I have always recommended multiple-layer closure of the uterus to minimize hematoma formation, and have advised skimming the myometrium rather than taking deep bites of tissue in order to minimize tissue destruction. When I began to perform laparoscopic myomectomy in earnest more than 20 years ago, closure of the uterine cavity was performed with Ethicon Inc.'s nonbraided PDS II 3-0 suture placed in an interrupted or mattress style using a “knot pusher.”
Even now, when the endometrial cavity is entered at the time of myomectomy, this is the technique I currently recommend, with the interrupted or mattress sutures placed immediately above the endometrium. During the past 15 years, I have advised repairing the uterus via a running-suture technique. After multiple layers are placed, the two suture ends are tied together via an intracorporeal suture technique. This has not only proved to be more efficient, but also allows the various layers to collapse upon themselves. Ultimately, the serosa is repaired via a baseball closure (suture placed in to out, in to out, and so on). (See
In my opinion, the recent introduction of barbed sutures has served as a monumental advance in our ability to repair the uterus in multiple layers. Both Covidien's V-Loc and Angiotech Pharmaceuticals Inc.'s Quill sutures do not have to be tied. Moreover, the barbs enable consistent tension on the suture line. In order to secure the suture from slipping, the Quill uses a bidirectional barb (See
My current barbed suture of choice is the 3-0 V-Loc, which is created from 2-0 suture. When a barbed suture is used, it is imperative that the physician “hide” the suture as much as possible and thus use a baseball closure; theoretically, the barbs could catch bowel or omentum, leading to adhesion formation.
To allow for a better cosmetic repair and to minimize the risk of postoperative hernia, I recommend utilizing a larger umbilical incision for tissue extraction – I use a 12-mm umbilical port – while maintaining other ports at 5 mm. At the conclusion of the uterine repair and after placement of an antiadhesive barrier (Ethicon Inc.'s Interceed), the umbilical port is removed. Large cervical dilators are then used to stretch the umbilical incision to allow direct placement of the 15-mm morcellator. Currently, I use Karl Storz Endoscopy America Inc.'s Storz Rotocut Morcellation System. This morcellator is reusable to decrease costs, and it has a beveled tip to enhance the “apple peel” shaving of the fibroid, a very durable blade to maximize cutting ability, and variable speed to enhance the morcellation procedure.
With this laparoscopic technique, I utilize laparotomy in fewer than 1% percent of more than 200 myomectomy cases per year, of which more than 30% involve fibroids greater than 8 cm and of which nearly 20% involve five or more fibroids.
Major complication rates continue to be fewer than 1% percent, and heterologous transfusions occur in fewer than 0.5% of cases.
More than 20 years after its inception, laparoscopic myomectomy continues to be an evolving procedure – one that, especially with current advancements, should become a more common technique in the armamentarium of the minimally invasive gynecologic surgeon.
Dr. Miller disclosed that he is a consultant for Covidien and Femasys Inc., and a consultant and speaker for Ethicon Endo-Surgery Inc.
Laparoscopic Myomectomy
In this month's installment of the Master Class in Gynecologic Surgery, we are taking an interesting twist and featuring the expertise of our own medical editor, Dr. Charles E. Miller, an internationally renowned expert in minimally invasive gynecologic surgery.
When Dr. Miller inaugurated this column more than 7 years ago with a feature on “Maximizing Myomectomy” (
In his opening Master Class feature, Dr. Miller detailed the advantages of laparoscopic myomectomy and shared some pearls he acquired from a retrospective study of almost 300 laparoscopic myomectomy patients whom he had managed. He advised us on patient selection, presurgery planning, port placement, equipment, and key components of surgical technique.
At this point, laparoscopic myomectomy is a procedure that Dr. Miller has been performing for more than 20 years. And as he tells us here, it is a procedure that is still evolving and one that – even more so than in the past – should become a more common technique in the armamentarium of the minimally invasive gynecologic surgeon.
Laparoscopic myomectomy is one of Dr. Miller's key research and practice concerns. In this Master Class, he gives us a valuable update. He explains how he has honed his selection of diagnostic tools for preoperative evaluation, and details how to minimize blood loss and the risk of adhesions and hematoma formation. He also provides some suturing pearls and weighs in on the role and use of recently introduced barbed sutures.