uterine leiomyomas are the most common of the pelvic tumors . lifetime incidence of benign uterine tumors among white women is 40% by the age of 35 and > 70% by the age of 50 .
adenomyosis is a benign gynecologic condition characterized by ectopic endometrial gland invasion of the myometrium associated with hyperplasia of the adjacent smooth muscle .
the therapeutic strategy for these benign uterine tumors has recently shifted toward conservative surgical treatment , to preserve the uterus and fertility .
this strategy has had widespread use in women who have had children but still want to preserve the uterus .
conservative surgical therapeutic methods for removal of these tumors include laparotomic and laparoscopic approaches , with laparoscopy being the procedure more commonly used for most benign gynecologic tumors .
however , some of the operative procedures , particularly those for laparoscopic myomectomy and adenomyomectomy , present challenges for surgeons , including complete excision of the tumor , firm suturing , reduction of dead space at the site of defects , and limitation of intraoperative blood loss .
a few reports have introduced techniques for laparoscopic myomectomy or adenomyomectomy . the most serious and frequent complication is pronounced and uncontrollable bleeding , but
few studies have reported techniques to reduce blood loss during surgery . in addition , the use of endoscopic vascular clips to limit blood loss during laparoscopic adenomyomectomy has not yet been thoroughly investigated .
safe conditions , such as controlled bleeding and a clean operative field , must be guaranteed for laparoscopic operations , regardless of operative time , to ensure fewer adverse events during laparoscopic myomectomy and adenomyomectomy , particularly during the learning curve necessary for novice surgeons to gain proficiency . in this study , we present data for the use of transient occlusion of uterine arteries ( toua ) during laparoscopic myomectomy and adenomyomectomy .
we introduce a technique for toua and describe its effectiveness for the excision of benign uterine tumors with preservation of fertility .
from february 1 , 2011 through march 31 , 2013 , 104 patients undergoing laparoscopic myomectomy ( n = 70 ) and adenomyomectomy ( n = 34 ) with toua were enrolled .
laparoscopic myomectomy without toua ( n = 40 ) during the study period and laparoscopic adenomyomectomy without toua ( n = 24 ) reported in a prior publication  and the toua groups are presented herein .
all operations were performed in consecutive patients by a single surgeon ( y .- s .
inclusion criteria were a symptomatic intramural uterine myoma or adenomyoma , diagnosed by ultrasonography , that was refractory to conservative medical treatment and the desire of the patient for uterine preservation .
conservative laparoscopic operations with toua were suggested to all patients who fulfilled the inclusion criteria .
the operating time was considered the period from skin incision to skin closure ; the size of the tumor was the maximum diameter of the tumor on ultrasonography ; toua time was the period from initial serosal incision of the triangular area ( defined by the round , ovarian , and infundibulopelvic [ ip ] ligaments and the psoas muscle ) to the occlusion of the opposite uterine artery ; and operative blood loss was estimated by subtracting the rinse volume from the blood volume that was collected in the suction apparatus .
surgical excision of benign uterine tumors , with toua to limit blood loss , is performed as follows .
general anesthesia is induced , and the patient is placed in a dorsal lithotomy position with endotracheal intubation . a uterine manipulator ( hangzhou shikonghou medical equipment co. ltd . ,
beijing , china ) is placed in the uterine cavity , to facilitate moving the uterus into the optimal position during excision and suturing .
once pneumoperitoneum is achieved , video laparoscopy ( storz , tuttlingen , germany ) is performed with a 10-mm trocar that has been introduced through the umbilicus . for the introduction of the surgical instruments , a 12-mm trocar for the endoscopic vascular clip
is placed through an incision on the left side , a 5-mm trocar through an incision on the right side of the lower abdomen , and another 5-mm trocar for both clips through a median line incision just above the mons pubis .
the peritoneum is incised with a cutting monopolar electrode through the triangular area ( round , ovarian , and ip ligaments , and the psoas muscle ) and along the ip ligament .
the umbilical artery is isolated by blunt - tip suction , and the assistant moves the artery upward and in a lateral direction .
it is possible to isolate the branching uterine artery along the umbilical artery using blunt - tip suction .
the isolated uterine artery is occluded with an endoscopic vascular clip ( temporary atraumatic endo - vessel - clips ; b. braun korea co. , ltd . ,
occlusion of the artery on the opposite side of the uterus is performed by the same method ( figure 1 ) .
about 3 minutes is spent expelling the arterial blood immediately after completion of both transient occlusions .
, the myometrium covering the myoma is deeply incised with a monopolar cutting electrode until the underlying myoma is visualized .
