8.1 Current State of Endoscopic Myomectomy

Minimally invasive surgery has one goal: getting patients back on their feet as quickly as possible with as little morbidity as possible. Modern instrumentation has made that possible in many surgical situations.

In the case of myomectomy, traditionally a very bloody procedure, newer instrument designs over the past century have changed the way gynaecologists deal with the condition.

In the twenty-first century, minimally invasive myomectomy is the gold standard in fertility‐sparing surgery for intramural, subserosal and broad ligamentary myomas [2]. Laparoscopic myomectomy, since its introduction by Semm [3], remains under‐utilized due to its objective technical difficulty. Robotic assistance, since its first reported use by Advincula et al. [4], has facilitated wider adoption of endoscopic myomectomy by newer generations. Despite major advances in the 1980s and 1990s, studies have shown that a disproportionately small number of surgeons do a small percentage of complicated surgeries by laparoscopy [5]. As regards submucosal fibroids, hysteroscopy is the gold standard for submucosal myomas, and the removal even of large (>4 cm) myomas is feasible this way [6].

Using traditional laparoscopic instruments, surgeons have to carry out every movement through a fulcrum action, moving their hand opposite to the instrument motion. Laparoscopic surgeons are at an ergonomic disadvantage, often forced to lean or bend uncomfortably while their arms are often held in excessive excursion/abduction in order to handle the long laparoscopic instruments. Cuschieri described a ‘surgical fatigue syndrome’ that occurs after lengthy laparoscopic surgery [7]. The lack of three-dimensional vision, the fulcrum effect of instruments and limited degrees of freedom of movement encountered with laparoscopic surgery all affect the efficiency of the surgeon. New instruments such as the FlexDex needle driver (FlexDex Inc., Brighton, MI) attempt to address some of these issues. It has a three-axis gimbal that attaches to a surgeon’s wrist and leverages a series of mechanical components to translate the movement of the surgeon’s hand to the tip of the instrument. The unique design of the instrument decouples these multiple degrees of freedom in a totally mechanical manner, something previously considered impossible without the use of computer control. FlexDex provides laparoscopic tactile feedback and robotic-like dexterity with six degrees of freedom (Figure 8.1)

Figure 8.1 The FlexDex needle-holder offers robot-like dexterity for laparoscopists.

Surgical robots, by contrast, are built ergonomically and the surgeon’s hand movements are mirrored in the movements of the instrument. On a global level, laparoscopy will remain more popular than robotics in the foreseeable future, access to robots and costs being major deciding factors. Currently only two robotic platforms are readily available for gynaecologic use, the da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) since 2000 and the recently FDA-approved Senhance (TransEnterix, Research Triangle Park, NC) that is just now coming onto market in 2018/2019. Both are approved for myomectomy and other gynaecologic procedures (Figures 8.2 and 8.3). The da Vinci has over 4,000 units installed worldwide and a base of over 18,000 trained surgeons. Intuitive Surgical is currently developing a single-port robot to be used for gynaecology and urology which allows for a reduced incision count versus the current 4-port techniques used. With the many thousands of robotic platforms currently installed, robotic surgery is here to stay, so it is inevitable that both young and experienced surgeons get to train in its usage [8].

Figure 8.2 The da Vinci robotic platform.

Figure 8.3 The Senhance robotic platform is the newest FDA-approved platform.

Both robotic platforms utilize a console/patient-cart system with the surgeon seated at a console providing joy-stick-like controls to remotely regulate the robotic arms and instruments. But they differ in ergonomics. The older da Vinci has a periscope-like console at which the surgeon bends forward and views the 3D image through a binocular interface while controlling camera motion and instruments via joysticks and foot pedals. Since there is no direct or mechanical connection between the system’s input and output, the surgeon receives no haptic feedback to gauge the forces exerted by the tool end effector. A single patient cart carries the articulated robotic arms and, with the new Xi system, any arm can hold the camera. The multiple actuators on the robotic arms translate the surgeon’s input motions to the end-effector instrument inside the patient’s body. Special trocars are needed.

