A successful laparoscopic myomectomy begins with the correct assessment of the size, number, and location of the myomata inside the uterus. In the past, I have recommended multiple techniques for evaluation, including hysteroscopy, two-dimensional (2-D) ultrasound (transvaginal, transabdominal), 3-D ultrasound (transvaginal, transabdominal), the 2-D saline infusion sonohysterogram (2-D SIS), the 3-D SIS, and magnetic resonance imaging (MRI).
At this juncture, because of improved diagnostic acumen, I now recommend MRI or saline infusion sonography. MRI (
In my estimation, the 3-D saline infusion sonogram is superior to 2-D evaluation. The ability to render a three-dimensional image – and thus manipulate the ability to visualize the saline infusion sonogram image further – enhances fibroid mapping.
Although the saline infusion sonohysterogram is far better for evaluating uterine leiomyomata than is the hysterosalpingogram, the technique does not allow evaluation of the fallopian tubes. Recently, I helped launch Femasys Inc.'s Femvue System (
This testing does not, however, diminish the importance of physician examination prior to surgery. Through the physical exam, the minimally invasive gynecologic surgeon is able to determine how large the uterus/leiomyomata complex is, relative to the patient's size, and therefore where ports should be placed, as well as the potential difficulty of surgery. If the surgeon considers the uterus/leiomyomata complex too large, or if anemia is noted, a gonadotropin-releasing hormone (GnRH) agonist can be given for 3 months to attempt shrinkage of the leiomyomata or to enable hemoglobin to rise (through the resultant amenorrhea) prior to surgery.
Laparoscopic Myomectomy
The laparoscopic surgery is scheduled in the proliferative phase of the cycle to avoid thickened endometrium. This is especially important in the case of removal of a type II submucosal leiomyomata or one that is impinging on the endometrial cavity.
On the day of surgery, prior to the laparoscopic myomectomy and after the patient has been placed into the dorsal lithotomy position and a Foley catheter has been placed in the bladder, hysteroscopy is performed to treat any abnormalities that are seen within the endometrial cavity. This may include hysteroscopic myomectomy on a leiomyomata previously believed to be located away from the endometrial cavity.
Once hysteroscopy has been completed, a uterine manipulator must be placed inside the uterine cavity. It is imperative to utilize a manipulator that can be placed deep enough into the cavity to enable anterior/posterior and lateral uterus flexion. I consider this function to be so important for the success of laparoscopic myomectomy that a surgical assistant, standing between the patient's legs, continues to manipulate the uterus throughout the duration of the procedure.
Generally, the 5-mm laparoscope is placed initially through the umbilicus, unless periumbilical adhesions are anticipated. In this latter case, I proceed to make a left-upper-quadrant incision. Lateral ports are then placed under direct visualization. These ports must be placed above and lateral to the uterus fibroid complex (See
To minimize blood loss, a dilute solution of vasopressin (30 U of vasopressin in 100 cc of normal saline) is placed in the myoma bed via an 18-gauge spinal needle placed percutaneously through a small skin nick. (See
If the myoma is pedunculated, on a broad base, the vasopressin should not be placed into the pedicle itself, as bleeding can be excessive; rather, the vasopressin is placed in the uterus around the pedicle. It is imperative to aspirate prior to injection of vasopressin in order to prevent inadvertent intravascular injection of the vasopressin.
If possible, to reduce the risk of adhesions, make an anterior incision in the uterus and try to remove as many fibroids through the single incision as possible. For years, my instrument of choice has been the curved blade of Ethicon Endo-Surgery Inc.'s Harmonic Scalpel. Harmonic energy allows excellent cutting with minimal tissue desiccation. Moreover, the curve of the blade allows easier dissection between the myoma and myometrium. When a posterior incision is required, I use a vertical incision to decrease risk of adhesion formation near the adnexa.
If multiple fibroids are removed, I place a #1 nylon suture with a Keith needle transcutaneously into the pelvis. The numerous leiomyomata are then strung on this suture to avoid losing a myoma in the abdomen or pelvis. (See
Although suturing in the “vertical zone” (with two ports placed on the same side of the pelvis) has become a popular technique, I continue to profess cross-table suturing. When the surgeon stands cephalad to the incisions, the repair is quite comfortable to perform. Furthermore, the ports can be placed higher on the abdomen to accommodate the very large uterus, and can be positioned more widely apart to improve triangulation.