Preoperative Evaluation and Imaging
Understanding the three-dimensional structure of the myoma node, myometrium and endometrium
are important to prevent perforation and any remaining myoma. For submucosal myomas
with a low-protrusion rate and large sized, the myometrium on the serosal side is
stretched and thinned. Consequently, a magnetic resonance imaging (MRI) which clearly
visualizes the border of the myoma node and myometrium is essential. Take images in
three directions, the sagittal, axial, and coronal planes, for reference, when considering
surgical indication and intraoperative orientation. Contrast-enhanced MRI is usually
not needed, but carcinosarcomas and endometrial stromal sarcomas tend to protrude
into the uterine cavity, so it may be taken. For small submucosal myomas which are
pedunculated or with a high-protrusion rate, transvaginal ultrasound, sonohysterogram,
and diagnostic hysteroscope also can be used.
Selection of Surgical Technique, Indications, and Contraindications
Hypermenorrhea and myoma with anemia are indications. Generally, transcervical resection
(TCR) can be used for submucosal myoma, as well as intramural myoma, which are large
and multiple, cases where the myometrium on the serosal side is thin and cases caused
inner cavity deformity and expansion, depending on operator technique and experience.
Myoma dimensions and protrusion rate are the most important factors affecting operation
time. Since risk of complication increases as surgery time increases, correctly evaluating
one's own techniques and myoma conditions is important when determining indications.
It is not unusual for myomas with a maximum diameter exceeding 10 cm to become less
than 5 cm with the administration of GnRHa (gonadotropin-releasing hormone agonist).
The author administered six doses of 3.75 mg of leuprorelin acetate to patients with
large myomas, greatly increasing the number of cases which satisfy as indications.
GnRHa definitely reduces endometrium. Usability is very high, such as to ensure the
visual field and to reduce contact bleeding when inserting the scope.
Malignant diseases are a contraindication of TCR. However, cases which are detected
by biopsy but cannot be confirmed by other tests are not considered to be a contraindication.
In cases with endometritis or salpingitis, there is a possibility of increased inflammation
and peritonitis. Hydrosalpinx is not a contraindication if signs of infection are
not observed. However care is needed to avoid postoperative infection. Even if the
protrusion rate is high, it is not rare to have myometrium on the endometrial side.
In such cases, laparoscopic resection is recommended, even when TCR is possible ([Fig. 1 ])
Fig. 1 Example of laparoscopic excision in cases where TCR is possible, and future childbirth
is desired. (A, B ) Presurgery MRI. The myometrium can be confirmed on the endometrial side. (C, D ) After TCR MRI, the myometrium is restored. (Reproduced with permission from Inoue
S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential
Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo:
Medical View; 2013:40–53. Copyright © Medical View.) MRI, magnetic resonance imaging;
TCR, transcervical resection.
Preparation Prior to Surgery
Fig. 2 Clinical path. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi
I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now,
No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright
© Medical View.) GnRHA, gonadotropin-releasing hormone agonist; IV, intravenous; MRI,
magnetic resonance imaging.
Fig. 3 Equipment used. Placement of devices and equipment (lighting is dimmed during surgery).
The MRI image: ① is placed where it can be easily referenced at any time. High frequency
current generator, ② Irrigation fluid bag, ③ and video system, ④ should be gathered
on the left side if the surgeon is right handed. Put the ultrasound on the right side.
Placement of the monitor above the patient is ideal. The electric scalpel indicator
should be placed where the operator can easily see it. Discharge from Irrigation fluid
drains into the pocket ⑥ in the drape ⑤ and is stored in the bucket ⑦. (Reproduced
with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds.
Mastering the Essential Surgical Procedures OGS Now, No.13.Function-preserving surgery
(Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
Fig. 4 Resectoscope cable tube. Although the camera cable can be used in common with laparoscope
etc., the camera head for the hysteroscope shown in the photograph has a small diameter
cable so it is lightweight and has excellent operability. (Reproduced with permission
from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the
Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese).
Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
Fig. 5 Resectoscope (handle part). (Reproduced with permission from Inoue S. In: Hiramatsu
Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures
OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013:
40–53. Copyright © Medical View.).
