During laparoscopic myomectomy, extract the fibroid by applying generous traction with the tenaculum and counter-traction with an atraumatic grasper and ultrasonic shears. Once you have entered the correct surgical plane, grasp the fibroid near the hysterotomy and simply roll it out of the uterus. 48 OBG Management | March 2010 | Vol. 22 No. 3 SURGICAL TECHNIQUES Laparoscopic myomectomy: 8 Pearls From preoperative imaging to postoperative analgesia, the choices you make determine the ease of the procedure and the quality of the outcome yomectomy is the surgery of choice for women Jon I. Einarsson, who have symptomatic fibroids and who wish to MD, MPH retain their uterus. And laparoscopic myomecto- Dr. Einarsson is Assistant Professor M of Obstetrics, Gynecology, and my is preferable to the abdominal approach in many ways, Reproductive Biology at Harvard offering:1-4 IN THIS Medical School and Chief of the ARTICLE Division of Minimally Invasive • faster recovery Gynecology at Brigham and • a shorter hospital stay When and how to Women’s Hospital in Boston. • diminished blood loss treat uterine fibroids The author reports no financial • decreased adhesion formation page 50 relationships relevant to this article. • a comparable or higher rate of pregnancy. Nevertheless, laparoscopic myomectomy is a techni- How MRI can guide cally challenging procedure with surgeon-specific limita- treatment: 3 cases tions. The biggest challenge: appropriately suturing the page 53 hysterotomy site. In this article, I share my experience with laparoscopic myomectomy and offer 8 pearls that may contribute to a Should you worry successful outcome. about uterine rupture in postmyomectomy pregnancy? Don’t settle on page 58 1.laparoscopy prematurely Given its advantages over the abdominal route, laparoscop- Watch the author ic myomectomy should be the preferred approach in the remove a fibroid at treatment of symptomatic uterine fibroids FIGURE( 1, page obgmanagement.com 50). However, not all patients are appropriate candidates for ›› SHARE YOUR EXPERIENCE! How do you select patients for laparoscopy. Several guidelines have recommended a max- laparoscopic myomectomy? imum number and size of fibroids for laparoscopic removal, E-MAIL [email protected] but practice varies widely, and experienced surgeons suc- FAX 973-206-9251 cessfully take on cases that are well beyond the limits set by 5-7 SCOTT BODELL FOR OBG MANAGEMENT most published guidelines. CONTINUED ON PAGE 50 obgmanagement.com Vol. 22 No. 3 | March 2010 | OBG Management 49 SURGICAL TECHNIQUES / LAPAROSCOPIC MYOMECTOMY FIGURE 1 When and how to treat uterine fibroids Uterine fibroids Infertility with NO Symptoms? submuscosal fibroid? YES NO YES Hysteroscopic or Future pregnancy laparoscopic fibroid No treatment needed possible or desired? resection NO YES Location of fibroids? Location of fibroids? Intramural or Intramural or Submucosal Submucosal subserosal subserosal Hysteroscopic Hysteroscopic Myomectomy fibroid resection fibroid resection Desires uterine Hysterectomy NO YES preservation? MRI-guided Laparoscopic uterine Uterine fibroid Medications Myomectomy focused ultrasound artery occlusion embolization Pro Pros Allows for concomitant Pro Pro Pro Allows for future fertility removal of uterine No surgery No surgery No surgery Excellent for fibroids and bulk symptoms other pathology Cons Cons Cons Cons Cons Limited data and Not suitable for 20%-25% Surgery 15%-20% experience all fibroids reoperation rate Unknown long-term reoperation rate Potential side effects High recurrence rate on Small risk of premature reoperation rate General anesthesia with long-term therapy short-term follow-up ovarian failure CONTINUED ON PAGE 52 50 OBG Management | March 2010 | Vol. 22 No. 3 SURGICAL TECHNIQUES / LAPAROSCOPIC MYOMECTOMY At our institution, we do not have firm demonstrated a significantly longer recovery guidelines in place for the number and size of with minilaparotomy than with laparoscopy, fibroids that can be removed laparoscopically. but these trials compared uteri of similar Other variables enter into decision-making size.4,8 We expect the laparoscopic approach to and counseling, among them any medical co- confer fewer advantages when operative time morbidity or history of uterine surgery the pa- is prolonged significantly. tient may have, as well as her desires in regard In our practice, we consider one or more to childbearing and uterine retention. of the following conditions appropriate for Hysterectomy may be the most straight- hand-assisted laparoscopic myomectomy: forward option for women who have symp- • a very large uterus (i.e., heavier than tomatic fibroids and who have completed 1,500 to 2,000 g). In these cases, operat- childbearing. However, myomectomy is also ing times