Isobaric gasless laparoscopic myomectomy for removal of large uterine leiomyomas

Minimally Invasive Myomectomy: An Overview on the Surgical Approaches and a Comparison with Mini-Laparotomy

Uterine fibroids (UFs) are the most common benign solid tumors of the female genital tract manageable by surgical of pharmacological approach. When the medical management is ineffective or surgery is primarily requested, several surgical approaches can be used. Among these, minimally invasive surgery might be preferred. Myomectomy is the standard surgical treatment when fertility sparing is claimed. It can be performed via laparoscopy, robotic surgery and hysteroscopy and the choice depend on UFs features and surgeon's skill. Alongside these minimally invasive options, mini-laparotomy has been proposed as a less invasive surgical approach comparable to the well-established minimally invasive options. The aim of this review is to describe the most recent advances in minimally invasive techniques to perform myomectomy, comparing them with mini-laparotomy approach.

A systematic review on efficacy and safety of gasless laparoscopy in the management of uterine leiomyoma

Uterine leiomyoma causes considerable morbidity in women. This study systematically reviewed the efficacy and safety of gasless laparoscopic myomectomy (GLM) in the management of uterine leiomyoma by comparing GLM with other minimally invasive procedures. Cochrane Library, Pub- Med, EMBASE, Web of Science, WANFANG database and China National Knowledge Infrastructure (CNKI) were searched for studies published in English or Chinese between January 1995 and May 2015, and related references were traced. Study outcomes from randomized controlled trials and retrospective cohort studies were presented as mean difference (MD) or odds ratio (OR) with a 95% confidence interval (CI). Seventeen studies (including 1862 patients) meeting the inclusion criteria, including 934 treated with GLM and 928 treated with other minimally invasive procedures were reviewed. The results of meta-analysis revealed that GLM resulted in significantly shorter operating time [MD=-10.34, 95% CI (-18.12,-2.56), P<0.00001], shorter hospital stay [MD=-0.47, 95% CI (-0.88,-0.06)], less time to flatus [MD=-2.04, 95% CI (-2.59,-1.48)], less postoperative complications [OR=0.20, 95% CI (0.06, 0.62)] and less blood loss [MD =-30.74, 95% CI (-47.50,-13.98)]. On the other hand, there were no significant differences in duration of post-operative fever [MD=-0.52, 95% CI (-1.46, 0.42)] between the two groups. Additionally, GLM was associated with lower febrile morbidity, lower postoperative abdominal pain, and higher postoperative hemoglobin than other minimally invasive procedures for the treatment of uterine leiomyoma. In conclusion, GLM and other minimally invasive procedures are feasible, safe, and reliable for uterine leiomyoma treatment. However, available studies show that GLM is more effective and safer than other minimally invasive approaches.

Hybrid laparoscopic myomectomy: A novel technique

The objective of this study was to report on a new surgical technique, hybrid laparoscopic myomectomy that integrates the advantages of transumbilical laparoendoscopic single-site surgery and those of isobaric laparoscopy, and the initial experience with 14 cases. All of the procedures were performed by a single surgeon who has over 18 years of experience in laparoscopic surgery and 4 years of experience in laparoendoscopic single-site surgery. All cases of hybrid laparoscopic myomectomy were completed safely and effectively without conversion to conventional laparoscopic procedure. The median operative time was 75 minutes (range, 30 to 100 minutes). No postoperative complication was observed. The findings show that hybrid laparoscopic myomectomy is a safe and feasible surgical technique, and therefore can be a feasible, minimally invasive alternative to either abdominal or laparoendoscopic single-site surgery myomectomy.

Transversus abdominis plane block associated with locoregional anesthesia with a laparotenser for gynecologic surgery in an awake state

The laparotenser instrument is used to perform isobaric laparoscopy to avoid adverse effects in the pneumoperitoneum. To decrease hospitalization time and increase the rate of same-day discharge, we investigated the safety of isobaric laparoscopy using the Laparotenser, a new subcutaneous abdominal wall-lifting system, with transversus abdominis plane (TAP) block combined with locoregional anesthesia (subarachnoid, peridural, spino-peridural) for patients undergoing minor and major gynecologic surgeries. With this combination of anesthetics, TAP block enabled us to anesthetize the supraumbilical region while the pelvic region was covered by locoregional anesthesia. We describe our experience with TAP blockade associated with locoregional anesthesia during gasless laparoscopy. We performed ultrasound-guided TAP block with ropivacaine 0.25% 20 mL to cover the supraumbilical region in association with locoregional anesthesia (lumbar subarachnoid-peridural-spinoperidural) and bupivacaine 0.5% (10 mg/3 mL) to cover the lower pelvic region. Successful outcome was reported in 81.3% (13/16) of the patients.

Multiple ectopic leiomyomas of the abdominal rectus muscles after gasless laparoscopic uterine myomectomy

PURPOSE

To describe and analyze the first case of multiple ectopic leiomyomas of the abdominal rectus muscles in a patient who had undergone gasless laparoscopic uterine myomectomy (GLM) 10 years before.

