Aparna Hegde

Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy?

STUDY OBJECTIVE To assess whether it is possible for an experienced laparoscopic surgeon to perform efficient laparoscopic myomectomy regardless of the size, number, and location of the myomas. DESIGN Prospective observational study (Canadian Task Force classification II-1). SETTING Tertiary endoscopy center. PATIENTS A total of 505 healthy nonpregnant women with symptomatic myomas underwent laparoscopic myomectomy at our center. No exclusion criteria were based on the size, number, or location of myomas. INTERVENTIONS Laparoscopic myomectomy and modifications of the technique: enucleation of the myoma by morcellation while it is still attached to the uterus with and without earlier devascularization. MEASUREMENTS AND MAIN RESULTS In all, 912 myomas were removed in these 505 patients laparoscopically. The mean number of myomas removed was 1.85 +/- 5.706 (95% CI 1.72-1.98). In all, 184 (36.4%) patients had multiple myomectomy. The mean size of the myomas removed was 5.86 +/- 3.300 cm in largest diameter (95% CI 5.56-6.16 cm). The mean weight of the myomas removed was 227.74 +/- 325.801 g (95% CI 198.03-257.45 g) and median was 100 g. The median operating time was 60 minutes (range 30-270 minutes). The median blood loss was 90 mL (range 40-2000 mL). Three comparisons were performed on the basis of size of the myomas (<10 cm and >or=10 cm in largest diameter), number of myomas removed (<or=4 and >or=5 myomas), and the technique (enucleation of the myomas by morcellation while the myoma is still attached to the uterus and the conventional technique). In all these comparisons, although the mean blood loss, duration of surgery, and hospital stay were greater in the groups in which larger myomas or more myomas were removed or the modified technique was performed as compared with their corresponding study group, the weight and size of removed myomas were also proportionately larger in these groups. Two patients were given the diagnosis of leiomyosarcoma in their histopathology and 1 patient developed a diaphragmatic parasitic myoma followed by a leiomyoma of the sigmoid colon. Six patients underwent laparoscopic hysterectomy 4 to 6 years after the surgery for recurrent myomas. One conversion to laparotomy occurred and 1 patient underwent open subtotal hysterectomy for dilutional coagulopathy. CONCLUSION Laparoscopic myomectomy can be performed by experienced surgeons regardless of the size, number, or location of the myomas.

Laparoscopic Excision of Very Large Myomas

STUDY OBJECTIVE To evaluate the feasibility, complications, and conversion rate of laparoscopic excision of very large myomas. DESIGN Prospective study (Canadian Task Force classification II-2). SETTING Private endoscopy center. PATIENTS Fifty-one women with at least one myoma larger than 9 cm. INTERVENTION Laparoscopic myomectomy. MEASUREMENTS AND RESULTS We removed 78 myomas laparoscopically in these 51 patients. Three patients had two myomas larger than 9 cm, three had two myomas between 5 and 9 cm (in addition to 1 > 9 cm), and one had three myomas between 5 and 9 cm (in addition to 1 > 9 cm). Mean number of myomas removed/patient was 1.53 +/- 1.17 (range 1-6); 12 women (23.5%) had multiple myomectomy. The largest myoma removed was 21 cm. Mean myoma weight was 698.47 +/- 569.13 g (range 210-3400 g). Mean operating time was 136.67 +/- 38.28 minutes (range 80-270 min). Mean blood loss was 322.16 +/- 328.2 ml (range 100-2000 ml). One patient developed a broad ligament hematoma, two developed postoperative fever, and one underwent open subtotal hysterectomy 9 hours after surgery for dilutional coagulopathy. CONCLUSION Myomectomy by laparoscopy is a safe alternative to laparotomy for very large myomas.

Laparoscopic Devascularization of Uterine Myomata Followed by Enucleation of the Myomas by Direct Morcellation

Most intraoperative conversions of laparoscopic myomectomy to laparotomy reported in the literature occur because of intraoperative bleeding. Devascularization of a uterine myoma at the start of myomectomy would help reduce the blood supply to the uterus and hence to the myoma. Another advantage of the procedure is that the need to separate the myoma from the uterus completely before morcellation, as in conventional laparoscopic myomectomy, is obviated. The tumor can be enucleated only up to about half its circumference by standard enucleation before morcellation is begun. Traction accorded by the 15-mm traumatic serrated-edge claw forceps of the morcellator during morcellation causes progressive separation of the myoma from the uterine wall, thus completing enucleation. In two patients, myomas were devascularized at the outset of myomectomy, in one by intracorporeal suturing of uterine vessels and in the other by laparoscopic bipolar coagulation of uterine vessels.