The much newer Senhance robot platform is quite different. Each articulated robotic arm has a separate mobile cart. The trocars are regular laparoscopic trocars allowing instant removal of the robotic arms if urgently needed. The surgeon sits in front of an open console with a 3D monitor and his or her eye motion is tracked, allowing the camera to move to where the surgeon looks. Eye motion control also allows instrument assignment to the robotic arm desired and/or to the left or right steering handle. Together with a normal seating position, these features decrease eye and neck strain compared to sitting for long periods at a da Vinci console. The instrument joystick controls offer haptic feedback. No randomized comparative trials have yet been done to see the real value of these innovative ideas relative to the da Vinci experience. Alletti et al. [9] recently published a series of robotic-assisted total hysterectomies in obese women using the Senhance platform. Indication for total hysterectomy was early-stage (FIGO Stage IA) endometrial cancer in 100% of patients. The median operative time was 110 minutes (70–200). Median docking time was 10.5 minutes (5–25). The median estimated blood loss was 100 mL (50–200). No conversions to laparotomy were recorded. No intra- and 30-day postoperative complications were registered.

A recent meta-analysis of 20 studies involving 2,852 patients undergoing laparoscopic myomectomy (LM), robotic-assisted laparoscopic myomectomy (RALM) and abdominal myomectomy (AM) showed the numbers of complications (odds ratio [OR] 0.52, p = 0.009), estimated blood loss (EBL) (weighted mean difference [WMD] −33.03, p = 0.02), conversions (OR 0.34, p = 0.03) and postoperative bleeding (OR 0.18, p = 0.03) in RALM cases were significantly lower than in LM cases. Compared with LM and AM, RALM is associated with significantly fewer complications, significantly lower EBL, significantly fewer conversions than both LM and AM, and significantly less bleeding than LM [10]. These updated findings are in line with an older Cochrane review involving 808 women that reported laparoscopic myomectomy is a procedure associated with less subjectively reported postoperative pain, lower postoperative fever and shorter hospital stay compared with all types of open myomectomy [11].

Robotic assistance is very useful for inexperienced laparoscopists performing complex tasks such as knot tying, and they experience an early and persistent enabling effect. In case of experts, robotics is most useful for improving economy of motion, which may have implications for highly complex procedures in limited workspaces [12]. Such issues are of course moot for surgeons in developing countries where laparoscopy remains king due to cost issues. But even in Egypt, where we only have one robotic system, the improvement of visualization, better handling of tissues and better suturing was found to be particularly helpful in radical surgery [13]. Falcone notes that currently no evidence exists to support the routine use of robotic assistance at the time of laparoscopic myomectomy [14].

Minimally invasive procedures such as uterine artery embolization (UAE), non-invasive magnetic-resonance-guided high-frequency focused ultrasound surgery (MRgFUS) (Figure 8.4) and cryomyolysis are increasingly used to treat symptomatic fibroids. All these modern techniques offer alternatives to surgery. Whether these will prove to be the future remains to be seen. But I personally believe that many gynaecologists are steering their patients to these treatments due to the lack of minimally invasive surgical skills. Case in point, young doctors think of robotic surgery as ‘easier’ than laparoscopy because the learning curve for robotic suturing and skills is far shorter than for laparoscopy [5].

Figure 8.4 MRgFUS is a non-invasive technique currently gaining increased use in select cases.

8.2 Planning the Procedure

A wise choice of surgical tools and materials by the surgeon performing an endoscopic myomectomy, whether laparoscopic or robot-assisted, will greatly facilitate his or her job. The following steps must be addressed in all cases:

1. 
   

   1. Port placement and cameras

   
   
2. 
   

   2. Haemostasis

   
   
3. 
   

   3. Incision placement

   
   
4. 
   

   4. Enucleation of the uterus/myoma(s)

   
   
5. 
   

   5. Suturing of the myoma bed and closure of uterus

   
   
6. 
   

   6. Tissue extraction.

8.3 Where to Place the Ports?

In both laparoscopic and robotic surgery, planning camera port location is important, especially so in robotic surgery since once docked, it is very difficult to change trocar positions with the standard daVinci Si system (Intuitive Surgical Inc., Sunnyvale, CA). The newer Xi systems are more flexible and allow introduction of the camera in any port; likewise, the robotic arms and instruments are far less bulky. The Senhance (TransEnterix, Research Triangle Park, NC) allows use of standard laparoscopic trocars, so at any given time the surgical assistant at the table can intervene laparoscopically or can use additional laparoscopic instruments through additional trocars.

