Laparoscopic myomectomy, although feasible, may be difficult to perform because proper closure of the myometrium requires laparoscopically directed suturing and, thus, requires more technical skills than many other endoscopic procedures. While it is possible that microprocessor-assisted (robotic) laparoscopic myomectomy may allow more surgeons to suture effectively under laparoscopic guidance, in expert hands there appears to be no benefit to robotic surgery in any measurable perioperative outcome (40).
There remain some questions regarding the efficacy of laparoscopic myomectomy, especially as it relates to the treatment of infertility and heavy menstrual bleeding, each of which are thought to be secondary to submucous myomas. Although there are some well-designed randomized clinical trials evaluating infertility outcomes comparing laparoscopic myomectomy to that performed by laparotomy, the sample sizes are still relatively small, and the cases are highly selected, limiting the size and number of the lesions to be removed (41,42). In these trials, fertility outcomes were similar between the laparoscopic and the laparotomic approaches. These and other trials evaluating perioperative outcomes, such as duration of admission, surgical pain, and operative complications, found the laparoscopic approach to be superior (43).
Proper patient selection for myomectomy, regardless of route, is extremely important, particularly because, by age 50, the prevalence of leiomyomas may be as high as 70% in whites and 80% in women of African ancestry (44). It is relatively easy to mistakenly ascribe symptoms to the presence of leiomyomas. Unless the myoma involves the endometrial cavity, it is unlikely to contribute to heavy menstrual bleeding or infertility; the impact of intramural myomas on infertility is not well understood (45). Leiomyomas that cause pressure are often large and may be located near vital vascular structures that may preclude the laparoscopic approach even in expert hands. Many women will do well with expectant or medical management or with procedural alternatives such as uterine artery embolization. The surgeon should freely select a laparotomic approach, either at the outset or during the procedure, if technical limitations put the patient at risk or otherwise compromise the potential relevant clinical outcomes (46). Patients who have pedunculated or subserosal leiomyomas that cause bothersome discomfort or pain in association with torsion are especially good candidates for laparoscopic excision (13,47).
Laparoscopic hysterectomy encompasses a variety of procedures, including the facilitation of vaginal hysterectomy with variable extents of endoscopic dissection, supracervical hysterectomy by dissection, amputation and mechanical removal of the fundus, and the removal of the entire uterus under laparoscopic direction (48–50). In most environments, the procedure is performed with a combination of electrosurgical vessel sealing devices and mechanical cutting systems, often incorporated into a single instrument. In some instances sutures, clips, and linear cutting and stapling devices are employed in the process of dissecting or occluding vascular pedicles.