Laparoscopic myomectomy called safe, reliable

OB/GYN News, Nov 15, 2004 by Miriam E. Tucker

NEW YORK -- Laparoscopic myomectomy is safe and reliable, even in the presence of multiple or enlarged myomas, Ornella Sizzi, M.D., said at an international congress of the Society of Laparoendoscopic Surgeons.

Although laparoscopic myomectomy was first performed more than 20 years ago, there is still debate about its indications, as well as postoperative reproduction outcomes and recurrence rates. However, compared with laparotomic myomectomy, the laparoscopic procedure has clearly been shown to result in a reduced hemoglobin drop, less postoperative pain, less febrile morbidity, and faster recovery time.

"Considering the high recurrence rate also with laparotomy and the consequent risk of repeated surgery, we think that patients should be offered the least invasive surgical approach available," said Dr. Sizzi of Villa Valeria Hospital, Rome.

She reported her institution's experience with 332 patients who underwent laparoscopic myomectomy between 1991 and 2003 and were not lost to follow-up. All had symptomatic myomas measuring at least 4 cm in diameter. The patients had an average of 2.23 myomas each (range 1-8), with an average size of 6 cm (range 1-20 cm).

The duration of the entire procedure ranged from 30 to 360 minutes, the average drop in hemoglobin was 1.06 g/100 mL. and the conversion rate to laparotomy was 1.5%.

Over a follow-up of 148 months, the recurrence rate was 25%, which is similar to rates reported in the literature for laparotomic myomectomy, she noted.

Pregnancies occurred in 56.5% of these patients, similar to the rates of 53.6% for laparoscopic myomectomy and 55.9% for laparotomic myomectomy seen in a previous prospective, randomized study (Hum. Reprod. 2000;15:2663-8). Spontaneous abortion rates did not differ from those reported with the laparotomic procedure.

The long duration of the procedure is a downside. However, duration is highly influenced by the learning curve: For a single intramural myoma 5 cm in diameter, the average operating time dropped from 158 minutes in 1992-1993 to 130 minutes in 1994-1995 at her hospital. "And now we've improved even more," Dr. Sizzi said.

The introduction in 1993 of the Steiner electromechanical morcellator has also considerably reduced the length of operating time. Still, the size of the dominant myoma dictates how long the procedure will take. "Laparoscopic myomectomy is still a long procedure," she said.

Other advances in technique, as practiced at her institution, have helped further optimize the laparoscopic procedure.

Currently, preoperative GnRH is used only in women with serious anemia resulting from persistent menometrorrhagia to improve hemoglobin concentration before surgery or, in cases of single, very large myomas, to improve mobilization. Otherwise, GnRH is not used because it has been shown to increase the risks of recurrence and conversion, and possibly to increase the difficulty in identifying and dissecting the cleavage plane between the myoma and its pseudocapsule.

Uterine cannulation is essential for obtaining optimal exposure of the myoma, maintaining the myoma in a central area of the operation field, and applying countertraction during enucleation and suturing, Dr. Sizzi said.

To reduce vascularization and blood loss, diluted vasoconstrictive agents are injected laparoscopically between the myometrium and the myoma capsule until blanching occurs. The use of vasoconstrictive agents has allowed for less use of electrosurgery to achieve homeostasis in favor of sharp dissection. As a result, "Our data showed significantly reduced hemoglobin drop after use of vasoconstrictive agents," she said.

Following enucleation, the uterine suture is made along one or two different planes, with one larger stitch reaching the deep layers and one more superficial suture to introflect the serosa. A too-superficial suture can lead to the buildup of an intramural hematoma, she said.

The use of a running suture--starting in the deeper plane at the apex of the myomectomy scar to the base and continuing along the more superficial plane from the base to the apex and tied intracorporeally--has also resulted in a reduced hemoglobin drop, compared with use of an interrupted suture (0.61 vs. 1.1 g/100 mL).

BY MIRIAM E. TUCKER

Senior Writer