Prophylactic Hemostasis
If we cut the myometrium without preparation, there will be bleeding. To control the
amount of bleeding, we use a local injection of a hemostatic agent. Diluted vasopressin
is commonly used in these scenarios, even though this is an off-label use. It is a
contraindication for patients with congestive heart failure, bronchial asthma, pregnancy-induced
hypertension syndrome, migraine and epilepsy. We use 1 ampule (20 international units)
of pittressin diluted with 70 mL of normal saline. This is infused into the myometrium
over the targeted fibroid using an 18-g PTC needle or a suction needle (Hakkou co.).
To avoid intravascular injection, we have to confirm no backflow in the syringe after
injection. For the most effective hemostasis, we have to inject this fluid into the
appropriate layer, indicated by the area of injection turning white and that white
area expanding as more fluid is injected ([Figs. 2a] and [3d]
[1], [2]). Once the fluid is infused, the incision and suture need to be performed quickly
and smoothly as this preparatory treatment is most effective for just 20 minutes postinjection.
Fig. 2 Enucleation (1). (a) Injection of diluted vasopressin using PTC needle. (b) Incision of myometrium. We use a monopolar hook. If active bleeding occurs, we control
bleeding using bipolar forceps. (Reproduced with permission from Andou M. Ota Y, Hada
T, Kanao H. Laparoscopic Myomectomy for huge fibroid- focusing on difficult cases.
In Hiramatsu Y, Konishi I, Sakuragi N, Takeda S eds. Mastering the Essential Surgical
Procedure. OGS Now, No.11 Uterine fibroid (Japanese). Tokyo: Medical View; 2010:58–69.
Copyright © Medical View.) PTC, percutaneous transhepatic cholangiography.
Fig. 3 Enucleation (2). (a) Finding an appropriate dissectible plane. (b) (1,2) 360-degree myometrial dissection—the fibroid is dissected from the myometrium
evenly and stepwise in all directions. Countertraction is of paramount importance.
(c) Postenucleation status. (d) (1,2) Aftereffects of the injection of diluted vasopressin—the surface becomes white
due to localized ischemia. (Reproduced with permission from Andou M. Ota Y, Hada T,
Kanao H. Laparoscopic Myomectomy for huge fibroid- focusing on difficult cases. In
Hiramatsu Y, Konishi I, Sakuragi N, Takeda S eds. Mastering the Essential Surgical
Procedure. OGS Now, No.11 Uterine fibroid (Japanese). Tokyo: Medical View; 2010:58–69.
Copyright © Medical View.)
Myometrial Incision Method
Now we move to the incision of the myometrium. As for the direction of the incision,
both longitudinal and transverse incisions are applicable. The needle driver is placed
into the median port. Our method of choice is the longitudinal incision as it is easier
to manipulate the needle driver than with the transverse incision. We can apply the
incision at any point and the suturing can be applied in the same way at every point.
If we use a parallel port configuration, the transverse incision is the preferred
technique as suturing can be performed easily.
To incise the myometrium, we use a harmonic scalpel or monopolar cautery (pure cutting
mode: 70 Watt; [Fig. 2b]). To minimize thermal spread to the myometrium, it is important to cut quickly.
In the case of subserosal myomas, we remove the ship-shaped segment of the myometrium
to reduce the amount of excess skin. As for the depth of the incision, it is important
to find the appropriate plane. It is better to cut into the fibroid and then find
the dissectible plane, rather than make a cut that is too shallow ([Fig. 3a]).
Note: With regard to the electric knife, we do not use coagulation mode because there
is a risk of unexpected organ heat injury via shunt burns.
Enucleation
First we grasp the fibroid with claw forceps and pull the fibroid while pushing away
the myometrium using an aspiration nozzle or forceps. The assistant places countertraction
on the myometrium. To dissect the fibroid smoothly, traction of the myometrium by
the assistant is extremely important ([Fig. 3a–c]). During the enucleation, if we encounter hard, fibrous tissue, we would cut the
tissue with a monopolar knife or scissors and then continue with blunt dissection.