Irrigation FLUID UROMARIC
Consumable items are electrodes for excision and coagulation, and irrigation fluid.
monopolar electrodes can be reused if they are not broken.
Multiple cables (electric scalpel cable, camera cable, light source fiber, and irrigation
fluid tube) are connected to the resectoscope, and these cables should be gathered
together to either the right or the left. If the surgeon is right-handed, maintain
the Tsukahara vaginal forceps in the left hand, and control the scope with the right
hand, and control the foot switch with the left foot. The equipment should be located
on the left side. To observe the monitor for a long time is tiring and the surgeon
must look up and maintain a posture while bending his/her neck. It is easy to lose
concentration. If the monitor can be moved by an extension arm, place it on the operating
table, and adjust it to the height of the surgeon's line of sight.
Choose from general anesthesia, lumbar anesthesia, and intravenous (IV) anesthesia
according to difficulty and required time of the surgery.
At the author's facility, there are many cases of large and multiple myoma, but the
patient can be discharged on the following day. General anesthesia is chosen for the
following reasons at the author's facility:
Cases where cervical dilatation is difficult, response by IV anesthesia and lumbar
anesthesia is not possible.
Severe headache continues after early discharge from the hospital in cases of lumbar
anesthesia.
Obturator nerve reflexes are not suppressed by lumbar anesthesia.
In an emergency, if general anesthesia is performed, immediate transfer to laparoscopic
myomectomy is possible.
For IV anesthesia and lumbar anesthesia performed by the surgeon, response to irregular
heartbeat when using pitressin is of concern.
Risk of general anesthesia by laryngeal mask is low.
Informed consent
Bleeding: there is a possibility of hemorrhage, blood transfusion, discontinuation of surgery,
and conversion to laparoscopic or laparotomy surgery when bleeding cannot be stopped.
Perforation: rarely, damage to other organs may occur. Conversion to laparoscopic or laparotomy
surgery requiring suture repair.
Recurrence: there is the possibility of remaining myomas, increase in the number of targeted
myomas, remaining/increase of myomas other than those targeted, possibility of new
occurrence.
Water intoxication: frequency is very low, but when prolonged surgery is expected, the risks are explained.
In-Depth Explanation
Cervical Dilatation
Wear Sakurai's colposcope to confirm the opening of uterus. Nip and hold the posterior
lip of the cervical duct using Tsukahara's vaginal forceps, and dilatate the cervical
canal using Hegar's cervical dilators (no. 17 for 26-Fr scope and up to no. 15 for
24 Fr). The author fully extends the cervical duct to a degree where irrigation fluid
can flow out from the gap between the cervical duct and the scope sheath. In cases
of cervical duct dilatation without outflow, smooth operation of the scope is difficult,
and surgeries with a high degree of difficulty cannot be performed ([Figs. 7 ] and [8 ]). Even in nulliparous cases, expanding up to Hagar's no. 17 by laminaria insertion
on previous day is possible. For cases without sexual experience, expansion under
full-anesthesia is performed and cervical laceration may occur.[1 ]
[2 ] Bleeding should not be severe, and can be easily stopped by suture by Vicryl 4–0.
Fig. 6 Resectoscope (tube connector part) inflow and outflow of irrigation fluid. (Reproduced
with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds.
Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery
(Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
Fig. 7 Required instruments—Hegar dilator, placental forceps, Sakurai Vaginal Speculum,
Tsukahara forceps etc. (Reproduced with permission from Inoue S. In: Hiramatsu Y,
Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures
OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013:
40–53. Copyright © Medical View.).
Fig. 8 Scope insertion. For efficient dissection, the insertion direction of the scope should
be adjusted according to the shape of myoma. Sufficient cervix dilation is important
to ensure free movement of the scope. (Reproduced with permission from Inoue S. In:
Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical
Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical
View; 2013: 40–53. Copyright © Medical View.)
