INTRODUCTION
Uterine myomas are the
commonest pelvic tumours found in at least 20% of the females over thirty years
of age. The incidence rises further with
age until the time of menopause.
Fibroids can be identified in as many as 50% of nulliparous women at the
age of fifty1. There is a spectrum of presentations but a large
proportion (1/4) are asymptomatic.2
Surgical management include hysterectomy and myomectomy for women
who wish to retain their uterus for enhancing their reproductive
potential. Recently, there has been a renewed interest in this procedure,
perhaps owing to the postponement of pregnancy until later age when myoma tends
to be found.Myomectomy by any route is still a controversial subject. According to the available evidence based on
a comprehensive review, slightly less than two thirds of the women with uterine
leiomyomas and otherwise unexplained infertility conceived after myomectomy 3.
Laparoscopy is presently the gold standard of treatment for benign adnexal
pathologies, although the evaluation of other techniques as myomectomy, through
laparoscopic route remains to be made 4. The surgeon’s experience in laparoscopic
suturing is a crucial requirement for laparoscopic myomectomy5.
INDICATIONS FOR MYOMECTOMY
Myomectomy is indicated in
women:
Who wish to preserve their fertility for child
bearing or personal reasons, or
Who are symptomatic, and are not expected to go into
menopause soon and want to retain their uterus.
The commonest symptoms are
excessive uterine bleeding, pelvic pressure and pain, recurrent pregnancy
losses and occasionally infertility2. The last two symptoms are particularly
related to sub mucous or intramural myomas distorting the uterine cavity5.
For conservative myomectomy by laparoscopy, usually the myoma should be about 6
centimetres in its largest diameter, although this depends much on surgeon’s
experience 6,7. Myomas causing ureteric obstruction also necessitate
removal8.
CONTRAINDICATIONS FOR LAPAROS-COPIC MYOMECTOMY
Contraindications to
laparoscopic myomectomy include the following:
Any medical conditions that are worsened with
abdominal distension and a Trendelenburgh position for a prolonged period.
Diffuse leiomyomata.
More than three myomas equal to or more than five
centimetres.
Uterine size more than sixteen weeks gestation.
A myoma more than fifteen cms in diameter.
ADVANTAGES OF LAPAROSCOPIC MYOMECTOMY
Laparoscopic myomectomy is
associated with:
Shorter hospitalization.
Faster postoperative recovery.
Decreased incidence of postoperative pain
Decreased incidence of ileus and thrombo-embolic
phenomenon 9.
LIMITATIONS OF LAPAROSCOPIC MYOMECTOMY
Laparoscopic myomectomy
requires a greater degree of skill and should only be performed by experienced
laparoscopists with sound laparoscopic suturing skills. The number of
instruments and various angles of insertion to approach the surgical site are
limited and therefore certain myomas may be technically difficult to
handle. The flexibility in planning the
surgical technique and removal of myoma from the abdominal cavity is often
limited and there is difficulty in obtaining the accurate apposition of the
edges of uterine wound10, 6.
This is particularly important in cases where future fertility is a
concern, as incorrect approximation can predispose to rupture during subsequent
pregnancy.There is concern regarding operation time. Depending on the surgeon’s experience,
closure of the uterine incision can be time consuming 11. In a study, the reported operation time
ranged from 25-400 minutes. This wide
range reflects relative lack of predictability in procedure times, meaning that
efficient utilization of fixed theatre sessions can be difficult 12The
automatic morcellator provides significant savings in operating room time and
is a cost effective application of a new technology from this point of view 13,14.
PREOPERATIVE EVALUATION AND TREATMENT
For all the listed
indications, other possible causes should be thoroughly excluded. When no other correctable findings are
identified, the patient must decide if her symptoms are sufficiently severe to
warrant surgery 15. In women who complain of menorrhagia, the
haematocrit is used to assess the degree of anaemia. For anaemic patients, preoperative
Gonadotrophin releasing hormone agonists (GnRHa) treatment may enable restoration
of a normal haematocrit, decrease the size of myoma and reduce the need for
transfusion. While some studies show a
decrease in intraoperative blood loss after a course of GnRHa therapy 16.
