|Year : 2011 | Volume
| Issue : 1 | Page : 43-46
Multiple layer closure of myoma bed in laparoscopic myomectomy
Vardhman Trauma and Laparoscopy Centre, A-36, South Civil Lines, Mahavir Chowk, Muzaffarnagar, India
|Date of Web Publication||22-Sep-2011|
Vardhman Trauma and Laparoscopy Centre, A-36, South Civil Lines, Mahavir Chowk, Muzaffarnagar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To assess the feasibility and outcome of laparoscopic myomectomy and multiple layer closure of the myoma bed, for management of myomas, at a tertiary care hospital . Materials and Methods: From September 2005 to September 2010, 417 patients, with large and moderate size myomas, were managed by laparoscopic myomectomy. Indications were subfertility, menorrhagia, and abdominal mass. Preoperative evaluation included history, clinical examination, and sonographic mapping. The myomas were enucleated and retrieved laparoscopically. Myoma beds were sutured in multiple layers by endoscopic intracorporeal suturing. Results: Three hundred and fifteen patients presented with subfertility, 45 with menorrhagia, and 57 with abdominal mass. The average maximum diameter of a myoma was 9 cm. The mean duration of surgery was 120 minutes. The mean postoperative stay was 24 hours. No intraoperative complication occurred and the hospital course was uncomplicated. In one case, a minilap incision was performed for retrieval of the myoma with suturing of the bed. Two patients had minor delayed wound healing of the morcellator port site. The patients did not report any complaints during the follow-up, except one patient who developed omental hernia at the morcellator port site. There was no rupture of the scar and very low adhesion scores in the subsequent cesarean sections or second-look scopies. Conclusion : With proper multilayer closure of the myoma bed, laparoscopic myomectomy was feasible for moderate and even large myomas and had excellent outcomes.
Keywords: Better reproductive outcome, laparoscopic myomectomy, large myomas, multilayer closure
|How to cite this article:|
Jain N. Multiple layer closure of myoma bed in laparoscopic myomectomy. J Gynec Endosc Surg 2011;2:43-6
| Introduction|| |
A uterine leiomyoma is the most common tumor of the female reproductive tract. An incidence of 20-25% in sexually active and 30-35% in all women, irrespective of age, has been reported.  The surgical management of myomas has advanced significantly. There has been a renewed interest in the removal of myoma alone, that is, myomectomy rather than hysterectomy, which was done historically. With the trends toward minimally invasive endoscopic surgery, procedures have been developed to accomplish myomectomy via either the laparoscopic or hysteroscopic route.  Just as these procedures have come up, they have met with several criticisms such as, lack of meticulous closure, inadequate hemostasis, chances of rupture in subsequent pregnancy, and high risk of adhesion formation. We report our experience of 417 cases of laparoscopic myomectomies, of large and moderate size myomas, in a tertiary care hospital
| Aims and Objective|| |
In this article, our objective is to describe our technique of laparoscopic myomectomy and multiple layer closure of the myoma bed, and discuss its outcomes and advantages, overcoming all the criticism surrounding Laparoscopic Myomectomy.
| Materials and Methods|| |
In a retrospective study conducted at our tertiary care hospital, we have evaluated 417 patients in the past five years, with large and moderate size myomas (more than 7 cm), largest being up to 17 cm, producing an abdominal mass corresponding to a 32-week size uterus.
Inclusion criteria mainly incorporated
- Patients being treated for subfertility, with myomas causing endometrial distortion or tubal occlusion, with normal ovulation and normal male factor.
- Patients with large myomas producing pressure symptoms.
- Asymptomatic large myomas producing palpable abdominal mass up to the umbilicus or above it.
Preoperative evaluation included history, clinical examination, basic investigation for pre-anesthetic checkup, and a detailed transvaginal scan. Sonography included mapping of the myomas, their number, size, and location, and most importantly differentiating them from adenomyosis and adenomyoma.  Although we carried out adenomyomectomy with almost an identical technique, yet surgical preparedness was present and patient counseling was done accordingly.
In all cases, an informed consent was taken. Hemoglobin was optimized using iron sucrose injections. Extensive bowel and rectal preparation was done in each case. No patient received GnRH analog prior to surgery, as it led to loss of cleavage plane during surgery. All operations were performed under general anesthesia, with inhalational anesthetics, avoiding nitrous oxide as it causes bloating of the bowel. 