The size of the uterus plays a great role in determining initial port placement in endoscopic myomectomy. The umbilicus is optimal both for cosmetic reasons and since it can be widened for morcellators or incision expanders when removing the myoma. Palmer’s point (left upper quadrant, LUQ) can be utilized initially in those cases where adhesions are suspected or assessment of uterine size is needed. In some cases, an LUQ camera can be used throughout the procedure, particularly if a 30° scope is used which will allow visualization of the right side of the uterus more easily. Optimally, a distance of around 15–20 cm is needed between the lens and fundus of the uterus. Non-bulky uteri with small-sized myomas can be operated using the umbilicus. In cases of large uteri reaching up to the umbilicus or where there is suspicion of adhesions, placing a supraumbilical port a few centimetres cephalad facilitates vision and accessibility [14, 15] Thirty-degree angled scopes are more popular in Europe and should be available in case the zero-degree scope does not allow proper vision with low anterior wall or broad ligamentary myomas. An additional three instrument ports are placed in the usual positions for myomectomy: two left lower quadrant ports, namely left and right side medial to the anterior superior iliac spines, and another 5 or 10 mm port is placed 10–13 cm lateral to the umbilicus. The larger the uterus the higher these should be. The port lateral to the umbilicus is usually used for insertion of a myoma screw or additional instrumentation.

When deploying the third arm in case of daVinci robotics, a single-tooth tenaculum forceps or Cobra grasper (Intuitive Surgical Inc., Sunnyvale, CA) can be utilized. It is worth noting that utilization of the third operative robotic arm in the 4-arm robot-assisted laparoscopic myomectomy technique accounted for a significant decrease in operative time [16]. To save costs, a regular trocar for the assistant can be used instead of using the third arm. In case of robotic-assisted surgery, particularly when used the older Si systems, it is best to use a side-docking method to free up space between the patient’s legs. Right-sided docking allows the assistant to use his or her dominant hand and frees up space.

From personal experience docking can, with time, be cut down to less than 5 minutes. The type of trocars used is mainly down to surgeon preference. A 12 mm umbilical trocar can be beneficial if a similar-sized morcellator is passed through it and a 5 mm camera is placed in an accessory port. In very obese patients, it is imperative that longer trocars be used.

Three-D cameras, while not essential in laparoscopic myomectomy, can be beneficial, as shown by their use in robotic surgery. Two-D laparoscopy is marred by the lack of depth perception and increases the strain on the surgeon, compromising the safety of laparoscopy. Research shows that 3D cameras shorten the learning curve for laparoscopists considerably, to much less than that of robotic surgery [17] and will enhance the skills of a good surgeon and shorten the learning curve of a novice surgeon, ultimately shortening the surgical time [18]. Single-site laparoscopy showed 86% increased efficiency for beginners and 100% in case of expert surgeons in phantom exercises in urological skills [19]. The current drawbacks of bulky headsets and glasses are being overcome with new glassless type 3D systems [20]. I believe that in the future, the merging of glassless 3D systems and instruments with more freedom of motion – such as the previously mentioned totally mechanical FlexDex (FlexDex Inc., Brighton, MI) – will allow the continued flourishing of laparoscopy.

8.4 Controlling Bleeding

Myomectomy is a bloody procedure, and as a result hysterectomy was always a more popular treatment. When Victor Bonney introduced his famous clamp in 1922, he gave life to a relatively unpopular procedure. Many techniques have been utilized since then, including the use of tourniquets. Contrary to popular belief, myomas have a network of blood vessels supplying them. During development of a leiomyoma, the pre-existing blood vessels undergo regression and new vessels invade the tumour peripherally where intense angiogenesis, probably promoted by growth factors secreted by the tumour, leads to the formation of a ‘vascular capsule’ responsible for supply of blood to the growing tumour [21]. Recent arterial spin labelling MRI studies have shown increased perfusion of myometrium on the myoma-positive areas that is significantly higher than that of the myoma-negative areas [22]. Other investigators studying the effect of myomas on IVF by 3D power Doppler showed that intramural myomas >4 cm significantly increase endometrial vascularity [23].

The uterus receives the majority of its blood supply via the uterine arteries, which are branches of the internal iliac artery. Additional blood supply arrives via the ovarian ligaments and the round ligaments. Extensive anastomoses occur between the uterine arterial supply and the ovarian supply on either side of the uterus which culminate in the arcuate arteries traversing the myometrium. Any method of decreasing the flow during myomectomy will provide diminished intraoperative blood loss and reduce morbidity. Upfront control of vascular supply, prior to further dissection of tissue, may be beneficial in minimizing blood loss during difficult gynaecological procedures [24].

