A novel modification of conventional laparoscopic myomectomy using manual assistance for multiple uterine myomas

Objectives

Endometriosis is a common gynaecological disease with clinical symptoms such as chronic pain, infertility and intra-abdominal adhesions. Different theories on the pathogenesis of endometriosis and especially its aggressive subtype with infiltrative growth have been discussed. The objective of this study is to evaluate differences in proliferation and invasive properties of invasive colorectal endometriosis, superficial peritoneal endometriosis and endometrial carcinoma (G1 and G2).

Study design

Paraffin embedded tissues of peritoneal endometriosis, endometriosis of the intestine and endometrial carcinoma from 97 patients were stained immunohistochemically to assess differences in expression patterns of matrix metalloproteinases (MMP-2, MMP-9) as markers of invasion and the marker of proliferation PCNA. MMP expression was evaluated using the Immuno Reactive Score (IRS) (combining positive cell ratio and staining intensity) and PCNA expression was assessed as the percentage of positively stained cells in representative areas.

Results

MMP-2, MMP-9 and PCNA showed differential expression patterns in the different tissues examined. MMP-2 and PCNA expression was stronger in invasive colorectal endometriosis than in superficial peritoneal endometriosis (p = 0.0394). MMP-9, however, was more frequently expressed in peritoneal endometriosis (59.1%) than in colorectal endometriosis (44.4%). This result did not reach statistical significance. When colorectal endometriosis was compared to low grade endometrial carcinoma, proliferation detected by PCNA was significantly higher in endometriosis (p = 0.0008). MMP-2 and MMP-9 showed higher expression in endometrial carcinoma than in endometriosis.

Conclusions

There are obvious differences in expression patterns of MMP-2, MMP-9 and PCNA in different stages of endometriosis and in endometrial cancer. These markers can be helpful to evaluate aggressiveness and invasiveness of endometriosis in different localizations. The results obtained could be of relevance for a better understanding of the pathogenesis of endometriosis and the development of an individual therapy concept.     

A randomized,controlled study comparing minilaparotomy versus isobaric gasless laparoscopic assisted minilaparotomy myomectomy for removal of large uterine myomas: Short-term outcomes

Objective

To compare the operative data and early postoperative outcomes for myomectomy performed by minilaparotomy (MLT) with isobaric laparoscopic assisted minilaparotomy myomectomy (LM) in a series of patients with large uterine myomas (≥5 cm) randomly assigned to each surgical technique.

Study design

80 patients were randomized blindly using a computer randomization list to MLT (n = 40) or LM (n = 40).

Results

The mean (±SD) operating time was significantly shorter after LM than after MLT (75.50 ± 25.70 vs 96.00 ± 26.20 min; p < 0.01). Intraoperative blood loss was less with LM (72.15 ± 44.00 vs 96.21 ± 38.50 ml; p < 0.05), and ΔHb was less with LM (1.21 ± 0.55 vs 1.64 ± 0.57; p < 0.05). No intraoperative complications occurred, and no case was returned to the theater in either group. No conversion to standard laparotomy was necessary. Hospitalization was shorter after LM than after MLT (4.30 ± 1.20 vs 6.90 ± 2.70 days; p < 0.01). Postoperative ileus was shorter after LM than after MLT (26.20 ± 4.20 vs 40.50 ± 4.90 h; p < 0.01). The mean VAS score at 12 h for abdominal pain was 5.5 ± 0.7 in the LM group and 5.2 ± 0.8 in MLT group (p < 0.05), whereas it was analogous in the two groups at 24 h, and at 48 h was 3.4 ± 1.1 in the LM group and 4.2 ± 1.1 in the MLT group (p < 0.05), and no difference between two groups was detected in the overall mean (at 12, 24 and 48 h).

Conclusions

Several surgical and immediate postoperative outcomes were significantly better in the LM group than in the MLT group.     

Laparoscopic myomectomy for symptomatic uterine myomas

OBJECTIVE: To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas. DESIGN: Medline literature review and cross-reference of published data. RESULTS: Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately. CONCLUSION(S): Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.     

Robotic myomectomy for large uterine myomas

Objective

To evaluate surgical outcomes and feasibility of robotic myomectomy in large uterine myomas.

