Summary Pedunculated myomas are easiest to remove by just coagulating and cutting the stalk. Diluted vasopressin may be injected in the base of stalk. Intramural fibroid require more manipulation so dilute vasopressin should be injected to multiple site between the myometrium and the fibroid capsule.
An Incision is made on the serosa overlying the leiomyomas using the monopolar electrode. The incision is extended until it reaches the capsule. The myometrium retracts as incision is made, exposing the tumour. Two grasping tooth forceps hold the edges of myometrium and the suction irrigator is used as blunt probe to remove covering of the leiomyomas from its capsule. The Myoma crew should be inserted into the fibroid to apply traction while the suction irrigation instrument can be used as a blunt dissector.
The CO2 laser is used to further dissect capsular attachment. Vessels are elecrocoagulated before being cut. After complete Myoma removal the uterine defect is irrigated, bleeding points are identified and controlled with the open jaw of bipolar. If the fibroid is small and patient does not want baby the edges of the uterine defects are approximated by coagulating the myometrium without suturing and tubeligation is performed. If the defect is deep situated, the edges of defect should be approximated by using 4-0 PDS. The repair mainly involve serosal and subserosal layer or can be in one layer.
Sutures are applied at a distance of 5mm. After repair thorough suction and irrigation should be performed. Some gynaecologist use adhesive medical glues over the suture line to prevent adhesion. Even in the hand of expert the laparoscopic myomectomy is difficult. Tumble square knot is better to use if the edges are in tension. Dundee jamming knot with continuous suturing may be used if there is not much tension followed by Aberdeen termination. Precise suturing of several layers is almost impossible laparoscopically. Intraligamentous and broad ligament fibroid are difficult to remove due to risk of injury to ureter and uterine artery at the time of dissection.
Following a thorough exposure of ureter and vessels and depending on the location of Myoma, an incision is made on the anterior or posterior leaf of the broad ligament and the leiomyomas is slowly shelled same as other subserosal or intramural fibroid.
Throughout the procedure the location of the ureter is monitored, bleeding points are controlled by bipolar. The broad ligament and peritoneum are not closed in cases of broad ligament Myoma. If post operative bleeding is suspected, a drain should be left.
The operation is used a fibrin glue at that site.
Technique + Approach - 4-trocar method was utilized in all operations during trocar insertion. - Differ according to the type and location : anterior cervical F, Posterior cervical F, Central cervical F.
Indications - Menometrorrhagia and anemia - pelvic pain and pressure - Enlarging leiomyoma and possibility of neoplasia - Associated fetal wastage or infertility - Gestational size greater than 12 weeks and inability to evaluate the adnexa - Ureteral obstruction
Contraindications - Desire fertility or uterine preservation - Endometrial cancer or uterine sarcoma - Pregnant - Strong possibility that a functional uterus could not be reconstructed. - Fibroid located in the region of the uterine vessels or broad ligament.