Laparoscopic blockage of uterine artery and myomectomy

Background The goal of this study was to evaluate the effects of laparoscopic coagulation or blockage of the uterine arteries and myomectomy in treating symptomatic myomas. Methods A total of 142 women with symptomatic fibroids warranting surgical treatment and wanting to retain their uteri were treated by laparoscopic coagulation or blocking of the uterine arteries and myomectomy. Results Most of the 142 patients had multi-myomas of the uterus, as intramural myomas (54), subserous myomas (65), and submucosal myomas (25). The number of myomas in each patient varied from 1 to 4. The size of the myomas in all patients ranged from 2 to 12 cm. In 86 cases (60.4%) the uterine wall was sutured in one layer. Average operating time was 124.2 ± 33.1 min, and average blood loss was 117.8 ± 48.6 ml. Mean postoperative hospital stay was 4.8 ± 1.2 days. All patients underwent technically successful laparoscopic coagulation or blocking of uterine arteries and myomectomy without intraoperative complications. The mean follow-up time was 16.2 months (16–26). Symptomatic improvement was achieved in all patients. Five patients experienced recurrence of myomas. Conclusions Laparoscopic coagulation or block of the uterine arteries and myomectomy appears to be a safe, effective, and promising new method for treating symptomatic uterine myomas.     

Laparoscopic-assisted vaginal myomectomy: a case report and literature review.

The purpose of this article is to present a case of laparoscopic myomectomy (LM) that led to the identification of a new minimally invasive technique [laparoscopic-assisted vaginal myomectomy (LAVM)] for removing multiple transmural uterine myomas and facilitating uterine suturing. In addition, we reviewed the literature to (1) describe the history leading up to LAVM, (2) relate the benefits of this technique to other more widely performed myomectomy procedures [LM and laparoscopic-assisted myomectomy (LAM)], and (3) identify criteria for LM and LAVM.     

Laparoscopic myomectomy for very large myomas using an isobaric (gasless) technique.

OBJECTIVES: Laparoscopic myomectomy using pneumoperitoneum for large myomas (> or = 8 cm) is hindered by several factors, such as the increased operative time, the risk of perioperative bleeding, and the risk of conversion to laparotomy. With the introduction of isobaric laparoscopy using abdominal wall lifting, this procedure can be performed using conventional surgical instruments introduced through small abdominal incisions. The aim of this study was to evaluate the feasibility, reproducibility, and safety of isobaric laparoscopic myomectomy for very large myomas > or = 10 cm using a subcutaneous abdominal wall-lifting device. METHODS: A series of 24 consecutive patients with at least 1 symptomatic myoma > or = 10 cm underwent a gasless laparoscopic myomectomy with the Laparotenser device. Conventional long laparotomy instruments were used. RESULTS: Gasless laparoscopic myomectomy was successful in all 24 consecutive patients. The size of the dominant myoma varied from 10 cm to 20 cm. The median operating time was 93 minutes. The median postoperative drop in hemoglobin was 2.8 g/dL. No surgical complications occurred. The median hospital stay was 2.8 days. CONCLUSION: Gasless laparoscopic myomectomy is feasible, reproducible, and safe for removing very large myomas. Therefore, it can represent an excellent option for the minimally invasive removal of very large myomas.     

腹腔镜宫颈肌瘤切除术的临床分析

目的:探讨腹腔镜宫颈肌瘤切除术的手术效果、适应证及技巧。方法:回顾分析腹腔镜宫颈肌瘤切除术36例患者的临床资料。结果:36例患者均在腹腔镜下顺利完成宫颈肌瘤切除术。肌瘤直径3~10 cm,平均5.7 cm。平均手术时间(86.8±46.75)m in,术中平均出血(66.6±35.5)m l。直径≥5 cm的肌瘤比<5 cm者平均手术时间及术中出血均明显增加(P<0.01)。术后随访症状均有改善。结论:腹腔镜宫颈肌瘤切除术安全可行,合理选择适应证及高超的手术技巧是手术成功的关键。     

Developments in techniques for laparoscopic myomectomy.

