Close the myometrium
In the event of inadvertent entry into the uterine cavity, close the endometrial defect using running 2-0 polyglactin 910 suture, taking care to avoid suture entry into the uterine cavity. Tie this suture using intracorporeal knot-tying.
Close the hysterotomy in layers using 14 × 14 cm bidirectional barbed 0 PDO suture on a 36-mm, half-circle, taper-point needle. If the hysterotomy is longer than 8 cm, we prefer to use 24 × 24 cm suture.
Tack the first needle into the opposite anterior abdominal wall to help prevent tangling of the suture. Close the deepest layer using the first needle and the more superficial layer and serosa using the second needle. Then cut the needles. Because of the uniform tension and bidirectional nature of the barbed suture, no knots are required.
We began using Quill bidirectional barbed suture (Angiotech) in March 2008.16 Since then, we have completed almost 300 laparoscopic cases using this material, including approximately 100 laparoscopic myomectomies. We compiled data on our first year of experience with this material ( TABLE ), during which we had no major complications related to use of the suture, no conversions to laparotomy, and no returns to the OR to address bleeding or complications arising from the use of bidirectional barbed suture.
The original version of barbed suture included a 6-cm segment of regular, smooth suture. If suturing extends to include this segment, apply a LapraTy clip (Ethicon). This use of LapraTy is off-label because the clip is intended for use with Vicryl 2/0, 3/0, and 4/0 (manufacturer). Nevertheless, our clinical experience with this approach has been favorable.16,17
When closing the uterus, use as many layers as necessary to eliminate all dead space within the myometrium. Sometimes, as many as five layers are needed to close a deep myometrial defect, but a two- or three-layer closure is most common.
TABLE
1 year of experience with laparoscopic myomectomy using bidirectional barbed suture
| Variable | Mean ± standard deviation |
|---|---|
| Duration of surgery (min) | 125.47 ± 55.30 |
| Estimated blood loss (mL) | 158.68 ± 252.35 |
| Number of fibroids removed | 4.01 ± 4.21 |
| Weight of fibroids (g) | 252.07 ± 196.43 |
| Hospital stay (days) | 0.73 ± 0.36 |
| Data represent the author's experience with 55 consecutive laparoscopic myomectomy cases between March 2008 and March 2009. | |
Ward off adhesions
We generally cover the hysterotomy site with an adhesion barrier such as Interceed (Gynecare). Although no adhesion barrier is ideal, Interceed has proved to be effective in this clinical scenario.18 Make sure that the hysterotomy site is completely hemostatic at the time the barrier is applied.
Morcellate with caution
We generally use a 12- to 15-mm electronic morcellator for fibroid removal. Morcellation through the umbilicus is often feasible and prevents the need for a large peripheral incision, which may be less cosmetically pleasing to the patient and potentially more painful than a 15-mm umbilical incision.
We place a 5-mm optic through a peripheral port on the ipsilateral side of the surgeon because it allows the surgeon to operate away from the camera, causing less disorientation. Morcellation is inherently dangerous because of the risk of injury to internal organs such as bowel and blood vessels. The best way to prevent such injuries is to:
- keep the rotating blade in view at all times
- stay on the surface of the fibroid during morcellation (avoid coring)
- hold the morcellator steady during morcellation, i.e., do not move it forward while it is active.
6. NSAIDs and few restrictions are the norm postoperatively
We discharge almost all of our patients postoperatively on the day of laparoscopic myomectomy. Patients who have several medical comorbidities may need to stay overnight, however. We have not yet had to readmit a patient after a day-of-procedure discharge, and patients generally recover fairly rapidly.
We are prospectively evaluating our patients' return to daily activities. Most have resumed normal preoperative activities within 10 days. We recommend the scheduled use of nonsteroidal anti-inflammatory medications (NSAIDs), such as 800 mg of ibuprofen every 6 to 8 hours, for the first 3 to 5 days after surgery.
We encourage patients to remain active after surgery, with no weight-lifting restrictions. Instead, we instruct patients to live by the rule, "If it hurts, don't do it." We do prescribe narcotics, but we instruct patients to limit their use as much as possible. We give IV ketorolac perioperatively.
7. Uterine artery occlusion may prevent recurrence
One treatment option that we occasionally use in conjunction with laparoscopic myomectomy is laparoscopic uterine artery occlusion (LUAO) because it can significantly reduce the recurrence rate of uterine fibroids.19 LUAO is especially valuable in the setting of multiple, small uterine fibroids ("bag of marbles") and other cases where it is unlikely that all fibroids will be removed during myomectomy.