Uterine fibroids or uterine myomas are benign smooth muscle neoplasms of the uterus, commonly affecting women of reproductive age. It is often associated with significant morbidity.
It is estimated to be found clinically in up to 25% of women of reproductive age group. Although often asymptomatic, it has been reported that approximately one-quarter of women with uterine fibroids have symptoms severe enough to seek medical attention.
Surgery is often indicated in symptomatic patients unresponsive to conservative medical forms of management.
Surgical management of uterine fibroids utilizing minimal access surgical techniques has revolutionized the management of patients with uterine fibroids.
Laparoscopic surgery for uterine fibroids compared to open surgery is associated with faster patient recovery, earlier discharge from hospital, higher patient satisfaction rate, and generally decreased morbidity and mortality.
Laparoscopic myomectomy implies the removal of uterine fibroids using the laparoscopic technique with the conservation of the uterus. This management option is often reserved for women desirous of future childbearing. This technique is especially advantageous for this group of women because of the reported reduced incidence of postoperative adhesions compared to open surgery.
However, laparoscopic myomectomy is not feasible in every case of uterine fibroids. Therefore careful patient selection based on the size, number, type, and localization of the fibroids or myomas is key. Additionally, the patient’s associated comorbidities where applicable warrant due consideration during patient selection.
Task analysis for Laparoscopic Myomectomy is at this moment outlined.
Laparoscopic myomectomy is done under general anesthesia. Therefore, standard preoperative evaluation of patient applies including ensuring adequate hemoglobin preoperatively and assessment of patient’s fitness for general anesthesia.
Positioning:
Following general anesthesia, the patient should be in the supine position with thighs abducted and flexed about 45 degrees at the hip and legs supported with stirrups. The patient’s buttocks are positioned just beyond the edge of the operating table to facilitate uterine manipulation with an intrauterine cannula /manipulator.
The surgeon should stand on the left side of the patient. However, where the pathology occurs on one side of the abdomen, it is generally recommended that the surgeon stand opposite to the pathology.
The monitor, target organ, and surgeon’s visual axis should be in the coaxial line; the camera assistant should be to the right of the surgeon.
The first assistant should be on the right of the patient opposite the surgeon, while the second assistant who would be handling the uterine manipulator should be between the patient’s legs.
Instrumentation:
Standard instrumentation in Laparoscopic surgery including electrosurgical generator, 10mm 30 degree telescope, light source, camera, Insufflator, CO2 cylinder, suction/irrigation system and suction cannula.
Other instruments required include Veres needle, ports ( 10mm and 5mm), Maryland, atraumatic grasper, strong grasping 10mm forceps(claw forceps or tenaculum), 5mm myoma screw, myoma rod, monopolar needle or hook, bipolar grasper, harmonic scalpel, curved scissors, sutures (1 vicryl), knot pusher,
Vasopressin (20units ) diluted in 100mls of normal saline, electric morcellation device which allows large myomas to be extracted.
Technique:
After routine cleansing and draping under aseptic conditions. The lower border of the umbilicus is held with 2 Allis forceps. Using a #11 blade, a small stab incision is made with the blade in a transverse position. The Veres needle is checked for patency and spring action. The Veres needle should be held at a distance equals the patient’s abdominal wall thickness plus 4cm, and it should be held like a dart.
The abdominal wall should be held full thickness with the help of thenar, hypothenar, and all four fingers of the other hand and pulled up or lifted as far as possible. As the Veres needle is inserted, there should be a 45-degree elevation angle, and it should be perpendicular to the abdominal wall, and the distal end should be pointed toward the anus.
With proper technique, the surgeon will hear two clicks as the needle penetrates the layers of the abdominal wall.
The proper placement is confirmed using an irrigation/aspiration test and a hanging drop test. Insufflator is turned on, and CO2 gas allowed to flow for a transient period to remove air from tubing before connecting it to the Veres needle.
Connect the CO2 gas tube to Veress needle and set to a flow rate of 1 L/min, Preset pressure should be 12 or 15mmHg
Observe Quadro-manometric indicators, which include the preset pressure, actual pressure, flow rate and volume of gas.
The flow rate may be increased to 3-6L/min after an initial 1-1.5L of gas has been insufflated.
Uniform abdominal distension, loss of liver dullness are some of the signs that confirm pneumoperitoneum.
Once adequate pneumoperitoneum is achieved, which in an average person often requires about 1.5Litres of gas, the 10mm cannula is used to make an impression on the skin of the abdominal wall at the proposed site for placement. This will guide the size of the skin incision made before port placement. A smiling shape infra umbilical incision approximately 11mm in size is made.
A 10mm port is held like a gun and inserted with a twisting action tilted about 60 degrees towards pelvis while the other hand provides minimal counter traction.
In obese patients, it should be inserted perpendicular to the abdomen wall.
The trocar is removed and with proper placement, the sound of escaping gas is heard. The CO2 tubing is connected to the primary port, and the flow rate is often set to 6L/min.
The camera should be focused at about 10cm from a gauze piece, and white balancing should be done before inserting the telescope. The telescope is held in such a way that the camera cable is positioned at 6 O’clock while the light source is held at 12 O’clock position.
Once inserted, a quick inspection of the intra-abdominal cavity should be done.