Uterine perfusion following laparoscopic clipping of uterine arteries at myomectomy

Laparoscopic clipping of uterine arteries facilitates laparoscopic myomectomy with minimal blood loss. This paper shows the return to normal myometrial perfusion following this procedure with literary evidence of the safety and efficacy of this technique.     

腹腔镜下子宫动脉阻断术联合肌瘤切除术治疗子宫肌瘤的临床研究

目的评价腹腔镜下子宫动脉阻断联合肌瘤切除术治疗子宫肌瘤的临床可行性及中远期疗效。方法对520例子宫肌瘤患者的临床资料进行回顾性分析,其中348例行腹腔镜下子宫动脉阻断联合肌瘤切除术（LUAO-M）;172例行腹腔镜下单纯肌瘤切除术（LM）,比较两种术式的相关手术指标及随访结果。结果LUAO组术中出血量（88．2±52．7）ml少于LM组（103．2±54．9）ml（P=0．003）;LUAO组术后病率5．7％低于LM组19．2％（P〈0．05）;LUAO组术后住院天数（7．7±2．5）d低于LM组（8．6±3．2）d（P=0．001）。LUAO组术后子宫体积缩小率（48．9±38．6）％大于LM组体积缩小率（39．2±41．6）％（P=0．019）;LUAO组月经过多缓解率97．0％高于LM组86．4％（P〈0．05）;LUAO组术后肌瘤复发率3．0％低于LM组10．7％（P=0．001）。结论腹腔镜下子宫动脉阻断术联合肌瘤切除术有助于拓宽腹腔镜下子宫肌瘤切除术的手术适应证,减少术中出血量,降低术后病率及子宫肌瘤复发率。     

Isobaric (gasless) laparoscopic uterine myomectomy. An overview

The aim of this review has been to assess the usefulness and effectiveness of isobaric (gasless) laparoscopic myomectomy using a subcutaneous abdominal wall lifting system, and to evaluate the advantages and disadvantages of this technique in comparison with the conventional laparoscopic myomectomy using pneumoperitoneum. Laparoscopy using CO2 is more frequently employed for small or medium-sized myomas. Furthermore, multiple myomectomies (>or=3 myomas per patient) are performed rarely. Gasless laparoscopy permits the removal of large intramural myomas overcoming the difficulties associated with laparoscopic myomectomy using pneumoperitoneum. It appears to offer several advantages over conventional laparoscopy, such as elimination of the adverse effects and potential risks associated with CO2 insufflation; use of conventional laparotomy instruments that facilitate several steps of the procedure; reduced operative times and costs. Indeed, this procedure associates the advantages of laparoscopy and minimal access surgery with those of using the laparotomic instruments that are more reliable for uterine closure. The only advantage of the laparoscopy with pneumoperitoneum is the tamponade effect generated by the gas on the small vessels, thus reducing intraoperative bleeding. Laparoscopic myomectomy using CO2 remains the preferred minimally invasive approach for small and medium-sized myomas and when the total number of myomas removed does not exceed 2 or 3. Gasless laparoscopic myomectomy could be mainly indicated for removal of large intramural myomas (>or=8 cm) and/or for multiple myomectomies (>or=3 myomas per patient). Anyhow, further controlled studies are needed to evaluate entirely their respective indications.     

Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy

OBJECTIVE: The objective of this study was to compare pregnancy outcomes in women with fibromyomata who were treated with uterine artery embolization to the outcomes in women who were treated with laparoscopic myomectomy. STUDY DESIGN: We compiled data from 53 pregnancies after uterine artery embolization and 139 pregnancies after laparoscopic myomectomy. We calculated and compared rates for spontaneous abortion, postpartum hemorrhage, preterm delivery, cesarean delivery, small for gestational age, and malpresentation. RESULTS: Pregnancies after uterine artery embolization had higher rates of preterm delivery (odds ratio, 6.2; 95% CI, 1.4, 27.7) and malpresentation (odds ratio, 4.3; 95% CI, 1.0, 20.5) than did pregnancies after laparoscopic myomectomy. The risks of postpartum hemorrhage (odds ratio, 6.3; 95% CI, 0.6, 71.8) and spontaneous abortion (odds ratio, 1.7; 95% CI, 0.8, 3.9) after uterine artery embolization were similarly higher than the risks after laparoscopic myomectomy; however, these differences were not statistically significant. CONCLUSION: Pregnancies in women with fibromyomata who were treated by uterine artery embolization, compared with pregnancies after laparoscopic myomectomy, were at increased risk for preterm delivery and malpresentation.     

