Page 24 - World Journal of Laparoscopic Surgery

Bhawna Bansal
• 7 out of 10 studies reported length of hospital Articles in this review have been consistent in the
stay. 1,2-6,10 finding of less intraoperative blood loss in the laparo-
• 8 out of 10 studies reported operating time. 1-8,10 scopic approach. This is undoubtedly due to the energy
• 2 out of 10 studies studied the fertility outcomes. 3,8 sources available which reduce blood loss in the same.
There have been two types of trials to compare Laparoscopic myomectomy is a less painful proce-
laparoscopy and laparotomy. The first type compares dure compared to open myomectomy, as indicated by
the short- and long-term intra- and postoperative param- lower visual analog scale (VAS) pain scores at 6 and
eters. The second type compares the fertility outcomes at 48 hours. However, no proof of a big difference in
of both the surgical approaches. pain scores was noted at 24 hours by VAS after surgery
Operating time has been one parameter consid- between laparoscopic myomectomy and all types of
ered. There has been a consistent finding of decreased open myomectomy. Moderate heterogeneity (43%)

operating time in minimal access approach except one for this assessment could be explained by Tan et al in
study. This study had compared laparoscopy-assisted 2008, which included laparoscopically assisted mini-
10
myomectomy with minilaparotomy. laparotomy myomectomy in which laparoscopy is
Intraoperative blood loss has been analyzed by 5 of employed for fibroid enucleation and rapport, and
the 10 studies. There has been found to be a significant specimen removal and suturing are carried out through
difference between the two surgical approaches as far small abdominal incision. This might reduce tissue
as blood loss is concerned with the minimal access damage and operating time compared with open
approach resulting in significantly less blood loss. myomectomy and may skew the results of pain scores.
Decrease in hemoglobin concentration is another way of The overall level of evidence for postoperative pain is
measuring blood loss and has been used by three studies. modest, which means that further research is more
All three studies found a significant difference. likely to have an important impact on our confidence
Postsurgery pain perception and pain relief require- in the estimate of effect of minimal access surgery.
ment have also been measured by 4 out of 10 studies, The minimal access approach also involves less bowel
and here also the laparoscopic approach was found to handling, which invariably results in less postoperative
be significantly better, as the patients perceived less pain paralytic ileus and a shorter time of return to normal
and required less amount of analgesia. bowel reactivity. This finding, however, has been refuted
Days of bowel reactivity/postoperative paralytic ileus by Tan et al.
was measured by 3 of the 10 studies considered in this All the above factors also are contributory toward
review. While two of these found a significant difference early discharge of the patient from the health care facility
with the laparoscopic approach, Tan et al failed to find a and better patient acceptance of the procedure.
significant difference. 6 Myomas have been considered a contributory factor
Duration of hospitalization is another important for infertility, and a lot of patients undergo myomectomy
aspect which is different for both surgical approaches. in order to conceive. Not many studies have compared
the fertility outcomes of myomectomy surgery vis-à-vis
The time to discharge was found to be significantly less
by all studies which analyzes this parameter, except by the surgical approach. However, the limited data available
does not indicate any significant difference in the results
Tan et al. 6 in patients of infertility problem.
Two of the 10 studies considered in this review have Laparoscopy is a technically challenging procedure
reported about fertility outcomes post myomectomy that requires both specialized instruments and advanced
and whether the surgical approach makes a difference intracorporeal suturing capability of the surgeon. Clearly,
8
to the same. Palomba et al did not find any significant laparoscopic myomectomy is not feasible to all patients,
difference in any of the outcomes except the time to and even skilled operative laparoscopists choose lapa-
3
first pregnancy, while Malzoni et al did not find any rotomy in patients with large multiple myomas.
difference in the pregnancy rate.
Many women choose minimally invasive surgery
because of obvious advantages, such as shorter post-
DISCUSSION
operative recovery time and a reduced risk of infection
Operating time has been found to be consistently less for laparoscopic hysterectomy or myomectomy com-
11
10
with laparoscopic approach, except in an earlier study. pared with abdominal hysterectomy or myomectomy.
This could also be due to the learning curve of minimal Nevertheless an important aspect of safety associated

access surgery. The availability of better instruments with laparoscopic hysterectomy or myomectomy is
and energy sources may also have contributed to decrease discussed in the recently published US Food and Drug
in operative time over the course of last 10 years. Administration (FDA) safety communication about
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