This combination of sharp and blunt dissection is repeated until the fibroid can be
removed. We use Probe Plus II (Ethicon endosurgery) for the blunt dissector. This
device allows monopolar incision, aspiration of smoke and blood as well as blunt dissection
capabilities, all without having to change devices. This makes for seamless stepwise
dissection. One negative point of the device is it has the tendency to bend when too
much pressure is applied. For this reason, we use the Probe Plus II at the circumference
of the fibroid, using blunt dissection to peel away the myometrium. We grasp close
to the dissecting point and push back the myometrium with the Probe Plus II on a tangent
so as to peel away the myometrium and expose the fibroid.
When we need stronger dissection power, we use a needle driver as it is stronger,
allowing more pressure to be applied to the instrument. As for the direction of the
dissection, we dissect evenly in each direction, careful not to work too much on one
side of the dissection ([Fig. 3b]). After enucleation, there are some fibrous tissues and we remove some of them,
using the Probe Plus II to draw the tissue up, then dissecting it with monopolar.
Suturing Methods
Trimming of excess myometrium is required in case of subserosal fibroid ([Fig. 4a1, 2]).
Fig. 4 Reapproximation of the myometrium. (a) (1,2) Trimming of excess myometrium in case of subserosal fibroid. (b) How to introduce the suture into the intraperitoneal cavity: (1) external view;
(2) internal view. (c) (1) Starting the continuous suture; (2) It is important to maintain tension by keeping
the suture tight. (d) Seromuscular suturing. (1,2) The edge of the wound needs to be inverted. (3) Tension
on the suture needs to be maintained at all times. (Reproduced with permission from
Andou M. Ota Y, Hada T, Kanao H. Laparoscopic Myomectomy for huge fibroid- focusing
on difficult cases. In Hiramatsu Y, Konishi I, Sakuragi N, Takeda S eds. Mastering
the Essential Surgical Procedure. OGS Now, No.11 Uterine fibroid (Japanese). Tokyo:
Medical View; 2010:58–69. Copyright © Medical View.)
We generally use synthetic suture 1.0 (Vicryl CT1). We apply interrupted or continuous
suture to reapproximate after the myoma is removed. Suture length is 30 cm for continuous
suture. If the suture shorter than 30 cm is used, several sutures would be required
into the abdominal cavity. Anything longer than 30 cm is difficult to manage and manipulate.
The suture is introduced into the intraperitoneal cavity via the port site ([Fig. 4b1, 2]).
When the defect is deep, we suture in several layers. While suturing, we make sure
that the needle is introduced into the tissue at 90 degrees. We also ensure that each
suture goes deep enough into the tissue to hold and prevent injury to the organ. The
deeper the myoma bed, the more difficult the suturing repair becomes. In the case
of a very deep defect, the assistant tracks the edge of the defect with suture. This
is to ensure that there is no dead space after the wound is closed as this can result
in hematoma. These deep defects often require suturing in four or five layers ([Fig. 4c1, 2]).
For superficial reapproximation, we use baseball suture or seromuscular reapproximation
([Fig. 4d1, 2], [3]). I prefer seromuscular reapproximation as, by this method, the edge of the wound
becomes inverted, prohibiting subserosal bleeding and lowering the risk of adhesion
of the bowel to the wound. Another advantage of large bite seromuscular suturing is
that the suture compresses the uterus tightly and by this we can lower the risk of
hematoma and postoperative bleeding.
Needle Driving
The most important point is to pass the need through the tissue perpendicularly. This
makes it possible to involve full layers of the tissue. This facilitates good perfusion
as not involving the full thickness of the tissue reduces blood perfusion, a disadvantage
for wound healing and adds the possibility that shallow driving could lead to tissue
laceration and bleeding.
When the Endometrium is Perforated
In the case that the endometrium is perforated, we close the opening of the uterine
cavity using 4.0 monofilament suture in a continuous fashion to prevent interuterine
adhesion. When this is difficult to perform, we place a Surgicel into the uterine
cavity and then reapproximate the myometrium.
The Location of the Fibroid
There are three types of fibroids depending on the location—subserosal, intramural,
and submucosal. When we perform the myometrial incision and enucleation for large
subserosal myomas, due to an excess of tissue, we need to trim the tissue by making
a “hip-shaped” incision. After dissecting the fibroid, the myometrium has the tendency
to shrink down; so not overestimating the amount of tissue to be trimmed is one important
point to keep in mind when making the initial “ship-shaped” incision.
