Task Analysis for Laparoscopic Myomectomy

Sukriti Malaviya

Definition: 

Uterine fibroids or uterine leiomyomas are benign smooth muscle tumours of the uterus.

Signs and Symptoms:

They are symptomatic in only 35-50% of patients and depending upon location, size, secondary changes & pregnancy status they may cause:

• Abnormal uterine bleeding
• Dysmenorrhoea
• Pressure Effect: when large in size may distort or obstruct other organs like ureters, bladder or rectum causing urinary symptoms, hydroureter, hydronephrosis, constipation, pelvic venous congestion & lower limb oedema. 
• Cervical tumours cause serosanguinous vaginal discharge, bleeding, dyspareunia or infertility.
• Infertility: multiple causes are there, fertility is affected more with endometrial cavitary tumours.
• Spontaneous Abortion: More with intracavitary tumour.

Imaging:

• Pelvic ultrasonography with doppler study is very helpful in confirming the diagnosis.
• Saline hysterosonography can identify submucous myoma that may be missed on USG and to differentiate it from polyp.
• MRI  highly accurate in delineating the size, location & no. of myomas.
• Ultrasound KUB for urinary symptoms including IVP to show ureteral dilatation.
• Hysteroscopy for identification & removal of submucous myomas.

Classification:

Grade 0	Pedunculated subserosal fibroid
Grade 1	Involvement of < 50% of outer uterine wall
Grade 2	Involvement of > 50% of myometrial wall
Grade 3	Fibroids that extend from mucosa to serosa

Laparoscopic management of fibroid uterus:

• Selection of patient: should be fit for surgery and general         anaesthesia.
• Preop evaluation: Only to be done for myomas not exceeding 10 cms in size or when uterus is less than 18 weeks in size,                 

Number, location, distance between the myomas and endometrial
cavity should be known by imaging.                                                 
Also myomectomy should not be done for multiple intramural myomas that is not more than 3-4 intramural myomas at one sitting and for myomas <1cm in size.

• Laparoscopic Myomectomy needs good suturing skill. Inadequate suturing has led to reports of uterine rupture in pregnancy and labour.

Pre operative preparation of patient:

• Consent for myomectomy
• Consent for conversion of procedure into open surgery in case of any complication.
• Consent for chances of hysterectomy in case of severe complications.
• Bowel preparation: On previous day of surgery patient is allowed soft diet till afternoon, followed by liquid diet up-till midnight. Nil by mouth for at-least 8hrs before surgery. PEGLEC powder can be given for bowel preparation on previous night of surgery. Pre-op medications and antibiotic dose to be given 1hr before surgery.

Laparoscopic myomectomy:

• Laparoscopic Myomectomy should be done under General Anaesthesia.
• Position of patient: at the time of pneumo-peritoneum by Veress needle, patient should be placed supine with 10 to 20 degree head down or supine position if Veress needle will be inserted perpendicular.                                                                                         

If uterine manipulator will be used then patient will be in lithotomy position, patient lies with thighs spread, with abduction, and buttocks over the edge of the table, with 30 degree trendelenburg position after placing the primary port.

• Patient return end plate should be attached to thigh.

 
Instruments and equipment required:
                                      

• Monitor CCD-camera, light source, insufflator with CO₂ cylinder, electrosurgical generator, and suction irrigation system- all in one cart.
• Veress needle, 10mm 30 degree telescope,10mm port, three 5mm ports, Maryland, atraumatic-grasper, semi-traumatic grasper, monopolar hook, bipolar grasper, harmonic scalpel, cold scissors, 5mm myoma screw, 2 needle holders, 10mm tenaculum, motorized morcellator, suture material no1 Vicryl, knot pushers and suction cannula and tubing, vasopressin in the dilution 5IU+20ml normal saline and 100-200ml of diluted vasopressin can be used.

Position of surgical team:

• Surgeon should stand on left side of the patient during Veress needle insertion and opposite to the side of pathology to start the surgery,          Monitor, target organ and surgeons visual axis should be in a coaxial line. 
• Camera assistant should be on right side of the surgeon, 

  Two assistant surgeons one on the right side, opposite to the main surgeon and second for holding the uterine manipulator (avoided in unmarried females).

• Scrubbed nurse should be on the left side of surgeon.
• Preparation of parts done by scrubbing and draping under aseptic techniques.

