Laparoscopic myomectomy: Enucleation of the myoma by morcellation while it is attached to the uterus

A Retractable Six-Prong Laparoscopic Grasper for Laparoscopic Myomectomy

The fixation and manipulation of fibroids during laparoscopic myomectomy is a persistent issue for gynecologic surgeons. In this paper, we present a laparoscopic grasper that, through a sheath-based deployment mechanism, opens into a larger multi-toothed grasper within the patient and collapses back for removal. Due to the increased number of contact points with the tumor, the expanded grasper allows for reliable fixation, aiding in manipulation during excision. We describe the nature-inspired design of the grasper from a physical foundation, establish the design theory and practical issues, and present manufacturing and testing of a full-scale 5 mm grasper. The unit was tested on synthetic fibroid models and was able to sustain a 50% higher load before tearing than a common single-tooth tenaculum. This development not only promises to improve fibroid fixation in myomectomy, but its design could be adapted to aid in the fixation of other difficult tissues in laparoscopic surgery.

New Surgical Technique for Robotic Myomectomy: Continuous Locking Suture on Myoma (LSOM) Technique

Robot-assisted laparoscopic myomectomy (RALM) has broadened the indications even in complex myomas. However, the high cost of RALM remains the main disadvantage. Therefore, a surgical technique that can reduce the cost of RALM and still has the advantages of robotic surgery is required. We propose a "locking suture on myoma (LSOM)" technique and compared the operative and perioperative outcomes of patients who underwent RALM with or without the LSOM technique. We included 337 patients who underwent RALM with (n = 160) or without (n = 177) the LSOM technique between March 2019 and August 2020. The LSOM group had low parity and gravidity, with a low rate of Cesarean sections. Myoma type was not different between the groups; however, patients in the LSOM group had larger, heavier, and higher number of myomas, although fewer patients had multiple myomas and were discharged earlier. Total operating time, estimated blood loss, pre- and postoperative hemoglobin levels, transfusion rate, and postoperative fever were not different between the two groups. In conclusion, the LSOM technique may be a viable surgical option for myomas, as it can reduce the cost of RALM by obviating the need for robotic Tenaculum forceps.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

OBJECTIVE

This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas.

DATA SOURCES

Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020.

METHODS OF STUDY SELECTION

Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis.

TABULATION, INTEGRATION, AND RESULTS

The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen.

CONCLUSION

Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

Intraoperative tranexamic acid to decrease blood loss during myomectomy: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Myomectomy is associated with a significant risk of hemorrhage. Tranexamic acid is a synthetic lysine derivative with antifibrinolytic activity used in other surgical disciplines to reduce blood loss during surgery. However, its utility in gynecologic surgery is not well understood.

OBJECTIVE

This study aimed to determine the effect of early administration of intravenous tranexamic acid on perioperative bleeding and blood transfusion requirements in women undergoing myomectomy.

STUDY DESIGN

This study was a double-blinded, randomized, placebo-controlled trial conducted in an academic teaching hospital. Women with symptomatic fibroids thought to be at risk for large intraoperative blood loss who met the following criteria were included in the study: (1) at least 1 fibroid ≥10 cm, (2) any intramural or broad ligament fibroid ≥6 cm, and/or (3) at least 5 total fibroids based on preoperative imaging. Patients were randomized to receive a single intravenous bolus injection of tranexamic acid 15 mg/kg (intervention group) versus an intravenous bolus injection of saline of equivalent volume (placebo group) 20 minutes before the initial surgical incision. Perioperative bleeding was defined by measuring intraoperative estimated blood loss, change between pre- and postoperative hemoglobin, and frequency of blood transfusions. Estimated blood loss was calculated by combining the blood volume collected within the suction canister and the weight of used sponges. The 2 groups were compared for age; body mass index; perioperative hemoglobin and hematocrit; perioperative blood loss; duration of surgery; blood transfusion requirements; and the number, total weight, and volume of myomas removed.

