Myomectomy. Comparison of open and laparoscopic techniques

Uterine rupture at 28 weeks of gestation after laparoscopic myomectomy - a case report

There are many reasons for sterility, and uterine malformations are of the greatest concern. Among uterine disorders, myomas play a significant role and are present in 27% of infertile women. The occurrence of myomas is frequent - 20-40% in women of reproductive age. Thus, for those infertile patients surgical treatment may be needed to preserve an opportunity to conceive. This case report refers to an uterine rupture at 28 weeks of gestation after laparoscopic myomectomy (3 months before conceiving). The myomectomy was conducted correctly and two layers of sutures on the myometrium were performed. The purpose of the myomectomy in a young woman should be well considered. In cases of infertility, removal of the lesions is usually necessary to give the patient a chance of pregnancy. At the same time, the risk of uterine rupture is increased. There are some suggestions referring to myomectomy to reduce the risk of uterine rupture in a subsequent pregnancy. It seems that the method of sewing the uterine closure is crucial. For example, multilayer uterine stitches, preservation of the endometrial cavity, and avoidance of using electrosurgery to prevent devascularization (to avoid haematoma formation) should be taken into consideration to prevent weakness of the wall of the uterus. Uterine scars differ histologically and biochemically.

Combining situ-morcellation with continuous-fill-mattress suture in laparoscopic myomectomy: A surgical approach of choice for patients with large uterine fibroids

BACKGROUND

To investigate the efficacy and advantage of combining situ-morcellation with continuous-fill-mattress suture compared with conventional morcellation and suture in laparoscopic myomectomy.

METHODS

One hundred sixteen patients who underwent laparoscopic myomectomy from March 2014 to October 2016.

INTERVENTIONS

Patients were divided into combining situ-morcellation with continuous-fill-mattress suture group (n = 62) and conventional group (n = 54), and subsequent statistical analysis the clinical data of the 2 groups.

RESULTS

The combining situ-morcellation with continuous-fill-mattress suture group shows significantly decrease of surgery time, incision size, blood loss, postoperative drainage volume and time, postoperative vent time, hospital stay and the loss of hemoglobin value. Moreover, there is significant significance between the 2 groups in the surgery time (P = .018), the postoperative drainage volume (P = .000), and the loss of hemoglobin value (P = .000).

CONCLUSIONS

The combining situ-morcellation with continuous-fill-mattress suture shows significant advantages in shortening surgery time and reducing blood loss compared with conventional group in laparoscopic myomectomy.

Uterine fibroids associated with infertility

In recent years, there has been an increasing focus on the contributory role of uterine fibroids to infertility. The prevalence of these tumors increases with age, which becomes significant as more women are delaying childbearing. Therefore, fibroids and infertility frequently occur together. Treatment varies with fibroid location and size. The various methods of treatment include open myomectomy, laparoscopic or robot-assisted myomectomy, medical treatment, uterine artery embolization and magnetic resonance guided focused ultrasound surgery. While there is a general consensus on the treatment of submucosal fibroids, the management of intramural fibroids in the infertility patient remains controversial. This paper aims to review and summarize the current literature in regards to the approach to uterine fibroids in the infertile patient.

Minimally invasive surgical techniques versus open myomectomy for uterine fibroids

BACKGROUND

Fibroids are common benign tumours arising in the uterus. Myomectomy is the surgical treatment of choice for women with symptomatic fibroids who prefer or want uterine conservation. Myomectomy can be performed by conventional laparotomy, by mini-laparotomy or by minimal access techniques such as hysteroscopy and laparoscopy.

OBJECTIVES

To determine the benefits and harms of laparoscopic or hysteroscopic myomectomy compared with open myomectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (inception to July 2014), the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of Controlled Trials (inception to July 2014), MEDLINE(R) (inception to July 2014), EMBASE (inception to July 2014), PsycINFO (inception to July 2014) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (inception to July 2014) to identify relevant randomised controlled trials (RCTs). We also searched trial registers and references from selected relevant trials and review articles. We applied no language restriction in these searches.

