Laparoscopic myomectomy: 8 pearls
From preoperative imaging to postoperative analgesia, the choices you make determine the ease of the procedure and the quality of the outcome
IN THIS ARTICLE
Myomectomy is the surgery of choice for women who have symptomatic fibroids and who wish to retain their uterus. And laparoscopic myomectomy is preferable to the abdominal approach in many ways, offering: 1-4
- faster recovery
- a shorter hospital stay
- diminished blood loss
- decreased adhesion formation
- a comparable or higher rate of pregnancy.
Nevertheless, laparoscopic myomectomy is a technically challenging procedure with surgeon-specific limitations. The biggest challenge: appropriately suturing the hysterotomy site.
In this article, I share my experience with laparoscopic myomectomy and offer 8 pearls that may contribute to a successful outcome.
1. Don't settle on laparoscopy prematurely
Given its advantages over the abdominal route, laparoscopic myomectomy should be the preferred approach in the treatment of symptomatic uterine fibroids ( FIGURE 1 ). However, not all patients are appropriate candidates for laparoscopy. Several guidelines have recommended a maximum number and size of fibroids for laparoscopic removal, but practice varies widely, and experienced surgeons successfully take on cases that are well beyond the limits set by most published guidelines. 5-7
At our institution, we do not have firm guidelines in place for the number and size of fibroids that can be removed laparoscopically. Other variables enter into decision-making and counseling, among them any medical comorbidity or history of uterine surgery the patient may have, as well as her desires in regard to childbearing and uterine retention.
Hysterectomy may be the most straightforward option for women who have symptomatic fibroids and who have completed childbearing. However, myomectomy is also appropriate as long as the patient is aware of the risk that fibroids may recur and the potential for further surgery. When the patient is in her late 40s or early 50s, the likelihood of fibroid recurrence may be lower than it is in the general population.
In my practice, submucosal and intracavitary fibroids smaller than 4 cm and more than 5 mm away from the uterine serosa are generally removed hysteroscopically, an approach beyond the scope of this article. In women who have completed childbearing but who wish to conserve the uterus, we deliberately enter the uterine cavity laparoscopically because this strategy allows for efficient removal of submucosal and intracavitary fibroids.
FIGURE 1 When and how to treat uterine fibroids
2. Estimate the duration of surgery
When the patient has fibroids that are intramural or subserosal, our general rule of thumb is to determine her suitability for laparoscopic myomectomy, based on the estimated duration of the operation. A surgeon's ability to calculate the length of the operation for a particular patient increases with experience.
We tend to recommend the laparoscopic approach when the procedure is expected to take less than 3 hours to complete. More than 95% of our patients fall into this category.
When we anticipate a prolonged operating time, we discuss the option of hand-assisted laparoscopic myomectomy. This approach involves two or three 5-mm trocar punctures high on the abdomen in conjunction with a suprapubic incision, 6 to 7 cm in length with a hand port in place. Prospective studies have demonstrated a significantly longer recovery with minilaparotomy than with laparoscopy, but these trials compared uteri of similar size. 4,8 We expect the laparoscopic approach to confer fewer advantages when operative time is prolonged significantly.
In our practice, we consider one or more of the following conditions appropriate for hand-assisted laparoscopic myomectomy:
- a very large uterus (i.e., heavier than 1,500 to 2,000 g). In these cases, operating times can be excessive because of the need for extensive suturing and morcellation, and bleeding may increase as a result
- more than 20 fibroids on magnetic resonance imaging (MRI). It can be a challenge to locate all of the fibroids; multiple uterine incisions may be necessary
- a medical comorbidity that renders the patient unable to tolerate prolonged anesthesia. For example, we operated on a patient who had Ehlers-Danlos syndrome and who needed to avoid a prolonged operation due to fragile bones and joint laxity.
Of necessity, these guidelines will vary from practice to practice, and gynecologic surgeons who are just beginning to perform laparoscopic myomectomy should not include multiple fibroids or a large uterus among their initial cases. Instead, perform the first few cases in patients who have not had abdominal surgery and who have a symptomatic intramural or subserosal fibroid that is close to the uterine fundus and no larger than 6 cm in diameter.
3. Consider preoperative MRI
Preoperative imaging greatly supplements the clinical examination and facilitates identification of the number, location, and characteristics of the fibroids. Pelvic ultrasonography (US) is appropriate for most patients. We prefer preoperative MRI of the pelvis in the following scenarios:
- uterus larger than 12 weeks (280 g) on clinical examination
- identification of multiple fibroids via US
- history suggestive of adenomyosis.
MRI facilitates preoperative planning by accurately delineating the size and location of the fibroids, and by distinguishing between an adenomyoma and fibroid in most cases. 9 For an example of its utility, see "How MRI can guide treatment: 3 cases."
4. Preoperative medical therapy may be indicated
When given preoperatively, gonadotropin-releasing hormone (GnRH) agonists have been shown to reduce blood loss and shorten operative time. The exception: cases involving hypoechoic fibroids, because the cleavage plane may be more difficult to identify, prolonging operative time. 10
We generally prefer to use a GnRH agonist in two clinical scenarios: 1) anemia and 2) a uterus that extends above the umbilicus. In the second scenario, the GnRH agonist helps reduce the uterus to a more manageable size.