Since this chapter deals with instrumental techniques, I will not expound on the most common method of controlling bleeding: the use of vasopressin. Vasopressin, a synthetic analogue of the posterior pituitary hormone – antidiuretic hormone – is often injected into the uterus to reduce blood loss during surgery. To temporarily minimize bleeding in the surgical field, subserosal injection of dilute vasopressin (20–40 IU in 100 mL of normal saline) until visible vessels blanch is done. This practice is more effective than deep myoma or myometrial injection. Due to safety concerns about the cardiac effects of vasopressin, a recent randomized trial by Cohen et al. [25] looked at whether more dilute concentrations of the drug would be more effective than conventional dosing, while preserving safety. It failed to find any benefit in injecting diluted high-volume vasopressin as compared to low-volume concentrated hormone. These findings agree with the 2014 Cochrane review that showed moderate-quality evidence supporting use of vasopressin to decrease blood loss at the time of myomectomy but note that the optimal dosing and concentration has yet to be determined.

In the past decade, several groups have published their experiences with planned preoperative uterine artery embolization (PUAE), particularly with regard to large uterine myomas, to improve the surgical outcome of subsequent myoma enucleation and to reduce intraoperative blood loss [26–28]. Between 24 and 48 hours after performing UAE, the patients underwent operative myoma enucleation by laparoscopy or by laparotomy. These ‘hybrid interventions’ were meant to reduce the risk of hysterectomy and substantial intraoperative blood loss in women with individual or multiple very large myomas, but who wished for uterine preservation. In fact, this was the original intention of Ravina, who first published the technique in 1995 [29]. Against this is the additional cost/inconvenience of having two procedures.

Less costly and more practical is performing permanent or temporary bilateral uterine artery occlusion (BUAO) during the actual procedure. In women who have completed child bearing, permanent uterine artery occlusion at the origin of the uterine arteries retroperitoneally prior to myomectomy is best. Temporary occlusion is reserved for fertility-seeking patients. Laparoscopic bulldog clips and other vascular occlusion devices (e.g., Crafoord, Satinsky and DeBakey types) and the Hem-o-lok™ clip system (Weck Closure Systems, Research Triangle Pack, NC) are in wide used in laparoscopic partial nephrectomies and can also be used to temporarily (or permanently in the case of Hem-o-lok or titanium clips) ligate the uterine vessels at the time of surgery. Although this can be done using suture material, the difficulty in removing the knot in cases where fertility needs to be preserved means clips/clamps are an easier alternative.

The bulldog clamp is a laparoscopic vascular clamp that may be used to decrease blood loss during surgical procedures. Made of titanium or stainless steel, it is a spring-loaded crossover clamp with serrated blades that effectively occlude vessels without slippage or significant crush injury. Several versions exist, depending on diameter and type of vessels to be occluded.

In my practice, I use 25 mm atraumatic curved arterial bulldog clips with DeBakey serrations (Aesculap AG, Tuttlingen, Germany). They are introduced via a special applier forceps and I recommend using one allowing angled application and removal since straight ones are sometimes difficult to reattach (Figure 8.5). When using a robotic platform the clips are introduced via a 5 mm × 12 mm accessory port. This was very beneficial in a case of cervical myomectomy that I performed robotically in a virgin (Figure 8.6 and Video 8.1), and has also been mentioned by others [30, 31]. As previously noted, the uterine artery may have a double c-shaped origin from the internal iliac, and in this case clamping both vessels or clamping the internal iliac artery before the bifurcation may be helpful in reducing uterine perfusion. It might be beneficial to also apply temporary clamps on the ovarian arteries in the infundibulopelvic ligaments in cases of very large fibroids.

Figure 8.5 Titanium bulldog clamps used for uterine artery occlusion.

Figure 8.6 Large cervical myoma in a 23-yr old virgin female.

Reperfusion occurs immediately after their removal and studies have shown no increased risk of embolization or irreversible uterine muscle damage with their prolonged use. Fibroids get their blood supply almost exclusively from the uterine arteries [32], whereas the uterine myometrium derives its blood supply from several vessels including the ovarian and round ligament arteries. The temporary ischaemia caused by bilateral uterine artery occlusion affects the fibroid with little or no effect on the normal uterine myometrium [33–35]. This procedure usually adds anywhere between 15 and 30 minutes to operating time; with experience, the time is considerably reduced.