METHODS

A 41-year-old woman, who had undergone GLM 10 years before, having presented multiple palpable masses of the abdominal wall, underwent minilaparotomic excision of six abdominal masses.

RESULTS

Six round well-circumscribed masses of the abdominal rectus muscles, measuring, respectively, 3.8 × 1.7, 2.9 × 0.9, 0.8 × 0.5, 0.7 × 0.3, 10 × 0.8 and 0.5 × 0.4 cm, were excised. The major lesion was situated close to the right trocar site of the previous GLM, the other smaller tumors were located in the umbilical area and left abdominal region. On histopathologic examination, the abdominal lumps were categorized as leiomyoma.

CONCLUSIONS

Ectopic leiomyomatosis is an uncommon complication after GLM, and does not justify follow-up in all asymptomatic cases. However, the gynecologists should bear this unusual condition in mind, and inform the patients that leiomyoma fragments can grow in ectopic sites.

Successful pregnancy outcome after laparoscopic-assisted excision of a bizarre leiomyoma: a case report

Introduction

Bizarre leiomyoma is a rare leiomyoma variant that requires a precise histopathological evaluation. Especially when diagnosed in a younger woman, this tumor leads to challenging treatment issues involving fertility preservation. Owing to the low incidence of bizarre leiomyoma, there is insufficient evidence to support myomectomy alone as an appropriate management option. Also, the impact of bizarre leiomyoma on fertility is not well known.

Case presentation

A 30-year-old Japanese woman who had never given birth was referred to us because of a uterine tumor with an unusual diagnostic image and was treated by a gasless laparoscopic-assisted excision with a wound retractor. Owing to an unclear margin between her uterine tumor and myometrium, a concomitant excision of adjacent myometrial tissue was required to achieve the maximum resection of her tumor. The histopathological diagnosis was bizarre leiomyoma. Seven months later, she conceived spontaneously and her pregnancy course was uneventful. At 37 weeks of gestation, an elective cesarean section was performed. Although a slight omental adhesion was noted at the postexcisional scar, her uterine wall structure was well preserved and a recurrence of bizarre leiomyoma was not noted.

Conclusions

A laparoscopic-assisted excision of bizarre leiomyoma is a feasible and minimally invasive conservative measure for a woman who wishes to preserve fertility.

Laparoscopic resection of endometriosis in a patient with a ventriculoperitoneal shunt using the LapDisc

The surgical approach in a patient with a ventriculoperitoneal shunt in need of abdominal surgery remains controversial. The risk of increased intracranial pressure with pneumoperitoneum in laparoscopy is still unresolved. We used the LapDisc (Ethicon, Inc., Somerville, New Jersey) to access the shunt and temporarily seal it, which enabled us to perform laparoscopic resection of endometriosis without subjecting the shunt to high intraabdominal pressure. The benefits of this approach are the ability to perform laparoscopy, less skin-to-shunt contact minimizing infection, and elimination of possible increased intracranial pressure secondary to pneumoperitoneum. With the progress made in the management of hydrocephalus, patients with ventriculoperitoneal (VP) shunts enjoy a longer lifespan. Therefore, the gynecologic laparoscopic surgeon can expect to treat a patient with a VP shunt in place.

Gasless laparoscopy for benign gynecological diseases using an abdominal wall-lifting system

OBJECTIVES

The use of gasless laparoscopy with an abdominal wall-lifting device for benign gynecological diseases was compared to conventional laparoscopy with CO(2) pneumoperitoneum.

METHODS

From February 2007 to July 2007, 76 women with uterine and/or adnexal benign diseases and candidates for laparoscopic surgery were recruited in this study. Thirty-two women underwent gasless laparoscopic surgery and 44 women underwent pneumoperitoneum laparoscopic surgery.

RESULTS

Diverse pathologies, including adnexal cyst, uterine myoma and ectopic pregnancy, were treated successfully with gasless laparoscopic surgery. Compared with the patients in the pneumoperitoneum group, the similar hospital stay (P=0.353) and intraoperative blood loss (P=0.157) were observed. However, the mean operative time in the gasless group was significantly longer than that in the pneumoperitoneum group (P=0.003). No severe intraoperative or postoperative complications were found in either group, except for one case of laparotomic conversion in the pneumoperitoneum group due to dense pelvic adhesions. The total hospital charges were significantly less in the gasless group than in the pneumoperitoneum group (P=0.001). In 38 cases of ovarian cyst resection, the mean operative time in the gasless group remained longer than that in the pneumoperitoneum group (P=0.017). The total hospital charges were also significantly less in the gasless group than in the pneumoperitoneum group (P<0.001).

CONCLUSION

Our preliminary results demonstrated that the laparoscopic procedure using the gasless technique was a safe, effective method to treat benign gynecological diseases. Moreover, it was easy to master. As a minimally invasive treatment, gasless laparoscopic surgery provides a good choice to patients in the undeveloped regions in China without increasing the patients' and the government's burden significantly.

Natural orifice surgery (NOS)--toward a single-port transdouglas approach for intra-abdominal procedures

OBJECTIVE

To describe a future method for abdominal surgical procedures in women using a single-port Transdouglas Endoscopic Device (TED).