Our innovative technique of port placement involved intraumbilical Veress needle insertion without any incision and utilizing the right upper 5 mm port for primary trocar insertion. The 10 mm port was optimized supraumbilically, under direct vision of a 5 mm telescope depending on the myoma size, which went up to even the xiphisternum in large myomas. All accessory ports were also made in such a way that they remained above and outside the biggest myoma. The most common port placement was - two ipsilateral ports for enucleation and suturing, one contralateral port for the assistant anywhere between the umbilicus and anterior superior iliac spine (depending on the myoma size), and a suprapubic port for a myoma screw. On peritoneal entry all pelvic and abdominal structures were inspected and other pathologies, if present, were noted. Pitressin was injected at the concentration of 20 units per 200 ml between the serosa and pseudocapsule of myoma, to decrease the bleeding and for hydrodissection. Hysteroscopy was done in the mean time to see and treat any submucous myoma.
In most of the cases, we preferred to make a transverse incision over the most bulging part of the myoma with the harmonic scalpel taking care not to extend it to the cornual ends. In case of multiple myomas, we preferred to give a single anterior or posterior incision in such a manner that most myomas could be enucleated by a single incision from the superficial to the deepest locations. If incision was expected to extend too far, vertical incision was resorted to, although very rarely. Sharp dissection was performed in the plane between the myoma and the pseudocapsule with a harmonic scalpel, coagulating and cutting all vascular bridges, causing very minimal blood loss. Two myoma screws were used in case of very large myomas, one was kept in a constant position from the suprapubic port and the other kept changing, to allow for traction near the working end. The myoma was finally enucleated from its bed by traction and counter traction. After enucleation, there was usually no bleeding, but if at all there was, then light minimal bipolar coagulation was done. After achieving adequate hemostasis, the myoma bed was sutured in a transverse, continuous, and non-locking fashion, in multiple layers. A suture 45-50 cm in length, with No. 1-0 vicryl, on a taper cut needle was loaded and introduced in the peritoneal cavity using the Clark Reich method for removing the 5 mm trocar. The angle knot was taken by passing the suture from the upper and lower edges of the myoma bed, and an intracorporeal, tight, surgeon's knot was secured. From this point on, continuous, non-locking, suturing was done, using needle holders in both hands, for a better grip. First, the layer of deep myometrium was completed and the same suture was used to take the second layer of superficial myometrium. The third layer of serosa was taken up to the starting point of the first layer at the angle and tied there. In very large myomas, which were very deep, intramural, and caused a symmetrical enlargement of the uterus, the myoma bed which came after myomectomy was very deep. Therefore, we preferred to go from the deepest myometrium working upward, layer by layer, till a total reconstruction was done, and the uterus appeared absolutely in shape with only one knot on the surface. In very large myomas, we sutured in even up to six layers, for proper approximation of the defect. While suturing all the layers, care was taken to take bites at equal distances and take adequate tissue to fully obliterate all the dead space and give a neat look. To minimize the exposed thread volume, we have also applied subserosal baseball sutures on the most superficial layer of late. In this way there was only one knot in the entire myoma bed, minimizing the knot volume and decreasing the potential for adhesion formation. Copious irrigation and lavage was done. The myomas were retrieved with a Rotocut G1 morcellator (Karl storz, Germany) via a 15 mm sleeve. Very large myomas were retrieved with the 20 mm sleeve of the Sawhle morcellator (Karl storz, Germany). The morcellator port site was meticulously closed with a port closure needle and the 20 mm site required rectus sheath closure.
All the patients were up and about within six hours of surgery, were orally allowed, started ambulation, as also deep breathing and leg raising exercises, and were discharged after 24 hours.
| Results|| |
The mean age of patients was 28±2 years. Three hundred and fifteen (75%) patients presented with sub-fertility, 45 (11%) patients with menorrhagia, and 57 (14%) patients with abdominal mass. The average maximum diameter of the myoma was 9 cm.
The mean duration of surgery was 120 minutes. No intraoperative complication occurred. Only in one case, a minilap incision was done, for retrieval of myomas and suturing of the myoma bed. This was, in fact, a case of a large uterus with multiple adenomyomas, which made a pure laparoscopic approach difficult due to lack of cleavage planes, leading to more bleeding and difficult closure in the adenomyotic tissue. Blood transfusion was required only in 25 (6%) patients with very large size myomas or multiple myomectomy sites. There were no conversions to laparotomy ever and never a hysterectomy.
The mean postoperative stay was 24 hours. All patients had an uneventful recovery. None of the patients had reactionary or late secondary hemorrhage.
Two patients reported delayed wound healing of the morcellator site and one patient developed omental hernia at the morcellator site on long-term follow-up.
Very low adhesion scores were observed in subsequent second-look scopies done by us. Other colleagues also reported very low adhesions in patients they delivered by cesarean section.
Among the subgroup of patients who presented with infertility, 198 (63%) patients conceived after the surgery, and had an uneventful antenatal and intranatal course. No patient had rupture of the myomectomy scar. Minimal adhesions were noted in the subsequent cesarean sections. Even the first myomectomy we did, conceived after 17 years of married life, just one month after myomectomy. She continued pregnancy up to term and an elective cesarean was done at term, no adhesions or even depressions were observed at the myomectomy site.