OBJECTIVES: Conflicting opinions about laparoscopic myomectomy (LM) are still present regarding indications and risks related to reproductive outcome. We reviewed our 13-year experience (1) to identify risk factors or changes in methods that have improved our myomectomy technique and (2) to evaluate how the learning curve and improved surgical devices influenced our procedures, and (3) to study the myomectomy scar with a power color Doppler ultrasound (US). METHODS: From January 1991 to December 2003, we studied 332 patients who underwent laparoscopic myomectomy. We analyzed, as the learning curve, how the introduction of the Steiner morcellator, the use of vasoconstrictive agents, and different techniques of suturing have influenced parameters such as operating time and blood loss. RESULTS: We performed 332 single or multiple myomectomies for symptomatic myomas. Most patients (47%) had more than one myoma, with a maximum of 8 per patient (average myomas removed for patients: 2.23, range 1 to 8). Myoma size ranged from 1cm to 20 cm (mean, 60.20+/-SD27.1 mm). Myomas <4cm were removed during myomectomy for larger ones. The conversion rate to laparotomy was 1.51%. The average drop in hemoglobin concentration was 1.06+/-SD0.86 g/100 mL (range, 0.7 to 2.2 g/100 mL). No blood transfusions were required. No major intraoperative complications occurred. The duration of the procedure ranged from 30 minutes to 360 minutes (mean, 124+/-SD52.6). The dimensions of the myomas removed increased with experience (4.91+/-SD2.2 cm of the earlier cases to 6.76+/-SD2.7 of the latest group, P<0.000). The learning curve positively influenced the length of the procedures in the first cases. The introduction of electromechanical morcellation in 1996 reduced the procedure time. Data showed significantly reduced Hb drop after the introduction in 1998 of vasoconstrictive agents (DeltaHb 1.62 g/100 mL versus 0.95; P<0.001). The running suture offered few advantages in terms of procedure time. However, the drop in hemoglobin was advantageous (DeltaHb 1.1 g/100mL vs 0.61, P<0.01). The overall rate of intrauterine pregnancy following LM was 65.5%. No uterine ruptures occurred. We had 2 serious postoperative complications. CONCLUSION: With increased experience, the technical improvements and clinical results have changed our approach and decision making regarding laparoscopic myomectomy. Our results and extremely low conversion rate suggest that laparoscopic myomectomy is a safe and reliable procedure even in the presence of multiple or enlarged myomas.     

较困难的腹腔镜子宫肌瘤剔除术——附142例临床报告

目的探讨腹腔镜进行较大及特殊部位子宫肌瘤剔除术的可行性、安全性。方法2003年3月-2008年6月,对142例肌瘤直径≥10 cm、后壁近宫颈处肌瘤、宫颈肌瘤、阔韧带肌瘤行腹腔镜子宫肌瘤剔除术。视肌瘤大小、部位的不同采取如下方法：①直接切开肌层剥出瘤体,较大肌瘤梭形切开瘤体肌壁,后壁肌瘤纵切或由远至近斜行向上切开;②较大的肌瘤可剥出部分瘤体后旋切碎解瘤体取出,剩下较小部分再完全剥出;③表面血管丰富的较大肌瘤或浆膜下肌瘤可采用套扎法;④阔韧带肌瘤则打开阔韧带牵出瘤体,旋切碎解至较小瘤体后于根部拧断。结果除1例采取腹腔镜辅助腹壁小切口剥除子宫肌瘤外,141例在腹腔镜下完成。剥除肌瘤标本重44-1903 g。手术时间30-175 m in。术中出血10-800 m。l无严重并发症发生。68例随访至术后2年,B超提示肌瘤复发2例。结论随着手术技术的提高,可以放宽腹腔镜子宫肌瘤剔除术的指征。     