SELECTION CRITERIA

All published and unpublished randomised controlled trials comparing myomectomy via laparotomy, mini-laparotomy or laparoscopically assisted mini-laparotomy versus laparoscopy or hysteroscopy in premenopausal women with uterine fibroids diagnosed by clinical and ultrasound examination were included in the meta-analysis.

DATA COLLECTION AND ANALYSIS

We conducted study selection and extracted data in duplicate. Primary outcomes were postoperative pain, reported in six studies, and in-hospital adverse events, reported in eight studies. Secondary outcomes included length of hospital stay, reported in four studies, operating time, reported in eight studies and recurrence of fibroids, reported in three studies. Each of the other secondary outcomes-improvement in menstrual symptoms, change in quality of life, repeat myomectomy and hysterectomy at a later date-was reported in a single study. Odds ratios (ORs), mean differences (MDs) and 95% confidence intervals (CIs) were calculated and data combined using the fixed-effect model. The quality of evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods.

MAIN RESULTS

We found 23 potentially relevant trials, of which nine were eligible for inclusion in this review. The nine trials included in our meta-analysis had a total of 808 women. The overall risk of bias of included studies was low, as most studies properly reported their methods.Postoperative pain: Postoperative pain was measured on a visual analogue scale (VAS), with zero meaning 'no pain at all' and 10 signifying 'pain as bad as it could be.' Postoperative pain was significantly less, as determined by subjectively assessed pain score at six hours (MD -2.40, 95% CI -2.88 to -1.92, one study, 148 women, moderate-quality evidence) and 48 hours postoperatively (MD -1.90, 95% CI -2.80 to -1.00, two studies, 80 women, I² = 0%, moderate-quality evidence) in the laparoscopic myomectomy group compared with the open myomectomy group. This means that among women undergoing laparoscopic myomectomy, mean pain score at six hours and 48 hours would be likely to range from about three points lower to one point lower on a VAS zero-to-10 scale. No significant difference in postoperative pain score was noted between the laparoscopic and open myomectomy groups at 24 hours (MD -0.29, 95% CI -0.7 to 0.12, four studies, 232 women, I² = 43%, moderate-quality evidence). The overall quality of these findings is moderate; therefore further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.In-hospital adverse events: No evidence suggested a difference in unscheduled return to theatre (OR 3.04, 95% CI 0.12 to 75.86, two studies, 188 women, I² = 0%, low-quality evidence) and laparoconversion (OR 1.11, 95% CI 0.44 to 2.83, eight studies, 756 women, I² = 53%, moderate-quality evidence) when open myomectomy was compared with laparoscopic myomectomy. Only one study including 148 women reported injury to pelvic organs (no events were described in other studies), and no significant difference was noted between laparoscopic myomectomy and laparoscopically assisted mini-laparotomy myomectomy (OR 3.04, 95% CI 0.12 to 75.86). Significantly lower risk of postoperative fever was observed in the laparoscopic myomectomy group compared with groups treated with all types of open myomectomy (OR 0.44, 95% CI 0.26 to 0.77, I² = 0%, six studies, 635 women). This indicates that among women undergoing laparoscopic myomectomy, the risk of postoperative fever is 50% lower than among those treated with open surgery. No studies reported immediate hysterectomy, uterine rupture, thromboembolism or mortality. Six studies including 549 women reported haemoglobin drop, but these studies were not pooled because of extreme heterogeneity (I² = 97%) and therefore could not be included in the analysis.

AUTHORS' CONCLUSIONS

Laparoscopic myomectomy is a procedure associated with less subjectively reported postoperative pain, lower postoperative fever and shorter hospital stay compared with all types of open myomectomy. No evidence suggested a difference in recurrence risk between laparoscopic and open myomectomy. More studies are needed to assess rates of uterine rupture, occurrence of thromboembolism, need for repeat myomectomy and hysterectomy at a later stage.