Aromatase inhibitors show great promise as preoperative agents because there is no initial flare. In addition, because fibroids have a higher concentration of aromatase activity than the surrounding myometrium, a low dosage of an aromatase inhibitor is effective and does not cause significant menopausal symptoms.
A recent comparative study found that fibroid shrinkage was greater after 3 months of letrozole (2.5 mg/day) than after use of a GnRH agonist. 11 Total myoma volume decreased by 45.6% in the letrozole group, compared with 33.2% in the group that received a GnRH agonist (P =.02). 11
Aromatase inhibitors have also been successfully used during the initial period of GnRH agonist therapy to prevent the symptoms of flare. 12 However, because clinical experience is limited, the long-term efficacy and safety of aromatase inhibitors in premenopausal women is unknown.
How MRI can guide treatment: 3 cases
Findings A 40-year-old nulliparous woman seeks treatment for menometrorrhagia and dysmenorrhea but wants to conserve her uterus. MRI reveals a 4.5-cm submucosal fibroid (arrow) that extends all the way to the uterine serosa, with no evidence of adenomyosis. Her thyroid-stimulating hormone (TSH) level is normal, as is an endometrial biopsy.
Outcome We decide to proceed with laparoscopic myomectomy because a hysteroscopic approach would carry a risk of uterine rupture.
Findings A 36-year-old nulliparous woman complains of significant "bulk" symptoms (heaviness, urinary frequency, and abdominal bloating). She has a visible mass that extends four finger-breadths above the umbilicus. Pelvic MRI reveals multiple intramural fibroids in a uterus estimated to weigh roughly 2,850 g. The patient is given a 3-month course of a GnRH agonist.
Outcome After treatment with the GnRH agonist, the patient undergoes hand-assisted, laparoscopic, multiple myomectomy. She is discharged home the following day and resumes normal activities within two weeks.
Findings A 32-year-old nulliparous patient seeks treatment for menomenorrhagia and symptoms of bulk and expresses a desire for uterine conservation. Pelvic MRI reveals two distinct intramural fibroids, 6 cm and 9 cm in size.
Outcome The patient undergoes laparoscopic myomectomy without preoperative treatment with a GnRH agonist and is discharged home the same day without postoperative complication. (Although the uterus had two large fibroids, we did not use a GnRH agonist because the uterus was well below the belly button.)
5. Use careful surgical technique
Pay attention to set-up, initial entry
Although we lack definitive data on the practical utility of preoperative, intravenous (IV) antibiotics, we administer cefazolin prophylactically, switching to IV clindamycin if there is a documented allergy to penicillin.
In addition, a uterine manipulator is helpful when the patient has a small or medium-sized uterus. A variety of manipulators are available, but we generally use the VCare manipulator (ConMed Corp) because it is easy to insert and provides excellent uterine mobility.
Initial entry is at the umbilicus, unless the uterus extends above the umbilicus, in which case we enter in the left upper quadrant. We generally place the camera through the umbilical port and use two parallel operative ports on the left side of the patient, where the primary surgeon stands. A detailed description of our laparoscopic entry technique was published recently. 13
Place the first trocar two finger-breadths medial and superior to the iliac spine and the second trocar 8 cm cephalad to the first port ( FIGURE 2 ). In a large uterus, trocars may have to be placed higher on the abdomen. A third operative port may be added on the right side, if it is needed.
FIGURE 2 Laparoscopic port placement
Place the camera through the umbilical port (A) and operate through two additional ports on the left-hand side of the patient, where the primary surgeon stands. Place the first operative port two finger-breadths medial and superior to the iliac spine (B) and the second port 8 cm cephalad to the first (C).
Incise the uterus
Infiltrate the uterus with dilute vasopressin (20 U in 60 mL of saline), taking care to administer no more than 10 U at a time to minimize the potential for cardiovascular side effects such as bradycardia and hypertension. 14 In the past, we periodically encountered episodes of bradycardia when we used 20 U in 40 mL of saline, but we have not had that problem since we changed to a more dilute vasopressin and used no more than 10 U at a time. It may be that an even smaller amount of vasopressin is just as effective, but we do not yet have sufficient data on myomectomy to determine whether that is the case.
Inject the vasopressin subserosally and along the planned hysterotomy. The fibroid itself contains no blood vessels, but the blood supply to the fibroid generally assumes a coronal pattern around it. 15 Therefore, it is important to inject the vasopressin into the correct subserosal plane.
We prefer to make a horizontal hysterotomy using the Harmonic Scalpel (Ethicon Endo-Surgery), but other energy sources, such as a monopolar hook or bipolar spatula, are also appropriate.
We choose a horizontal incision because of the ipsilateral port placement we use for suturing. Surgeons who use a midline or contralateral port for suturing may find it easier to repair a vertical hysterotomy. The pattern of blood vessels along the uterus is heterogeneous and variable, and there is no evidence that blood loss or other outcomes are affected by the direction of the uterine incision.15
Once the uterus has been incised, it is important to work efficiently because bleeding will probably continue until the hysterotomy site is completely closed.
Extract the fibroid ("rock and roll")
Extract the fibroid from the uterus by applying generous traction using a tenaculum, and by applying counter-traction using an atraumatic grasper and the Harmonic Scalpel, as needed. We try to limit the use of thermal energy during this step.