Preparation of equipment:

• Insufflator is turned on to remove air from tubings and preset pressure is set at 12-15mm Hg for myomectomy surgery and set flow rate is set

at 1 l/min initially, for veress or open technique,                                    Total volume of gas required to create pneumoperitoneum may vary according to patient’s body type from 1.5-6 litres,                        
Camera is turned on and white balancing followed by focusing is done at a distance of 10 cms.

• Tubings of insufflator and the connections of required instruments, bipolar/harmonic with electrosurgical generator are checked and set up. All the cables should be arranged in proper position.

 
Operative Steps proper: -   Take 10cm Veress needle and check for its spring action and patency.

• Take 2 Allis forceps to evert and hold each side of umbilicus.
• Use blade to place small horizontal stab wound for primary port. Depending upon the size of uterus and likelihood of adhesions

(previous surgery etc), primary port is placed such that the target of
dissection is at a distance of 18-24cm,                                                      If uterus is less than 12 wks size, primary port is kept at inferior
umbilical crease,                                                                                    
If uterus is 14 to 18 wks size then primary port will be supra-umbilical,    If uterus is 20 wks size, primary port should be placed at palmar’s
point, and                                                                                                  
In case of previous lower abdominal surgery with scar below umbilicus, supra-umbilical port is preferred and in case of scar till umbilicus, palmer’s point is preferred.                                                   Also, in obese patients, 20cm Veress needle is used and entry point is usually through infra-umbilical area, 22.5cm from xiphisternum.  Hasson’s open access technique can also be used in case of
suspicion of adhesions due to previous surgery etc.                                

• Then use mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath.
• Measure abdominal wall thickness and add 4cm for distance to hold Veress needle.
• Hold Veress needle at calculated length like a dart.
• Assistant and surgeon to hold the lower abdomen up, abdominal wall should be held in full thickness.
• At the time of insertion of Veress needle, there should be 45 degree elevation angle (perpendicular entry in case of adhesions and obese patients), and the distal end of the Veress needle should be pointed toward the anus and perpendicular to abdominal wall.
• Insert Veress needle until two clicks felt.
• Confirm correct Veress needle placement by irrigation test, aspiration test, plunger test and hanging drop test.
• Connect CO₂ gas tube to Veress needle and turn on CO₂ and allow flow rate of 1 l/min, insufflation pressure ideally should be 12-15mmHg in myomectomy surgery.
• Observe quadro-manometric indicators to rise in parallel for volume of gas and actual pressure and observe for general distension of abdomen and percuss for obliteration of liver dullness. Once 1litre of gas has entered increase flow rate to 2-3 l/min                               Always keep a watch on gas leak by co-relating total volume of gas, actual pressure, actual flow rate and ETCO_2. While anaesthetist should keep a watch on vitals of patient and capnograph and ETCO_2, so as to detect any complication early.
• Once pneumo-peritoneum is achieved extend skin incision, smiling shape to 11 mm in size.
• Hold 10mm port like a gun and insert it perpendicular to abdomen & tilt to 60-70 degree towards pelvis when there is loss of resistance.
• Confirm intra-abdominal placement of primary port with escaping air sound and audible click and take out trocar.
• Set the flow rate to 6-10 litres/minute.
• Connect gas tubing to primary port.
• Insert telescope and inspect entry point to exclude any bowel or vessel injury.
• Request for Trendelenburg position of 30 degrees.
• Camera cable should be at 6 o’clock and light source should be at 12 o’clock.
• Apply baseball diamond shape principle for secondary port insertion (ipsilateral and contralateral). Make a diamond shape with thumbs at umbilicus and index fingers towards target organ.   .
• Transilluminate at target organ, the uterus with fibroids and confirm  position of secondary ports.
• Incise skin along Langer lines for two secondary ports.
• Insert lateral ports under vision (5mm x 2 at LIF and RIF) at position of snuff box, which is about 18cm from target i.e base of myoma. They should be placed, high and outside the epigastric vessels so that good access is provided and distance between two working ports is not less than 5cm and not more than 15cm and between telescope and working port 5-7.5cm.
• Additionally, suprapubic port can be used for anterior wall myoma to

insert myoma screw, and                                                                        
liver retractor can be used for post wall myoma in unmarried female as uterine manipulator cannot be used.

• All secondary trocar should be inserted perpendicular to the abdominal wall till tip enter peritoneum and then oblique.                  Trocar on the opposite side of the body of patient is introduced by holding in suicidal knife position.
• Diagnostic laparoscopy should be done first with atraumatic grasper to perform systematic inspection of entire abdomen and pelvis in clockwise fashion.