RESULTS

A total of 60 patients (30 per arm) were enrolled into the study between March 1, 2015, and January 29, 2018. Age, body mass index, baseline hemoglobin and/or hematocrit, number and total weight of myomas removed, and size of myomas did not differ between arms. Of 60 patients, 32 (53%) had laparoscopic myomectomy, 24 (40%) had robotic myomectomy, and 4 (7%) had laparotomy. Median estimated blood loss was 200 mL for the tranexamic acid group and 240 mL for the placebo group (P=.88). There was no difference in median duration of surgery (165 vs 164 minutes; P=.64) or change in perioperative hemoglobin (1.00 vs 1.1 g/dL; P=.64). Patients in the tranexamic acid group did not require blood transfusions; however, 4 patients (13.3%) in the placebo group (P=.11) required blood transfusions.

CONCLUSION

Intravenous administration of tranexamic acid in patients undergoing laparoscopic or robotic myomectomies was not associated with decreased blood loss.

Robotic Surgery in Gynecology

The robotic-assisted laparoscopic surgical approach has improved complex gynecologic surgeries. It has the advantages of excellent visualization through the high-resolution 3-dimensional view, a wrist-like motion of the robotic arms and improved ergonomics. Similar to conventional laparoscopic surgeries, it is associated with a decrease in long-term surgical morbidity, early recovery and return to work, and improved esthetics. We discuss preoperative planning, surgical techniques, and some of the latest clinical results of robotic-assisted laparoscopic gynecologic surgery.

Feasibility, Safety, and Prediction of Complications for Minimally Invasive Myomectomy in Women With Large and Numerous Myomata

OBJECTIVE

To assess perioperative outcomes and identify predictors of complications for minimally invasive surgery (MIS) myomectomy in a cohort of women with large and numerous myomata.

DESIGN

Case-control study (Canadian Task Force classification II-2).

SETTING

Academic tertiary care medical center.

PATIENTS

Women undergoing MIS myomectomy performed by 3 high-volume surgeons between April 2011 and December 2014.

INTERVENTIONS

Characteristics were compared between women who experienced complications and those who did not. Factors predictive of complications were then identified.

MEASUREMENTS AND MAIN RESULTS

A total of 221 women underwent an MIS myomectomy, 47.5% via a laparoscopic approach and 52.5% via robotic surgery. The mean ± SD specimen weight was 408.1 ± 384.9 g, uterine volume was 586.1 ± 534.1 cm³, dominant myoma diameter was 9.6 ± 5.1 cm, and number of myomata removed was 4.5 ± 4.1. The most common complications were hemorrhage >1000 mL (8.6%) and blood transfusion (4.1%). The conversion rate was 1.8%. A dominant myoma diameter of ≥12 cm and a uterine volume of ≥750 cm³ increased the odds of complications (odds ratio [OR], 7.44; 95% confidence interval [CI], 2.03-31.84; p = .004 and OR, 6.15; 95% CI, 1.55-30.02; p = .014 respectively). A receiver operating characteristic curve considering dominant myoma diameter and uterine volume had an area under the curve of 0.81. A combination of dominant myoma diameter of ≥10 cm and uterine volume of 600 cm³ predicted complications with 79% sensitivity and 79% specificity.

CONCLUSION

Our cohort had large and numerous myomata with high specimen weights, but complications were comparable to those reported in previous studies of MIS myomectomy with less complex pathology. Hemorrhage and transfusion accounted for the majority of complications, and a combination of dominant myoma diameter and uterine volume was predictive of complications. Both factors can be easily defined before surgery and may be used to guide patient counseling, referrals, and implementation of preventative measures for hemorrhage and transfusion.

Comparison of Laparoscopic Myomectomy in Large Myomas With and Without Leuprolide Acetate

STUDY OBJECTIVE

To evaluate the efficacy of gonadotropin-releasing hormone analogue (GnRHa) use before laparoscopic myomectomy (LM) in large myomas.

DESIGN

Prospective study (Canadian Task Force classification II-1).