GnRHa therapy is associated with hypo estrogenic side effects and an increased
incidence of tumour recurrence 8.
About ten percent of the myomas do not respond to GnRHa. Presence of
underlying chromosomal aberration t(12;14) has also been suggested as a cause
of resistance to GnRHa.17
Some surgeons have also found that pre-treatment with LHRHa is
associated with loss of cleavage planes as there is hydropic degeneration of
myoma. This may make dissection difficult in some patients. Others, however, don’t share this experience 18. Ultrasonography provides information about
the site, size and number of fibroids.
Fluid contrast ultrasonography determines endometrial distortion by sub
mucous fibroids 15. Periodic
pelvic ultrasound examinations help monitor the growth rate of asymptomatic
myomas. Sub mucous tumours can be
detected by pelvic ultrasound, a hysterogram, or hysteroscopy. The presence of large broad ligament myoma
emphasizes the need for an intravenous urography to look for ureteral
obstruction8.
PROCEDURE SPECIFIC DETAILS
REMOVAL OF PEDUNCULATED SUBSEROUS MYOMAS
The myoma is grasped and
held in a position to allow bipolar cautery paddles to be placed across the
pedicle. If the myoma stalk is thin, an
endoloop can be placed and secured at the base.
For a thicker stalk, a suture placed through the base of the stalk, tied
fore and aft will ensure haemostasis.
The bipolar instrument is then passed through the incision opposite the
retracting instrument and placed over the entire pedicle. Alternatively, base can be coagulated in two
or more sections. The bipolar cautery is activated until coagulation has
stopped and there is no current flow.
The stalk is then sharply resected.
Alternatively, monopolar cutting current can be used to divide the
pedicle between two secured ligatures on the stalk. Any subsequent bleeding points are secured
with bipolar coagulation 15.
Use of dilute vasopressin injection (0.2-1 U in 100 millilitres lactated
Ringer’s solution) helps control uterine bleeding as recommended by Nezhat et
al 8.A fibroid less than one centimetre in diameter can be pulled
directly through the 10 mm trocar with a grasping forceps or a myoma
screw. For a larger myoma sharp
morcellation can be attempted.
Alternatively, myoma can be grasped with one instrument and
progressively cut into smaller pieces with a monopolar cautery or
scissors. Shaving should be performed in
the anterior cul-de-sac to reduce the possibility of injury to the bowel. Fragments can be removed through the 10 mm
laparoscope channel. Other options
include removal through a colpotomy or an abdominal incision15.
INTRAMURAL MYOMAS
For intramural myomas,
dilute vasopressin is injected in multiple sites between the myometrium and the
fibroid capsule. An incision is made in
the serosa overlying myoma, using the CO2 laser (superpulse or
ultrapulse mode), a monopolar electrode, a fibre laser or a harmonic
scalpel. The incision is extended until
it reaches the myoma capsule. Two grasping, toothed forceps are used to hold
the edges of the myometrium/fibroid capsule. The suction irrigator is used as a
blunt probe to shell the leiomyoma from its capsule; sharp scissors may be used
as required. A myoma screw is inserted
into the tumour to apply traction while the dissection is being carried
out. If there are multiple myomas,
efforts should be made as far as possible to remove them through one
incision. 4-0 Polydioxanone for
superficial suturing approximates the edges of the uterine defect. If the myometrial defect is deep or large, it
is repaired with 1-0 or 2-0 Polygalactin suture followed by serosal repair with
4-0 Polydioxanone. Though difficult, at
times myometrium is required to be sutured in two layers. The sutures are applied at 1 cm increments
using extracorporeal19 or intracorporeal knot tying.8 The
use of vasopressin has been reported to be associated with severe
cardiopulmonary complications20.
There are also some specific procedural difficulties.19 The
location of uterine incision is very important as it affects the whole of the
operation. Preoperative ultrasonography is invaluable in planning the incision
accurately on the uterine wall. The second difficulty lies in planning the type
of myometrial incision. The standard
approach is a vertical incision in the uterus.