As for the pedunculated subserosal fibroid, there are often blood vessels at the stork
which need suture ligation to prevent excessive bleeding.
Submucosal fibroid removal always carries a high risk of perforating the endometrium.
Because of this, we need to control the power of retraction. We must dissect the fibroid
from the endometrium using scissor in a meticulous manner to prevent injury. Although
it is important not to create dead space when suturing the myometrium, it is also
important to be aware of the balloon manipulator inside the uterus as puncturing the
balloon or including the balloon in a suture bite is a real possibility in this scenario.
Accurate suturing is vital for avoiding these potential complications.
Suture Ligation Methods
To reapproximate the myoma bed, we need intracorporeal ligation techniques. Due to
the amount of tension on the sutures in these circumstances, to prevent loosening
we use a slip knot or a surgeon's knot and sometimes a modified surgeon's knot—our
triple throw surgeon's knot.
The Number and the Size of Fibroids
Number
A large number of fibroids are not always a barrier. One of our cases managed a successful
pregnancy after more than 30 fibroids were removed. However, there are limitations
when it comes to fibroid removal. As the number of fibroids increases, the chance
of blood loss and surgical time also naturally increase. As wounds finally become
scar tissue, there is a risk of uterine rupture during pregnancy after fibroid removal,
and the number of fibroids determine the risk of rupture due to the increased number
of fibroids equating to the amount of scar tissue. There are limitations in what can
be addressed in terms of removing multiple or very large fibroids and these risks
need to be considered thoroughly with every case.
Size
If the diameter is over 7 cm, there is a sudden increase in the difficulty in LM,
and the difficulty increases exponentially. It takes longer to enucleate larger fibroids.
The blood loss also increases and reapproximation and extraction get increasingly
difficult with the increase in the size of the fibroid. If the diameter of the fibroid
exceeds 13 cm, enucleation becomes almost impossible as the fibroid is pushed against
the abdominal wall with dissection from the uterus. As a result, we have defined our
limit as 12 cm. Although we set our size limit at 12 cm, this is not to say that we
can remove any fibroid under this limit. There are several factors that determine
whether a fibroid is operable via LM. They include the shape of the fibroid, the number
of fibroids, the location of the fibroid, as well as the experience of the surgeon.
Extraction of the Specimens
In our institute, we use vaginal retrieval since we began LM in 1998. While we have
always used scissors morcellation at our institute, the use of electric morcellators
was once popular for extraction. On April 17, 2014, the Federal Drug Administration
(FDA) in the United States reported a warning regarding the use of electric morcellators
in laparoscopic hysterectomy and myomectomy for patients with fibroids. Unexpected
malignancy, especially uterine sarcoma may have been caused by the dissemination of
tumor cells during morcellation for the removal of fibroids. At that time, the FDA
removed its recommendation for the use of electric morcellators in such surgery. According
to the FDA, the incidence of sarcoma after fibroid removal operations is reported
at 0.28%. Due to this warning from the FDA, the use of electric morcellation devices
has suddenly decreased. Recently, “in-bag” morcellation and vaginal extraction after
creating an opening in the posterior vaginal fornix is a popular trend in this surgery.
Vaginal Extraction
First, we pass suture through the biggest fibroid. In the case of multiple fibroids,
we place suture through each of the fibroids, from the biggest to the smallest. Once
the fibroids are strung together like beads, the uterine manipulator is removed and
replaced with the Vagi-Pipe. We create the exit in the posterior vaginal fornix with
a transverse incision, 1 to 2 cm below the cervix ([Fig. 5a, b1, 2], [3]) and then we introduce the suture stringing the fibroids together into the Vagi-Pipe
via the vaginal opening using a needle driver ([Fig. 6a, b]). This suture is pulled from the vagina and the fibroids are extracted. The surgeon
moves to the vaginal area for the retrieval.