Total Laparoscopic Hysterectomy with Earlier Uterine Artery Ligation

We compared the feasibility, blood loss, duration of surgery, and complications between patients in whom both uterine arteries were sutured at the beginning of total laparoscopic hysterectomy (TLH) and patients in whom suturing was done after cornual pedicles. Using a prospective study (Canadian Task Force classification II-2) at a dedicated high-volume gynecologic laparoscopy center, a total of 350 women who underwent TLH from January 2005 through January 2007 were assigned into 2 groups. The indications for TLH were predominantly myomas and menorrhagia. In group A, TLH was done by suturing both uterine arteries at the beginning of the procedure. In group B, the uterine arteries were sutured after the cornual pedicles as done conventionally. All the other pedicles were desiccated and cut either with harmonic ultracision or bipolar diathermy. The uterus with cervix was removed either vaginally or by morcellation. The median age of patients in group A was 46 years and in group B was 44 years. Mean uterine size, weight, estimated blood loss, total operating time, need for blood transfusion, and complications were analyzed. In group A the total duration of surgery was 60 minutes (range 20-210). In group B, the total duration of surgery was 70 minutes (range 30-190). In group A, the median total blood loss was 50 mL (range 10-2000). In group B the total blood loss was 60 mL (range 10-2500). The comparison between the 2 groups revealed a statistically significant difference (p <.05, Mann-Whitney test). Need for blood transfusion was less in group A. One patient in group A had secondary hemorrhage 3 weeks later and the vaginal vault was resutured. In group B, 2 patients had blood loss more than 1500 mL (uterus weight > 1000 g) and required 4 units of packed cell transfusion in each. One patient in group B with previous cesarean section had a bladder wall rent and this was sutured laparoscopically using 3-0 delayed absorbable sutures. Uterine artery ligation at the beginning of TLH as done in group A is a technically feasible procedure. It reduces the total blood loss and decreases the time taken for the procedure.

Cervical Myomectomy with Uterine Artery Ligation at Its Origin

This study was performed to examine the feasibility, blood loss, duration of surgery, and complications in patients with cervical myomas in whom the uterine artery was ligated before myomectomy. Laparoscopic cervical myomectomy was performed in 12 women with cervical myomas and menorrhagia. The uterine artery was ligated at its origin from the internal iliac as an initial step to reduce the blood loss. Myomectomy was subsequently performed, and the myomas were enucleated by incising the capsule anteriorly or posteriorly depending on their location. Hysterectomy was not necessary in any patient. Even large cervical myomas were removed with minimal blood loss. Laparoscopic cervical myomectomy is a minimally invasive and technically safe procedure.

Pelvic Schwannoma Masquerading as Broad Ligament Myoma

Two cases of pelvic schwannoma appeared as broad ligament myoma. Laparoscopic myomectomy was planned for both patients in view of suspected broad ligament myoma. Intraoperative findings appeared to be degenerated myomas with suggestion of malignancy. Both patients underwent complete tumor excision laparoscopically and had uneventful postoperative recovery. Histopathologic examination confirmed them to be schwannomas. Solitary nerve sheath tumors such as benign schwannomas arising in pelvic retroperitoneum are infrequently reported and difficult to diagnose preoperatively. Complete surgical excision is the treatment of choice. Benign retroperitoneal schwannomas in 2 patients primarily given the diagnosis of myoma were treated by laparoscopic excision. A MEDLINE search did not reveal reports of removing these tumors laparoscopically.

Laparoscopic Removal of Large Multiple Myomas with Cumulative Weight of 2.3 kg

Large multiple myomas with a cumulative weight of 2.3 kg were removed laparoscopically from a nulliparous 32-year-old woman. The patients recovery was uneventful, and she has been eumenorrheic in the 2 years since surgery.