, the uterine serosa covering the adenomyoma is deeply incised with a monopolar cutting electrode until the underlying endometrium is visualized .
the adenomyoma is distinguished from normal myometrium by tactile and visual means for complete cytoreductive excision .
the serosa covering the adenomyoma is maintained at a 5-mm depth , to facilitate the suturing of excisional defects , and the involved endometrium is spared as much as possible to preserve fertility .
three layers of sutures are used in the defect area after excision of the myoma or adenomyoma : a wide , deep , single interrupted suture in the first layer ; a continuous , nonlocking , running suture in the second layer ; and a continuous interlocking suture in the third layer .
the first assistant holds the stitch to maintain suture tension throughout the repair ( figures 2 and 3 ) . finally , both endoscopic vascular clips are removed safely , and the excised tumor is removed with an electric morcellator ( ethicon , inc . , somerville , nj , usa ) .
serial steps of laparoscopic excision of a uterine myoma a , a 6.0-cm posterior uterine myoma compressing the endometrium .
the statistical package for the social sciences ( spss , inc . , chicago il , usa ) was used for statistical analysis .
data are expressed as the mean  sd or the absolute number ( with percentage of total group ) .
surgical excision of benign uterine tumors , with toua to limit blood loss , is performed as follows .
general anesthesia is induced , and the patient is placed in a dorsal lithotomy position with endotracheal intubation . a uterine manipulator ( hangzhou shikonghou medical equipment co. ltd . ,
beijing , china ) is placed in the uterine cavity , to facilitate moving the uterus into the optimal position during excision and suturing .
once pneumoperitoneum is achieved , video laparoscopy ( storz , tuttlingen , germany ) is performed with a 10-mm trocar that has been introduced through the umbilicus . for the introduction of the surgical instruments , a 12-mm trocar for the endoscopic vascular clip
is placed through an incision on the left side , a 5-mm trocar through an incision on the right side of the lower abdomen , and another 5-mm trocar for both clips through a median line incision just above the mons pubis .
the peritoneum is incised with a cutting monopolar electrode through the triangular area ( round , ovarian , and ip ligaments , and the psoas muscle ) and along the ip ligament .
the umbilical artery is isolated by blunt - tip suction , and the assistant moves the artery upward and in a lateral direction .
it is possible to isolate the branching uterine artery along the umbilical artery using blunt - tip suction .
the isolated uterine artery is occluded with an endoscopic vascular clip ( temporary atraumatic endo - vessel - clips ; b. braun korea co. , ltd . ,
occlusion of the artery on the opposite side of the uterus is performed by the same method ( figure 1 ) .
about 3 minutes is spent expelling the arterial blood immediately after completion of both transient occlusions .
transient occlusion of uterine arteries ( toua ) with endoscopic vascular clips . a , left side .
in myomectomy , the myometrium covering the myoma is deeply incised with a monopolar cutting electrode until the underlying myoma is visualized .
enucleation of the myoma is completed with endoscopic scissors and a dissector . in adenomyomectomy ,
the uterine serosa covering the adenomyoma is deeply incised with a monopolar cutting electrode until the underlying endometrium is visualized .
the adenomyoma is distinguished from normal myometrium by tactile and visual means for complete cytoreductive excision .
the serosa covering the adenomyoma is maintained at a 5-mm depth , to facilitate the suturing of excisional defects , and the involved endometrium is spared as much as possible to preserve fertility .
three layers of sutures are used in the defect area after excision of the myoma or adenomyoma : a wide , deep , single interrupted suture in the first layer ; a continuous , nonlocking , running suture in the second layer ; and a continuous interlocking suture in the third layer .
the first assistant holds the stitch to maintain suture tension throughout the repair ( figures 2 and 3 ) .
finally , both endoscopic vascular clips are removed safely , and the excised tumor is removed with an electric morcellator ( ethicon , inc . , somerville , nj , usa ) . a drainage tube is inserted through the suprapubic incision .
serial steps of laparoscopic excision of a uterine myoma a , a 6.0-cm posterior uterine myoma compressing the endometrium .
d , sutured uterus after removal of both vascular clips from the uterine arteries . three - layer suturing method for laparoscopic adenomyomectomy . a , a 5.0  6.0-cm posterior uterine adenomyoma .
the statistical package for the social sciences ( spss , inc . , chicago il , usa ) was used for statistical analysis .
data are expressed as the mean  sd or the absolute number ( with percentage of total group ) .
from february 1 , 2011 through march 31 , 2013 , 144 patients with a diagnosis of symptomatic benign uterine tumors and a desire for uterine preservation were enrolled .
in addition , 24 patients with symptomatic adenomyoma who had undergone laparoscopic adenomyomectomy without toua before this study were enrolled .