Spontaneous rupture of uterine leiomyoma during labour

Uterine rupture in labour requires an emergency caesarean section. In women with a uterine scar, either from gynaecological surgery or from a previous caesarean section, it is well documented that the risk of rupture is higher than in those without. Spontaneous uterine rupture in a uterus with fibroids during pregnancy or labour is extremely rare. We present a case of a 33-year-old, unbooked pregnant woman from Nigeria who had a uterine rupture secondary to fibroids. She required an emergency caesarean section in labour. The fibroids were not removed. Her baby was born alive and in good condition and she made an uneventful recovery.

Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy

OBJECTIVE

Because of concerns about uterine rupture, many obstetricians recommend elective Caesarean section for women with a prior myomectomy. This practice has led to an increased rate of elective CS and subsequently of repeat Caesarean sections. The purpose of this study was to evaluate the perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy.

METHODS

We conducted a survey of 49 practising obstetricians from July 2012 to January 2013, using a standard questionnaire. This included questions on labour and delivery after myomectomy by laparotomy or laparoscopy.

RESULTS

Overall, the inter-respondent agreement was fair (kappa 0.3; P < 0.001). There was no significant difference in the likelihood that respondents would allow vaginal delivery after myomectomy by laparotomy and by laparoscopy (27% and 14% if the uterine cavity was entered and 76% and 71% if the uterine cavity was not entered, respectively). However, the likelihood that respondents would allow vaginal delivery was significantly reduced if the uterine cavity was entered, regardless of the surgical approach (P < 0.001). Entry into the uterine cavity during myomectomy also significantly increased the likelihood that obstetricians would recommend elective CS rather than induction of labour. There was no significant difference in practice regarding the use of oxytocin with amniotomy, oxytocin infusion, or prostaglandins.

CONCLUSION

Despite a lack of evidence, obstetricians consider entry into the uterine cavity at myomectomy to be an important factor in determining the method of delivery, the use of oxytocin, and delivery by elective Caesarean section. This was independent of the myomectomy approach.

Meta-analysis: the comparison of clinical results between vaginal and laparoscopic myomectomy

PURPOSE

To evaluate the clinical results of vaginal myomectomy and laparoscopic myomectomy (LM).

METHODS

The database of PubMed, EMBASE, Web of Science, ProQuest, Cochrane library and China Biological Medicine Database (CBM), Chinese National Knowledge Infrastructure (CNKI), Wanfang (Chinese) and VIP (Chinese) were searched using the keywords "laparoscopic", "laparoscopically", "vaginal", "trasvaginal", "myomectomy", "randomized", "randomised" and "randomly" to identify randomized controlled trails which compared vaginal myomectomy and LM. Studies are also searched by hand. No language restrictions were made.

RESULTS

Four trials were studied and the analysis was performed using Review Manager Version 5 and R software Version 2.11.1. The results had shown that vaginal myomectomy was associated with less operation time significantly, but reduced blood loss, hospital stay and gas recovery and more minor complications without significant difference.

CONCLUSIONS

This meta-analysis was not powerful to form an accurate conclusion because of less number, low quality of included studies and no data on major complications and long-term outcomes such as recurrence and pregnancy. Hence, more studies and data should be awaited and involved for further evaluation.

Interest of uterine artery embolization with gelatin sponge particles prior to myomectomy for large and/or multiple fibroids

PURPOSE

To evaluate the efficacy of pre-myomectomy uterine artery embolization with gelatin sponge particles to reduce operative blood loss and facilitate removal of fibroids.

MATERIALS AND METHODS

This retrospective study included 33 women (mean age, 36 years; range, 24-45 years), of whom at least 18 wished to preserve fertility. They presented with at least one large myoma (mean diameter, 90 mm; range, 50-150 mm) and had undergone preoperative uterine artery embolization with resorbable gelatin sponge by unilateral femoral approach between December 2001 and November 2008. Clinical, radiological and surgical data were available for all patients. Mean haemoglobin levels before and after surgery were compared with Student's t-test.

