Making Laparoscopic Myomectomy Safe

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1 Making Laparoscopic Myomectomy Safe Head of Department, Dept. of Obstetrics and Gynecology Chief, IVF and Endoscopy Centre,Ruby Hall Clinic, Pune Elected Board Member, ISGE ( ) Executive Board Member, IAGE Librarian, ISAR Founder Secretary Maharashtra Chapter, ISAR Co-Chairperson Research Committee of ISAR FOGSI Infertility Committee Chairperson ( ) Dr. Sunita Tandulwadkar MD, FICS, FICOG Reviewer, Fertility and Sterility Reviewer, Journal of Human Reproductive Sciences. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy for subserous and intramural myomas 1,2. It is no longer a subject of debate 2,3 Though opinion may differ in cases of large & multiple myomas among the endoscopist 2. Number of instruments & various angles of insertion to approach surgical site are limited & therefore myomas may be technically difficult to remove laparoscopically but with experience, sound knowledge of suturing & acquiring greater skill over a period of time one can overcome these technical difficulties 4. It is always wise to start with smaller,singular & subserous than deep intramural or multiple myomas. As experience increases the exclusion criteria relaxes considerably & one proceeds for more complicated cases. The comfort level expands. More one does, more number of patients he/she will be able to count as good candidates as one becomes adapt at managing large &/or multiple myomas. It is important for surgeon to know that safety of patient is more important than type of surgery (laparoscopic or open) 5. Hence before proceeding for laparoscopic surgery it is mandatory for the surgeon to ask himself/herself Is it possible for me to give the best of the result by laparoscopy in this patient with my setup and experience? and then proceed accordingly Pre-operative Requisites : A thorough ultrasonographic evaluation of pelvis for location, size & number of myomas is a must 6,7. In laparoscopic surgery tactile sensation is lacking. In cases of large & multiple myomas it is better to have a limited MRI of pelvis done as surgeon can decide preoperatively his incision sites, number of incisions, how many myomas can be removed via one incision & relation of myomas with uterine cavity. Though after putting a laparoscope one needs to re-evaluate his/her own pre-operative decisions.

2 It is advised to perform hysteroscopy in all cases of multiple myomas before proceeding for laparoscopic myomectomy 8 as smaller submucosal myomas can be missed out in presence of large & multiple myomas. 1a. 1b. 1c. 1d. 1e. Fig 1 a-e: Preoperative imaging is essential to know the size, number, location and relation of the myomas to each other and to the cavity. Practical tips of myomectomy Thorough preoperative preparation can improve his/her intraoperative performance. The following aspects should be well planned in mind by the surgeon well before the start of surgery: Trocar entry Inspection and assessment of the myoma(s). Direction of the incision Energy source to be used Enucleation technique Closure of the myoma bed Extraction Adhesion prevention

3 Trocar Entry: Port Placement Port placement depends upon size of myoma, its location and total number of myomas 4. It is always wise to shift upwards towards upper abdomen as the size of myoma increases, so as to ensure a good panaromic view. Ancillary ports have to be taken in such a way that one can reach to the myoma without making acute angles with each other. If necessary apart from 3 ancillary ports one can add on more ports especially in cases of large and multiple myomas as these myomas with different location can be approached through different ancillary ports. The port of a telescope should always be at least 5-6 cm above the upper margin of myoma to have good field of vision telescope helps tremendously to reach difficult site myomas.fig.2 a,b,c Fig. 2a.Routine placement upto 14 wks Fig. 2b.Veress needle at Palmer s point Fig.2c For larger myomas shift upwards Epigastric port Epigastric port Palmer s point Primary port-supraumbilical Contralateral secondary upper port Contralateral secondary lower port Ipsilateral secondary upper port Ipsilateral secondary lower port

4 Procedure 9 - Placement of primary and secondary trocars depends upon the size and site of myomas. After primary port entry, reanalysis of size and site of myoma is done and then accordingly sites of secondary ports are decided. Relation of myomas with the uterus and fallopian tube should be carefully assessed Examination of the pelvic cavity is also performed to ascertain relation of the fibroids to other pelvic structures. (Fig 3a,b) Fig. 3a,b Insepction of myoma and examination of pelvic cavity Vasopressin 1 in 100 dilution is injected into myomas at 3 to 4 sites to minimize bleeding (action will remain only for min). Careful planning of incision is done: The incision should be taken carefully to avoid any cornual damage. In case of multiple myomas one should optimize the incision so as to remove many myomas from a single incision, as far as possible. Incision can be taken with a scissors, monopolar hook, harmonic scalpel or Enseal vessel sealing device Fig. 4 a,b,c Fig. 4a Incision with monopolar hook

