LAPAROSCOPIC MYOMECTOMY: AN IDEAL TREATMENT FOR PEDUNCULATED SUBSEROSAL MYOMAS
Dr. Pallavi Singh MS, DMAS
Project submitted towards the completion of diploma in Minimal Access Surgery, World Laparoscopy Hospital, Gurgaon, NCR Delhi, India 110018.
Fibroids are benign tumors of the muscle of the uterus. They are the most common tumors found in women during their reproductive years. Increased estrogen stimulation alone or together with growth hormone or human placental lactogen appears to be the major growth regulator of fibroids (1). The commonest ones are intramural and subserosal. Recently, there is an increasing trend for minimal access surgery for treatment of uterine myomas. Laparoscopic myomectomy has provided minimal invasive alternative to laparatomy with advantage of faster recovery and less postoperative adhesions. The pedunculated subserosal myomas can easily be removed by coagulation and cutting the stalk of the myoma (2). The idea of this review is to analyze laparoscopic myomectomy results in subserosal and intramural myomas. Recent evidence favors safety and reliability of laparoscopic removal of pedunculated subserosal myomas. Review of comparative studies will clarify the further status.
Laparoscopic myomectomy, pedunculated subserosal myoma, intramural Myoma, fibroid.
Uterine myomas are the commonest pelvic tumours found in at least 20% of the females in reproductive age group. There is a spectrum of presentations but large proportions are asymptomatic (3). Based on location the various types of myoma are-subserous, intramural and submucous fibroid. Increased eostrogen stimulation alone or together with growth hormone or human placental lactogen appears to be major growth regulator of fibroids (1).
The aim of this review is to compare the effectiveness and safety of laparoscopic myomectomy done on subserosal and intramural myoma.
Material and Method:
A literature search was performed using Highwire press, Springerlink, Pubmed and the search engine Google. The following search terms were used: Myomectomy, laparoscopy myomectomy on subserous and intramural fibroids. Selected papers were screened for further references. Criteria for selection of literature were types of myoma, operative procedure and the institution where the study was done. Numbers of cases were not considered as criteria since laparoscopic myomectomy is a controversial subject.
Preoperative evaluation and patient selection
Symptomatic women who want to retain uterus for future reproductive function or personal reasons are advocated myomectomy. Women who were symptomatic and were not expect to go into menopause. The commonest symptoms considered were menorrhagia, pelvic pressure and pain, recurrent pregnancy losses and occasionally infertility (3). The last two symptoms are particularly related to submucous or intramural myomas distorting the uterine cavity (4). Fibroid size not more than 6 cms was considered. However there is no universally accepted criterion regarding number and size of myoma to contraindicate laparoscopic myomectomy. The decision solely depends upon surgeon's confidence for laparoscopic techniques. According to a review by N. Hameed and Asgar Ali contraindications for laparoscopic myomectomy include any medical illness contraindicating laparoscopy due to inability to tolerate pneumoperitoneum or trendelenburg position, or diffuse myoma, more than 3 myomas of more than or equal to 5 cms, uterine size 16 weeks or myoma size 15 cms (5). According to Dubuisson and Chaperon 1996 laparoscopy can be used for medium sized myoma of 5 cms and better avoided for more than 8 cms and if more than 3 in number (6).
Laparoscopic myomectomy was first described by Semm and Metler in 1980 for subserosal fibroid. In 1990 the technique was developed to include intramural fibroid by Dubuisson et al 1991; Hasson et al 1992. However laparoscopic myomectomy is a subject of debate especially for intramural fibroid due to technical difficulty and increased blood loss (7).
Removal of Pedunculated subserous myoma
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 is placed through the base of stalk. The bipolar is then passed through the incision and placed over the entire pedicle (8). The stock is than sharply resected. Use of dilute vasopressin injections in 100 milliliters lactated Ringer's solution helps control uterine bleeding as recommended by Nezhat et al (9). A fibroid less than one centimeter in diameter can be pulled directly through the 10mm trocar with a grasping forceps or a myoma screw. For larger myoma sharp morcellation can be attempted.
This would need more manipulation for removal. So dilute vasopressin should be injected to multiple sites between myometrium and fibroid capsule. Incision is made over serosa overlying fibroid with monopolar electrode and is extended until it reaches the capsule. Two grasping forceps are used to hold the edges of myometrium and the suction irrigator is use as blunt probe to remove serosal covering of the leiomyoma from its capsule. The Myoma screw is inserted into the fibroid as it helps to apply traction while the suction irrigation instrument can be used as a blunt dissector. Vessels are electro coagulated and then cut. After complete Myoma removal the uterine defect is irrigated, bleeding points are controlled with the open jaw of bipolar. If there are multiple myomas, efforts should be made as far as possible to remove them through one incision. 4-0 Polydioxanone or 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. Sometimes myometrium is required to be sutured in two layers. The sutures are applied at 1 cm increments using extracorporeal (10) or intracorporeal knot tying (9). Some gynecologist use adhesive medical glues over the suture line to prevent adhesions. Tumble square knot is preferred when edges are in tension (1). The location of uterine incision is very important as it affects the whole of the operation.