Fig. 5 Extraction of the fibroids (1). (a) Placement of the vaginal pipe. The vaginal pipe is inserted and the posterior vaginal
fornix is pushed to elucidate the appropriate incision line. (b) (1,2) How to maintain the operative field during the incision of the posterior vaginal
fornix. The surgeon pushed the uterine cervix anteriorly while the assistant pushed
the rectum posteriorly. (3) The surgical view of opening the posterior vaginal fornix
using a monopolar hook. (Reproduced with permission from Andou M. Ota Y, Hada T, Kanao
H. Laparoscopic Myomectomy for huge fibroid- focusing on difficult cases. In Hiramatsu
Y, Konishi I, Sakuragi N, Takeda S eds. Mastering the Essential Surgical Procedure.
OGS Now, No.11 Uterine fibroid (Japanese). Tokyo: Medical View; 2010:58–69. Copyright
© Medical View.)
Fig. 6 Extraction of fibroids (2). (a) In the case of multiple fibroids, we use suture to connect the fibroids like beads
on a string. (b) This suture is introduced into the vaginal opening for extraction. (c) Extraction from the vagina. (1) Suture connecting the fibroids in pulled out of
the vagina, introducing the fibroids into the vaginal opening. (2) The fibroids are
grasped with two Museux forceps. (3) We core the fibroids with scissors. (Reproduced
with permission from Andou M. Ota Y, Hada T, Kanao H. Laparoscopic Myomectomy for
huge fibroid- focusing on difficult cases. In Hiramatsu Y, Konishi I, Sakuragi N,
Takeda S eds. Mastering the Essential Surgical Procedure. OGS Now, No.11 Uterine fibroid
(Japanese). Tokyo: Medical View; 2010:58–69. Copyright © Medical View.)
Small fibroids only require gentle pulling of the suture for extraction. However,
in the case of larger fibroids, we need to reshape the fibroids by cutting using strong
scissors to enable exit. To prevent pelvic organ injury, like injury to the bladder
or the rectum, maintenance of the operative field is of paramount importance. We maintain
the extraction space using a bent ribbon retractor (width 2.5 cm). The bent ribbon
retractor pushes the vaginal incision dorsally, while a rectangle retractor expands
the opening ventrally. We grasp the fibroids using tenaculum and cut the fibroids
and reshape them in the space between the two retractors ([Fig. 6c1, 2], [3]).
Sometimes the fibroid is too large to descend into the small pelvic area. In that
case, we remove the trocar from the center abdominal port site and insert a long scalpel
(19 cm) into the abdominal cavity via this port for morcellating the fibroid ([Fig. 7a]). We remodel the fibroid without cutting it into pieces to enable it to descend
([Fig. 7b1, 2]). The fibroid is sliced in parallel cuts, eventually, to take on an accordion shape
and then the fibroid is introduced into the small pelvis. We grasp the fibroids via
the vagina and morcellate using long scissors. If the scalpel is directed to the adjacent
organs, it can cause serious organ injuries. Therefore, we do not begin slicing until
the scalpel is completely introduced into the body and is under complete control.
The scalpel has the potential to drop into the abdominal cavity and cause organ injury
so constraint grasping of the scalpel is extremely important. The direction of cutting
needs to be upward, cutting toward the space between the fibroid and the abdominal
wall. If the fibroid is cut into pieces, extraction of the fibroid becomes difficult.
This is the reason we chose to remodel the fibroid—to ensure its complete removal.
Fig. 7 Transabdominal morcellation. (a) Introduction of a long handled scalpel into the abdominal cavity via the midline
port site. (b) Real surgery long scalpel morcellation. (Reproduced with permission from Andou M.
Ota Y, Hada T, Kanao H. Laparoscopic Myomectomy for huge fibroid- focusing on difficult
cases. In Hiramatsu Y, Konishi I, Sakuragi N, Takeda S eds. Mastering the Essential
Surgical Procedure. OGS Now, No.11 Uterine fibroid (Japanese). Tokyo: Medical View;
2010:58–69. Copyright © Medical View.)
First, the leading surgeon's assistant pulls the fibroid bilaterally using craw forceps.
Then the center of the fibroid is cut and parallel slices are made into the fibroid
without cutting through it completely. We then place the fibroid upside down and do
the same kind of parallel-intermittent cutting on the other side without cutting the
fibroid into pieces. We place a stitch in the fibroid to create an anchor point. The
tail of this suture is fed into the vagina and pulled to extract the fibroid through
the vagina.