SETTING

University-affiliated hospital.

PATIENTS

Ninety-one women with large myomas (≥10 cm) or more than 2 myomas ≥ 5 cm underwent LM between July 2011 and March 2014.

INTERVENTIONS

Forty patients underwent LM after GnRHa use (group A) and 51 underwent LM only (group B). GnRHa was used for 3 doses every 4 weeks before LM in group A.

MEASUREMENTS AND MAIN RESULTS

Group A had a significantly smaller maximum diameter of the largest myoma than group B (8.5 ± 2.1 vs 10.7 ± 2.4, p < .001) and fewer patients with myomas larger than 10 cm after GnRHa administration (33% vs 67%, p = .001). In group A, there was a decrease in 2 or more myomas ≥ 5 cm (20% vs 50%) after GnRHa use. Group A also had significantly smaller mean myoma weight (448 vs 567 g, p = .045) and significantly shorter mean operative time (129 ± 30 vs 152 ± 34 minutes, p = .001). Most patients in group A (40%) had an operative time < 119 minutes, whereas most patients in group B (37%) had an operative time between 150 and 179 minutes. Group A also had less intraoperative blood loss (84 ± 53 vs 137 ± 166 mL, p < .001), drop in hemoglobin (1.5 ± 0.8 vs 3.0 ± 1.7 g/dl, p < .001), excessive bleeding (5% vs 33%, p = .001), postoperative hematoma (2.5% vs 9.8%, p = .168), and blood transfusion (7.5% vs 35%, p = .001).

CONCLUSION

GnRHa before LM in large myomas may be an effective adjuvant treatment for women with large and multiple myomas. This method is beneficial in decreasing operative time, intraoperative bleeding, postoperative hemorrhage, and need of blood transfusion.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Benign smooth muscle tumours of the uterus, known as fibroids or myomas, are often symptomless. However, about one-third of women with fibroids will present with symptoms that are severe enough to warrant treatment. The standard treatment of symptomatic fibroids is hysterectomy (that is surgical removal of the uterus) for women who have completed childbearing, and myomectomy for women who desire future childbearing or simply want to preserve their uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding. Excessive bleeding can necessitate emergency blood transfusion. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library (2011, Issue 11).

OBJECTIVES

To assess the effectiveness, safety, tolerability and costs of interventions to reduce blood loss during myomectomy.

SEARCH METHODS

In June 2014, we conducted electronic searches in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO, and trial registers for ongoing and registered trials.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) that compared potential interventions to reduce blood loss during myomectomy to placebo or no treatment.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the risk of bias and extracted data from the included RCTs. The primary review outcomes were blood loss and need for blood transfusion. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI). We assessed the quality of evidence using GRADE methods.