The third practical difficulty is proper uterine repair. Stringer et al
have reported the Endostitch to be the best instrument for laparoscopic closure
of uterine defects.21 Recently a continuous spiralling suture for
uterine wall reconstruction after laparoscopic myomectomy has been reported.
Long term safety however is yet to be proved.22 Removal of myoma
from abdomen is time consuming and no method is ideal. Growth of myomas in the
trocar incision has been reported.23
RESULTS
In general, laparoscopic
myomectomy is associated with a shorter hospital stay, faster recovery and less
blood loss that is be explained in part by the tamponade effect of the
pnuemoperitoneum. The results of some of studies are shown in the table.
INTEGRITY OF MYOMECTOMY SCAR
This is an important
consideration for those women desiring pregnancy. Although uterine ruptures during pregnancy
have been reported after myomectomies via laparotomy, these are usually
sporadic 24,25.
Risk factors for uterine
rupture after laparoscopic myomectomy can be :
An intramural haematoma at the point of incision
Tissue necrosis because of thermal damage, leading
to defective scar formation
Incorrect approximation of incision edges leading to
healing by secondary intention.
Uterine rupture and fistula
formation after laparoscopic myomectomy have been reported. However, none of
these investigators closed the uterine defect in layers 11, 26,27,28,29.
In a recent series reported by Nezhat et al 30, no case of uterine
rupture has been reported following pregnancies after laparoscopic
myomectomies. The authors have
emphasized the importance of avoiding excessive thermal damage and of adequate
uterine repair using multiple layer suturing techniques. In cases of deeply embedded myomas, larger
than six to seven centimetres in size, laparoscopic myomectomy may be replaced
with laparoscopic assisted myomectomy.31 Suturing the myometrium in
layers during a laparoscopic myomectomy is also necessary to prevent iatrogenic
adenomyosis.32
ASSESSMENT OF SCAR HEALING AND STRENGTH IN THE POSTOPERATIVE PERIOD
Various modalities have been
suggested which include:
a) ULTRASONOGRAPHY
Ultrasonography is used to
detect the haematoma formation along the uterine scar. Doppler studies can be
used to assess the uterine scar, possibly recognizing the irregularities in the
vascular patterns and haematoma formation , which depict
poor quality uterine scar. Velocimetric findings at 30th
postoperative day may be able to assess the healing process. A high resistance index may suggest abnormal
healing and an area of fibrosis.33,34
b) HYSTEROSALPINGOGRAPHY
Hysterosalpingography may be
performed to detect the presence of any fistulae.27The test however,
is non-specific.
c) SECOND LOOK LAPAROSCOPY
This is carried out between
four to eight weeks postoperatively and a methylene blue test is carried out to
check any uterine fistula. The place of
second look laparoscopy has been particularly emphasized in relation to
assessment of any postoperative adhesions and its treatment.35,36
POSTMYOMECTOMY ADHESION FORMATION
Bulleti and co-workers37
compared postoperative adhesions after laparoscopic versus laparotomy
myomectomy in a prospective case control study.
At the time of second look laparoscopy, adhesions were found less
frequently and were less extensive in patients who had laparoscopic
myomectomy. The critical risk factors
being the posterior location of the myoma and the number of uterine incisions.38
High CO2 pneumoperitoneum insufflation's pressure is a
cofactor in adhesion formation. Adequate
humidification of CO2 , especially at high flow rates is being
emphasized.39 Although several substances have been used in an
attempt to decrease adhesion formation, none of these have been found to be
unequivocally effective Most data to
date describe the use of oxidized regenerative cellulose (TC 7, Interceed) and
expanded Polytetrafluoroethylene (Preclude, Gortex).40,41 Several
investigators have recommended second and even third look laparoscopy to
diagnose and treat postoperative adhesions.