At this point, the operating table should be placed in Trendelenburg's position about 15 degrees. Up to 30 degrees Trendelenburg may be required but should not be maintained for long periods to avoid respiratory complications. This position helps mobilization of bowel from the pelvis aided by the atraumatic grasper.
The telescope is advanced just to the target, and with transillumination, the target point is noted on the abdominal wall. From this point, the sites for port placement are identified using the baseball diamond concept. In this case, the uterus with fibroids is considered the target.
The primary port is often placed at the Infra umbilical position for uterine sizes less than 12weeks. For uterine sizes for more than 12 weeks, the primary port position may be above the umbilicus. Palmer’s point is often utilized for the primary port in cases with uterine sizes exceeding 18weeks.
Accessory ports are inserted under direct vision. Two 5mm ports or one 10mm and a 5 mm port may be inserted.
For Ipsilateral ports on the left side, the first accessory port is placed at a point corresponding to the snuff box position of the left hand when placed on the abdomen using the diamond shape concept. This position is approximately 7.5cm inferior and lateral to the primary port. The second accessory port is placed about 5-7.5cm inferior and lateral to the first accessory port and above the anterior superior iliac spine. The port should be lateral to the inferior epigastric identified by direct visualization or transillumination.
The additional contralateral port may be required in cases of very large fibroids. Diagnostic laparoscopy should be performed at this time. For patients with concomitant infertility, tubal patency may be evaluated by injection of dilute methylene blue through the intrauterine cannula. This additionally helps to identify endometrium during the procedure.
The procedure involves four main phases:
Hysterotomy and exposure of the myoma,
Enucleation of myoma,
Suture of hysterotomy or myoma cavity and
Extraction of myoma.
Hysterotomy or incision of myometrium and exposure of the myoma:
Dilute vasopressin (20units in 100mls of normal saline) is injected just beneath the capsule of the fibroid enough to make a bleb. Enough is injected to penetrate the capsule of the fibroid, causing the area injected to appear white or pale. This also facilitates dissection of the fibroid.
Hysterotomy incision is made over the fibroid obliquely in the case of anterior fibroids and sagittally in cases of posterior fibroids.
In cases of multiple fibroids, it is planned so that a maximal number of fibroids is removed through one incision, although in such cases, closure of hysterotomy can be difficult and require skill and experience.
Monopolar current in low voltage cutting mode or harmonic scalpel may be used to make the incision.
The incision is extended into the capsule exposing the site of cleavage between myometrium and the fibroid.
Enucleation of myoma:
Using a Maryland and a grasper, the edges are pulled apart. Myoma screw may be inserted at this point to help with traction.
Blunt dissection may be carried out with blunt instruments such as myoma rod or suction cannula.
The dissection proceeds from the superficial areas inwards. In some cases, sharp dissection with scissors may be required.
Hemostasis of the intramyometrial vessels is carried out progressively, using bipolar forceps or harmonic scalpel where applicable.
Care should be taken to avoid excessive coagulation, as this may lead to weak scar formation.
Dissection is continued by the process of traction and counter traction until the myoma is enucleated.
Hysterotomy suture:
Absorbable sutures such as #1 vicryl are often used.
The extracorporeal or intracorporeal suturing technique may be utilized.
In the case of subserosal myomas, the hysterotomy is closed in one plane.
When the myomectomy is located deeply, several sutures may be required using the extracorporeal suture knotting technique.
An attempt should be made to close the defect as completely as possible to reduce the chances of hematoma formation with consequent postoperative febrile morbidity.
The serosal layer is closed using Dundee jamming knot continuous suturing technique with Aberdeen termination.
Myoma extraction:
Common methods of extraction include removal via posterior colpotomy and by electric morcellation.
The performance of posterior colpotomy is facilitated by an assistant elevating the posterior fornix of the vagina from below with a veil held by a sponge forceps. The posterior colpotomy is made about 2cm above the vaginal attachment of the uterosacral ligaments using monopolar cutting current or harmonic scalpel.
A 10mm forceps with jaws is inserted through the colpotomy under direct vision and this is used to grasp the myoma.
Depending on the size, the myoma may be extracted whole or if large morcellated before extraction through the colpotomy.
Alternatively, the 10mm accessory port may be enlarged to 12 or 15mm to allow the introduction of an electric morcellator. A claw forceps is inserted through the morcellator channel and used to grasp the myoma, which is then progressively cut by the morcellator and extracted piecemeal.
The morcellator should be held as if pointing to the abdominal wall in such a way as to avoid the risk of injury to surrounding organs by the morcellator blade.
Following extraction, irrigation is performed as deemed adequate using normal saline.
Especially in cases with associated infertility, Interceed may be placed along suture lines as further prophylaxis against adhesions.
Upon completion, ports are removed under vision. It is important to ensure that all gas is let out.
The 12 mm port is closed using cobbler’s needle or Veres needle technique under vision.
The port with the telescope is removed last with the telescope in place such that the cannula comes out of the incision before the tip of the telescope. This technique is employed to prevent omentum or bowel entrapment in the incision.
The port is closed with sutures previously placed with cobblers or Veress needle technique. The 5mm ports do not require closure.
The skin incision is closed with staples or steri strip, and a dry dressing applied.