MAIN RESULTS

Eighteen RCTs with 1250 participants met our inclusion criteria. The studies were conducted in hospital settings in low, middle and high income countries.Blood lossWe found significant reductions in blood loss with the following interventions: vaginal misoprostol (2 RCTs, 89 women: MD -97.88 ml, 95% CI -125.52 to -70.24; I(2) = 43%; moderate-quality evidence); intramyometrial vasopressin (3 RCTs, 128 women: MD -245.87 ml, 95% CI -434.58 to -57.16; I(2) = 98%; moderate-quality evidence); intramyometrial bupivacaine plus epinephrine (1 RCT, 60 women: MD -68.60 ml, 95% CI -93.69 to -43.51; low-quality evidence); intravenous tranexamic acid (1 RCT, 100 women: MD -243 ml, 95% CI -460.02 to -25.98; low-quality evidence); gelatin-thrombin matrix (1 RCT, 50 women: MD -545.00 ml, 95% CI -593.26 to -496.74; low-quality evidence); intravenous ascorbic acid (1 RCT, 102 women: MD -411.46 ml, 95% CI -502.58 to -320.34; low-quality evidence); vaginal dinoprostone (1 RCT, 108 women: MD -131.60 ml, 95% CI -253.42 to -9.78; low-quality evidence); loop ligation of the myoma pseudocapsule (1 RCT, 70 women: MD -305.01 ml, 95% CI -354.83 to -255.19; low-quality evidence); and a fibrin sealant patch (1 RCT, 70 women: MD -26.50 ml, 95% CI -44.47 to -8.53; low-quality evidence). We found evidence of significant reductions in blood loss with a polyglactin suture (1 RCT, 28 women: MD -1870.0 ml, 95% CI -2547.16 to 1192.84) or a Foley catheter (1 RCT, 93 women: MD -240.70 ml, 95% CI -359.61 to -121.79) tied around the cervix. However, pooling data from these peri-cervical tourniquet RCTs revealed significant heterogeneity of the effects (2 RCTs, 121 women: MD (random) -1019.85 ml, 95% CI -2615.02 to 575.32; I(2) = 95%; low-quality evidence). There was no good evidence of an effect on blood loss with oxytocin, morcellation or clipping of the uterine artery.Need for blood transfusion We found significant reductions in the need for blood transfusion with vasopressin (2 RCTs, 90 women: OR 0.15, 95% CI 0.03 to 0.74; I(2) = 0%; moderate-quality evidence); peri-cervical tourniquet (2 RCTs, 121 women: OR 0.09, 95% CI 0.01 to 0.84; I(2) = 69%; low-quality evidence); gelatin-thrombin matrix (1 RCT, 100 women: OR 0.01, 95% CI 0.00 to 0.10; low-quality evidence) and dinoprostone (1 RCT, 108 women: OR 0.17, 95% CI 0.04 to 0.81; low-quality evidence), but no evidence of effect on the need for blood transfusion with misoprostol, oxytocin, tranexamic acid, ascorbic acid, loop ligation of the myoma pseudocapsule and a fibrin sealant patch.There were insufficient data on the adverse effects and costs of the different interventions.

AUTHORS' CONCLUSIONS

At present there is moderate-quality evidence that misoprostol may reduce bleeding during myomectomy, and low-quality evidence that bupivacaine plus epinephrine, tranexamic acid, gelatin-thrombin matrix, a peri-cervical tourniquet, ascorbic acid, dinoprostone, loop ligation and a fibrin sealant patch may reduce bleeding during myomectomy. There is no evidence that oxytocin, morcellation and temporary clipping of the uterine artery reduce blood loss. Further well designed studies are required to establish the effectiveness, safety and costs of different interventions for reducing blood loss during myomectomy.

Laparoscopic myomectomy with uterine artery ligation: review article and comparative analysis

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.

Handling cervical myomas

Compared to myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified, as the organs that have to be considered differ depending on the location of the myoma. Surgical difficulties associated with these cases are, poor access to the operative field, difficulty in suturing the repairs, increased blood loss, and distortion of the anatomy of the vital neighboring structures in the pelvic cavity.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, can be associated with life-threatening bleeding and prolonged postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. This is an update of the review published in The Cochrane Library Issue 3, 2009.

OBJECTIVES

To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy.

SEARCH STRATEGY

Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), and PsycINFO (1801 to February 2011).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI).

MAIN RESULTS

Twelve RCTs with 674 participants met our inclusion criteria. The interventions were intramyometrial vasopressin (two RCTs), intravenous oxytocin (two RCTs), peri-cervical tourniquet (two RCTs), and one RCT each for vaginal misoprostol, gelatin thrombin matrix, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid, and myoma enucleation by morcellation. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin (MD -298.72 ml, 95% CI -593.10 to -4.34; I(2) = 99%), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), peri-cervical tourniquet (MD -289.44, 95% CI -406.55 to -172.32; I(2) = 95%), and gelatin-thrombin matrix (MD -545.00 ml, 95% CI -593.26 to -496.74). There was no evidence of an effect on blood loss with oxytocin or morcellation. None of the interventions significantly increased myomectomy-related complications. The trials did not assess the costs of the different interventions.