RESULTS

No complication or technical failure of embolization occurred. The myomectomies were performed during laparotomy (25 cases) or laparoscopy (8 cases). Dissection of fibroids was easier (mean, 3 per patient; range, 1-11), with a mean operating time of 108±50 min (range, 30-260 min). Bloodless surgery was the rule with a mean estimated peroperative blood loss of 147±249 mL (range, 0-800 mL). Mean pre-(12.9±1.3g/dL) and post-therapeutic (11.4±1.2g/dL) haemoglobin levels were not statistically different (p>0.05). There was no need for blood transfusion. None of the patients required hysterectomy. The mean duration of hospital stay was 7.5±1.3 days (range, 3-12 days).

CONCLUSION

Preoperative uterine artery embolization is effective in reducing intraoperative blood loss and improves the chances of performing conservative surgery. It should be considered a useful adjunct to myomectomy in women at high hemorrhagic risk or who refuse blood transfusion.

Unmet therapeutic needs for uterine myomas

Uterine myomas may develop in many women, but only become clinically significant in about one third of the affected population. Although uterine myomas are most often benign, they are associated with debilitating symptoms and commonly result in hysterectomy. Current treatments for uterine myomas include pharmacologic therapies, delivery of focused energy, alteration of uterine vascular supply, or surgical procedures. Factors such as the woman's desire for future pregnancy, the importance of uterine preservation, symptom severity, and tumor characteristics direct the choice of therapeutic approach. The ideal treatment will have the following characteristics: easy to perform, minimally invasive, cost effective, preserves fertility, preserves the uterus, efficacious, acceptable tolerability and durability, and low incidence of myoma recurrence.

La myomectomie par cœlioscopie en 2007: état des lieux

With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.

A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes

OBJECTIVE

To assess the reproductive outcomes after minilaparotomic and laparoscopic myomectomy in patients wishing to conceive.

DESIGN

Randomized controlled trial.

SETTING

Departments of obstetrics and gynecology of the universities of Catanzaro, Rome, and Florence, Italy.

PATIENT(S)

One hundred thirty-six women with symptomatic uterine leiomyomas or unexplained infertility.

INTERVENTION(S)

Laparoscopic and minilaparotomic myomectomy.

MAIN OUTCOME MEASURE(S)

Pregnancy, abortion, and live-birth rates.

RESULT(S)

Between the laparoscopic and minilaparotomic groups no difference was observed in cumulative pregnancy, live-birth, and abortion rates, whereas pregnancy and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly higher in the laparoscopic than in the minilaparotomic group. Categorizing the patients according to surgical indication for myomectomy, cumulative pregnancy rate, pregnancy, and live-birth rates per cycle, and time to first pregnancy and live-birth were significantly better after laparoscopic myomectomy in symptomatic patients, whereas all reproductive outcomes were similar between the two groups in patients with unexplained infertility.

CONCLUSION(S)

Minilaparotomic and laparoscopic myomectomy improves in a similar manner the reproductive outcomes in patients with unexplained infertility, whereas the laparoscopic approach provides the best benefits in fertile patients with symptomatic leiomyomas.

A modified suture technique for laparoscopic myomectomy

STUDY OBJECTIVE

The safety and efficacy of a modified laparoscopic suture performed by a surgeon assisted by an under-training assistant in the repair of uterine defect during laparoscopic myomectomy (LM) was evaluated.

DESIGN

Prospective clinical study (Canadian Task Force classification II-2).

SETTING

Tertiary care university hospital.

PATIENTS

Sixty-two women scheduled for myomectomy because of symptomatic uterine myomas.

INTERVENTION

Group A (n = 31): LM with a modified laparoscopic suture technique (the suture line was pulled out of the trocar, and tension of the suture was maintained by the surgeon's or assistant's hand). Group B (n = 31): LM with a traditional laparoscopic suture technique (intracorporeal continuous suturing with a string trimmed to 30 cm).

MEASUREMENTS AND MAIN RESULTS

The median operative time (100 minutes vs 90 minutes, p = .436) and blood loss (200 mL vs 150 mL, p = .771) were slightly greater in the LM with a modified laparoscopic suture technique group (group A), although these differences were not statistically significant. The total specimen weight, number of myomas removed, and length of hospital stay were similar in both groups. No patients in either group had serious complications.