阴道超声在腹腔镜多发子宫肌瘤剔除术中的应用价值

目的探讨在腹腔镜剔除子宫多发肌瘤术中应用阴道超声减少肌瘤残留及降低复发的临床价值。方法2010年1月一2011年12月85例多发子宫肌瘤按入院日期单、双号分为阴道超声引导腹腔镜组（n=42）与腹腔镜组（n=43）。阴道超声引导腹腔镜组于腹腔镜手术后经阴道超声引导将残留的子宫肌瘤继续在腔镜下剔除。结果2组术中出血量、术后排气时间、术后住院时间无统计学差异（P〉0．05）。阴道超声引导腹腔镜组术中发现11枚残留肌瘤,均为肌壁间肌瘤,肌瘤直径1．5—2．5cm。腹腔镜组7例复发（16．3％,7／43）,阴道超声引导腹腔镜组1例复发（2．4％,1／42）,均为肌壁间肌瘤,2组复发率比较无统计学差异（x2=3．321,P=0．068）。结论阴道超声引导下腹腔镜子宫肌瘤剔除术可以最大限度地避免肌瘤残留。     

Isobaric gasless laparoscopic myomectomy for removal of large uterine leiomyomas

Background This study aimed to evaluate the feasibility and safety of isobaric laparoscopic removal of large myomas (≥8 cm) using the Laparotenser, a subcutaneous abdominal wall-lifting system. Methods A series of 63 consecutive patients with at least one large symptomatic subserosal or intramural uterine myoma (≥8 cm) underwent an isobaric gasless laparoscopic myomectomy. Conventional laparotomy instruments were used. Results The procedure was successfully completed for all 63 consecutive patients. The average size of the dominant myoma was 11 cm. The mean number of myomas removed from each patient was 3.6. The mean blood loss was 143 ml, and the mean operating time was 72 min. No intraoperative complication occurred. Conclusions Gasless laparoscopic myomectomy for the removal of large myomas using the Laparotenser is feasible and safe. It offers several advantages over laparoscopy with pneumoperitoneum.     

腹腔镜辅助腹壁小切口与单纯腹腔镜子宫肌瘤切除术的对比研究

目的:对比分析腹腔镜辅助腹壁小切口与单纯腹腔镜子宫肌瘤切除术的手术效果.方法:回顾分析2008年7月至2009年12月施行98例腹腔镜辅助腹壁小切口子宫肌瘤切除术(1aparoscopic-assisted myomectomy,LAM)和95例腹腔镜子宫肌瘤切除术(laparoscopic myomectomy,LM...     

经阴道与腹腔镜下子宫肌瘤剔除术的对照研究

目的探讨经阴道与腹腔镜下子宫肌瘤剔除术的疗效及临床应用价值。方法回顾分析2007年3月～2008年10月58例经阴道子宫肌瘤剔除术(阴道组)和55例腹腔镜下子宫肌瘤剔除术(腹腔镜组)的临床资料,对2组患者的手术时间、术中出血量、剔除肌瘤重量、术后病率、肛门排气时间、住院时间、住院费用等进行对照分析。结果 2组术后肛门排气时间、住院时间均无统计学差异(P=0.056,P=0.067),但经阴道组手术时间(62±13)min显著短于腹腔镜组(97±18)min(t=-11.895,P=0.000),术中出血量(105±30)ml显著少于腹腔镜组(180±25)ml(t=-14.396,P=0.000),术后病率(48.3%)显著高于腹腔镜组(23.6%)(χ2=7.410,P=0.006),住院费用(5216.4±28.5)元显著低于腹腔镜组(7421.6±31.2)元(t=-392.597,P=0.000)。结论 2种术式各有适应证而不可完全互相替代,但从卫生经济学角度而言,经阴道手术可作为治疗的首选术式,并值得在临床推广应用。     

