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Suturing Skill Required for Laparoscopic Myomectomy
December 16th, 2017


Introduction

Uterine Myomas are known to be the main cause of gynaecological disease in women who are yet to reach their menopause. If a myomectomy is indicated laparoscopic myomectomy should be the procedure of choice. Laparoscopic myomectomy when done by a very qualified surgeon is always associated with improved short-term results. Any procedure that involves laparoscopy is further associated with less adhesion formation. Additionally pregnancy rates after a laparoscopy is done is often higher than after laparotomy. Although laparoscopic myomectomy has several advantages, abdominal myomectomy still remains the frequently performed procedure. Lack of training in the advanced laparoscopic procedures is what leads the use of the abdominal myomectomy and not the laparoscopic myomectomy. Therefore there is need to undergo proper laparoscopic training in order to implement this procedure as the frequent practice of the treatment of the uterine myomas.
Myomectomy

The surgeon can choose a procedure of his choice to perform myomectomy. However, due to its effectiveness and less complications, laparoscopic myomectomy is the standard procure and should always be the procedure of choice. Depending on the physician’s skills there are different ways to modify the technique in what matters placement of the trocar, instruments used, methods to reduce bleeding and suture material used.
When conducting the procedure it is very easy for the surgeon to use the uterus manipulator which facilitates myomectomy as well as suturing. The uterus manipulator enables the surgeon to position the uterus depending on the location of the myoma. Laparoscopic myomectomy is sometimes said to be a difficult procedure to perform due to the location and the size of the myoma. Therefore, for this procedure to be effective one must be very well trained and equipped with advanced skills in order to ensure the procedure is a success with very little or no complications.
 
At the beginning of the procedure, the surgeon can inject a diluted vasopressin between the myoma capsule and the normal muscle layer. By injecting the diluted vasopressin in that specific location, it becomes a very effective procedure to reduce the internal bleeding. After the injection is done, the myometrium that is on top of the myoma becomes pale. A horizontal incision is made on the pale myometrium. The horizontal incision enables the subsequent suturing of the myometrial defect without any complications. When the myoma is reached, it can be grasped with a myoma screw, which enables traction and counter traction on the myoma which is very necessary for the enucleation. In order to ensure the strength of the uterine scar, the surgeon should suture the myometrial defect, coupled with a single or multilayer closure which can minimize the risk of hematoma, bleeding after the procedure and the uterine rupture.
 
Training of Laparoscopic Myomectomy

As earlier mentioned laparoscopic myomectomy has many advantages over all the other procedures of myomectomy, however, despite that fact, abdominal myomectomy is still a frequently performed procedure. According pot various studies, the number of conducted laparotomies are still very high despite being associated with various complications. This is so because of the challenges of acquiring laparoscopic skills which are more than acquiring skills needed for conducting the open surgery.
There is a small number of surgeons who are able to perform the advanced laparoscopic procedures such as the laparoscopic myomectomy.  According to a study done in various cities, it was established that very few surgeons perform laparoscopic myomectomy the main challenge or obstacle being the lack of training in the procedure. In fact very few surgeon have the opportunity to gain practical experience in the advanced laparoscopic procedures such as myomectomy.
In order to ensure the implementation of laparoscopic myomectomy, having the opportunity to be trained and gain laparoscopic skills is very important. One of the best ways of training surgeons in advanced laparoscopic procedures is known as the simulator training which is an effective training tool to enhance basic laparoscopic skills. Basic laparoscopic skills can be termed as the first steps that lead to better performance during future procedures. After undergoing the simulator training, it is very important to go acquire advanced laparoscopic skills. However, this can be difficult especially if there is no opportunity for proper and appropriate teaching as well as training. One of the best ways to ensure proper teaching and training is by having a highly experienced laparoscopic surgeon who will train surgeons who are interested in the advanced laparoscopic skills. This is an effective way that will enhance the safety of the patients.
Acquiring advanced laparoscopic skills ensures that the surgeon is equipped with the best and most needed suturing skills when performing laparoscopic procedures such as myomectomy. It should be noted that if suturing is not conducted well on the myometrial defects then the safety of the patient is at stake meaning that the procedure may not be a success and will highly likely lead to various postoperative complications such as bleeding and uterine rupture. Although not all surgeons are similarly skilled, each should make personal efforts to acquire advanced skills required to perform laparoscopic myomectomy as well as other laparoscopic procedures. Laparoscopic skills are increasing in demand by patients, therefore there is need to acquire the practical laparoscopic skills. A patient who happens to be a candidate for laparoscopic myomectomy, should have the procedure performed by a highly trained surgeon who will provide the best care.
 
Suturing Skills for Laparoscopic Myomectomy

Laparoscopic myomectomy is good procedure that should always be the method of choice, however, this procedure raises doubts about how solid is the uterine wall after laparoscopic myomectomy for patients desiring to get pregnant. The uterine defective healing mostly depends on the training and what type of the suture is applied. If there is no proper training then the uterine defective healing will not be effective also the application of too superficial suture can lead to formation of the fistulas, indentations and intramural haematomas.
 
Suture effects can affect the length of the entire procedure where the surgeon will have to perform the procedure for a longer time. When looking to remove myomas of size 6-8 cm in diameter, the surgeon would be required to use 4-5 stitches where on average the surgeon will take around 5 minutes to apply each stitch and tie the suture and another 3 minutes to cut the suture inserting ad removing the needle. Therefore the surgeon would take around 40 minutes for the whole suture. More often than not, the suture is applied using the simple, interrupted or more frequently cross-stitches that are tied intracorporeally using 1 or 0 polyglactin sutures.
 
Usually there are various possible single sutures which include suture in two layers, a deep suture in one layer and a deeper suture with a more superficial one including the suture in two layers. The option to incorporate a running suture is good since it can lead to a reduction of 30% of the suturing time compared to traditional suture which usually takes a longer time. Also, this leads to a good healing of the uterine defect without any hematomas around the site of the myomectomy wound.
When using this new suturing technique, better postoperative results are achieved but the surgeon will have to deal with a longer suture which can be tiresome especially when one is dealing with a narrow field. The surgeon, therefore should choose a good team of other qualified surgeons who will bring about good coordination. One mat hold the running suture without interrupting the operator. This ensures the operating surgeon is able to cope with the long suture.
 
Like any other surgery, complications from laparoscopic myomectomy may occur, but there are those complications that can be greatly reduced if the operating surgeon is equipped with advanced suturing skills. If suturing is done properly with the utmost care that is required, the uterine defective healing will be enhanced thus the uterine rupture will not occur ensuring the fertility of a woman who wants to get pregnant.
Conclusion:

Laparoscopic myomectomy has several advantages over the abdominal myomectomy. Despite being the best procedure for the removal of myomas, appropriate skills especially the suturing skills are highly required. According to studies it is evident that many surgeons do not perform laparoscopic myomectomy simply because they are not equipped with the relevant advanced skills for advanced laparoscopic procedures such as the myomectomy. Most of the times surgeons are usually very interested to acquire these skills but they lack appropriate teaching and training. Suturing skills matter a lot when it comes to performing the laparoscopic myomectomy. When the surgeon is equipped with the best skills, the procedure will result in better healing of the myomectomy scar which will therefore mean a stronger uterine wall. Additionally, with advanced laparoscopic skills, laparoscopic myomectomy is greatly associated with a reduction in the risk of adhesion formation which can lead to very serious complications. When laparoscopic myomectomy is done by a surgeon who is highly skilled in laparoscopic surgery, any complications are rare events, thus laparoscopy should be the standard method for myomectomy. 
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