CONCLUSION

A modified laparoscopic suture by controlling the tail of the suture with the surgeon's hand while sewing laparoscopically can achieve a good approximation of uterine defect and is an acceptable alternative to help laparoscopic surgeons performing surgery assisted by an under-training assistant to complete the procedure.

Prevention of adhesions in gynaecological endoscopy

Adhesions resulting from gynaecological endoscopic procedures are a major clinical, social and economic concern, as they may result in pelvic pain, infertility, bowel obstruction and additional surgery to resolve such adhesion-related complications. Although the minimally invasive endoscopic approach has been shown to be less adhesiogenic than traditional surgery, at least with regard to selected procedures, it does not totally eliminate the problem. Consequently, many attempts have been made to further reduce adhesion formation and reformation following endoscopic procedures, and a wide variety of strategies, including surgical techniques, pharmacological agents and mechanical barriers have been advocated to address this issue. The present review clearly indicates that there is no single modality proven to be unequivocally effective in preventing post-operative adhesion formation either for laparoscopic or for hysteroscopic surgery. Furthermore, the available adhesion-reducing substances are rather expensive. Since excellent surgical technique alone seems insufficient, further research is needed on an adjunctive therapy for the prevention and/or reduction of adhesion formation following gynaecological endoscopic procedures.

Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynaecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study

BACKGROUND

Following myomectomy, postoperative adhesions occur in many patients with adverse effects on fertility. This study investigated the applicability, safety and efficacy of an auto-crosslinked hyaluronan gel in preventing adhesion formation after laparoscopic myomectomy.

METHODS

Fifty-two patients aged 22-42 years, undergoing surgery at four centres, were randomly allocated to receive either the gel or no adhesion prevention. The incidence and severity of postoperative adhesions were assessed laparoscopically after 12-14 weeks in a blinded, scored fashion. The primary efficacy variable was the presence/absence of postoperative adhesions at second-look.

RESULTS

A nonsignificantly higher proportion of patients receiving the gel were free from adhesions (13 of 21; 62%) compared with control patients (9 of 22; 41%), with a statistically significant difference between the severity of uterine adhesions at baseline and at second-look (0.3 +/- 0.9 versus 0.8 +/- 1.0, P < 0.05). In subjects undergoing myomectomy without concomitant surgery, the proportion of adhesion-free patients was 8 of 12 (67%) and 4 of 11 (36%) (not significant) in the gel and control groups, respectively, with a significant difference in the mean severity scores (P < 0.05). In subjects without uterine adhesions before myomectomy, 12 of 18 (67%) and 8 of 20 (40%) patients in the gel and control groups, respectively were adhesion-free (not significant), with a significant difference in the severity of uterine adhesions (P = 0.05).

CONCLUSIONS

Our results suggest that the auto-crosslinked hyaluronan gel may have a favourable safety profile and efficacious antiadhesive action following laparoscopic myomectomy.

Spontaneous uterine rupture at 35 weeks' gestation, 3 years after laparoscopic myomectomy, without signs of fetal distress

Laparoscopic myomectomy (LM) is a recently developed surgical technique, and every obstetrician should be aware of its possible complications, which can occur not only during labor but also during pregnancy. We report a case of a primigravid woman who was hospitalized at 35 weeks' gestation because of irregular abdominal pain. She conceived spontaneously 3 years after LM. After a 20-h stay on the obstetrician ward due to increased abdominal tenderness and vaginal bleeding, the patient was qualified for an emergency cesarean section without any symptoms of fetal distress in cardiotocography. During cesarean section a newborn with 9 Apgar points was delivered and a rupture of the uterine wall was seen. Dehiscence of the pregnant uterus following LM is an incidental case, and can therefore be misdiagnosed. Close attention should be paid to every pregnancy in previously operated uteri as the dehiscence of the pregnant uterus can occur without symptoms of fetal distress.