腹腔镜辅助下腹壁小切口子宫肌瘤剔除术的临床应用研究

目的探讨腹腔镜辅助下腹壁小切口子宫肌瘤剔除术(laparoscopically assisted myomectomy,LAM)治疗子宫肌瘤的临床意义。方法2007年7月~2008年7月30例行LAM,与同期130例腹腔镜子宫肌瘤剔除术(laparoscopic myomectomy,LM)进行对比分析。结果LAM组术中出血量(73±28)ml与LM组(81±27)ml无统计学差异(t=1.453,P=0.148),2组手术时间(t=-0.741,P=0.460)、术后病率(χ2=0.000,P=1.000)、术后肛门排气时间(t=0.000,P=1.000)、中转开腹率(0vs12.3%,P=1.000)、并发症发生率(LM组2例,LAM组0例,P=1.000)、术后复发率(LM组8例,LAM组1例,χ2=0.027,P=0.869)差异均无统计学意义。结论LAM治疗子宫肌瘤与LM疗效相当,但LAM可以较LM剔除体积更大、数目更多、生长部位更复杂的子宫肌瘤。     

腹腔镜与开腹子宫肌瘤剔除术的比较研究

目的探讨腹腔镜子宫肌瘤剔除术的安全性、可行性与临床效果。方法回顾分析2008年1月～2010年9月腹腔镜子宫肌瘤剔除术97例（腹腔镜组）与开腹子宫肌瘤剔除术90例（开腹组）的临床资料。对2组手术时间、术后血红蛋白下降值、镇痛药物使用率、住院时间、住院费用、术后病率、术后并发症、术后复发情况进行比较。结果与开腹组相比,腹腔镜组术后血红蛋白下降少[（14.3±6.4）g/L vs.（17.4±7.4）g/L,t=-3.152,P=0.002],使用镇痛药者少[4例（4.1%）vs.31例（34.4%）,χ2=28.211,P=0.000],术后住院时间短[（5.0±1.3）d vs.（6.9±1.3）d,t=-10.106,P=0.000],但手术时间长[（120.2±39.3）min vs.（99.8±36.8）min,t=3.646,P=0.000];住院费用高[（7216.0±850.9）元vs.（6531.6±875.6）元,t=5.419,P=0.000]。2组术后病率和并发症发生率差异无显著性（P〉0.05）。2组术后1个月肌瘤残留率、术后6个月后肌瘤复发率差异均无显著性（P〉0.05）。结论腹腔镜子宫肌瘤剔除术是一种安全、可行的微创手术方式,但仍有一定的局限性,并不能完全代替开腹手术。     

腹腔镜巨大子宫肌瘤切除术的临床体会

目的:探讨腹腔镜巨大子宫肌瘤切除术(laparoscopic myomectomy,LM)的可行性及临床价值。方法:回顾分析2003年1月至2007年8月我院妇科收治的直径8~13cm子宫肌瘤患者的临床资料,比较34例LM及28例同期开腹子宫肌瘤切除术的手术效果和术后康复情况。结果:两组手术均获成功,无并发症发生。手术时间腹腔镜组显著长于开腹组,术中出血量腹腔镜组与开腹组无统计学差异,术后平均排气时间及住院时间腹腔镜组显著短于开腹组。结论:LM安全可行,但需要医师有丰富的腹腔镜手术经验及缝合技术。与开腹手术相比LM创伤小、住院时间短、康复快。术中出血量无增加,但手术时间延长,可能与肌瘤较大取出费时及缝合困难有关。     

子宫大切口、分层缝合方式在腹腔镜下子宫肌瘤剔除术中的应用

目的评价子宫大切口、分层缝合方式在腹腔镜下子宫肌瘤剔除术中的价值。方法选择2010年7月～2011年8月因浆膜下或肌壁间子宫肌瘤需要行子宫肌瘤剔除术并选择腹腔镜手术的88例,均无高血压、哮喘、心肺功能不全及血液系统疾病,按住院日期的单双数分成2组。改良组45例为肌瘤表面大切口、瘤腔分层缝合;常规组43例采用肌瘤表面纵行切口,瘤腔一层连续缝合。2组年龄、肌瘤数目、肌瘤直径、肌瘤的位置、盆腔手术史等方面差异均无显著性(P>0.05)。观察2组手术时间、术中出血量、术后体温≥38℃例数、术后肛门排气时间、住院时间等指标。结果与常规组相比,改良组手术时间短[(67.9±5.7)min vs.(71.2±6.8)min,t=-2.471,P=0.015],术中出血量少[(56.8±10.3)ml vs.(62.1±12.6)ml,t=-2.165,P=0.033],术后体温≥38℃例数少[5例(11.1%)vs.12例(27.9%),χ2=3.980,P=0.046],术后肛门排气时间、术后住院时间差异无显著性(P>0.05)。术后3个月73例复查B超,发现肌瘤改良组5.6%(2/36),常规组2.7%(1/37)(χ2=0.001,P=0.981)。结论腹腔镜下子宫肌瘤剔除术中,子宫大切口、分层缝合方式技术可行,值得临床推广应用。     