Electric Scalpel
Place the foot switch and indicator of electric scalpel in a location where the surgeon
can visually confirm them. Switching between coagulation mode and cutting mode is
frequent and as a result, the electrode is sometimes pressed into the myometrium in
the cutting mode, instead of coagulation mode. This may result in perforation. To
avoid this, visually confirm the indicator regularly. Start with a lower voltage at
approximately 30-W coagulation, 60-W cutting, and use the lowest voltage possible
to excise the myoma smoothly. Myomas, which soften due to edema and degeneration,
can be cut at a lower voltage but hard myomas with abundant fiber components cannot
be cut without increasing voltage to 70 W. Myomas sometimes become calcified. Highly-calcified
myomas cannot be cut even if the voltage is increased. For large myomas, at the stage
where one is confident that “the part I am cutting now is definitely a myoma,” voltage
can be increased in consideration of efficiency. However, when close to the serosal
side, do not increase the voltage because a sharp cut may be deeper than expected.
When cutting the edge of a pedunculated myoma, the electrode may slip due to unexpected
myoma movement, damaging the myometrium on the other side. However, if voltage is
not too high, damage will be minor. Generally, electrodes of a resectoscope are used
when TCR is monopolar. The current is carried between the counter electrode and electrode,
so an electrolyte solution cannot be used for the irrigation fluid. Therefore, TCR
may have unique complications, including obturator nerve reflex and water intoxication.
To prevent these, a bipolar resectoscope has been developed, and is marketed by Olympus
and Stolz. However, an exclusive generator is required and the electrodes, which are
consumables, are expensive. Occurrence frequency of obturator nerve reflex is higher
than water intoxication, and unpredictable body movement can cause of perforation,
for which there are reported cases. This can be suppressed by obturator nerve block;
however, occurrence at low voltage is rare.
Irrigation Fluid
For the resectoscope, the tube connector has an in and out, as a tract for inflow
of irrigation fluid and outflow from uterine cavity ([Figs. 5 ] and [6 ]). If the in/out are connected incorrectly, irrigation cannot be performed well.
If a good visual field cannot be ensured after starting surgery, check this. As the
route of irrigation fluid flowing out of the body, besides the route from inside the
scope, there is natural outflow from the gap between the cervical duct and the scope
sheath when the scope is removed. Consequently, the author does not connect the tube
on the outside and closes the cock to increase operability. To prevent water intoxication,
irrigation volume (reflux pressure) should be at minimum so that blood can be flushed
out and the visual field can be ensured. The irrigation fluid inflow cock ([Fig. 6 ]) should be opened and closed depending on bleeding and adjusted accordingly. In
cases of heavy bleeding, a large amount of irrigation fluid will needed, but on average,
one pack (approximately 3,000 mL) is consumed in 15 minutes.
Intraoperative Ultrasound to Prevent Water Intoxication and Perforation
Water loading that exceeds kidney function causes water intoxication, so irrigation
fluid usage “in” and discharge “out” should be measured as a countermeasure. This
is useful to estimate the amount of irrigation fluid which enters the body. However,
TCR surgery often causes more bleeding per unit time than expected and blood is mixed
in the discharge fluid, so it is difficult to identify. In cases of severe bleeding,
the influx of irrigation fluid into the body is often underestimated. The most reliable
countermeasure is electrolyte determination in surgery.
The inflow path of the irrigation fluid into the body is considered as follows: (1)
inflow from cut blood vessels (especially veins); (2) it flows into the abdominal
cavity through the fallopian tube or perforation site and is absorbed from the peritoneum;
(3) cut arteries that bleeding are closed by coagulation hemostasis. However, veins
are easily overlooked because they do not bleed due to irrigation pressure. Veins
should also be coagulated. Fluid accumulation is often observed around the uterus
by intraoperative ultrasound. A rapid increase strongly suggests perforation of the
uterus. Perforation of the uterus does not always cause a rapid, worsening visual
field, so this observation is important. Considering the dimensions and permeability
of peritoneum, flow of irrigation fluid into abdominal cavity can be presumed to be
a major cause of water intoxication. In other words, perforations of uterus that go
unnoticed can cause water intoxication.