Intraoperative ultrasound in reconstructive surgery for multiple uterine myomas

In this paper, we describe a case of successful surgical treatment of multiple uterine myomas in an open reconstructive operation with intraoperative ultrasound (IOUS) guidance. Eight nodules were removed during myomectomy. Three of them, the smallest nonpalpable tumors, were detected only by IOUS examination. The patient had remained asymptomatic and free of recurrence at follow-up 27 months postoperatively. Future studies in a larger number of series are needed before any final conclusions are reached about the effectiveness of IOUS during reproductive gynecologic procedures.     

A case-controlled study comparing harmonic versus electrosurgery in laparoscopic myomectomy

Objective

To compare the safety and effectiveness of the harmonic scalpel and conventional electrosurgery in laparoscopic myomectomy (LM).

Randomized study of laparoscopic versus minilaparotomic myomectomy for uterine myomas

STUDY OBJECTIVE: To compare the postoperative recovery of patients undergoing laparoscopic and minilaparotomic myomectomy. DESIGN: Randomized study (Canadian Task Force classification I). SETTING: University hospital. PATIENTS: One hundred forty-eight women requiring surgical myomectomy. INTERVENTIONS: Myomectomy by minilaparotomy or laparoscopy. MEASUREMENTS AND MAIN RESULTS: Operation time was significantly lower in the minilaparotomy group (p < .001). When compared with minilaparotomy, laparoscopy was associated with a lower decline of hemoglobin concentration (p <.001), a reduced length of postoperative ileus (p < .001), and a shorter time to discharge (p <.001). Pain intensity at 6 hours after surgery was significantly lower in the laparoscopy group (p <.001); also, patients who underwent laparoscopy requested analgesics less frequently in the first 48 hours after the operation (p < .001). Patients included in the laparoscopy group were fully recuperated on postoperative day 15 more frequently than those included in the minilaparotomy group (p = .012). No complications were observed in the minilaparotomy group. There were two complications in the laparoscopy group (one laparoconversion caused by difficulties of hemostasis and one acute diffuse peritonitis caused by ileal perforation). Laparoscopic and minilaparotomic myomectomy cost, respectively, 2250 euros and 1975 euros. CONCLUSION: When compared with minilaparotomic myomectomy, laparoscopic myomectomy may offer the benefits of lower postoperative analgesic use and faster postoperative recovery.     

腹腔镜子宫肌瘤剔除手术的相关因素分析

目的探讨腹腔镜子宫肌瘤剔除的指征、局限、技巧和影响手术疗效的因素.方法对2001年1月～2003年8月167例腹腔镜子宫肌瘤剔除术患者的临床资料进行回顾性分析.结果 167例患者共剔除肌瘤293个,每例患者剔除肌瘤数目1～9个不等;其中单发肌瘤102例,多发肌瘤65例;肌壁间肌瘤92例,浆膜下肌瘤50例,25例子宫肌壁间与浆膜下肌瘤同时存在;平均肌瘤三径分别为:(6.30±1.49)cm、(5.62±1.41)cm、(5.49±1.30)cm.最大肌瘤体积为11.3 cm×10.0 cm×8.7 cm.腹腔镜下完成手术操作157例,10例小切口辅助或中转开腹手术,包括1例肠管损伤,2例腺肌瘤无明确肌瘤包膜,开腹行腺肌瘤挖除及子宫体重建术.平均手术时间114.80 min,平均术中出血量87.28 ml.肌瘤直径大于等于6 cm时手术时间和术中出血量明显延长和增加(P<0.05);肌壁间肌瘤的手术时间和术中出血量明显高于浆膜下肌瘤(P=0.001);手术并发症1.19%.结论腹腔镜子宫肌瘤剔除是一种微创伤、安全、有效的手术方法,合适的指征选择和镜下缝合技术是保证手术成功的关键.