Minilaparoscopy performed with the patient under conscious sedation may
overcome the drawback of repeated anaesthesia.11, 42
POSTOPERATIVE CARE AND COMPLI-CATIONS
Patients having resection of
a pedunculated myoma can be discharged the same day. However, a patient who has undergone
successful subserous or intramural laparoscopic myomectomy needs an inpatient
observation for at least twenty-four hours, with vital signs recording and
serial haemoglobin assessment. Early ambulation
is allowed if vital signs are stable.
Delayed complications like secondary haemorrhage may occur necessitating
a probable re-operation, laparoscopy or possibly a laparotomy.15 Myomectomy
has been found to be an independent risk factor (after controlling for
confounding variables) for fever in the first forty-eight hours after the
operation 43.Gastrointestinal injuries may go unsuspected
intraoperatively necessitating a later laparotomy 44. There is also a risk of recurrence. The cumulative risk increases with the
observation period45, and decreased with the parity after myomectomy
46. A recent study by Rossetti
A et al concluded that the recurrence rate was similar to that seen
after abdominal myomectomy47.
MYOMECTOMY AND REPRODUCTIVE OUTCOME
Despite the risk of adhesion
formation, myomectomy seems to enhance the reproductive outcome48.
The quoted conception rates for abdominal myomectomy in infertile patients have
been up to 40% in one series2, and 58% in another 49.After
laparoscopic myomectomy, conception rates have been quoted to be 71% and 75%
respectively in two different series 50, 51. Provided no other
associated factor for infertility is found, laproscopic myomectomy enhances
fertility rate52. In
a series reported by Seinera et al 53, 65 pregnancies were achieved
in 54 patients with no case of uterine rupture.
In another study by Dubuisson et
al54 the estimated risk of uterine rupture has been reported to be
1.0% (95% CI 0.0-5.5%). However, particular care however must be
given to the uterine closure. The patient satisfaction with operative scar
after laparoscopic myomectomy is good55 and as well as fertility
satisfaction and reproductive outcome56.
LAPAROSCOPIC ASSISTED MYOMEC-TOMY (LAM)
It involves a combination of
laparoscopy, with 2-4 centimetres abdominal incision and is usually done for
myoma of more than eight centimetres, many myoma requiring extensive
morcellation and large, deep intramural myoma that require uterine repair in multiple
layers. Laparoscopically assisted
myomectomy, with morcellation and conventional suturing reduces the duration of
the exposure and the need for more extensive laparoscopic experience.5,8 Laparoscopic
ultraminilaparotomic myomectomy and laparoscopic ultra minilaparotomic
embolised myomectomy are some recently adopted surgical alternative with
abdominal incision as small as 2.5 cms to apply suture on uterine incision.
They may be used to remove myomas >9cms58.
LAPAROSCOPIC ASSISTED TRANS-VAGINAL MYOMECTOMY
Pelosi MA et al59
and Wang CJ et al60 reported a review of twenty one and thirty one
cases of combined laparovaginal myomectomies for extensive and deep
infiltrating fundal and posterior wall leiomyomata. Laparoscopy confirms the size, number and the
location of myomas. Intramyometrial
vasopressin is then injected. This is followed by posterior colpotomy allowing
delivery of myomata and uterus. Uterine
reconstruction is then performed by conventional suturing performed
transvagin-ally. The uterus is then replaced in its anatomical position and
colpotomy repaired. A final laparoscopic
survey and lavage is performed. This technique can be especially applicable for
posterior and fundal myomas.
LAPAROSCOPIC MYOMA COAGULA-TION (MYOLYSIS) AND CRYOSURGERY
Myoma size can be reduced by
coagulation of its blood supply with the neodymium: yttrium aluminium garnet
(ND: YAG) laser or with a long bipolar needle electrode. . The long-term effects of the procedure are
still unknown. The procedure seems to be
effective and regrowth of the myoma doesn’t occur61.However, there
has been a report that three patients who conceived three months
postoperatively developed a uterine rupture in the third trimester 62.A
newer technique that is currently under investigation is laparoscopic treatment
of myoma by cryosurgery (cryomyolysis).
The myoma is frozen with liquid nitrogen delivered with a special
probe. The efficacy of this technique
remains to be determined 63.