive methods being preferred more in gynecology, laparoscopic myomectomy has started to be preferred for many reasons such as less blood loss and pain, lower complications and adhesion formation, faster post-operative recovery, and shorter duration of hospital stay ( 4 ). Even though laparoscopic myomectomy has been accepted as a preferable alternative to abdominal myomectomy in women having a desire for uterine preservation, laparoscopic myomectomy is not a simple and easy method and requires a learning curve for the surgeon. Together with the basic steps, some tips and tricks make the process more safe and feasible for surgeons. In this review article, we aimed to review the main tips and tricks for laparoscopic myomectomy, under evidence-based approaches in women with uterine leiomyomas.

Women with symptomatic intramural or subserosal leiomyomas are good candidates for laparoscopic myomectomy in whom future childbearing is also desired. Age and fertility status of the patient, the location, size, and number of leiomyomas as well as surgical expertise are determinants of laparoscopic myomectomy rather than open abdominal myomectomy ( 5 ). The International Federation of Gynecology and Obstetrics (FIGO) classification system for the location of leiomyomas is helpful to decide and plan operation route ( 6 ). According to this classification system, uterine leiomyomas are named as submucosal (type 0–2), intramural (type 3–5), and subserosal (type 6–7) leiomyomas ( 7 , 8 ). Although there is no definite indication, all fibroids except type 0–2 can be removed laparoscopically by considering other variables. Despite no routine preoperative use, gonadotropin-releasing hormone (GnRH) agonists may be offered to decline the size of the uterus allowing for laparoscopic approach. However, this treatment may result in more difficult removal of myomas and higher risk of persistent myomas. Informed consent is the first important step during the decision-making process. All details including other medical, interventional radiology, and surgical options; potential complications of the procedure such as conversion to laparotomy, the likelihood of recurrence of fibroid-associated symptoms, and reproductive issues following myomectomy; the risk of malignancy and risks and benefits of power morcellation should be shared clearly with the patients ( 9 ). The second step is the evaluation of the patients with imaging methods to confirm the diagnosis of uterine leiomyomas with their correct size, location and number, to have a surgical mapping for the operator and to recognize if there is any other leison in the uterus and ovaries. For this aim, transvaginal ultrasound (or transabdominal ultrasound in virgin cases) is preferred as the initial imaging method and the best diagnostic modality for uterine leiomyomas. Magnetic resonance imaging may be performed to get more accurate and detailed information about uterine leiomyomas and to differentiate any malignant component regarding uterine sarcoma and it should be reserved for exceptions ( 10 ). Another important issue during laparoscopic myomectomy is to reduce blood loss during the operation ( 11 ). Pharmacologic or mechanical (e.g., uterine artery tourniquet) methods may be considered aiming by the reduction of uterine blood supply. Vasopressin is the most commonly used pharmacologic agent despite no high-quality data proving to reduce the risk of blood transfusion and no FDA approval. Intramural vasopressin injection, constricting the smooth muscle in the walls of vessels, significantly declined blood loss more than placebo and less than tourniquet ( 12 ). However, side effects of vasopressin use such as bradycardia, cardiovascular collapse, and death should be kept in mind. Uterotonics such as misoprostol may be applied vaginally before surgery and it was found to decrease blood loss significantly in a small randomized trial ( 13 ). Tranexamic acid which is another agent to diminish blood loss during laparoscopic myomectomy has been shown to have a similar effect with placebo in a recent study ( 14 ). Prophylactic antibiotics should be applied in the case of entrance into vagina, uterine cavity or bowel based on the American College of Obstetricians and Gynecologists recommendations ( 15 ). It is difficult to predict in which patients this condition will be experienced, even with preoperative imaging. Thus, decision for prophylactic antibiotics use should be individualized regarding the characteristics of the patients. However, prophylactic antibiotic use is not a routine recommendation during laparoscopic myomectomy ( 15 ). Women who have undergone laparoscopic myomectomy should be treated with appropriate thrombophylaxis, as they are considered to be low-risk according to Modified Caprini risk assessment model in terms of venous thrombophlaxis ( 16 ).