METHODS AND DESCRIPTION

The first successful laparotomy was performed in the 19th century, and the first endoscopic operation in the 20th century. The 21st century started with experimental operations using the natural body openings. Various abdominal procedures have already been performed through the stomach, but it seems that the transdouglas pathway in women is the most promising access into the peritoneal cavity, for its safety and cost-effectiveness. The TED is designed to perform operations in the upper and the lower abdomen. The New European Surgical Academy (NESA) founded the first European based interdisciplinary working group in order to plan and design instruments toward future gynaecological, urological and surgical applications.

CONCLUSION

The single-port TED is expected to replace many of today's endoscopic procedures due to its probably higher safety and better ergonomics.

A randomized, controlled study comparing minilaparotomy versus isobaric gasless laparoscopic assisted minilaparotomy myomectomy for removal of large uterine myomas: short-term outcomes

OBJECTIVE

To compare the operative data and early postoperative outcomes for myomectomy performed by minilaparotomy (MLT) with isobaric laparoscopic assisted minilaparotomy myomectomy (LM) in a series of patients with large uterine myomas (>or=5 cm) randomly assigned to each surgical technique.

STUDY DESIGN

80 patients were randomized blindly using a computer randomization list to MLT (n=40) or LM (n=40).

RESULTS

The mean (+/-SD) operating time was significantly shorter after LM than after MLT (75.50+/-25.70 vs 96.00+/-26.20 min; p<0.01). Intraoperative blood loss was less with LM (72.15+/-44.00 vs 96.21+/-38.50 ml; p<0.05), and DeltaHb was less with LM (1.21+/-0.55 vs 1.64+/-0.57; p<0.05). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary. Hospitalization was shorter after LM than after MLT (4.30+/-1.20 vs 6.90+/-2.70 days; p<0.01). Postoperative ileus was shorter after LM than after MLT (26.20+/-4.20 vs 40.50+/-4.90h; p<0.01). The mean VAS score at 12h for abdominal pain was 5.5+/-0.7 in the LM group and 5.2+/-0.8 in MLT group (p<0.05), whereas it was analogous in the two groups at 24h, and at 48h was 3.4+/-1.1 in the LM group and 4.2+/-1.1 in the MLT group (p<0.05), and no difference between two groups was detected in the overall mean (at 12, 24 and 48h).

CONCLUSIONS

Several surgical and immediate postoperative outcomes were significantly better in the LM group than in the MLT group.

The uterus and fertility

OBJECTIVE

To review the current understanding of the role the uterus plays in embryo implantation and to outline congenital anomalies and acquired diseases that impact normal uterine function.

DESIGN

The publications related to the embryo implantation, Mullerian anomalies, uterine polyps, uterine synechiae, and myomas were identified through Medline and reviewed.

CONCLUSION(S)

Congenital anomalies and acquired diseases of the uterus may negatively impact on the complex processes of embryo implantation. Hysteroscopic surgery to correct uterine septa, intrauterine synechiae, and myomas that distort the uterine cavity may benefit women with infertility or recurrent pregnancy loss. The effect of endometrial polyps on fertility is uncertain, but their removal, once identified, is justifiable. Complex congenital anomalies such as unicornuate uterus and uterus didelphys may negatively affect fertility and pregnancy outcome, and surgical treatment may benefit select patients.

Isobaric gasless laparoscopy versus minilaparotomy in uterine myomectomy: a randomized trial

BACKGROUND

Isobaric gasless laparoscopy and minilaparotomy have been used as more recent minimally invasive approaches to myomectomy. This randomized trial aimed to compare the surgical and immediate postoperative outcomes for myomectomy performed by isobaric gasless laparoscopy with those for minilaparotomy.

METHODS

A total of 100 patients with symptomatic uterine myomas requiring myomectomy were randomly allocated to the gasless laparoscopy group or the minilaparotomy group. The randomization procedure was based on a computer-generated list. The primary outcome was a comparison of the discharge times between the two procedures. A power calculation verified that more than 26 patients for each group was necessary to detect a difference of more than 24 h in discharge time with an alpha error level of 5% and a beta error of 80%. Continuous outcome variables were analyzed using the Student's t-test. Discrete variables were analyzed with the chi-square test or Fisher's exact test. A p value less than 0.05 was considered statistically significant.

RESULTS

The mean discharge time was longer for minilaparotomy than for gasless laparoscopy (98.4 +/- 1.4 vs 52.8 +/- 1.6 h; p < 0.001). Gasless laparoscopy resulted in shorter times for canalization (21.6 +/- 1.1 vs 32 +/- 1.3 h; p < 0.05) and surgery (79.5 +/- 25.1 vs 103.5 +/- 24.9 min; p < 0.001). The intraoperative blood loss was less with gasless laparoscopy (154.2 +/- 1.2 vs 188.6 +/- 1.3 ml; p < 0.001). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary.

CONCLUSIONS

Isobaric gasless laparoscopy and minilaparotomy can be suitable options for uterine myomectomy. Several surgical and immediate postoperative outcomes were significantly better in the gasless laparoscopy group than in the minilaparotomy group. However, further controlled prospective studies are required to confirm the results.