Ins and outs of straight-stick laparoscopic myomectomy

How to minimize blood loss

Blood loss during laparoscopic myomectomy generally is less than during laparotomy due to venous compression from pneumoperitoneum. However, blood loss remains a chief concern when performing laparoscopic myomectomy. A variety of techniques have been described to minimize blood loss, including injection of dilute vasopressin⁶ and tourniquet placement around uterine vessels.⁷

Injection. To temporarily minimize bleeding in the surgical field, we routinely utilize subserosal injection of dilute vasopressin (20 IU in 100 mL of normal saline) until visible vessels blanch. This practice is more effective than deep myoma or myometrial injection.

Tourniquet. We selectively use a laparoscopically placed tourniquet to compress uterine arteries at the mid-cervix during surgery. One approach is as follows (see VIDEO 1):

1. Open windows in bilateral broad ligaments lateral to the uterine pedicles and medial to the ureters.
2. Pass the end of a 14-16 French red rubber catheter through one of the low lateral port sites with the port removed.
3. Tag the trailing end of the tourniquet outside the abdomen and replace the port alongside the catheter.
4. Pass the end of the catheter down through the ipsilateral broad ligament window and under the posterior cervix.
5. Pass the end of the catheter up through the contralateral broad ligament window and over the anterior cervix.
6. Pass the end of the catheter through each of the broad ligament windows a second time and then out through the contralateral port site.
7. Pull the tourniquet tight from both port sites (which will occlude the uterine arteries). Place Kelly clamps on the catheter ends where they exit the port sites to maintain tension until the end of the uterine repair.

Lateral ports can still be utilized with the tourniquet in place.

Permanent occlusion. In women undergoing laparoscopic myomectomy who have completed child bearing, we advocate permanent uterine artery occlusion at the origin of the uterine arteries retroperitoneally. This can be performed in a number of ways— utilizing clips, suture, or transection. Uterine artery occlusion not only leads to less operative blood loss but preliminary studies also suggest it decreases the risk of fibroid recurrence.⁸

Surgical technique

After the patient is prepped and draped in low lithotomy position with her arms tucked at her sides, drain the bladder with an indwelling catheter. Insert a uterine manipulator, such as the VCare (Conmed Corporation), into the uterus.

Obtain umbilical entry for a 30° optic scope, and place the patient in steep Trendelenburg position. We use two 5-mm lateral ports and one 12-mm suprapubic port. The level of placement of the lateral ports is tailored to the size of the fibroids; it can be anywhere from the level of the anterior iliac spine to the level of the umbilicus for fibroids contained in the pelvis or in the abdomen, respectively.

Uterine incision

After vasopressin injection, tourniquet placement, or permanent uterine artery occlusion is performed as described above, we advocate a transverse uterine incision. We do so mainly because:

• The transverse incision runs parallel to the arcuate vessels of the myometrium, leading to less bleeding.
• We suture from the lateral ports so the transverse incision facilitates a more ergonomic repair.

Perform the uterine incision (we use the Harmonic Ace [Ethicon Endo-Surgery, Inc]) through the uterine serosa deep toward the myoma. Incision size should be appropriate to the diameter of the fibroid; smaller incisions result in unnecessary struggling during enucleation of the fibroid. Incision depth should reach the fibroid capsule, and this incision should be developed over the entire fibroid. Tunneling in the myometrium is undesirable and should be avoided because it increases myometrial injury as well as the risk of hematoma.

Fibroid enucleation

Once the initial uterine incision is complete, enucleate the fibroid using a combination of traction, countertraction, sharp, and blunt dissection (see VIDEO 2). Pearls to successful enucleation include:

• Maintain traction and countertraction when cutting tissue. This helps to identify appropriate planes and allows tissue to separate quickly, minimizing thermal energy spread.
• Replace the tenaculum or myoma screw regularly at the border of the myoma and myometrium. The ultrasonic scalpel blade can be drilled into the myoma in order to create traction on the myoma.
• Bluntly peel tissue from the myoma outward. Ideally all myometrium and vessels should stay with the uterus. A properly enucleated fibroid will be pearly in appearance and avascular.
• Be particularly careful when in contact with the endometrium. Even submucous fibroids can be enucleated regularly without entering the endometrial cavity.

Uterine repair

If the endometrial cavity is inadvertently entered, close the defect (we use a 2-0 monocryl or Vicryl suture). Next, imbricate the endometrium over with successive layers, taking special care not to pass a needle into the endometrial cavity. In cases in which significant endometrial disruption cannot be avoided, use a postoperative intrauterine balloon stent. This is placed postoperatively and left in place for 2 weeks. To stimulate endometrial proliferation, we prescribe oral estradiol 1 mg twice per day for 4 weeks. Following endometrial stimulation, we prescribe a 10-day progestin withdrawal and ask the patient to return to the office for a flexible diagnostic hysteroscopy following her first menses to ensure cavitary integrity.