Page 28 - World Journal of Laparoscopic Surgery

World Journal of Laparoscopic Surgery, May-August 2009;2(2):33-36
Laparoscopic Myomectomy: Does it have any Advantages over Conventional Laparotomy?

Laparoscopic Myomectomy: Does it have any

Advantages over Conventional Laparotomy?

Cromwell HM Mwakirungu
Consultant, Obstetrics and Gynecology, Nairobi, Kenya

Abstract not complain while some suffer debilitating symptoms from very
Uterine myoma commonly referred to as fibroids, are so far the small myomas.
commonest benign tumors of the female genital tract and are the The pathogenesis of myomas is ill understood though it is
commonest soft tissue tumors of all. Worldwide, several thousand well known that multiple myomas in the same uterus are derived
patients suffer yearly and some undergo surgery as a result of from individual myometrial cells and not through a metastatic
symptoms and complications of fibroids. Myomectomy, the removal process. Myoma growth is hormone dependent explaining why
6
of fibroids has always been done by laparotomy but recently, they are rare prior to menarche and regress after the menopause.
laparoscopic myomectomy has been started and is really getting
support from endoscopic surgeons. Laparoscopic myomectomy, a This is the time when sex steroids mainly estrogens and
heterogenous procedure, ranges from a simple procedure to a more progesterone are at their lowest. Studies have found that
complex one requiring expert laparoscopic suturing skills. Large estrogen and progesterone receptors are over expressed in
pedunculated myomas are easily removed laparoscopically, but myoma tissues compared to other normal myometrial tissue. 7
intramural ones really pause a challenge for these surgeons. Several Uninterrupted estrogen supply encourages myoma growth;
studies have been conducted mainly nonblind ones and the results, however growth is interrupted in low levels as in smokers and
though encouraging, do not look scientifically convincing. Laparoscopic
myomectomy has its advantages but as is any new mode of treatment pregnancy. Growth may at times be excessive in pregnancy.
or surgery, it has its opponents and proponents. This is explained by increased blood flow to the uterus during
The few double blind studies done have good convincing pregnancy. 8
conclusions but more really needs to be done. The biggest challenge The main symptoms which make patients visit their doctors
in laparoscopic surgery in general, is the cost of the equipment and are:
therefore the cost of surgery. 1. Abnormal uterine bleeding
When this study was undertaken, initially it was thought no data
would be obtained, but by the time of completion of the study, there 2. Pressure
was enough data collected. Only that, different investigators, looked 3. Pelvic/abdominal pains
at different issues differently. It was concluded that more research 4. Rapid growth
work needs to be done so that we may have more convincing, well 5. Infertility
researched issues to lay the fears of the doubting at rest. 6. Repeated abortions.
Keywords: Myoma, myomectomy, laparoscopy, hysteroscopy, Management of fibroids is varied and may depend on the
GnRH agonists.
physician the patient visits first. This can be medical or surgical.
Medical treatment uses GnRH analogues which produce an
INTRODUCTION
estrogen deficient milieu thereby reducing the symptoms of the
Uterine leiomyomas are the commonest tumors of the uterus patient. Unfortunately for the medical treatment, it cannot be
and the female pelvis. The incidence amongst women ranges offered over a long time. It is therefore used while waiting for
1
from 20 to 25% but have been shown to be as high as 70 to the patient to make up their mind through proper counseling.
80% in studies using histologic or sonographic exami- GnRH analogues help reduce the size of myomas enabling easy
nations. 2-4 Women of African and Caribbean origin are said to surgery or building up of the hemoglobin levels of the patient
have the highest incidences. 5 before surgery. 9-11
Myomas arise from the smooth muscle cells of the uterus Myomectomy or hysterectomy are the other treatment modes
and as they grow, depending on the resistance against them, a patient with symptomatic fibroids is offered. Hysterectomy is
they may remain within the muscle (intramural), push their way usually proposed to those who might have completed their
to just below the serous covering of the uterus (subserous), or family size while, myomectomy is proposed for those who for
just beneath the mucous lining of the endometrial cavity (sub- one or other reason (fertility or personal) would want to keep
mucous). Myoma symptoms have a good correlation with their their uterus. A patient should also be educated to help her or
location explaining why some patients with large myomas may together with her spouse to make an informed decision.

33