Applications of intraoperative ultrasound in gynecological surgery

PURPOSE OF REVIEW

Gynecologists are well trained in office-based ultrasound, but are less experienced in the field of intraoperative ultrasound. Many gynecologic procedures may benefit from the use of real-time ultrasonography. The purpose of this review is to summarize the current use of intraoperative ultrasound in gynecologic procedures.

RECENT FINDINGS

Evaluation and assessment of the value of intraoperative ultrasound in gynecological procedures is essentially non-existent. The role of intraoperative ultrasound in gynecology is in its infancy, with anecdotal experience and literature involving predominantly case reports. Intraoperative ultrasound is helpful in laparoscopic myomectomy, particularly when the uterine contour is normal. It is also useful in defining pelvic anatomy in cases of complex reproductive procedures. Intraoperative ultrasound improves precision in characterizing ovarian lesions, particularly in the setting of endometriomas or dermoid cysts. It has been shown to decrease both operative time and complication rates in dilation and curettage procedures. Intraoperative ultrasound reduces recurrence and re-operation rates after hysteroscopy by facilitating more-complete resection of uterine myomas. Ultrasound guidance improves the efficiency of embryo transfer in in-vitro fertilization and could potentially be beneficial in other 'blind' gynecological procedures.

SUMMARY

Intraoperative ultrasound appears to be a safe and valuable tool for the gynecologic surgeon. Ultrasound improves visualization of anatomy, reduces complication and re-operation rates, and facilitates completion of more cases via less-invasive endoscopic approaches.

Alternative medical and surgical options to hysterectomy

The range of alternatives to hysterectomy includes 'expanded' oral medical regimens, the levonorgestrel-releasing intrauterine system (LNG-IUS), a wide range of endometrial ablative techniques, and-where fibroids are the primary pathology-myomectomy and uterine artery embolization. Since research has shown that hysterectomy is a highly effective treatment, these alternatives must be assessed against the recognized high satisfaction rates and improved quality of life reported following hysterectomy. Additional issues that would also need to be addressed include complication rates, side-effects, and cost-effectiveness. For women with prolonged abnormal uterine bleeding, recent research suggests that hysterectomy is significantly superior to an expanded medical treatment regimen for health-related quality-of-life measures. Satisfaction with treatment, and health-related quality of life and psychosocial well-being, are reportedly similar between hysterectomy and the LNG-IUS, but the latter has the advantage of reduced cost. Endometrial ablation reduces menstrual blood flow, but its benefits relative to hysterectomy lessen over time. No large-scale studies have adequately compared uterine artery embolization or myomectomy to hysterectomy. Perhaps the most telling finding from recent research with respect to the place of alternative therapies to hysterectomy is that the existence or advent of these alternatives has not reduced hysterectomy rates, but merely increased treatment options and interventions for excessive menstrual loss.

A retrospective multicentre study comparing myomectomy by laparoscopy and laparotomy in current surgical practice. What are the best patient selection criteria?

OBJECTIVE

To determine the differences in myoma characteristics before laparoscopic myomectomy (LM) and abdominal myomectomy (AM) and to compare outcomes in current practice.

STUDY DESIGN

We analysed retrospectively the data for 126 LMs and 176 AMs performed between January 1996 and January 2000 in 11 centres. Myomas were examined by transvaginal B-mode, colour and pulsed energy Doppler ultrasonography. The following data were collated: (i) pre-operative: myoma size, number, type and location and medical treatment, (ii) per-operative: operator, blood loss, surgical procedure and operative time, and (iii) post-operative: myoma weight and number, haemoglobin decrease, complications and length of hospital stay.

RESULTS

Compared to women undergoing LM, women undergoing AM had more myomas that were larger and that were generally interstitial and anterior. More of them received GnRH analogues. Excised myomas weighed four times more, the decrease in haemoglobin was greater (1g/dl), fever was more frequent, and nine patients needed transfusions (compared to none for LM). There were 37 laparoconversions (29%) after LM. The conversion rate was high for inexperienced surgeons. Length of hospital stay was reduced by half for LM (without laparoconversion). Recurrence rate at 2 years was 2.5% for LM versus 3.6% for AM (P = 0.506).