Stringer et al state that the Endostitch is the best instrument for laparoscopic closure of uterine defects (11).
Recently a continuous spiraling suture for uterine wall reconstruction after laparoscopic myomectomy has been reported (12).
Patients' undergone laparoscopic myomectomy for pedunculated subserosal fibroids can go home the same day. However, a patient who underwent intramural laparoscopic myomectomy needs an inpatient observation for at least twenty four hours, with vital signs recording and hemoglobin estimation. Delayed complication like secondary hemorrhage may occur (8). Gastrointestinal injuries may get ignored intraopeartively necessitating laparatomy (13). There is risk of recurrence. A recent study by Rossetti A et al concluded that the recurrence rate was similar to that seen after abdominal myomectomy (14). L. Mettler et al conducted a retrospective analysis of 178 patients who underwent laparoscopic myomectomy at university hospital, campus keil, Germany in 2000 to 2003. Only 2 patients had a small haematoma in the abdominal wall. No late complications were found. Pregnancy rate was more than 55% achieved in infertility cases. He concluded laparoscopic myomectomy to be the technique of choice for pedunculated-subserosal and small intramural fibroids in properly selected patients (15).
Newer modalities of laparoscopic myomectomy
Less than a decade ago, removing fibroids by laparoscopic myomectomy was a difficult and time-consuming task. However, a few years ago an electrically powered device, called a morcellator, was invented and now allows us to quickly cut up the fibroid and easily remove it from the abdomen. The device is a hollow tube with a sharp circular blade at the end that rotates quickly and takes small slices off the fibroid in a few seconds. A large fibroid can now be removed in about fifteen minutes (20). The limits to laparoscopic myomectomy depend on a number of factors - the size(s), number and position of the fibroids, whether future fertility is desired, and the experience of the surgeon.
Size: Many experienced laparoscopic surgeons are comfortable removing fibroids less than 8 cm (3.5 inches) in diameter (21).
Number: It is actually easier to remove 1 large fibroid than 10 small ones, because each fibroid may require a separate incision which then needs to be sutured. Suturing laparoscopically is more tedious than through an abdominal incision and is a skill that takes many years to perfect. Many experienced laparoscopic surgeons are comfortable removing up to 5 fibroids, but more may be reasonable in some situations (22).
Position: The easiest fibroids to remove are those that are outside the uterus on a stalk (subserosal pedunculated). Once the stalk is cut, the fibroid can be cut up into small pieces with a specially designed instrument called a morcellator and brought out of the abdomen through a small incision. The deeper the fibroid is into the uterine muscle wall, the more difficult it is to remove, and the more suturing needs to be done to repair the muscle wall. Other considerations regarding position include how close the fibroids are to the fallopian tubes (if fertility is desired) or to the uterine blood vessels, and whether there is any risk of damage to these areas. Skill, experience and judgment of the surgeon all come together here (23). Pedunculated myomas are easiest to remove by just coagulating and cutting the stalk (24). Dr. Shirish Kumar from Sir Ganga Ram hospital in his review article states that fibroids that are attached to the uterus by a stalk are the easiest to remove by laparoscopy (25). In yet another article from Women,s Health states that due to the placement of pedunculated subserosal fibroids on the uterine surface laparoscopy is considered to be the most practical technique for their removal (26). Fertility: If future fertility is desired, then the strength of the uterine wall repair is important. Despite the risk of adhesions myomectomy seems to enhance the reproductive outcome. The quoted conception rate after laparoscopic myomectomy was 71% and 75% respectively in two different series (27). Seinera et al reported 65 pregnancies in 54 patients with no scar rupture (28).
All reviews favor that pedunculated subserosal myomas can be removed easily by laparoscopy. Though even intramural fibroids can also be enucleated by laparoscopy but the number of myomas and there size makes a difference. The known complications of laparoscopic myomectomy are also less when subserosal myomas are resected then when intramural myomas are removed.
Laparoscopic myomectomy is a very recent advance in the field of gynaecological surgery. It requires proper patient selection, meticulous technique, manual dexterity and experience in Laparoscopic suturing skills. If strict criteria are used Laparoscopic myomectomy is as effective as abdominal myomectomy . The procedure should involve multilayered uterine closure to avoid a weaker scar and subsequent rupture in case of intramural myomas. Different gynecologists will give different opinions about whether laparoscopic myomectomy is feasible and appropriate - it is complicated. And, to a large degree, opinions will be based on the surgeon's experience, skill and comfort doing laparoscopic myomectomy. Laparoscopic myomectomy is the technique of choice for pedunculated-subserosal and intramural fibroids in properly selected cases.
I am grateful to Prof. R. K. Mishra, World Laparoscopy Hospital, Gurgaon, NCR Delhi for his guidance in preparation of this review article.