During laparoscopic myomectomy, a 10-mm subumbilical vertical incision is done under general anesthesia. After establishment of pneumoperitoneum with the Veress needle through this incision, the primary trocar is placed through the abdominal wall and then a 10-mm laparoscope was introduced. Following the insertion of laparoscope which is a narrow tube fitted with a camera into the abdomen, all abdominal cavity should be observed if there is any condition that may contraindicate laparoscopic surgery. If there is no such situation such as extensive adhesions, two to three additional 5-mm trocars were placed through other small incisions on the abdominal wall. We prefer to perform laparoscopic access this way, but there are other alternative ways such as open (Hasson) or closed (optical entry trocar) technique. However, neither method is suitable as an all-purpose method for laparoscopic access with different advantages and disadvantages. Transverse myometrial incision over the myoma itself is preferred which is more suitable to suture uterine defect laparoscopically. The incision should be continued until reaching the avascular space deep to the capsule of the uterine leiomyomas. This is the most importatnt step that helps to perform myomectomy eaisly. Traction and countertraction should be applied using a tenaculum to provide blunt and sharp dissection and to separate the plane between the myometrium and myoma. Bleeding from the myometrial defect can be controlled using bipolar energy or sutures. Delayed absorbable baseball sutures are usually used to provide closure of uterine defect in one, two or three layers according to the size and depth of the myometrial defect ( 17 ). We have no data comparing the effectiveness of different sutures for postoperative improvement. However, a recent study comparing the reproductive outcomes between conventional sutures and barbed suture for myometrial defect closure showed that barbed sutures are safe and an easier option without affecting pregnancy outcomes in laparoscopic myomectomy ( 18 ). In the case of suspicious for entrance into endometrial cavity, dye named as methylene blue can be injected into uterine cavity through transcervical cannula and it should be reapproximated more gently and ensured that there are no sutures in the endometrial cavity. Since closure of the uterine defect is important for the safety of subsequent pregnancies, the laparoscopic suturing is thought to have similar results compared to laparotomy depending on the experience of the surgeon and the correct patient selection ( 19 ). Several physical barriers including solid materials (absorbable sheets, nonabsorbable prosthetic materials) and viscous fluids may limit the extent of adhesion formation for aiming at keeping damaged peritoneal surfaces separated during the first postoperative days until after reepithelialization has occurred ( 20 ). Most of the time, it is necessary to cut the uterine leiomyomas into pieces, named as morcellation and removed through one of the small incisions on the abdominal wall. It can be removed through either trocar sites or an incision in the vagina, named colpotomy. The use of uterine morcellation raises several concerns including dissemination of tissue in the abdomen, disruption of the tissue specimen for pathology evaluation, and electromechanical injury to adjacent structures. In-bag containment systems can be used to avoid these morcellation-associated complications.

Intraoperative or postoperative complications such as hemorrhage, fever and infection, visceral injury and development of adhesions are similar to abdominal myomectomy ( 21 ). Improvement in postoperative quality of life is also similar between laparoscopic and abdominal myomectomy ( 22 ). However, lower overall morbidity and a shorter recovery time are experienced in women undergoing laparoscopic myomectomy comparing with abdominal myomectomy ( 23 - 25 ). Even if large or type 2 submucous myomas are removed through laparoscopic approach, comparable perioperative outcomes and immediate complications are encountered with laparoscopic surgeries of other uterine leiomyomas ( 26 ). On the other hand, based on the possibility for residual myoma masses higher recurrence rate has been supposed with laparoscopic myomectomy rather than with open surgery in some studies ( 27 ).

No additional postoperative care is necessary following laparoscopic myomectomy and a one-day hospitalization is enough for these patients. In women having a desire to become pregnant, 3 to 6 months before attempting to conceive is necessary, similar to abdominal myomectomy ( 28 ). Since the risk of uterine rupture in future pregnancies is directly related to how well the uterine defect is repaired, laparoscopic surgery performed by experienced hands will not pose an additional risk compared to open surgery ( 29 , 30 ). Although the effect of myomectomy performed by laparoscopic and other methods on obstetric outcomes is not yet fully known ( 31 ), we prefer to wait for 3–6 months postoperatively and to give birth cesarean section in our clinic.

There are some limitations to laparoscopic myomectomy such as time-consuming procedure, prolonged time of anesthesia, inability to control bleeding during enucleation phase of myomectomy, reapproximation of the uterine wall following enucleation and extraction of solid myomas from the abdominal cavity ( 32 , 33 ).

Laparoscopic removal of leiomyomas from the uterus is defined as laparoscopic myomectomy. Women with symptomatic intramural and subserous uterine leiomyomas who want to preserve their fertility are candidates for laparoscopic myomectomy. The location, size, and number of leiomyomas are the most important variables to decide laparoscopic myomectomy.

The article’s supplementary files as