Advantages of uterine artery occlusion prior to myomectomy:

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  The major advantage is that blood loss is considerably reduced.

  
  
• 
  

  Studies show that there is shrinkage of very small fibroids that are not removed during the surgery.

  
  
• 
  

  There is significant reduction in the recurrence rate of uterine fibroids. [32].

8.5 Incision and Enucleation

Traditionally, a vertical incision was used to eliminate the need to incise vascular areas and avoid the injury of the interstitial portion of the fallopian tube. Many surgeons prefer a transverse uterine incision because it runs parallel to the arcuate vessels of the myometrium, leading to less bleeding, in their opinion. But myomas apparently disrupt the normal uterine blood flow and change the spatial positioning of the arcuate arteries within the uterine wall, the anatomy of which has been well detailed in previous studies [38]. This can induce vascular congestion and venous engorgement leading to an abnormal vascularization and bleeding pattern. This has implications for the incision into the uterus since transverse incisions should potentially have less bleeding.

An important and often overlooked fact is the ergonomics of wound closure. With improper positioning of the needle holders, the laparoscopic surgeon may have difficulty suturing the deep areas of the myoma bed, leading to postoperative bleeding. Many surgeons like a transverse incision since it facilitates closure from the lateral ports. Vast experience with caesareans verified that low transverse scar wound rupture in subsequent pregnancy is far less than with a vertical incision. But an oblique incision has been proposed by some when dealing with an anterior myoma and lateral ports. A vertical incision and a suprapubic placement of the needle holder is suggested to be more ergonomic for fundal and posterior wall myomas [24]. Broad ligamentary myomas require careful observation of the course of the ureters and large blood vessels. Depending on the location of the myoma, an incision is made on the anterior or posterior leaf of the broad ligament.

Tinelli et al. have described the myoma fibroneurovascular pseudocapsule and the importance of identifying and sparing as much as possible of it [39]. Their intracapsular approach to myomectomy helps preserve the integrity of the remaining uterine muscle and promotes better healing and functionality.

Laparoscopically, the incision can be made with a simple monopolar knife electrode with pure cutting current (40–60 W) to minimize damage to adjacent myometrium and decrease subsequent risk of rupture [40]. Better, if available, ultrasonic shears can be used (Harmonic scalpel; Ethicon Endosurgery, Cincinnati, OH or Thunderbeat, Olympus). Some surgeons who have CO₂ lasers available in the OR utilize them for a bloodless incision. Scalpel holders are available that allow the use of a #11 scalpel, and this can also be used, especially if vasopressin has been injected.

In robotic-assisted cases, it is best to use the tip of one blade of the sharp monopolar scissors (HotShears) with low wattage pure cutting current, or to use an ultrasonic shear (Harmonic Ace, Intuitive Surgical Inc., Sunnyvale, CA). The da Vinci permanent cautery hook is a monopolar instrument that is very effective and likewise should be used on a pure cut. Because robotic instruments have a fixed number of uses, surgeons should choose an instrument they can use for both incising and assisting in dissection of the myoma, to minimize changing and increasing costs.

A prior MRI or ultrasound will allow the surgeon to assess the depth of the initial incision. Not reaching the proper plane and capsule will be cause for difficult dissection and extraction. The incision should extend as close as possible to the width of the myoma in view to allow easy extraction.

Once the shiny pseudocapsule is reached, either a myoma screw is inserted for traction (through an accessory port in case of robotic-assisted) or a claw or tenaculum forceps is applied. The edges of the wound can then be grasped by atraumatic forceps or similar and gradually spread apart while simultaneously pulling on the myoma. This works well with bulging myomas or broad ligamentary ones: the overlying myometrium is thin enough to be stripped away. When dealing with deep intramural myomas, this approach is more difficult; a very useful technique is to extract the fibroid by applying generous traction with the tenaculum and counter-traction with an atraumatic grasper and suction device. Alternatively, using scissors in one hand the surgeon can, as in open surgery, open the blades and dissect gently between capsule and myometrium while applying traction on one side of the wound with the other hand and helped by an assistant pulling on the myoma screw. This use of sharp dissection can sometimes help dislodge a myoma in patients pretreated with GnRh. Repositioning the tenaculum or myoma screw regularly at the border of the myoma and myometrium allows better traction. In this fashion, total enucleation of the myoma from its pseudocapsule is achieved.