of the 168 patients , 110 underwent laparoscopic myomectomy with ( n = 70 ) or without ( n = 40 ) toua , and 58 underwent laparoscopic adenomyomectomy with ( n = 34 ) or without ( n = 24 ) toua .
all procedures were performed by a single surgeon ( y .- s.k . ) using the aforementioned procedures .
the mean age in the laparoscopic myomectomy group with toua was 42.15  5.24 years and that in the non - toua group was 41.96  6.56 years .
the mean ages in the laparoscopic adenomyomectomy groups with or without toua were 43.79  4.94 and 42.89  3.98 years , respectively .
the mean maximum diameters of the uterine myomas in the toua and non - toua groups were 5.87  1.68 and 6.19  1.93 cm , respectively .
the mean maximum diameters of the uterine adenomyomas in the toua and non - toua groups were 5.29  1.82 and 3.9  1.48 cm , respectively .
the operative outcomes compared between the 2 groups included operation time , estimated blood loss ( ebl ) , and number of conversions to laparotomy ( table 1 ) .
the mean operative time was longer in the toua groups than in the groups without toua .
the mean time needed to perform toua was significantly longer in the myoma ( 13.9  5.61 min ) group than in the adenomyoma ( 7.33  4.12 min ) group ( p < .05 ) .
comparison between the toua and non - toua groups for laparoscopic myomectomy and adenomyomectomy data are expressed as the mean  sd , or number .
toua time : from the time of incision of the serosa of the right adnexa to the time of occlusion of the left uterine artery .
vascular injury : any injury during toua to such vascular structures as the adnexal and pelvic side retroperitoneal vessels .
abbreviations : ebl , estimated blood loss ; toua , transient occlusion of uterine arteries .
comparative data were analyzed between groups with the same tumor type , with or without toua .
comparative data were analyzed between the toua group with uterine myoma and the toua group with uterine adenomyoma .
the mean ebl during laparoscopic myomectomy was significantly less in the toua group than that in the non - toua group ( mean ebl : 109  73.28 ml in the toua group ; 203.4  152.39 ml in the non - toua group ; p < .05 ) .
although the mean maximum diameters of the adenomyomas were significantly different between the 2 laparoscopic adenomyomectomy groups ( 5.29  1.82 cm with toua ; 3.9  1.48 cm without toua ) , ebl in the toua group was less than that in the non - toua group ( mean ebl : 148.1  93.99 ml in the toua group ; 158.9  103.56 ml in the non - toua group ; p < .05 ) . no conversion to laparotomy or vascular injury occurred in either of the toua groups . none of the patients had fever during the hospital stay .
less bleeding during laparoscopic operations can make the surgery easier and help keep the patient stable .
therefore , the development of methods to lessen bleeding in the operative field is important .
several reports have described different techniques for limiting intraoperative blood loss during laparotomic myomectomy or adenomyomectomy , 2 for laparoscopic myomectomy , but none for laparoscopic adenomyomectomy . at our center , we have a great deal of experience with laparoscopic myomectomy and adenomyomectomy , with or without toua . in our department
, conservative surgical therapy is preferred rather than hysterectomy for benign uterine tumors , and laparoscopy is the main approach , rather than laparotomy .
an injection of vasopressin is widely used to reduce intraoperative blood loss , but it has some disadvantages , including uncontrolled duration of effectiveness , delayed bleeding due to exhaustion of effectiveness during or after surgery , and systemic side effects due to incorrect injection into vessels .
another method is ligation of uterine arteries , in which both arteries are occluded permanently .
unlike these methods , toua with endoscopic vascular clips controls the duration of action , but has no systemic side effects , and its effect is transient , returning blood flow to the uterine arteries when the clips are unlocked .
injuries to the nerves , vessels , and ureters are possible during toua procedures that use endoscopic vascular clips ; however , such injuries can be avoided by an experienced surgeon using blunt dissection to isolate the uterine arteries .
no injuries to nerves , vessels , or the ureters occurred in the operations involving toua in this study .
toua with endoscopic vascular clips can be a challenge in procedures in which clips must be applied to both uterine arteries .
first , it is difficult to approach both uterine arteries in the presence of a large myoma because of the narrow pelvic space , in which an 8-cm - diameter tumor is the upper limit .
second , when the operator stands to the left of the patient with a large myoma , the uterus can be an obstacle to applying the clip to the uterine artery on the opposite ( right ) side
. there could be some differences in time required to perform toua and in the feasibility of its application on both sides .
the time is dependent on the experience of the surgeon , and feasibility can be determined in the surgical planning .
they found no signs of negative effects linked to the use of clips , as both groups showed no difference in the pre- and postoperative doppler values of the uterine vessels . in the present study ,
the postoperative follow - up of all cases showed no signs of insufficient uterine blood supply .