5 Fig. 4b Incision with Harmonic scalpel Fig. 4c Incision with Enseal vessel sealing device Most preferred incision is transverse incision, as it will cut fewer vessels. Incision should be of sufficient depth, so that capsule of myoma is visualized. With 2 non-traumatic forceps, cut edges are pulled apart so as to expose capsule of myoma well and make space for myoma screw insertion. Once the myoma screw is inserted, myoma is pulled outward and upward keeping counter traction on uterus downward with 2 Allis forceps applied on the anterior lip the cervix. If one is in the right plane, myoma is usually extracted easily and there is minimal bleeding. Position of myoma screw is changed from time to time so that traction is applied next to cleavage line. For a larger myoma, 10 mm myoma screw helps in better extraction & hence shortens operative time. Usually the base of myoma will have large feeding vessels, which should be cauterized and cut. ( Cuatery more on myoma than on myoma bed ) Only active bleeders of the bed are cauterized which can be easily identified by underwater inspection. Undue cautery should be avoided, as it will give defective healing. Myoma after removal is parked at right paracolic gutter.

6 Closure of uterine flap- Reconstruction of myoma bed can be performed with Vicryl no. 1 suture or barbed suture (see table 1) / V loop (table no2) Whether single or multiple layer closure is individual s decision-but the ultimate aim is to obliterate the dead space completely so as to avoid hematoma formation, which is another cause of weakening of scar. Start from one angle, first stitch is placed beyond angle either with intra-corporeal or extra-corporeal suture and then rest of defect is closed by taking deep continuous locking sutures and the end suture should be again beyond the angle of opposite side. If it is a single layer closure, ensure that stitches are deep enough to obliterate the dead space. Studies have shown that three-layer closure with first layer, as endometrial layer doesn t compromise pregnancy or pregnancy outcome. Fig. 5a Placement of suture beyond the angle Fig. 5b Continuous locking sutures Fig. 5c Baseball sutures

7 Strengthening of myoma scar : Laparoscopic myomectomy has received many controversies & debates for the obvious reason that strength of myomectomy scar gets tested in subsequent pregnancies & rupture of uterus can sometime lead to maternal morbidity & mortality apart from fetal mortality To prevent the weakening of a scar one has to take care of following triad. Hematoma Tissue Necrosis Infection Weakening of scar A) One can think of avoiding hematoma formation by 1.Using excellent energy source for incision & extraction of myoma so that vessels get sealed before cutting. 2. Remaining in right plane hence less bleeding 3. Excellent closure Barbed / V Lock / vicryl no 1 ( Obliterate the dead space ) B) Avoiding tissue necrosis 1. Cauterisation of myoma bed for sealing of vessels should be avoided unless it has a large bleeder. 2. Compression of myoma bed by assistant till surgeon gets in suture material will help to seal smaller veins and cappilaries Fig 6. Compression rather than cauterization of the myoma bed to achieve hemostasis

8 3.Immediate and excellent suturing will also achieve hemostasis. Needless to say good sterile precautions, shorter duration of surgery, avoidance of hematoma formation will avoid infections. Extraction of myoma- Myomas are extracted by electronic morcellation. Fig. 5 a, b, c Smaller myomas can be extracted by colpotomy. A meticulous lavage is given and hemostasis is checked. End result should be a clean pelvis. To keep a drain in the postoperative period is again an individual s choice. In difficult situations-!! Fig 5a. Extraction of myoma Fig 5b. Morcellation in process Pedunculated myomas with a broad base- Fig. 5c Morcellated pieces of myoma Instead of transverse incision, circular incision should be taken at the base of myoma in a circumferential manner. With myoma screw, myoma is pulled up and enucleated after cauterizing base of the pedicle. ( Again ensure no cauterization un uterus) Adhesion prevention: Studies have shown that long term complications of adhesion formation can be prevented by use of absorbable adhesion barriers such as Interceed. Other measures that can be taken by the surgeon to avoid adhesions are ensuring proper hemostasis, thorough lavage of the pelvic cavity after the operation and early post-operative mobilization.