If vasopressin has been used it helps to inject a large quantity in the plane of the capsule, which greatly facilitates enucleation. Low-wattage bipolar coagulation to stop bleeding should be kept at a minimum. Haemostatic agents such as SurgiFlo (Ethicon Inc.) can help minimize usage of electrical coagulation. If proper haemostatic techniques are utilized then most blood encountered will be accumulated blood within the venous sinuses of the myometrium. If active bleeding is encountered then either inject more vasopressin or think of temporary uterine artery/ovarian artery ligation.

Enucleation of degenerated myomas can be difficult due to their friability. Placing an endobag around or under the uterus is beneficial to catch any pieces of myoma that might be ripped off during the unlodging of the tumour from its bed. Myoma screws should be of the 10 mm variety to allow better traction. Sharp dissection of the myoma from its bed is oftentimes helpful. Pedunculated fibroids are usually easily removed. The broad base of the pedicle can be bisected close to the myoma and the defect sutured in two layers.

In the past decade, several authors have reported using a hybrid technique variation in robotic myomectomy where a conventional laparoscopic enucleation of the myoma is followed by reconstruction with the da Vinci robot. They justified it by noting preservation of tactile sensation while separating very large tumour masses from delicate reproductive structures, and allowing the use of a rigid (not articulated) tenaculum that was capable of exerting significant pull at every angle with the benefit of haptic feedback and without risk of equipment damage [41, 42]. Gaining more experience in both laparoscopic and robotic-assisted myomectomy will allow the surgeon to choose a single method rather than this very wasteful and expensive method.

8.6 Suturing

Uterine Repair –– Suturing has been one of the main factors dividing laparoscopists into average and above average. Advances in instrumentation over the past decade have helped surgeons become more efficient. Suturing devices such as the Endostitch (Covidien), facilitators such as Laparotie (Ethicon, Somerville, NJ) and the newer intuitive needle holders such as the Flexdex are allowing more surgeons to perform more technically difficult suture procedures.

Traditionally, synthetic absorbable polyglactin sutures have been used for closure of the defect, but over the past decade barbed sutures have become very popular. These knotless sutures have either uni- or bi-directional cuts made into their surface during manufacture. The resulting ‘barbs’ anchor into the tissue at multiple points, locking the suture and preventing slippage. Pulling on the stitch serves to further pull and compress the opposing sutured edges. Examples include QUILL™ (Angiotech Pharmaceuticals, Inc., Vancouver, BC, Canada), the V-Loc™ (Covidien, Mansfield, MA) and STRATAFIX™ (Ethicon Inc.). Available in many sizes, the advantages include the complete absence of knots, the even distribution of tissue strength along the wound, decreased blood loss and great reduction in operative time especially for suture-challenged surgeons.

The technique and number of suture layers is not fixed but should vary according to the location/depth of the myoma. One, two and even three layers may be needed. In case of a superficial subserosal myoma and a shallow incision, bed closure is mandatory, but only one suture layer is needed. Separate single sutures of absorbable regular suture material (Vicryl 0, or 00) or continuous barbed sutures (V-Loc or STRATAFIX) are used for proper re-approximation of the edges. With a very shallow bed, the defect can be closed with a running non-locking imbricating ‘baseball stitch’ suture. In case of barbed suture material, it is important to cut the suture flush to the surface of the uterus to prevent bowel adhesions.

With deep intramural myomas, closure in several layers is important to prevent dead spaces and haematoma formation. Barbed suture (2-0 or 0) is best used as a continuous running suture for the deep bed. The final superficial layer can be closed with 2-0 baseball-type stitching. If properly done, then the barbed suture is hidden within the depths of the stitching. If the endometrial cavity is inadvertently entered (easily noticed by seeing the balloon of the uterine manipulator or sudden appearance of gas bubbles), the defect can be closed with a 3-0 Monocryl or Vicryl suture, taking special care not to pass the suture into the endometrial cavity. Overlapping sutures in the overlying myometrium cover the defect.

Tinelli and Malvasi [39] believe that the defect should be closed by simply introflecting muscle edges and approximating in one or two layers. They are of the opinion that proper technique of myoma intracapsular enucleation and preservation of the neurovascular capsule will allow for better healing with less foreign stitch material.