AUTHORS' CONCLUSIONS

There is limited evidence that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, gelatin thrombin matrix, peri-cervical tourniquet, and mesna may reduce bleeding during myomectomy. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small. There is no evidence that oxytocin and morcellation reduce blood loss. Further well designed studies are required to establish effectiveness, safety and the costs of different interventions for reducing blood loss during myomectomy.

Application of simultaneous morcellation in situ in laparoscopic myomectomy of larger uterine leiomyomas

OBJECTIVES

To describe the efficiency, blood loss, operating time and mean hospital stay of enucleation of a large myoma by 'simultaneous morcellation in situ' (SMI) in laparoscopic myomectomy (LM).

PATIENTS AND METHODS

Twenty-six patients with leiomyomas >9 cm in diameter were treated using LM and SMI from January 2006 to December 2009. Patient characteristics and operative data were collected and analyzed.

RESULTS

The average operating time was 106.4 ± 38.5 min (range 50-175 min). The average blood loss was 278.2 ± 164.6 ml (range 50-800 ml). There was no other complication, and no patient underwent conversion to laparotomy. The average postoperative hospital stay was 5.4 ± 0.2 days (range 5-7 days).

CONCLUSION

Our study confirmed that SMI is an efficient and safe way to remove large uterine myomas (>9 cm) during LM.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of myomas, is an important treatment option especially for women who wish to preserve their uteri. The major problem with myomectomy is excessive bleeding, which can be life-threatening and prolong postoperative stay. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions.

OBJECTIVES

To assess the effectiveness, safety, tolerability, and costs of interventions to reduce blood loss during myomectomy.

SEARCH STRATEGY

Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to September 2008), EMBASE (1980 to September 2008), CINAHL (1982 to September 2008), and PsycINFO (up to September 2008).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) that compared the use of interventions to reduce blood loss during myomectomy to placebo or no treatment were included.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the methodological quality of trials, and extracted data. We expressed study results as mean differences (MD) for continuous data and odds ratios for dichotomous data, with 95% confidence intervals (CI).

MAIN RESULTS

Ten RCTs with 531 participants met our inclusion criteria: intramyometrial vasopressin and analogues (two trials), intravenous oxytocin (two trials), and one RCT for each of the interventions vaginal misoprostol, peri-cervical tourniquet, chemical dissection with sodium-2-mercaptoethane sulfonate (mesna), intramyometrial bupivacaine plus epinephrine, tranexamic acid and the enucleation of myoma by morcellation while it is attached to the uterus. We found significant reductions in blood loss with misoprostol (MD -149.00 ml, 95% CI -229.24 to -68.76), vasopressin and analogues (MD -298.72 ml, 95% CI -593.10 to -4.34), bupivacaine plus epinephrine (MD -68.60 ml, 95% CI -93.69 to - 43.51), tranexamic acid (MD -243 ml, 95% CI -460 to -25.98), and peri-cervical tourniquet (MD -1870.00 ml, 95% CI -2547.16 to -1192.84). There was no evidence of effect on blood loss with myoma enucleation by morcellation or oxytocin. The trials did not assess the tolerability and costs of the different interventions.

AUTHORS' CONCLUSIONS

Evidence is limited from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tranexamic acid, tourniquet, and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is a need for adequately powered RCTs to shed more light on the effectiveness, safety, and costs of different interventions in reducing blood loss during myomectomy.

Laparoscopic management of large myomas

The objective of this article is to review the different techniques that have been adopted for removal of large myomas laparoscopically. We have also quoted literature about the impact of myomas on Pregnancy and obstetrical outcome and the effect of laparoscopic myomectomy on the same. Technical modifications to remove large myomas have been described along with methods to reduce intraoperative bleeding. This comprehensive review describes all possibilities of laparoscopic myomectomy irrespective of size, site and number.

Laparoscopic myomectomy: an intent-to-treat study

INTRODUCTION

Laparoscopic myomectomy can be performed by most advanced laparoscopic gynecologic surgeons if they have appropriate mentoring. Despite this, it is still an underused procedure. In this article, we report our ten-year experience with laparoscopic myomectomy with focus on blood loss and hemostasis.

