Dilute ornitin vasopressin and a myoma drill for laparoscopic myomectomy

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.

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.

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.

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.

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.

Italian multicenter study on complications of laparoscopic myomectomy

STUDY OBJECTIVE

To study intraoperative and postoperative complications of laparoscopic myomectomy and patients' characteristics influencing this risk.

DESIGN

Prospective study, with a review of the patient records by the first author (Canadian Task Force classification II-2).

SETTING

Four Italian referral centers.

PATIENTS

The incidence and type of complications occurring in 2050 laparoscopic myomectomies undertaken from January 1998 through December 2004 were recorded.

INTERVENTIONS

The surgical technique, as well as the expertise of the operators, was the same for the 4 centers. Injection of vasoconstrictive agents was used in 37%. The serosa was always incised in a vertical fashion; mechanical enucleation of the myoma was completed whenever possible; suture was performed in 1 or 2 layers with deep and large stitches swaged to 1 or 0 polyglactin sutures that were tied intracorporeally or extracorporeally.

MEASUREMENTS AND MAIN RESULTS

Single or multiple myomectomies (n = 2050) for symptomatic myomas measuring at least 4 cm in diameter were performed. Most patients (48%) had more than 1 myoma, with a maximum of 15 per patient (myomas removed for patients: 2.26 +/- 1.8, mean +/- SD). Myoma size ranged from 1 to 20 cm (mean 6.40 +/- 2.6 SD). Myomas smaller than 4 cm were removed during myomectomy for larger ones. Total complication rate was 11.1% (225/2050 cases). Minor complications accounted for 9.1% (187/2050 cases) and major complications for 2.02% (38/2050 cases). The most serious events were hemorrhages (14 cases, 0.68%) requiring blood transfusions in 3 cases (0.14%); 10 postoperative hematomas (0.48%, one in the broad ligament and 9 in the myomectomy scar); 1 bowel injury (0.04%); 1 postoperative acute kidney failure (0.04%); and 2 unexpected sarcomas (0.09%). Failure to complete planned surgery occurred in 7 cases (0.34%). Two patients were readmitted for surgery (0.09%): 1 had a laparoscopic hysterectomy because of a severe blood loss, and the other had drainage of a hematoma in the broad ligament. After a follow-up period of 41.70 +/- 23.03 months (mean +/- SD), 386 (22.9%) patients conceived, with a pregnancy rate in patients wishing pregnancy of 69.8%; among them, 1 (0.26%) recorded spontaneous uterine rupture at 33 weeks gestation. Odds ratio computed to estimate the risk of complications in relation to the patient characteristics showed that the probability of complications significantly rises with an increase in the number (more than 3 myomas OR: 4.46, p <.001) and with the intramural (OR: 1.48, p <.05) or the intraligamentous location of myomas (OR: 2.36, p <.01) whereas the myoma size seems to influence particularly the risk of major complications (OR: 6.88, p <.001).

CONCLUSIONS

This is one of the largest series reported of laparoscopic myomectomy and the first focused on complications. The complication rate appears to be better than acceptable in comparison with complication rates reported after laparotomic myomectomies. Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique with an extremely low failure rate and good results in terms of pregnancy outcome.

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.

Effect of thread pitch on pull-out strength of laparoscopic myoma screws

AIM

The purpose of this study was to evaluate the effect of thread-pitch on pull-out strength and bending strength of buttress-thread screws designed for laparoscopic myoma extraction.

METHODS

The ultimate failure load of four 5-mm diameter buttress-thread screws with 3-, 4-, 5-, and 6-mm thread pitch, 40 mm in thread-length were examined on fresh myoma specimens. The myoma tissue at each traction site was evaluated histologically to determine its density. The critical minimal pull-out strength based on moderate-density myoma group was estimated. The bending strength was also determined for each screw.