therefore , a routine examination to determine uterine arterial flow may not be needed because of additional collateral blood flow to the uterus .
our data show a difference in performance time for toua between laparoscopic myomectomy and laparoscopic adenomyomectomy however , there was a definite difference in tumor size between uterine myomas and adenomyomas ( myomas have a larger diameter ) and a large benign tumor causing the uterus to be enlarged can be an obstacle during toua procedures . in the present cases of laparoscopic adenomyomectomy , we did not have control data for procedures without toua during the study period . because it involves a much more difficult technique and heavy bleeding in the operative field
thus , we used data for laparoscopic adenomyomectomy without toua taken from a previously published report by the same surgeon . in the comparative analysis , significantly different mean size of uterine adenomyoma was observed between the 2 groups ( 5.29  1.82 cm in the toua group ; 3.9  1.48 cm in the non - toua group ; p < .05 ) . despite the larger size of the adenomyomas in the toua group , laparoscopic adenomyomectomy with toua
had significantly less ebl ( 148.1  93.99 ml with toua ; 158.9  103.56 ml without toua ; p < .05 ) .
we therefore suggest that toua can help ensure patient safety during laparoscopic adenomyomectomy by limiting blood loss and can enable removal of large uterine adenomyomas .
a definite difference in operative time can be observed between novice and expert surgeons , and prolonged laparoscopic procedures can cause serious intra- and postoperative complications .
for surgeons inexperienced in laparoscopic myomectomy or adenomyomectomy , toua can provide stable conditions with limited blood loss during the operation , regardless of operative time .
we suggest that toua is much more helpful during laparoscopic adenomyomectomy than during laparoscopic myomectomy , because the basic principle in myomectomy is pseudocapsulectomy , which is a procedure with less bleeding than occurs with an initial incision of the myometrium ; therefore , myomectomy may involve less blood loss than adenomyomectomy . in adenomyomectomy ,
the tumor is not surrounded by a pseudocapsule and is obscure from normal surrounding myometrium , which could cause heavy bleeding during the operation .
therefore , toua may be more helpful during adenomyomectomy . for the performance of safe toua in benign gynecologic surgeries
, an adequate learning curve should be required , and careful attention should be given during the operation to the risk of injury to the pelvic organs .
no intraoperative or postoperative complications or injuries to nerves , vessels , or the ureters occurred . with the increasing trend toward conservative surgery for benign myomas and adenomyomas , we favor laparoscopy rather than laparotomy .
toua with endoscopic vascular clips could be a useful technique for both experts and novices in laparoscopic myomectomy or adenomyomectomy .
 background and objectives : this study was conducted to determine the feasibility and effectiveness of transient occlusion of the uterine arteries ( toua ) during laparoscopic surgery for benign uterine tumors , with preservation of fertility.methods:patients with uterine myoma or adenomyoma underwent laparoscopic uterine surgery , with or without toua , performed by a single surgeon ( y .- s.k . ) . 
 surgical outcomes included operative time ; occurrence of intraoperative injury of blood vessels , nerves , and pelvic organs ; and intraoperative blood loss.results:of the 168 surgical patients included in this study , 144 were enrolled consecutively during the study period , and 24 had undergone adenomectomy before the study period . 
 a total of 104 women ( 70 with myoma ; 34 with adenomyoma ) seeking uterine preservation underwent laparoscopic surgery with toua for benign uterine tumors . 
 sixty - four women ( 40 with myoma ; 24 with adenomyoma ) underwent surgery without toua . 
 the mean total surgical time of the toua groups was 74.85 minutes for uterine myoma and 84.09 minutes for uterine adenomyoma . 
 the mean estimated blood loss during laparoscopic myomectomy and adenomyomectomy was less in the toua groups than in the non - toua groups ( 109 vs. 203.4 ml in myomectomy , p < .05 ; 148.1 vs. 158.9 ml in adenomyomectomy ; p < .05 ) . 
 time to perform toua was 13.9 minutes in laparoscopic myomectomy and 7.33 minutes in laparoscopic adenomyomectomy . 
 the hospital stay of the toua groups was 3.32 days for uterine myoma and 3.82 days for uterine adenomyoma . 
 no intraoperative conversion to laparotomy was necessary , and no major complications occurred during any of the procedures.conclusion:laparoscopic uterine surgery with toua could be a safe and effective surgical method for women with symptomatic benign uterine tumors who wish to preserve fertility . 
INTRODUCTION
METHODS
Surgical Technique
Laparoscopic Myomectomy and Adenomyomectomy
Statistical Analysis
RESULTS
DISCUSSION
CONCLUSIONS