can be excessive because of the appropriate as long as the patient is aware of need for extensive suturing and morcella- the risk that fibroids may recur and the poten- tion, and bleeding may increase as a result tial for further surgery. When the patient is in • more than 20 fibroids on magnetic res- her late 40s or early 50s, the likelihood of fi- onance imaging (MRI). It can be a chal- broid recurrence may be lower than it is in the lenge to locate all of the fibroids; multiple general population. uterine incisions may be necessary In my practice, submucosal and intracav- • a medical comorbidity that renders the itary fibroids smaller than 4 cm and more than patient unable to tolerate prolonged anes- 5 mm away from the uterine serosa are gener- thesia. For example, we operated on a pa- ally removed hysteroscopically, an approach tient who had Ehlers-Danlos syndrome and beyond the scope of this article. In women who needed to avoid a prolonged operation who have completed childbearing but who due to fragile bones and joint laxity. wish to conserve the uterus, we deliberately Of necessity, these guidelines will vary enter the uterine cavity laparoscopically be- from practice to practice, and gynecologic Submucosal and cause this strategy allows for efficient removal surgeons who are just beginning to perform intracavitary fibroids of submucosal and intracavitary fibroids. laparoscopic myomectomy should not include smaller than 4 cm multiple fibroids or a large uterus among their and more than 5 mm initial cases. Instead, perform the first few cases away from the Estimate the in patients who have not had abdominal sur- duration of surgery gery and who have a symptomatic intramural uterine serosa are 2. When the patient has fibroids that are intra- or subserosal fibroid that is close to the uterine generally removed mural or subserosal, our general rule of thumb fundus and no larger than 6 cm in diameter. hysteroscopically is to determine her suitability for laparoscopic myomectomy, based on the estimated dura- tion of the operation. A surgeon’s ability to Consider calculate the length of the operation for a par- 3.preoperative MRI ticular patient increases with experience. Preoperative imaging greatly supplements We tend to recommend the laparoscopic the clinical examination and facilitates approach when the procedure is expected to identification of the number, location, and take less than 3 hours to complete. More than characteristics of the fibroids. Pelvic ultra- 95% of our patients fall into this category. sonography (US) is appropriate for most pa- When we anticipate a prolonged operat- tients. We prefer preoperative MRI of the ing time, we discuss the option of hand-assist- pelvis in the following scenarios: ed laparoscopic myomectomy. This approach • uterus larger than 12 weeks (280 g) on involves two or three 5-mm trocar punctures clinical examination high on the abdomen in conjunction with a • identification of multiple fibroids via US suprapubic incision, 6 to 7 cm in length with • history suggestive of adenomyosis. a hand port in place. Prospective studies have MRI facilitates preoperative planning by CONTINUED ON PAGE 53 52 OBG Management | March 2010 | Vol. 22 No. 3 SURGICAL TECHNIQUES / LAPAROSCOPIC MYOMECTOMY accurately delineating the size and location of the fibroids, and by distinguishing between How MRI can guide treatment: 3 cases an adenomyoma and fibroid in most cases.9 For an example of its utility, see “How MRI can CASE 1 guide treatment: 3 cases.” Findings A 40-year-old nulliparous woman seeks treatment for meno- metrorrhagia and dysmenorrhea but Preoperative medical wants to conserve her uterus. MRI 4.therapy may be indicated reveals a 4.5-cm submucosal fibroid When given preoperatively, gonadotropin- (arrow) that extends all the way to releasing hormone (GnRH) agonists have the uterine serosa, with no evidence been shown to reduce blood loss and shorten of adenomyosis. Her thyroid-stimu- operative time. The exception: cases involv- lating hormone (TSH) level is normal, ing hypoechoic fibroids, because the cleavage as is an endometrial biopsy. plane may be more difficult to identify, pro- Outcome We decide to proceed with laparoscopic myomectomy be- longing operative time.10 cause a hysteroscopic approach would carry a risk of uterine rupture. We generally prefer to use a GnRH agonist in two clinical scenarios: 1) anemia and 2) a CASE 2 uterus that extends above the umbilicus. In Findings A 36-year-old nulliparous the second scenario, the GnRH agonist helps woman complains of significant reduce the uterus to a more manageable size. “bulk” symptoms (heaviness, urinary Aromatase inhibitors show great prom- frequency, and abdominal bloating). ise as preoperative agents because there is She