腹腔镜下子宫肌瘤剔除术中行子宫动脉阻断术对卵巢功能的影响

目的探讨腹腔镜下子宫肌瘤剔除术中行子宫动脉永久阻断术或临时阻断术对卵巢功能及妊娠率的影响。方法将2008年2月～2009年11月120例子宫肌瘤患者采用简单随机化分组方法（随机数字表法以及随机数余数分组法）,分为A组（腹腔镜下子宫肌瘤剔除术中行子宫动脉永久阻断术）、B组（腹腔镜下子宫肌瘤剔除术中行子宫动脉临时阻断术）及C组（对照组,单纯行腹腔镜下子宫肌瘤剔除术）,各40例,比较3组手术前后血雌二醇（E2）、卵泡刺激素（FSH）、黄体生成素（LH）的变化及术后妊娠率。结果 3组术前、术后激素水平都在卵泡期激素正常范围内。分别比较3组术前、术后3个月、术后6个月及术后12个月的E2、FSH及LH水平,A组术后3个月E2水平较术前下降,FSH升高,差异有显著性（P〈0.05）,术后6个月及术后12个月与术前比较差异无显著性（P〉0.05）,A组LH和B、C组各激素不同时点差异无显著性（P〉0.05）。3组间比较,A组术后3个月E2水平明显低于B组及C组（P〈0.05）,其余3组间差异无显著性（P〉0.05）。随访2年,3组妊娠率差异无显著性（P〉0.05）。结论腹腔镜下子宫肌瘤剔除术中行子宫动脉永久阻断术对卵巢功能的影响是短暂、可逆的,而子宫动脉临时阻断术对卵巢功能几无影响。     

Highly effective method for myoma excision and suturing in laparoscopic myomectomy

Background  

Laparoscopic myomectomy rather than abdominal myomectomy has been well documented as a treatment option for uterine myomas. However, laparoscopic myomectomy has serious limitations in two of its steps: excision of myoma with strong traction and suturing of the uterine defect. These steps are a challenge even for experienced surgeons. The authors introduce a simple but highly effective technique for excision of myoma and suturing using standard instrumentation in laparoscopic myomectomy.     

Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain

The advantages of laparoscopic over open surgery have been documented in nonblinded settings. Our prospective, double-blind setting evaluated pain scores 72 h after surgery by comparing patients who underwent laparoscopic myomectomy or with laparotomy. Forty women referred for conservative myomectomy were included in the study. After stratification (myoma size, number of myomas, and surgeon), patients were randomized to either laparoscopy (n = 19) or laparotomy (n = 21) and received a standardized anesthesia and patient-controlled analgesia for 24 h after surgery. Identical wound dressings were applied to blind the patient and the observer to the surgical approach. The postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 10 = unbearable pain) at 24, 48, and 72 h after surgery. As the primary outcome variable, we calculated the mean overall VAS-score at these time points. P < 0.05 (t-test and analysis of covariance) was considered statistically significant. There were no differences in patient characteristics among the groups. The mean overall VAS score at 24, 48, and 72 h was statistically significantly lower in the laparoscopic group compared with the laparotomy group (2.28 +/- 1.38 versus 4.03 +/- 1.63; P < 0.01). Our data demonstrate, for the first time in a double-blind setting, that laparoscopic myomectomy reduces postoperative pain for 72 h after surgery compared with laparotomy.     