9 Fig. 7: Use of Interceed adhesion barrier ; also note clean pelvis Tips In case of multiple myomas where the shape of the uterus is distorted, round ligament helps in identification. As far as possible, incision should be taken anteriorly than on posterior wall. Self preoperation USG always helps to enhance surgical performance on table especially in cases of multiple myomas. One can decide the number of myomas that can be taken out through a single incision. There is no tactile sensation in laparoscopy so small myomas hidden under large myomas, if known beforehand, can be removed successfully. We don t advocate use of pre-op GnRH analogues to reduce the size of myoma. Traction on uterus downwards with Allis forceps applied to anterior lip of cervix and upward counter traction on myoma with myoma screw, next to cleavage line will facilitate extraction. Myomas up to 5-6 cm can be delivered with colpotomy. Proper serosal approximation, hemostasis, clean pelvis at the end, early mobilization will help in prevention of postoperative adhesions. Instillation of vasopressin, speedy surgery, skillful and rapid suturing, good knot tying techniques will help to minimize bleeding. Determination of surgeon, his/her operative skills, willingness to learn and use newer modalities of energy sources & suture materials, learning with his/her own mistakes will make an excellent laparoscopic surgeon. It is important for every surgeon to ask himself/herself at the end of the day, whether I would have done the same case in better way? And if yes what way? Adopt that technique or mind for the next case & needless to say he/she becomes better, faster & safer day by day.

10 Limitations of Laparoscopic Myomectomy: The size Number & positions of myomas Whether future fertility is desired The experience of surgeon especially mastery over endosuturing How big is big? & How many are too many? The answer varies from surgeon to surgeon depending upon which part of learning curve he/she is on. It is a relative term but - The easiest myomas to remove are those that are subserous than deep intramural & anterior & fundal than posterior & isthmic. References: 1. Laparoscopic Myomectomy : A Current View Jean Bernard Dubuisson, Chapron C, Arnaud Fauconnier Et Al, Human Reproduction Update 2000, Vol 6, No 6, Pp Endoscopic Management Of Uterine Fibroids. : Agdi M, Tulandi T., Best Pract Res Clin Obstet Gynaecol Aug;22(4): Epub 2008 Mar Pregnancy Outcomes after Laparoscopic Myomectomy with Ultrasonic Energy and Laparoscopic Suturing of the Endometrial Cavity: Nelson H et al, The Journal of the American Association of Gynecologic Laparoscopists; Volume 8, Issue 1, February 2001, Pages Treatment Of Myomas By Laparoscopic And Laparotomic Myomectomy And Laparoscopic Hysterectomy : L. Mettler, T. Schollmeyer, E. Lehmann, Willenbrock, J. Dowaji And A. Zavala, Informa Healthcare, Minimally Invasive Therapy And Allied Technologies, 2004, Vol. 13, No. 1, Pages Factors Influencing Laparoconversions During The Learning Curve Of Laparoscopic Myomectomy : H. Marret, M. Chevillot, B. Giraudeau, K. Lalitha, Acta Obstetricia Et Gynecologica Scandinavica, March 2006, Volume 85, Issue 3, Pages ,

11 6. Nezhat's Operative Gynecologic Laparoscopy And Hysteroscopy Camran Nezhat, Farr R. Nezhat, Ceana Nezhat, Page 155, Uterine Leiomyoma (Fibroid) Imaging: Hilip Thomason, Director Of Diagnostic Radiology, Department Of Radiology, Beverly Hospital Contributor Information And Disclosures Emedicine WebMD Updated: May 6, Laparoscopic Myomectomy: Feasibility And Safety A Retrospective Study Of 762 Cases : P. G. Paul, Aby Koshy And Tony Thomas, Gynecological Surgery, 2006, Volume 3,, Endoscopy Simplified : Practical Tips By Experts Dr. Sunita Tandulwadkar, Jaypee Publication, The Power Of The Barbed Suture : Michael S. Kluska, Plastic Surgery Practice, Jan Motion Study Comparison Of Wound Closure Time Using Conventional Techniques And Knotless, Self Anchoring Surgical Sutures In Ex-Vivo Porcine Model For Single Layer Closure With Barbed Devices Vs. Double Layer Closure With Traditional Suture. Royal College Of Surgeons, London, UK; Covidien, Time Study - V-Loc 180 Absorbable Wound Closure Device, Robert T. Grant, MD, Msc, FACS, New York-Presbyterian Hospital, Argent Global Services, Utilization Of A Porcine Model To Demonstrate The Efficacy Of An Absorbable Barbed Suture For Dermal Closure, UTSW, S. Brown, 2010