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LAPAROSCOPIC MYOMECTOMY

Currently available instruments make laparoscopic myomectomy feasible, although the wide application of this approach is limited by the size and number of fibroids reasonably removed, and the technical difficulty of the procedure and of laparoscopic suturing (69). However, prospective, randomized studies comparing abdominal and laparoscopic myomectomy (fibroid removal) in selected patients show that the laparoscopic procedure is associated with less postoperative pain, shorter hospital stay, and shorter recovery than is abdominal surgery (70).

In 40 women with subserosal and intramural fibroids of <6 cm who were randomized to abdominal and laparoscopic myomectomy, estimated blood loss and surgical times were similar, and there were no major complications in either group. A study of 131 women randomized to laparoscopic and abdominal myomectomy (but not robotic myomectomy) for non-pedunculated fibroids of >5 cm (mean, 7 cm) found significantly higher postoperative hemoglobin concentrations, lower incidence of postoperative fever, and shorter hospital stays with laparoscopic myomectomy (71).

Case series without controls show the feasibility of laparoscopic surgery in women with large fibroids. In a series of 144 women in whom the largest fibroid was %18 cm (mean, 7.8 cm), only 2 (1.4%) required conversion to laparotomy (72). Of 332 consecutive women undergoing laparoscopic myomectomy for fibroids of <15 cm, only 3 (0.9%) women required conversion to laparotomy (73). Port placement should be based on the position and size of the fibroids to be removed. Laparoscopic suturing may be more ergonomic if there are two ports on either the patient’s right side, for right-handed surgeons, or left side, for lefthanded surgeons: a 12-mm port, about 2 cm medial to the iliac crest, for suture access and another 5-mm lateral port, at the level of the umbilicus (74). A left upper quadrant approach may be used for initial access when uterine size is near or above the umbilicus (75).

Pitressin is injected into the fibroid. A transverse incision is made directly over the fibroid and carried deeply until definite fibroid tissue, and the avascular plane, is noted. The fibroid is grasped with a tenaculum for traction, and the plane between the myometrium and fibroid is dissected until the myoma is free. Bleeding vessels in the myometrial defect are desiccated with bipolar electrosurgical paddles. Delayed absorbable sutures are placed in one, two, or three layers, as needed, adhering to surgical technique at laparotomy. Morcellation of the fibroid, which now is easier with electromechanical devices, is accomplished under direct vision. The pelvis and abdomen are irrigated, the fluid suctioned, and Interceed (Gynecare, Somerville, NJ) is placed as an adhesion barrier.