RESULTS

A wide range of ultimate failure loads with a mean +/- SE of 129.3 +/- 5.5 N (range, 30.4-255.7 N) for all screws and tissue densities was recorded. In moderate-density myomas, the mean ultimate failure loads decreased linearly with increasing thread-pitch from 3 mm (148.0 +/- 9.5 N) to 6 mm (119.8 +/- 9.4 N) (test for trend: P < 0.05). Based on the criterion of a minimum pull-out strength of at least 50 N in not less than 95% of tractions in medium-density myomas, the 3-mm and 5-mm pitch screws were found to have acceptable properties. The 5-mm pitch screw had less thread-turn than the 3-mm pitch for the same thread-length and would need less application time. The bending strength also decreased with increasing thread pitch from 3 to 5 mm, then became stable at around 15 N.

CONCLUSIONS

The pull-out strength of soft tissue buttress-thread screws decreased linearly with increasing thread-pitch. Thread-pitch should be considered when designing laparoscopic myoma-screws.

Assessment of the physical properties of laparoscopic myoma-fixation devices

BACKGROUND

The physical properties of three commercial 5-mm myoma-fixation devices available for clinical use (short-pitch corkscrew, long-pitch corkscrew, buttress-thread screw) and a standard wood screw were examined.

METHODS

Fresh specimens of uterine leiomyoma masses were used to test the maximum traction force obtained from each device on 31 occasions. The myoma tissue at each traction site was evaluated histologically to determine its density. The maximal traction forces in each myoma density group were compared using a generalized estimating equations approach to linear regression based on repeated measures within each myoma. The bending strength also was determined for each device.

RESULTS

A wide range of maximum traction forces with a mean of 130.8 +/- 71.5 N (range, 21.6-341.6 N) over all devices and tissue densities was recorded. The mean maximum traction force provided by the short-pitch corkscrew (159.2 +/- 12.2 N) was significantly higher (p < 0.01) than that of the other devices in medium-density myomas, and not significantly lower than that of other devices in low-density myomas. The mean maximum traction force provided by the buttress-thread screw was significantly lower than that of the short-pitch corkscrew only in medium density myomas, and did not differ significantly from that of the wood screw in any density group. The wood screw provided the highest bending strength (6.73 x 10(4) N/m) (whereas the short- and long-pitch corkscrew provided the lowest (9.70 x 10(2) N/m and 1.95 x 10(3) N/m, respectively) and the buttress-thread screw an intermediate (2.24 x 10(4) N/m) strength (p < 0.0005 for all comparisons except for the two corkscrews).

CONCLUSIONS

Screw-type myoma-fixation devices can provide comparable traction force with high bending strength. A long-pitch corkscrew should not be used for laparoscopic myomectomy because of its low traction force and bending strength. When a commercial screw is not available, a standard wood screw can be used with acceptable traction force and very high strength for bending.

Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial

OBJECTIVE

To evaluate the effectiveness of the injection of bupivacaine plus epinephrine before laparoscopic myomectomy.

METHODS

Sixty premenopausal women with uterine leiomyomata were enrolled in a randomized controlled design and intraoperatively treated with injection of bupivacaine plus epinephrine (group A) or saline solution (group B) during laparoscopic myomectomy. Uterine size and volume, number of leiomyomata, hematological parameters, total operative time, enucleation time of each myoma, suturing time of the myomectomy, blood loss, degree of surgical difficulty, and postoperative pain were evaluated. Just before and after the injection of vasoconstrictive or saline solution, systolic and diastolic blood pressure and heart rate were recorded in each subject.

RESULTS

Blood loss, total operative and enucleation time, and degree of surgical difficulty was significantly (P <.05) lower in group A than in group B. No difference was observed between groups in suturing time of the myomectomy. The number of vials of pain medication used postoperatively was significantly (P <.05) lower in group A than in group B. No differences in systolic and diastolic blood pressure or heart rate was recorded between the 2 groups.

CONCLUSION

The injection of bupivacaine plus epinephrine during laparoscopic myomectomy is effective in reducing blood loss, total operative and enucleation time, degree of surgical difficulty, and postoperative pain.