When the fibroid is degenerated we use an extraction bag. We carry the fibroid into
this bag and close the bag's purse-string suture. This is introduced into the vagina
and pulled to extract the fibroid.
The exit at the posterior vaginal fornix is closed in two layers using continuous
2.0 or 1.0 synthetic suture ([Fig. 8a, b]).
Fig. 8 Closure of the vaginal opening. (a) How to suture the opening of the vagina—needle driving. (b) Postclosure status in real surgery. (Reproduced with permission from Andou M. Ota
Y, Hada T, Kanao H. Laparoscopic Myomectomy for huge fibroid- focusing on difficult
cases. In Hiramatsu Y, Konishi I, Sakuragi N, Takeda S eds. Mastering the Essential
Surgical Procedure. OGS Now, No.11 Uterine fibroid (Japanese). Tokyo: Medical View;
2010:58–69. Copyright © Medical View.)
Hemostasis and Irrigation
Clots or blood coagula is completely removed as coagula is one cause of the intraperitoneal
adhesion. At this time we confirm complete hemostasis. According to the guidelines
of JSGOE (Japanese Society of Gynecology and Obstetrics Endoscopy), the usage of an
antiadhesion barrier is beneficial, however, we do not use it. From our experience,
most of the cases that have undergone a cesarean section after our myomectomy have
not had any adhesions found. After placing a drain, the port sites are closed ([Fig. 9]).
Fig. 9 Abdominal wounds—One 12-mm umbilical port and three 5-mm manipulation ports. (Reproduced
with permission from Andou M. Ota Y, Hada T, Kanao H. Laparoscopic Myomectomy for
huge fibroid- focusing on difficult cases. In Hiramatsu Y, Konishi I, Sakuragi N,
Takeda S eds. Mastering the Essential Surgical Procedure. OGS Now, No.11 Uterine fibroid
(Japanese). Tokyo: Medical View; 2010:58–69. Copyright © Medical View.)
Conclusion
In LM, there are three important steps—enucleation, repair, and extraction. Each of
them requires advanced laparoscopic skills. Laparoscopic suturing and knot tying are
important prerequisites for attempting this kind of surgery. We need to continually
train ourselves in basic laparoscopic skills like suturing, knot tying, and needle
driving using a dry box to achieve the level required to manage this kind of surgery
safely. To achieve healthy wound healing, accurate intracorporeal suturing is vital.
Until suturing and ligation are complete, bleeding from the wound continues and when
the speed of suturing and ligation is slow, blood loss is increased. Thus, the role
of speed in these basic skills is of extreme importance ([Fig. 10]).
Fig. 10 Postdissection status. (a) Closure status from the view of the vagina. (b) The specimen. (Reproduced with permission from Andou M. Ota Y, Hada T, Kanao H. Laparoscopic
Myomectomy for huge fibroid- focusing on difficult cases. In Hiramatsu Y, Konishi
I, Sakuragi N, Takeda S eds. Mastering the Essential Surgical Procedure. OGS Now,
No.11 Uterine fibroid (Japanese). Tokyo: Medical View; 2010:58–69. Copyright © Medical
View.)
Even when preoperative diagnosis shows a benign fibroid, we sometimes encounter a
sarcoma or malignant uterine tumor, so we need to explain the risks of these possibilities
to the patient. However, in our institute, the incidence of malignant disease is very
low compared with published data from Europe and the United States. In our data, 9,645
cases underwent hysterectomy or myomectomy from 1994 to 2015. A total of 9,594 of
these were leiomyoma, three cases were STUMP (Smooth muscle Tumor of Uncertain Malignant
Potential), 13 cases leiomyosarcoma, six cases of endometrial stromal sarcoma, two
cases of adenosarcoma, and 27 cases of carcinosarcoma. Among these cases, preoperatively
undetected cases were 3 per 9,645 (0.00031%). Of course, this kind of incidence means
that it is difficult to encourage patients of child-bearing age to undergo hysterectomy,
but we need to obtain informed consent and accurately explain the risks of more conservative
approaches.