If possible, have the assistant perform intraoperative continuous monitoring by transabdominal
ultrasound. Clear perforations, such as “the resectoscope is sticking out of the abdominal
cavity,” are thought to be rare. Perforations can also be avoided by warnings such
as “I'm excising in a thin area in the myometrium,” or “I don't think I'm excising
myoma.”
1. Confirmation of myoma nodules and Fallopian ostia ([Figs. 9 ]
[10 ]
[11 ]):(see video Roller ball hysteroscopic technique for fundal submucous myoma at:
https://www.youtube.com/watch?v=jiTcrYdAwj4&t=20s
.[3 ] 10 cm type-2 fibroid hysteroscopic resection.
https://www.youtube.com/watch?v=K8nmkR99GXA&t=7s
.[4 ] Hysteroscopic resection of a huge myoma weighing 360 g is available at:
https://www.youtube.com/watch?v=_kHBAzI0RAU&t=173s
.[5 ])
Fig. 9 Confirmation of both sides of Fallopian ostium. (Reproduced with permission from
Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential
Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo:
Medical View; 2013: 40–53. Copyright © Medical View.)
Fig. 10 Resectoscope insertion. Insert the scope into the uterine cavity with the electrode
stored inside the sheath. (Reproduced with permission from Inoue S. In: Hiramatsu
Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures
OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical View; 2013:
40–53. Copyright © Medical View.)
Fig. 11 Myoma on the right posterior wall with a wide base. Excision method that focuses
first on dissection of myoma nodules. (A ) Dissect the edges of the myoma in coagulation mode, (B ) point the loop toward the myoma, move back and forth, (C ) excise in cutting mode with the myometrium in the back, (D ) dissection can be done efficiently with the loop in the upward direction. (E ) Continue to excise the protrusion (f) When the protrusion has been eliminated, dissect
it again. (G ) The myometrium contracts thickly and the myoma starts to stick out (H ) If the section has accumulated, remove with placental forceps (I ) Dissect the last slice, and remove it with a forceps also. (Reproduced with permission
from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the
Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese).
Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
With the electrode in the sheath, insert the scope into the uterine cavity at maximum
irrigation flow. Remove any blood clots by operating the handle, confirm the uterine
ostium of the fallopian tube on both sides, and confirm the number and locations of
myomas. Remove the scope once, then locally inject saline-diluted pitressin to reduce
bleeding from the myoma and myometrium connected to the myoma.
2. Dissection of myoma nodules ([Fig. 11 ]):
Reinsert the scope, and continue dissection by moving the loop electrode at 200-W
coagulation mode along the myoma attachment site.
3. Excision of myoma nodules ([Figs. 11 ]
[12 ]
[13 ]
[14 ]):
Fig. 12 Insert the scope upside down. When the scope is rotated 180 degrees, the electrode
and the handle are turned upside down. However, the irrigation fluid tube can be rotated,
so point it downward. Even if the camera cable is rotated, the top and bottom on the
monitor screen will not change. When current is applied in cutting mode, always point
the loop electrode toward the myoma. (Reproduced with permission from Inoue S. In:
Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical
Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical
View; 2013: 40–53. Copyright © Medical View.)
Fig. 13 Broad based myoma. Myoma nodules before dissection method. (A ) If the electrode can be inserted deep into the myoma, excision in large strokes
is possible. If the points indicated by the arrow can be dissection points before
excision, only the myoma can be excised. (B ) Excision efficiency of the bottom of the myoma is poor since the large strokes with
the electrode are not possible. (c) As the myoma nodules continue to be dissected,
the electrode can enter deep inside the myoma. Excision of the myoma can be safely
performed in the direction toward the center of the uterine cavity with the myometrium
in the back. (Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I,
Sakuragi N, Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13.
Function-preserving surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright
© Medical View.)
Fig. 14 Successive removal of myoma slices. (A ) The electrode is exposed deep inside of myoma. While turning on the cutting mode
with the foot switch, move the scope to the front and excise the myoma. (B ) The electrical current is stopped just before finishing excision. Grasp the excised
myoma slice between the electrode and the sheath, and then pull the scope forward.
