Laparoscopic Uterine Artery Ligation Studied

OB/GYN News, Oct 1, 2001 by Betsy Bates

OR ORLANDO, FLA. -- Laparoscopic uterine artery ligation may be the gynecologic surgeon's best answer to uterine artery embolization performed by interventional radiologists, Dr. Leroy Charles said at a meeting of the One Kilo Club.

The delicate procedure performed through four surgical ports has produced good results in 33 of Dr. Charles' patients, including 1 woman with multiple leiomyomas who avoided a hysterectomy and was able to become pregnant.

Not all patients with uterine leiomyomas are candidates for uterine artery embolization (UAE) or laparoscopic uterine ligation. Some fibroids require hysterectomy, said Dr. Charles of Tufts University in Boston.

But for the many patients with fibroids and menometrorrhagia, a simpler alternative is in great demand. Laparoscopic surgery could meet that patient desire, perhaps with fewer drawbacks than the UAE procedure, in which particles or Gelfoam are inserted via a catheter threaded from the groin through the femoral artery to the uterine artery.

"Transcatheter arterial embolization is successful and safe most of the time," Dr. Charles said. But serious complications, including necrosis, peritonitis, and one death from septicemia, have been reported.

Uterine artery embolization is also expensive, reportedly reimbursed by some insurance companies at up to S 17,000. The cost of a laparoscopic hysterectomy by contrast, is reimbursed at about $600-$1,800, Dr. Charles said at the meeting held in conjunction with the 37th International College of Surgeons' North American Federation Congress.

Dr. Charles' technique for uterine artery ligation was perfected by practicing on cadavers, he explained at the first meeting of the One Kilo Club, the ob.gyn. section of the U.S. Section of the International College of Surgeons.

He explained that while the patient is under general anesthesia, one 10- to 12-mm laparoscope is placed at or above the umbilicus. Three other 3- to 5-mm ports are placed, two suprapubically and the other parallel to, and left of, the umbilical port while the surgeon stands to the left. The surgeon follows the internal iliac vessels and lifts the ovary to expose the ureter from the pelvic brim to the ureteric canal. The uterine vessels are identified, dissected, and separated from the endopelvic fascia. A nonresorbable nylon suture tie or clip is placed on each vessel, and the ureters are inspected for motility

A second technique for larger uteri utilizes an approach anterior to the uterus. The bladder flap is opened and the bladder dissected down until the uterine vessels are exposed lateral to the cervix. Each uterine vessel is then dissected and can be tied off with a nylon suture or clip.

"Where there is a good dissection of uterine vessels, bipolar forceps could be used to coagulate and desiccate the uterine vessels. It's a question of preference," Dr. Charles said in an interview.

"There is very, very little bleeding with this technique and I am very pleased with it," he said. Patients' uteri "shrink down nicely."

Postprocedural pain control, which has been a significant problem with UAE, is not a major issue since fibroids do not necrose as they do following UAE.

Submucosal or pediculated fibroids that are most likely to cause pain and postembolization syndrome can be identified and removed during the laparoscopic procedure.

Following laparoscopic uterine artery ligation, patients take 800 mg of ibuprofen three times daily. No patient has been readmitted for pain or infection.

Dr. Charles considers the opportunity to perform a combination myomectomy/uterine artery ligation a major advantage of laparoscopic surgery over UAE. Endometriosis and dermoid cysts have also been treated in conjunction with uterine artery ligation.

One patient's uterus size was reduced from an 18-week size to a 12-week size, at which time she became pregnant and gave birth successfully at term.

Most patients return home 2-3 hours after the procedure, even though they had fibroids removed or other concomitant procedures during the same surgery.

Dr. Charles, who is in private practice in Springfield, Mass., examines patients before discharge, 1 week later, and at every 3 months thereafter to conduct a Doppler flow examination. He said he is preparing two reports on the procedure for publication.