Page 40 - World Journal of Laparoscopic Surgery

Hanom Husni Syam

vaginal delivery at term. Cesareans were performed in 22 cases, Most studies have reported an increased incidence of
including 21 at term and one at 26 weeks gestation. Two cesarean section (Hurst et al, 2005). This is not unexpected in
pregnancies were associated with a normal delivery, but the the presence of a scarred uterus. In addition, most patients
mode of delivery is unknown. Eight resulted in first trimester have a history of infertility and are in the older age groups. This
pregnancy loss, one was an ectopic pregnancy, and one patient though does not make myomectomy a mandatory indication for
underwent elective termination. Spontaneous uterine rupture elective cesarean sections, high vaginal delivery rates have
was not noted during pregnancy or at term in any of the cases. been achieved in studies by Dubuisson et al, (2000).
Our series did not confirm the hypothesis that laparoscopic Recommendations for a waiting period before attempting
myomectomy is associated with an increased risk for uterine pregnancy to ensure adequate wound healing though
dehiscence during pregnancy. recommended have been questioned (Landi et al, 2003), and are
Dubuisson JB et al (1996), reported that the overall rate of not backed by good evidence. Paul et al (2006), showed that the
intrauterine pregnancy, after laparoscopic myomectomy, was majority of their patients conceived in the first year after surgery
33.3% (seven patients). Out of the seven pregnancies, four (82.6%) and a significant number in the first six months (55.6%).
were spontaneous and began within 1 year of the operation. Nezhat et al (1999), described that the increased incidence of
The other three were achieved after in vitro fertilization in cesareans is not surprising, since this is the recommended
patients with associated infertility factors. In the four patients method of delivery for women in whom the uterine wall has
who gave birth by cesarean section, no adhesions were found been deeply penetrated. All of the patients who delivered
on the myomectomy scar. From these preliminary results, vaginally had pedunculated or subserosal myomas.
laparoscopic surgery for myomas seems to offer comparable Pregnancies following any surgical procedure involving the
results with those obtained by laparotomy. No uterine rupture uterus have an increased risk of rupture or dehiscence during
was observed. pregnancy and labor. Such risks in relation to cesarean sections
Ribeiro SC et al (1999), laparoscopic myomectomy can be have been well quantified. This has helped in improved
offered to patients who want to have children and who refuse management of post-cesarean pregnancies before and during
to undergo an abdominal myomectomy. Patient selection as labor. The same cannot be applied in cases of women with a
well as meticulous surgical technique is the key factors in previous history of myomectomy, whether open or laparoscopic,
achieving a successful outcome. because of the absence of good quality studies. One possible
Daraï E et al (1997), reported that of 19 pregnancies were cause of uterine rupture after laparoscopic myomectomy is the
obtained in 17 patients after laparoscopic myomectomy (38.6%): wide use of electrosurgery that may result in poor vascularization
eight vaginal deliveries, three cesarean sections, four and tissue necrosis with an adverse effect on scar strength
miscarriages, two abortions, one ectopic pregnancy and one (Nezhat et al, 1996). Electrosurgery was used to remove the
therapeutic abortion. No uterine rupture was noted. Pelvic myoma and obtain hemostasis in five out of the six reported
adhesions were found in the four patients who underwent uterine ruptures. In one case the uterus ruptured at 26 weeks
second-look procedure. Their preliminary results indicate that following laparoscopic myolysis of a 3 cm intramural myoma
laparoscopic myomectomy is a useful technique. (Arcangeli and Pasquarette, 1997). Myolysis is an endoscopic
technique in which the tumor is coagulated with the help of
bipolar probes inserted into the myoma. In the reported case
DISCUSSION
there was no suture of the uterine wound.
Myomectomy is a challenging procedure because it involves Although many studies did not show any cases of uterine
the reconstruction of an organ that can undergo remarkable rupture, the occurrences mentioned above should serve as a
structural changes, as it does in pregnancy. The literature warning. Considering that the procedure of laparoscopic
documents normal reproductive performance of uteri after myomectomy is rather new, it may not be efficacious for patients
laparotomic myomectomy (Li et al, 1999). Paul et al (2006), found who desire future pregnancy, especially when performed by
that the frequencies of early pregnancy losses and preterm the novice endoscopic surgeon. In any case, laparoscopic
deliveries in their series were within normal limits, though that myomectomy should be performed cautiously. Excess thermal
for ectopic pregnancies was higher (4.3%). This is consistent damage should be avoided and adequate uterine repair must be
with the higher incidence of ectopic pregnancies in patients assured using multiple layer suturing techniques. Both thermal
with infertility (Pisarska and Carson, 1999). Nezhat et al (1999) damage and hematoma formation have been blamed as causes
found that in their series, the observed frequency of miscarriages, for suboptimal healing and rupture during a future pregnancy
ectopic pregnancies and preterm deliveries was within normal (Dubuisson et al, 2000; Landi et al, 2003). Thermal damage has
limits. The present 19% miscarriage rate matches the 19% been especially blamed in cases where subserous myomas were
reported after myomectomy at laparotomy (Buttram and Reiter, removed (Nkemayim et al, 2000). Correct reapproximation is not
1981). dependent on the number of layers of sutures but on the

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