MATERIALS AND METHODS

From July 1999 to May 2009, forty-one patients from our suburban gynecology practice underwent laparoscopic myomectomies which were performed by one surgeon (Dr Heaton). We studied the most important factors that affect the completion of the procedure without conversion to the open route.

RESULTS

Fibroids measured up to 15.6 cm on preoperative ultrasound and weighed up to 555 g from pathology report with no malignancy found. Eight patients were treated with Lupron before surgery to reduce the size of the fibroids. Pitressin was used in twenty-three patients during surgery to decrease bleeding. Nineteen cases required morcellation. Blood loss range was 20-1,200 cc and was dependent on the myoma size. One case required staged myomectomy because of bleeding (800 cc) after the large fibroid was removed. No patient required transfusion. No patient required conversion to the open technique. Patients were discharged the day of surgery in the majority of cases. No infections occurred. Two patients had successful pregnancies after myomectomy in this series and were delivered by C-section. Subsequent hysterectomy was performed in six patients at 3-72 months.

CONCLUSIONS

Laparoscopic myomectomy is a safe procedure in the hands of an experienced advanced laparoscopic surgeon. Blood loss is dependent on the myoma size and bleeding is the most serious intraoperative complication which may require performing a staged laparoscopic myomectomy, conversion to open myomectomy or blood transfusion. Maintaining homeostasis is the chief requirement to successfully and uneventfully complete the procedure without conversion to the open route.

Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy?

STUDY OBJECTIVE

To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas.

DESIGN

Prospective observational study (Canadian Task Force classification II-1).

SETTING

Tertiary endoscopy center.

PATIENTS

A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas.

INTERVENTIONS

Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization.

MEASUREMENTS AND MAIN RESULTS

In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (<or=4 and >or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy.

CONCLUSION

Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Effect of simultaneous morcellation in situ on operative time during laparoscopic myomectomy

BACKGROUND

Laparoscopic myomectomy (LM) is technically difficult and time consuming procedure that requires surgical skill and modifications. The aim of this study was to assess factors which affect operative times in LM.

METHODS

From March 2003 to June 2007, 174 women, who underwent LM for symptomatic myomas, were enrolled. Standard LM was performed in the first 4 years and simultaneous morcellation in situ (SMI) method was applied in the fifth year.

RESULTS

The mean myoma weight was 213.5 +/- 190.4 g and the mean operative time was 117.0 +/- 39.6 min. No laparoconversions occurred and there was a 2.3% rate of complications. Total myoma weight increased and operative time declined significantly over time. The surgeon's learning curve and the effect of SMI on operative time were identified by establishing a nonlinear multiple regression model. Model assumptions showed little violation by residual plots. Slopes of the average myoma weight (total myoma weight/number of myoma operated) for describing the operative time declined along with the study year, suggesting that operative experience is a major factor influencing operative time. SMI showed a further 19 min reduction in the predicted operative time.

CONCLUSIONS

Operative time in LM is dependent on a multitude of factors including surgical experience. Applying SMI during LM is an efficient way to further reduce operative time.

A systematic review of randomized controlled trials to reduce hemorrhage during myomectomy for uterine fibroids

OBJECTIVE

To assess the effectiveness and safety of interventions to reduce blood loss during myomectomy.

METHODS

Electronic searches of the Cochrane Library, MEDLINE, and EMBASE, between 1966 and 2006 for randomized controlled trials (RCTs).

RESULTS

We found significant reductions in blood loss with vaginal misoprostol (weighted mean difference [WMD] -149.00 mL, 95% confidence interval [CI] -229.24 to -68.76); intramyometrial vasopressin and analogues (WMD -298.72 mL, 95% CI -593.10 to -4.34); intramyometrial bupivacaine plus epinephrine (WMD -68.60 mL, 95% CI -93.69 to -43.51); and pericervical tourniquet (WMD -1870.00 mL, 95% CI -2547.16 to -1192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin.

