Page 22 - Laparoscopic Journal - WJOLS

Vaibhav A Dunghav
4 months after surgery and delivered a baby girl at In the experimental group, the median hemoglobin
38 weeks gestation via cesarean section. drop measured on day 3 postoperatively was 1.2 g/dl. In
Another study performed by Ji Hae Bae et al in 90 the control group, the mean hemoglobin drop measured
patients. Results show 51 patients (56.6%) underwent on day 3 postoperatively was 1.45 g/dl. The time needed
laparoscopic myomectomy with uterine artery ligation to put the clips in place (the time from the opening of the
(group A), and 39 patients (43.3%) underwent laparoscopic retroperitoneum and the positioning of the clips) varied
myomectomy alone (group B). The mean operating time between 6 and 40 minutes. No patient required blood
was 100.0 ± 33.8 minutes in group A and 90.0 ± 37.1 minutes transfusion. There were no conspicuous complications.
in group B. Both groups were similar with respect to
mean blood loss (72.3 ± 109.0 vs 62.6 ± 77.3 ml). The myoma DiSCUSSion
recurrence rate in group A was significantly less than in Excision of fibroids from the uterine corpus, repair of
group B after a median follow-up period of 11.1 months the uterine incision, control of operative blood loss, and
(2 vs 13%). removal of large fibroids are major concerns during LM.
A study by Z Holub et al assessed the effect of lateral Control of operative blood loss might be the most cri-
uterine artery dissection (LUAD) on clinical outcomes tical consideration. Most intraoperative conversions to
in laparoscopic myomectomy (LM). Fifteen women with laparotomy reported in the literature have been because
symptomatic fibroids (dominant fibroid size: 3–6 cm) of intraoperative bleeding. Previous studies study also
12
were randomly allocated to laparoscopic myomectomy confirmed the most serious complication during LM for
(group A) and 16 women to the combined operative large fibroids is severe intraoperative hemorrhage and
procedures LM and LAUD (group B). They assessed subsequent blood transfusion. More women with symp-
13
the clinical outcomes: intraoperative and postoperative tomatic uterine fibroids request laparoscopic manage-
blood loss, operating time, hospital stay, hemoglobin fall, ment with preservation of the uterus. As the size of
inflammatory response and tissue markers [C-reactive fibroids increases, it is necessary to develop a manage-
protein (CRP), creatinin kinase and white blood cells ment strategy to circumvent surgical problems related
(WBC)]. The mean operating time was 69.5 minutes to large fibroids. Pretreatment with GnRH agonist can
in group A and 76.5 minutes in the group B, and the shrink the fibroids and theoretically simplify myomec-
mean length of hospital stay was 2.6 days vs 2.1 days, tomy. However, GnRH agonist therapy may alter the
respectively (p > 0.05). For the laparoscopic myomec- myoma-myometrium interface and induce the disap-
tomy and combined operative procedure, respectively, pearance of small fibroids; therefore, it may increase
the intraoperative blood loss was 134 ml (10–400 ml) the difficulty of fibroid enucleation and the incidence of
and 93.7 ml (10–200 ml) (p > 0.05); the difference (92.4 recurrent fibroids. 14-16 In addition, GnRH agonist therapy
vs 46 ml) in estimated postoperative blood loss was provides only a slight benefit in reducing blood loss. 17
statistically significant (p < 0.05), and the decline in the Therefore, it is suggested that pretreatment with GnRH
–1
hemoglobin level was 1.2 g/dl (group A) vs 0.6 g/dl –1 agonist be used in selected LM cases.
(group B) on the 3rd postoperative day (p < 0.05). Group Vasopressin is a posterior pituitary hormone with a
B demonstrated a less intense stress response in terms of strong vasoconstrictive effect on smooth muscle. Local
CRP (p < 0.001) and WBC (p < 0.01). The LUAD had little administration of vasopressin to the uterus is helpful in
impact on intraoperative blood loss. This may be due to controlling bleeding during myomectomy. 18,19 Possible
the smaller fibroid size, but the statistical difference in drawbacks include bleeding from the needle puncture
hemoglobin fall on the 3rd postoperative day was signifi- sites, which often persists throughout the procedure,
cant. The dissection of the uterine artery in laparoscopic requiring later electrosurgical coagulation, and delayed
20
myomectomy is a feasible surgical procedure with a low bleeding in the myometrium. If unexpected bleeding
rate of complication. occurs, the goal of controlling operative bleeding will not
A study by Giuseppe Vercellino et al of 166 women be achieved.
with symptomatic uterine myomas necessitating surgical Placing a tourniquet around the lower uterus to stop
intervention who wished to retain their uteri, 80 under - the blood flow to the uterus can facilitate a myomectomy.
went laparoscopic uterine artery clipping and myomec- It is, however, difficult to perform during a laparoscopy
tomy (experimental group) and 86 received laparoscopic because there are no appropriate instruments. Modified
myomectomy only (control group). Main outcome mea- procedures have been introduced for this purpose in
sures were operating time, number and weight of leio- laparoscopic surgery. 7,21 They can effectively reduce blood
myomas, blood loss, Doppler examination of the uterine loss during LM and have the potential to prevent fibroid
arteries and complications of procedure. recurrence. Nevertheless, suture and hemoclip ligations
54