Recurrence of myomas was seen in 50 (12%) patients. Three (0.7%) patients out of these, who were around 35 years of age when myomectomy was performed, for menorrhagia, later underwent hysterectomy. Two (0.5%) patients desirous of pregnancy, had a repeat myomectomy done on account of recurrence of myoma during the study period.
| Discussion|| |
In this era of minimally invasive endoscopic surgery, laparoscopic myomectomy has become the order of the day. It offers several advantages over laparotomy including less operative trauma and blood loss, reduced postoperative morbidity, shorter hospital stay and recovery time, earlier return to normal activity, fewer postoperative adhesions, better cosmesis, improved patient compliance, and better pregnancy outcome. Furthermore, the magnification it provides allows careful microsurgical dissection, development of avascular planes, and perfect hemostasis. 
Many surgeons still prefer to do open myomectomy due to technical difficulties or lack of endosuturing skills. One of their major concerns is the risk of hemorrhage and uterine rupture in the subsequent pregnancies.  It has been reported that rupture can occur during the course of pregnancy or during delivery after removal of myomas.
However, in experienced surgeon's hands, with superior skill of endosuturing, laparoscopic myomectomy is a very safe procedure and such complications are rare.
A long-term survey by Dubuisson et al., found three cases of spontaneous uterine rupture in 15 pregnancies and only one occurred at the laparoscopic myomectomy site.  The strength of the scar largely depends on proper meticulous closure of the incision site. That is why a multiple-layer closure gives much better results than single- or two-layer closures. It also gives a much better approximation of the defect and a neat finish at the end of the procedure. Based on the clinical trials and case series, it would appear that the risk of uterine rupture during pregnancy is no higher than 1% when the myomectomy incision is appropriately repaired.  We had no scar rupture even in very big myomas or multiple myomas.
Another complication causing much concern, is the subsequent adhesion formation. We, at our institute, perform continuous suturing of the myoma bed using No. 1-0 polygalactin sutures on a taper cut needle in multiple layers so that there is only one knot on the surface. The amount of adhesions formed per suture line is directly proportional to the number of knots; lesser the number of bulky knots, lesser the adhesion scores. We have observed that this technique gives much better results than those obtained from interrupted knotting, which leads to tremendous knot volume. However, this requires advanced suturing skills.
Retrieval of a large myoma also poses technical difficulties to most of the surgeons. Morcellators have made this task much simpler.  As the myoma is progressively morcellated and the uterine size reduced, additional space is created for the optimum movement of instruments. The 12 or 15 mm claw forceps of the morcellator offer a better grip and steady traction. This greatly reduces the operating time and reduces the technical difficulty of the procedure. We took extreme care to remove the myomas in longer chips, to reduce the morcellation time. The exact count of myomas and location of their parking in the abdomen was kept, to avoid misplacing any myoma. Such misplaced myomas are a common cause of iatrogenic myomas, as reported by Nezhat et al. in their study. 
The only complications we observed were that of delayed wound healing of the morcellator site, in two patients. This was probably due to the jagged margins created by repeated manipulations at the morcellator site. We thus recommend that one should avoid using towel clips to avoid gas escape around the morcellator site, which starts off in prolonged morcellation time.
Another safer and relatively simpler procedure in the hands of an experienced laparoscopist as well as novices is the Laparoscopic Assisted Minilap Myomectomy (LAM).  In this procedure laparoscopy is performed initially, giving an incision over the myoma with the ultrasonic shears. The myoma is partly enucleated by traction of the myoma screw. A 3 - 4 cm minilap pfannenstiel incision is done. Through this minilap incision enucleation, morcellation, and suturing of beds are carried out on all multiple and big myomas. Subsequently, minilap incision is sutured back, the laparoscope re-inserted, and thorough suction irrigation and lavage done. However, it should be planned preoperatively and there is no sudden conversion on the table from Laparoscopic to Laparoscopic Assisted Myomectomy.
Our experience demonstrates the feasibility of dealing with even large size myomas laparoscopically and successfully, and we encourage multiple layer closure to decrease the dead space and avoid hematoma formation, and in turn, achieve a good reproductive outcome.
| Conclusion|| |
Laparoscopic myomectomy is a safe and favorable alternative to open myomectomy, as it offers several advantages over laparatomy, with minimal complications.  It is equally feasible for large size myomas also, in experienced hands with advance suturing skills. Multilayer closure of the myoma bed in a continuous, non-locking fashion gives excellent reproductive outcomes in terms of very low adhesion scores and negligible risk of scar rupture in subsequent pregnancies. However, one should appropriately select the myoma size according to one's suturing skills, the instruments available, and experience.
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