Chaitali Mahajan

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.

Parasitic myoma after morcellation

We report an interesting case of parasitic fibroid which developed from a morcellation remnant following laparoscopic myomectomy. The patient presented with incidental finding of pelvic mass in 2005. She underwent laparoscopic myomectomy for a myoma extending from the Pouch of Douglas to both sides of broad ligament. She subsequently presented with abdominal pain 3 years later in 2008. She underwent total laparoscopic hysterectomy with removal of broad ligament fibroids. During her hysterectomy, a right lumbar mass attached to the omentum was detected, which was excised laparoscopically. Histopathology of the mass confirmed it to be consistent with leiomyoma. This mass could probably be a morcellation remnant that has grown to this size taking blood supply from the omentum. We report this case to emphasize that all tissue pieces that are morcellated should be diligently removed. Even small bits displaced into the upper abdomen can result in parasitic fibroids. Thus, it can be concluded that parasitic myomas can arise from morcellated remnants and grow depending on the blood supply.

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.

Total laparoscopic hysterectomy for large uterus

Aim: In this review, we assessed the feasibility of total laparoscopic hysterectomy (TLH) in cases of very large uteri weighing more than 500 grams. We have analyzed whether it is possible for an experienced laparoscopic surgeon to perform efficient total laparoscopic hysterectomy for large myomatous uteri regardless of the size, number and location of the myomas. Design: Retrospective review (Canadian Task Force Classification II-1) Setting: Dedicated high volume Gynecological laparoscopy centre. Patients: 173 women with symptomatic myomas who underwent total laparoscopic hysterectomy at our center. There were no exclusion criteria based on the size number or location of myomas. Intervention: TLH and modifications of performing the surgery by ligating the uterine arteries prior, myomectomy followed by hysterectomy, direct morcellation after uterine artery ligation. Results: 72% of patients had previous normal vaginal delivery and 28% had previous cesarean section. Average clinical size of the uterus was 18 weeks (10, 32). The average weight of the specimen was 700 grams (500, 2240). The average duration of surgery was 107 min (40, 300) and the average blood loss was 228 ml (10, 3200). Conclusion: Total laparoscopic hysterectomy is a technically feasible procedure. It can be performed by experienced surgeons for large uteri regardless of the size, number or location of the myomas.

Single-incision total laparoscopic hysterectomy.

Single-incision laparoscopic surgery is an alternative to conventional multiport laparoscopy. Single-access laparoscopy using a transumbilical port affords maximum cosmetic benefits because the surgical incision is hidden in the umbilicus. The advantages of single-access laparoscopic surgery may include less bleeding, infection, and hernia formation and better cosmetic outcome and less pain. The disadvantages and limitations include longer surgery time, difficulty in learning the technique, and the need for specialized instruments. Ongoing refinement of the surgical technique and instrumentation is likely to expand its role in gynecologic surgery in the future. We perform single-incision total laparoscopic hysterectomy using three ports in the single transumbilical incision.

Laparoscopic myomectomy with uterine artery ligation: Review article and comparative analysis

Uterine leiomyomas are one of the most common benign smooth muscle tumors in women, with a prevalence of 20 to 40% in women over the age of 35 years. Although many women are asymptomatic, problems such as bleeding, pelvic pain, and infertility may necessitate treatment. Laparoscopic myomectomy is one of the treatment options for myomas. The major concern of myomectomy either by open method or by laparoscopy is the bleeding encountered during the procedure. Most studies have aimed at ways of reducing blood loss during myomectomy. There are various ways in which bleeding during laparoscopic myomectomy can be reduced, the most reliable of which is ligation of the uterine vessels bilaterally. In this review we propose to discuss the benefits and possible disadvantages of ligating the uterine arteries bilaterally before performing laparoscopic myomectomy.

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.

Multiple and bilateral dermoids: a case report.

A 27-year-old nulliparous woman presented with pain in the lower abdomen for six months. She was diagnosed to have bilateral dermoid cysts. Ovarian dermoid tumors can be bilateral in up to 15% of cases. After laparoscopy, we found that she had 7 dermoid cysts on the left side and 2 dermoid cysts on the right side, which is a rare occurrence. All the dermoid cysts were enucleated laparoscopically. The cysts were placed in an endobag and retrieved by morcellation. A one year follow up showed no evidence of recurrence or granulomatous peritonitis.

Retained Uterine Fundus after Vaginal Hysterectomy

We report a case of retained uterine fundus after vaginal hysterectomy that was subsequently removed at laparoscopy. The patient had undergone vaginal hysterectomy 8 years previously and came to our hospital with abdominal pain. Examination revealed a supravesical mass. Laparoscopy was performed and showed the uterine fundus with its cornual attachments. The mass was excised and sent for histopathologic analysis, which confirmed that it was uterine tissue. Retained uterine tissue or myoma tissue has been reported, usually after morcellation. However, to our knowledge, our case is only the second reported case of retained fundus after complete vaginal hysterectomy. Because of adhesions, it is possible that the uterus was not completely removed. In such cases, laparoscopic assistance is extremely useful.

Vaginal vault dehiscence with evisceration after total laparoscopic hysterectomy

Vault dehiscence and evisceration of peritoneal contents is a rare complication following total hysterectomy. A 43-yearold lady presented with history of something soft coming out per vaginum. She underwent total laparoscopic hysterectomy 2 months back for 16-week fibroid uterus. The surgery was uneventful, vaginal vault was sutured laparoscopically with no 1 polyglactin, interrupted figure of eight sutures. She was discharged after 48 h with uneventful recovery and subsequently presented with mass protruding per vaginum. Speculum examination showed loops of small bowel protruding in the vagina (Fig. 1). She was hospitalized and scheduled for reduction of the prolapsed bowel with vault repair. On examination under anaesthesia, there was complete dehiscence of the vaginal vault with loops of small bowel protruding through the defect. To maintain the pneumoperitoneum vagina was blocked using a simple vaginal tampon soaked in betadine solution (Fig. 2) [1]. On Laparoscopic evaluation the entire vault was deficient. There were no bowel, bladder or omental adhesions to the vault. The prolapsed ileal loops were seen just at the vault, with healthy pink colour and regular peristalsis. On giving Trendelenburg’s position the reposition was smooth. After confirming that the vault was free of any adhesions, the vault was closed vaginally using interrupted no 1 Polydioxone II sutures (Fig. 3). Patient was discharged on the third post-operative day and is asymptomatic at 6-month follow-up. Vaginal vault dehiscence with evisceration posthysterectomy can occur up to few weeks to even few years after hysterectomy. The commonest organ to eviscerate is small bowel, particularly terminal ileum. Several factors which may contribute to weakness of vaginal apex are poor surgical techniques, post-operative wound haematoma and cuff infection, post-menopausal status, any activity resulting in increased intra-abdominal pressure, early resumption of sexual activity, chronic steroid administration, history of previous radiotherapy in cases of radical hysterectomy [2] and systemic illness like diabetes mellitus and immunecompromised status [3].