Hysteroscopic myomectomy: our experience and review.

OBJECTIVE: To analyze the results of hysteroscopic myomectomy in our center and to compare the results to those published in the literature. METHODS: We performed a retrospective study of the clinical histories of patients who had undergone hysteroscopic myomectomy with a resectoscope between January 1992 and December 1999. Procedures were performed at a hysteroscopic clinic in the Department of Obstetrics and Gynecology at the University Public Hospital in Madrid's south zone. One hundred twenty pre-, peri-, and postmenopausal women with submucous myomas were included in the study. All patients underwent hysteroscopic resection with a monopolar loop. RESULTS: We performed 120 hysteroscopic myomectomies. The patients' median age was 44.8 years (23 to 74). Abnormal uterine bleeding (AUB) was the most frequent indication (84.1%). Inability to reproduce was the indication in 14 (11.6%) cases. GnRH analogue preparation was used in 60% of cases. We operated on 52 (43.3%) type 0, 51 (42.5%) type I, and 17 (14.1%) type II myomas, according to Wamsteker and Blok classification. A median of 32.5 (10 to 105) minutes was required for the interventions. The myomectomy was combined with another operation (12 polypectomies, 24 endometrial resections, and 1 laparoscopic ovarian cystectomy) in 32 patients. The median retention of glycemia was 281 cc (0 to 1300). We could not complete the resection in 22 patients. Twelve underwent reoperation (3 hysterectomies and 9 second myomectomies). No serious complications occurred, and the median hospital stay was 25.4 hours. The histological study confirmed leiomyoma in all the cases. The intervention results were satisfactory after a follow-up period of 12 months to 7 years, AUB being controlled in 88.5% of the patients. CONCLUSION: Hysteroscopic myomectomy is a reliable procedure that is effective in controlling abnormal uterine bleeding. It is a good alternative to hysterectomy and has an acceptable surgical time and minimum hospital stay. To reduce the need of reintervention, appropriate patient selection and improved technique are necessary. The technique also offers significant economic savings compared with the conventional surgical methods.     

腹腔镜下子宫肌瘤切除术120例临床分析

目的:探讨腹腔镜下子宫肌瘤切除术的可行性及临床效果。方法:回顾分析腹腔镜子宫肌瘤切除术120例(腹腔镜组)及同期开腹子宫肌瘤切除术120例(对照组)患者的临床资料,比较两组手术效果和术后康复情况。结果:(1)腹腔镜下切除浆膜下肌瘤和最大直径<6 cm肌瘤的平均手术时间短于对照组,术中出血量少于对照组(P<0.05);(2)腹腔镜下切除最大直径≥6 cm肌瘤的手术时间长于对照组,术中出血量多于对照组(P<0.05);(3)腹腔镜下切除肌壁间肌瘤的手术时间和术中出血量与对照组差异无显著性(P>0.05);(4)腹腔镜组患者术后的平均排气时间、住院时间短于对照组,术后使用镇痛剂的比例低于对照组(P<0.05),而术后病率、使用抗生素时间、住院费用及术后并发症发生率两组差异无统计学意义(P>0.05)。结论:腹腔镜下切除中等大小的子宫肌瘤,尤其是浆膜下肌瘤的手术时间短,患者出血少,术后康复快。     

腹腔镜下阔韧带子宫肌瘤剔除术32例临床分析

目的探讨腹腔镜手术治疗阔韧带子宫肌瘤的临床价值。方法 2011年1月～2012年1月,行腹腔镜下阔韧带子宫肌瘤剔除术32例。直径3～11 cm,平均7.5 cm。均采用全身麻醉,已婚者术前放置举宫器,术中用垂体后叶素减少出血量,术后残腔内放置引流管。结果 32例均成功手术,无输尿管等周围脏器损伤。手术时间60～125 min,平均78.8min。出血量20～150 ml,平均80.7 ml。肛门排气时间6～30 h,平均18.5 h。术后住院时间3～6 d,平均4 d。结论腹腔镜下阔韧带子宫肌瘤剔除术安全、有效。