Task analysis after Access:

• Preventive Haemostasis
• Fixation of Myoma
• Enucleation Myoma
• Obliteration of Dead space
• Retrieval of Myoma

Preventive haemostasis: 

• Vasopressin 5IU+20ml normal saline is the dilution, 100-200ml of diluted vasopressin can be used. It is injected at the stalk of the fibroid or at the junction of the fibroid with the uterus at 30 degree angle ( for pedunculated fibroids generally vasopressin is not required).
• Now look for blebbing or marble white appearance of fibroid due to injected vasopressin.
• Carefully plan for incision, if ipsilateral ports are used then horizontal/ oblique incision is recommended and in case of contralateral port position vertical or oblique incision is recommended.
• In case of multiple fibroids incision is planned in such a way that maximum myomas can be removed from one incision.
• Now incise the most bulging part on the fibroid with harmonic scalpel or low voltage monopolar current in cutting mode until the capsule of the myoma is visualised.

Fixation of myoma and enucleation:

• With two graspers, cut edges are pulled so that the capsule is exposed and tenaculum or myoma screw is inserted.
• Now with myoma screw give gradual traction preferably antero-medial traction and counter traction with blunt instrument like suction cannula and blunt dissection is done.
• Position of myoma screw is changed from time to time to apply traction on cleavage line until enucleation is done.
• The large feeding vessels at the base of the fibroid are cauterised with bipolar and cut with scissor or harmonic scalpel is used.
• At the base, careful dissection is done so as to slowly separate and detach the myoma and not to avulse the entire endometrium by abruptly pulling the myoma and tearing the tissues. Also, bleeding is less this way.                                                                                           

Hence pushing the tissue towards uterus is better rather than pulling the myoma.

• Care is also taken not to open the cavity. Always, when required remain as nearer as possible to the myoma. 
• Undue use of cautery is avoided as it leads to defective healing and weak scar formation.
• Myoma after removal is placed in the cul-de sac or para-colic gutters.
• In Broad ligament myoma, anterior leaf of broad ligament is cut parallel to the round ligament i.e. in the grey area so that bleeding is less, care should be taken never to cut in mesosalpinx.                          Ureter must be identified and careful dissection and enucleation of the myoma is done, should not be pulled abruptly, or else ureter or uterine artery can be avulsed. Repair of peritoneum not required.
• In case of subserosal (grade 0) myoma it can be directly cut from the base with harmonic scalpel or monopolar spatula/hook/scissors (taking care with monopolar that bladder is behind and there should be no overshooting) or an extracorporeal knot can be tied towards the uterus and myoma can be cut out with bipolar maryland and scissor and no need to close the serosa in these cases.

Obliteration of dead space:

• Reconstruction of myoma bed is done with no 1 Vicryl suture.
• The main aim of suturing is to obliterate the dead space to avoid haematoma formation.
• Many types of suturing techniques can be used.
• Start from one angle, first suture should be placed beyond the angle.
• The rest of the defect is closed.
• Last suture should be beyond the other angle.
• For grade 1 myoma single layer continuous or extracorporeal tension sutures can be applied. 
• For grade 2 or deep intramural myoma double layer continues suturing is required or extracorporeal knots for inner muscle layer and continuous suture for outer serosal layer.
• When cavity is opened three layer of suturing is required:                     

First, endometrium closed by continuous suture,                      Second, muscle layer closed by continuous suture or with
extracorporeal knots, and                                                                 
Third, serosal layer again closed by continuous suture. -  Spread Intercede over raw area.
Extraction of myoma: It can be done by

• Morcellator: One of the ports is converted to 15mm and morcellator inserted. The myoma is held with tenaculum and is fed to motorized morcellator. Take care not to move morcellator near the tissue instead tissue to be fed to morcellator with tenaculum.
• By colpotomy in multipara women - pressure with sponge is given in posterior fornix and incision is made 3cm below cervix and myoma is removed by claw forceps. The colpotomy wound is closed by extracorporeal square knot or is sutured vaginally.
• A meticulous lavage is given, haemostasis is checked and preceded with port closure.
• Port closure is done under vision with outer sheath of Veress needle or suture passer, after slightly deflating the abdomen so that sutures are not in tension.
• The last port to be closed is the telescope port, done after completely deflating the abdomen, and keeping the telescope in and removing the cannula followed by telescope at last.
• The skin incision is closed with staplers and dressing done.