CONCLUSION

Pre-operative evaluation by ultrasound is essential to establish myoma number, size, type and location in order to choose the most appropriate surgical procedure.

Repair of uterine dehiscence with continuation of pregnancy

BACKGROUND

Uterine dehiscence in the past has been treated with delivery of the pregnancy and repair of the uterus or cesarean hysterectomy. Uterine repair and continuation of the pregnancy has not been attempted to our knowledge.

CASE

A patient with a history of a laparoscopic myomectomy presented at 28 weeks of gestation with a uterine dehiscence. This was repaired and the pregnancy continued until fetal lung maturity at 34 weeks.

CONCLUSION

Repair of a uterine dehiscence in a hemodynamically stable patient and continuation of the pregnancy should be considered in a very premature pregnancy to improve neonatal outcome.

Les limites de la myomectomie cœlioscopique

Feasibility of laparoscopic myomectomy has been already shown with numerous clinical studies. Short-term benefits of this procedure are nowadays established. Its limits are related to the surgical technique, the myoma process, and the clinical context of the patient. By using preoperative exclusion criteria, particularly the size and the number of myomas, laparoscopic treatment is possible with little laparoconversion and complications rates. One could be in doubt about the risk of uterine rupture during a pregnancy occurring after laparoscopic myomectomy. In infertile patients, this procedure is as effective as laparotomy, even though its benefits in terms of postoperative adhesions should be demonstrated. Less invasive surgery should be preferred.

Intraoperative ultrasound during a laparoscopic myomectomy

OBJECTIVE

To report a gynecologic use of a laparoscopic ultrasound transducer to isolate a myoma for surgical removal.

DESIGN

Case report.

SETTING

University-based infertility practice.

PATIENT(S)

A 44-year-old woman gravida 1 para 1 with history of a first trimester miscarriage who desired pregnancy as a participant in the donor egg program.

INTERVENTION(S)

Before she entered the assisted reproduction program, a patient was found to have a myoma that was greater than 2 cm with both intramural and submucosal components. During the laparoscopic evaluation, a laparoscopic ultrasound transducer helped identify and properly locate the myoma in what otherwise appeared to be a normal uterus. Appropriate laparoscopic hysterotomy incision was then made, thereby minimizing uterine trauma.

MAIN OUTCOME MEASURE(S)

Appropriately placed hysterotomy incision and successful reconstruction of uterus.

RESULT(S)

After the successful laparoscopic myomectomy, the patient achieved a pregnancy in our donor oocyte program.

CONCLUSION(S)

Laparoscopic intraoperative ultrasound can help gynecologic surgeons complete a laparoscopic myomectomy.

Effectiveness of autocrosslinked hyaluronic acid gel after laparoscopic myomectomy in infertile patients: a prospective, randomized, controlled study

OBJECTIVE

To assess the efficacy of autocrosslinked hyaluronic gel in postsurgical adhesion prevention after laparoscopic myomectomy.

DESIGN

Prospective, randomized, controlled study.

SETTING

University of Naples "Federico II".Thirty-six infertile women with symptomatic myomas were randomly divided into two groups of 18 patients each.

INTERVENTION(S)

Laparoscopic myomectomy with subserous sutures or interrupted figure 8 sutures, with (group A) or without (group B) application of autocrosslinked hyaluronic acid (HA) gel.

MAIN OUTCOME MEASURE(S)

Rate of postsurgical adhesions at 60-90 days of follow-up. The rate of subjects who developed postoperative adhesions was significantly lower in group A in comparison with group B (27.8% vs. 77.8%). In both groups, the rate of adhesions was significantly higher in patients treated with interrupted figure 8 sutures than with subserous sutures.

CONCLUSION(S)

Autocrosslinked HA gel is a promising resorbable agent barrier for the reduction of postoperative adhesions after laparoscopic myomectomy. Moreover, the type of suture is a factor influencing the postsurgical adhesion formation.