Limiting the number of uterine incisions has been suggested in order to reduce the risk of adhesions to the uterine serosa (126). However, in this manner tunnels must be created within the myometrium in order to extract distant fibroids, making hemostasis more difficult within these defects. Hemostasis is important in order to avoid adhesion formation, and fibrin, leucocytes, and platelets in the presence of erythrocytes leads to adhesion formation. If tunneling incisions are avoided and hemostasis secured immediately, the risk of adhesion formation should be lessened. Therefore, if incisions are made directly over the fibroids and only those fibroids that are easily accessed are removed, the defects can be promptly closed and hemostasis can be secured immediately (112). Multiple uterine incisions may be needed, but adhesion barriers may help limit adhesion formation (127).
Currently available instruments make laparoscopic myomectomy feasible, although the size and number of fibroids reasonably removed limits the wide application of this approach because of the technical difficulty of both the procedure and laparoscopic suturing (128). Although microprocessor-assisted myomectomy (robotic) may obviate some of these technical problems, the added cost and longer operating times associated with this approach must be considered (see Chapter 25).
A systematic review of randomized controlled trials of laparoscopic versus open myomectomy included six studies with a total of 576 patients (129). Laparoscopic myomectomy was associated with longer operating times but reduced operative blood loss, less postoperative decline in hemoglobin levels, reduced postoperative pain, more patients fully recuperated at day 15, and fewer overall complications. Major complications, pregnancy rates, and new appearance of fibroids were comparable in the two groups.
Case series without controls show the feasibility of laparoscopic surgery in women with large fibroids. In a series of 144 women with mean fibroid diameter of 7.8 cm (range, 5 to 18 cm), only 2 women required conversion to laparotomy (130). In another series of 332 consecutive women undergoing laparoscopic myomectomy for symptomatic fibroids as large as 15 cm, only 3 women required conversion to laparotomy (131).
Port placement should be based on the position and size of the fibroids to be removed (Fig. 15.5). Laparoscopic suturing may be more ergonomic if there are two ports on either the patient’s right side for right-handed surgeons or left side for left-handed surgeons; a 12-mm port about 2 cm medial to the iliac crest for suture access, and another 5-mm lateral port near the level of the umbilicus (132). A left upper quadrant approach may be used for initial access when uterine size is near or above the umbilicus (133).
Pitressin is injected into the fibroid. An incision is made directly over the fibroid and carried deeply until definite fibroid tissue and the avascular surgical plane is noted. Transverse incisions permit more ergonomic suturing. The fibroid is grasped with a tenaculum for traction and the plane between the myometrium and fibroid is dissected until the fibroid is free. Bleeding vessels in the myometrial defect are desiccated sparingly with bipolar electrosurgical paddles, taking care not to devascularize the myometrium and interfere with wound healing. Delayed absorbable sutures are placed in one, two, or three layers, as needed, adhering to accepted surgical technique at laparotomy. Morcellation of the fibroid with an electromechanical device is accomplished under direct vision. The pelvis and abdomen are irrigated, the ﬂuid suctioned, and an adhesion barrier may be placed.