CONCLUSION

There is limited evidence from a few RCTs that some interventions may reduce bleeding during myomectomy. There is need for adequately powered RCTs to shed more light on the effectiveness, safety, and cost of different interventions to reduce blood loss during myomectomy.

Laparoscopic myomectomy for large myomas

The aim of this study was to assess the feasibility and efficacy of laparoscopic myomectomy (LM) for large myomas. A subpopulation of 51 patients with myomas 8 cm or larger in diameter was selected from 155 patients who underwent LM at Kangbuk Samsung Hospital from July 2003 to November 2006. The mean age of the patients was 34.9 +/- 5.6 yr, mean parity was 0.6 +/- 0.9, and 8 patients had a previous operative history. The most common operative indication was a palpable abdominal mass (24 patients, 47%). The mean operating time was 85.6 +/- 38.9 min, and the mean diameter of the largest myoma was 9.3 +/- 1.8 cm. The mean change in hemoglobin concentration was 2.1 +/- 1.2 g/dL. Histopathological diagnosis included 49 patients of leiomyoma (96.1%) and 2 patients of leiomyoma with adenomyosis (3.9%). Postoperatively, a transfusion was done in 7 patients, and a case of subcutaneous emphysema was noted. None of the operations was switched to laparotomy. With the newly-developed screw and the port placement system that was modified from the Choi's 4-trocar method to obtain better surgical vision, LM of large myomas proved to be one of the efficient and feasible methods.

Interventions to reduce haemorrhage during myomectomy for fibroids

BACKGROUND

Uterine myomas (fibroids) are benign tumours of the uterus. Myomectomy, the surgical removal of the myomas, is an important treatment option especially for women who desire to preserve their uteri. The major problem with myomectomy is excessive bleeding from increased uterine blood supply, and this can be life-threatening and prolong postoperative stay. Knowledge of the effectiveness of the interventions used to reduce blood loss during myomectomy is essential to enable evidence-based clinical decisions.

OBJECTIVES

To assess the effectiveness and safety of interventions (other than GnRH analogues) to reduce blood loss during myomectomy.

SEARCH STRATEGY

Electronic searches were undertaken in the Cochrane Menstrual Disorders and Subfertility Group specialised register, CENTRAL (Cochrane Library Issue 1, 2006), MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), Current Contents (1993 to March 2006), the National Research Register, and the National Library of Medicine's Clinical Trial Register (up to March 2006).

SELECTION CRITERIA

Only randomised controlled trials (RCTs) that compared interventions to reduce blood loss during myomectomy to placebo or no treatment were included.

DATA COLLECTION AND ANALYSIS

The two authors independently selected RCTs for inclusion, assessed the methodological quality and extracted data. We expressed study results as weighted mean differences (WMD) for continuous data, and odds ratios for dichotomous data.

MAIN RESULTS

Eight RCTs met the inclusion criteria: two on intramyometrial vasopressin and analogues, and one each on vaginal misoprostol, IV oxytocin, pericervical tourniquet, chemical dissection with mesna, intramyometrial bupivacaine plus epinephrine and the enucleation of myoma by morcellation while it is attached to the uterus. We found significant reductions in blood loss with misoprostol (WMD -149.00 ml, 95% confidence interval [CI] -229.24 to -68.76), vasopressin and analogues (WMD -298.72 ml, 95% CI -593.10 to -4.34), bupivacaine plus epinephrine (WMD -68.60 ml, 95% CI -93.69 to - 43.51), and pericervical tourniquet (WMD -1870.00 ml, 95% CI -2547.16 to -1192.84). There was no evidence of effect in blood loss with myoma enucleation by morcellation and oxytocin. The trials did not assess the tolerability and costs of different interventions.

AUTHORS' CONCLUSIONS

There is limited evidence from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is need for adequately powered RCTs to shed more light on the effectiveness, safety and costs of different interventions in reducing blood loss during myomectomy.