describe how we do laparoscopic myomectomy, advantages, complications

1. MAGDY ABDELRAHMAN MOHAMED
LECTURER OF OB/GYN
2015

2.  Nomenclature
 Fibroid--------Fibroids
 Myoma--------Myomata
 Fibromyoma—Fibromyomata
 Leiomyoma---Leiomyomata

3.  Fibroids (leiomyomas) are benign
smooth muscle cell tumors of the uterus.
 Although they are extremely common,
with an overall incidence of 40% to 60%
by age 35 and 70% to 80% by age 50,
the precise etiology of uterine fibroids
remains unclear.

4.  Described based on location in the
uterus:
• Intramural: develop from within uterine
wall, do not distort uterine cavity, <50%
protruding into serosal surface.
• Submucosal: develop from myometrial
cells just below endometrium, often
protrude into and distort uterine cavity.

5. • Subserosal: originate from
serosal surface of uterus, >50%
protrudes out of serosal surface.
• Cervical: located in the cervix,
rather than uterine corpus.

10.  It was first described at 1979 by Semm,
exclusively for subserous myoma.
 From the beginning of 1990s, the
technique was developed to include
extraction of intramural myoma.

11.  Should be particularly meticulous, there is
no intraoperative palpation.
• TAS , TVS.
• Doppler assement.
• MRI.
• Diagnosic hysteroscopy, In selected cases.

12.  Correction of anemia.
 GnRH analogues (controversial).

13.  Size of myoma < 10 cm.
 Number ≤ 3.

14.  Each myoma must be excised via its own
hysterotomy.
 Preventive occlusion of the uterine artery,
using a clip, is prefered to decrease intra-
operative Hge.

15.  Dissection must take place along the
cleavage plane.
 Avoid iatrogenic lesions of the other pelvic
organs.
 Meticulous closure of myomectomy site.

22.  Direct suprapubic extraction for small
myoma.
 Posterior colpotomy.
 Electric morcellation.

23.  Broad ligament access to the uterine
artery.
 Posterior access to the uterine artery.

24. Dissection of the right broad ligament

26. Posterior access to perform occlusion of
the uterine artery

30.  Incidence: variable (5-40%)
 Factor increase the conversion rate:
• Size of the dominant myoma at ultrasonography.
• Anterior location.
• Intramural type.
• Preoperative use of GnRH agonists.

31.  There are several arguments suggesting
that the laparoscopic approach reduces
the risk of postoperative adhesions after
myomectomy.

32.  Only 2 randomized controlled trials
compared myomectomy by laparotomy or
laparoscopy.
 There was no significant differences in the
pregnancy and abortion rate.
 Seracchioli et al 2000, Palomba et al 2007.

33.  There is considerable debate concerning
the strength of hysterotomy scars after
laparoscopic myomectomy.
 Particular care must be given to uterine
closure.

35.  Rate is higher than laparotomy & the time
lapse before recurrence is shorter.
 It is impossible to palpate the myometrium
thoroughly, and small intramural nuclei
which do not deform the uterine serosa
can be overlooked.

37.  Advantages:
• 3-dimensional image.
• Absence of tremor.
• Superior instrument articulation.
• Comfort for the surgeon.
• Faster learning curve.

39.  Laparoscopic myomectomy is a safe
technique which has several advantages,
including less postoperative pain, shorter
recovery time and reduced post-
myomectomy adhesion formation in
comparison with the laparotomy.

40.  However, it is a difficult operation, and the
surgeon needs to be well experienced in
laparoscopic surgery.