(C ) Remove the scope while holding the excised myoma slice. (D ) Extend the electrode outside the tissue body and remove the myoma. (Reproduced with
permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering
the Essential Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese).
Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
The myoma nodule can be excised even when the resectoscope is rotated 180 degrees
and turning the loop electrode downward ([Fig. 12 ]). However, dissection is more effective when the electrode is in the upward direction.
For myomas attached to the posterior wall, proceed with the myoma dissection prior
to excision, excision of only myomas can be safely performed using the electrode in
an upward direction.
As the myoma is excised, protrusions will disappear. Then once again, proceed with
dissection ([Fig. 11f ]). In myoma nodule dissection by laparotomy, the dissecting layer can be observed
macroscopically. But precise dissection is possible because the image from the hysteroscope
can be enlarged. If the loop electrode cannot be inserted, separate the nodule with
the ball electrode. If blunt dissection is easy, do not use the electrical current.
However, if there are blood vessels and funicular tissue, pass the current in coagulation
mode. If myoma protrusion appears during dissecting operation, excise it with the
loop electrode in cutting mode. When inserting the scope into the back, move the loop
electrode in coagulation mode forward and backward in small strokes. In this way,
if the loop can reach deep within the myoma, a hooking “response” on the myoma protrusion
can be felt. If it is small stroke in low-voltage coagulation mode, there is no risk
of perforation even if the electrode contacts the myometrium, and in cases where the
bleeding point is not clearly identified, a coagulation effect can be achieved. When
you can feel the loop electrode caught on the myoma, lightly pull the electrode, and
switch to cutting mode to excise the myoma, using caution not to contact the myometrium
in the back.
If the myoma has a high-protrusion ratio, dissection may be possible by searching
for the boundary of the myoma in the myometrium after shaving up to the height of
the surrounding myometrium, but when excising a large myoma, sometimes you do not
know “where the electrode is and what is being cut now.” If dissection is performed
first, losing sight of the dissection site does not occur, and excising only the myoma
is possible. This is a safe procedure.
As the volume of the myoma nodule decreases, the myometrium shrinks and pushes out
any remaining myomas. This is promoted by dissection operation. The myometrium which
was stretched and thinned due to the myoma, shrinks as the myoma volume decreases,
and becomes thicker, reducing the risk of perforation.
If slices have not been removed and remain in the cavity, remove them using a placental
forceps. The last remaining myoma can be removed as dissection operation continues,
but it can be quickly resected by drawing it with placental forceps.
Recommendation for Successive Removal
Avoid waste due to cutting a separated slice twice, and try to perform successive
removal by taking out each myoma slice one by one, to promote myometrium shrinkage
as the inner cavity volume is reduced ([Fig. 14 ]). Just before excision is finished, turn off the foot switch, release the scope
handle, and take out the slice from the uterine cavity as if lightly tearing it off.
And place it in the pocket of the drape collecting irrigation fluid. Once accustomed,
a slice can be released by lightly shaking the scope outside the body. In this way,
excision and removal can be performed in one stroke, and at the same time, the traction
effect of the myoma node occurs.
Scope Insertion in the Dark
During endoscopic surgery, the lights in the room are dimmed to increase visibility
of the monitor screen. Although newer equipment has better definition, a detailed
feel and visual recognition of blood vessels are needed for better surgery, so a darker
room is recommended. During hysteroscopic myomectomy, the scope is repeatedly removed
and inserted. However, if the external os of uterus must be confirmed in the dark
each time, surgical time will be longer. To smoothly insert the scope, sufficient
cervical dilatation is important. Shrinkage sometimes occurs during surgery, so using
Hegar's cervical dilators to reextend it when changing electrode or when using placental
forceps is recommended. The scope can be inserted without taking one's eyes off to
the monitor, by placing the scope on the Tsukahara vaginal forceps, which can grip
and hold the cervicovaginal posterior lip.
Tips and Warnings How to Use Placental Forceps
When taking out a remaining slice in the uterine cavity using placental forceps, uncut
myoma is sometimes pulled out. This encourages protrusion of myoma in the uterine
cavity, just as pulling a myoma node in laparoscopic myomectomy is important.
Placental forceps can effectively remove myomas. However, forcibly excising a myoma
that is solidly attached to the myometrium, carries the risk of uterine inversion,
rupture of the thinned part, damage on the uterine ligament, subserous hematoma of
the uterus, etc. Caution is required, especially in cases with a history of myomectomy
and Caesarean section. Grab out with placental forceps of only that which can be lightly
held is safer.
Excision without Perforation
Even if the cardinal rule of “only pass a current when performing loop operation from
back to front” is observed, perforation may occur ([Fig. 15 ]). The surrounding condition in the back cannot be fully understood, and it is difficult
to determine where the electrode is within the whole uterus, so cuts in the myometrium
may perforate. On the other hand, in the cervical duct and nearby areas, surrounding
conditions can be observed within the visual field. So, if an excision is made here,
risk of cutting into the other side is reduced. By focusing on dissection, the myoma
will come out in front, making this possible.
Identify the myometrium and myoma by the color tone, texture, and feel from the electrode.
Try to grasp the slice by hand. Generally, a myoma is harder than the myometrium.
However, degenerated myoma is soft, and the myometrium affected by adenomyosis is
hard, so it is sometimes difficult to differentiate. Even with years of experience
in places, such as the surrounding area of a lobulated myoma, one will sometimes wonder
“am I cutting myoma?” At such a time, consult the ultrasound and MRI. Prepare the
MRI image in the operation room so that it can be easily reviewed.
Fig. 15 Excision without perforation. (A, B ) In deep sections, positional relationship with the myometrium is difficult to determine,
and perforation while trying to excise the myoma may occur. (C, D ) When myoma protrudes from a shallow area where the relationship with the myometrium
can be determined as the myoma nodules are dissected, the myoma alone can be excised.
(Reproduced with permission from Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N,
Takeda S, eds. Mastering the Essential Surgical Procedures OGS Now, No.13. Function-preserving
surgery (Japanese). Tokyo: Medical View; 2013: 40–53. Copyright © Medical View.)
4. Stop bleeding (coagulation/manual compression):
As irrigation inner pressure increases, bleeding from minute blood vessels temporarily
stop. This is useful to ensure the visual field during operation. However, as pressure
decreases, bleeding will occur, so this cannot be called a hemostatic method. Cases
of bleeding during TCR which are difficult to stop include (1) large intramural myomas
(large contact dimensions with the myometrium, and rich vascular network around the
myoma), (2) Multiple intramural myomas (poor myometrial contraction), (3) When cutting
into the myometrium of the uterine side where branches of uterine artery are located,
etc. In such cases, uterine contraction is important as a hemostatic mechanism. Compression
on the cavity using a balloon is not recommended because it hinders uterine shrinkage.
Basics of hemostasis are suture and compression. However, in TCR, the same manner
as uterine bleeding at delivery/recover, compression is basic. After ergometrine and
a hemostatic agent are intravenously injected and urethral catheterization, insert
two/three pieces of gauze into the vagina, and press the uterus from the vagina and
abdominal wall using a pelvic examination procedure (bimanual compression of the uterus
[Fig. 16 ]). Change the gauze approximately in every 10 minutes and confirm hemostasis. Once
bleeding has decreased, insert the laparoscope, and coagulate the blood vessel using
the ball electrode as much as possible, and continue compression. If bleeding still
does not decrease, inject prostaglandin F2α in the uterine corpus locally, and continue
compression. If bleeding still does not stop, prepare for a blood transfusion, and
consider suturing with the laparoscope. If the bleeding is caused by perforation,
suturing is effective for hemostasis. For bleeding which was not caused by perforation,
uterine artery embolization is useful. However, emergency performance is not always
possible. In a case where bleeding without perforation and which did not stop even
after suturing the uterine wall, the author could stop the bleeding by tying off both
sides of the uterine artery. In this case, menstrual period started again. Patients
who wish to have hysteroscopic myomectomy and have a strong desire to preserve their
uterus, avoiding a total hysterectomy is desired as much as possible.
Fig. 16 Bimanual compression of the uterus. (Reproduced with permission from Inoue S. In:
Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential Surgical
Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo: Medical
View; 2013: 40–53. Copyright © Medical View.)
Vasopressin is widely used to control bleeding during laparoscopic myomectomy. Although
there is no evidence of bleeding control in TCR, the author has transcervically injected
it in almost all cases. Almost no uterine contraction is expected. Side-effects include
irregular pulse, cardiac arrest, and pulmonary edema. Increased risk of water intoxication
due to antidiuretic effect is also present. For cases with asthma, use is not recommended.
If PGF2α (ProstaglandinF2α [Dinoprost]) is used in the myoma with lower protrusion
rate after excision of a protrusion, myoma nodules protrude due to strong contraction
of the myometrium, making excision easier. Ergometrine is used for the same purpose
as PGF2α, but with lower effect. It is not locally injected, but administered by IV.
It can be used in cases with asthma.
5. Confirmation by ultrasound:
Transvaginal injection is better than transabdominal. Even if the monitor is omitted
during surgery, postoperative confirmation by ultrasound is recommended. Record any
remaining myomas and fluid accumulation around the uterus.
Prevention of Postoperative Adhesion
One opinion is to “insert intrauterine device (IUD) to prevent intrauterine adhesion,
and enhance regrowth of the endometrium by estrogen.” However, there is no evidence
to this. In most cases where the author has performed TCR for large myomas, IUD is
thought to drop rapidly, so it is not performed. In addition, preoperative pseudomenopause
therapy with GnRHa is performed in almost all cases, although hurried regrowth the
endometrium is not considered to have any significance. Approximately 10 weeks after
the final GnRHa injection, menstrual period starts again. Sexual intercourse is not
restricted during that time but birth-control is recommended.
Even in cases where a thinned myometrium on the serosal side was observed by preoperative
MRI, restoration of myometrium can be confirmed by postoperative MRI ([Fig. 17 ]). If the myometrium is not excised or ruptured, vaginal delivery is considered possible.
However, in cases indicated for TCR, avoiding damage to the endometrium cannot be
completely ensured, so an explanation that “defective endometrium can be regrown and
recover, but there is a risk of placental polyps and placenta accreta.” HSG is recommended
to prevent adhesion. Minor adhesions can be resolved by inserting a “Hyscath” (catheter
for fallopian tube patency test) and injecting a contrast agent.
Fig. 17 Cases of baby achievement. (A ) TCR performed for submucosal myoma, and laparoscopic surgery for subserosal and
intramuscular myomas at the same time. (B ) Eighty days after surgery transvaginal ultrasound. (Reproduced with permission from
Inoue S. In: Hiramatsu Y, Konishi I, Sakuragi N, Takeda S, eds. Mastering the Essential
Surgical Procedures OGS Now, No.13. Function-preserving surgery (Japanese). Tokyo:
Medical View; 2013: 40–53. Copyright © Medical View.)
How to Improve TCR Techniques
To improve TCR techniques, become accustomed to the three-dimensional movement of
the scope, taking the sheath in and out, stepping on and off the foot pedal to switch
between coagulation and cutting modes, which is determined according the monitor image
and feeling of the electrode, and the smooth collaborative coordination of these movements.
TCR greatly differs from abdominal surgery and laparoscopic surgery only in the fact
that surgery is performed in a smaller visual field, which is usually the uterine
cavity, only using the scope. Laparoscopic surgery is similar to endoscopic surgery,
but when using a laparoscope, such as in abdominal surgery, the overall visual field
can be seen and cutting, dissecting, disconnecting, suturing, and tying are possible.
In TCR, an overall visual field is difficult, and suturing and tying are not possible.
In TCR, the three-dimensional structure of MRI equipped in the head, the image on
the monitor screen, and the feel of the tissue obtained from the electrode must be
relied on. The author reviews the MRI image after each surgery, and considers the
structure captured prior to surgery, whether the operation developed as expected,
and seeks to improve MRI image interpretation ability.