8.7 Extraction of the Myoma

Over the last 20 years, leiomyomas were usually removed with a power morcellator. Many devices have been marketed and one review documented 11 different types available as recently as 2014 [43]. Power morcellation of the uterus and uterine tumours permits the extraction of large tissue masses through small laparoscopic incisions in a very short time and became extremely popular. However, open power morcellation is associated with an increased risk of dispersing benign myoma tissue and occult malignant leiomyosarcoma tissue throughout the abdominal cavity. Donnez et al. [44] described the risk of uterine fragment dispersion with the subsequent appearance of parasitic leiomyomas. But since their first publication, Donnez no longer encountered this complication in a subsequent series of 400 laparoscopic hysterectomies when caution was exercised and extensive lavage used [45].

A lengthy debate started after the Food and Drug Administration (FDA) warning in 2014 about the use of electromechanical power morcellation, and clinical practice changed as a result. The FDA’s latest [46] white paper suggests the prevalence of uterine sarcoma in women undergoing surgery for presumed fibroids to be in the range of approximately 1 in 225 to 1 in 580, and that for leiomyosarcoma (LMS) to be approximately 1 in 495 to 1 in 1,100, based on an analysis of 23 studies.

These numbers are at odds with other studies. In a series of 10,731 uteri morcellated for myomas during laparoscopic hysterectomy, the prevalence of sarcoma was just 0.06% [47]. A similar low incidence (1/2,000) was observed in a meta-analysis by Pritts et al. [48] and in a retrospective study including 4,791 women in Norway [49]. In my opinion, the debate on the use of electric morcellation has probably been overstated due to emotional and medicolegal reasons.

Gynaecologic surgeons should try, whenever possible, to reduce the use of open power morcellation. Several alternatives have emerged in a bid to minimize the risk of inadvertent tissue spread. Some gynaecologists propose vaginal removal through the cul-de-sac of Douglas or mini-laparotomy to avoid the risk of dispersing tissue fragments during sarcoma morcellation. Others have promoted the use of bags to contain the specimens. Many of the companies previously producing morcellators have stopped manufacture/recalled their products due to multiple law suits.

Alternative methods of safer morcellation were devised as a result of the decrease in use of power morcellation.

Power morcellation within a containment bag. The Lahey bag (Becton Dickinson, Franklin Lakes, NJ) is also known as an ‘isolation’ bag. Cohen, in 2014, reported a technique for the use of power morcellation within an insufflated Lahey bag [50]. The Lahey bag measures 45 cm × 45 cm and is sufficiently large to hold large uterine fibroid tumours. The bag is rolled up and inserted through an open single port cannula, the cannula recapped, the fibroid inserted in the bag, opening the port to bring the opening of the bag up through the port, recapping the port cannula, insufflating the bag and performing power morcellation within the bag. Power morcellation in the bag should thus reduce the risk of spreading tumour pieces throughout the abdominal cavity.

Serur et al. [51] reported on 5 years of their experience with a manual morcellation technique for all uteri >500 g at laparoscopic hysterectomy that can be also used for myomas. In this technique, once the uterus is separated from its vascular and supporting structures, an Endo Catch II 15 mm polyurethane specimen pouch (Covidien Surgical, Mansfield, MA) is inserted through an abdominal port or vaginally. The bag is opened and the uterus is placed inside it. An abdominal port incision is then enlarged to 20–30 mm so that the opening edge of the bag can be brought out through the incision to the skin surface. Clamps are used to hold the uterus against the abdominal wall while it is circumferentially cored with a scalpel. The median duration of morcellation was 14.8 minutes (range, 4.5–21.6 minutes) for the abdominal route and 11.7 minutes (range, 5.2–16.8 minutes) for the vaginal route. Occult malignancy was identified in two patients. There were no complications related to the morcellation technique or gross bag rupture. A simple technique but it can be time-consuming with very large myomas.

A recent study compared contained manual morcellation (n = 38) versus contained power morcellation (n = 62) in robotic-assisted myomectomies. A significant decrease in operating time was noted with manual technique, together with no difference in postoperative narcotic usage and discharge time compared to power morcellation [52].

Technical difficulties. Techniques that use morcellation in a bag are currently plagued by a number of technical difficulties. It can be very difficult to place a large tumour in a floppy bag. Current advances in bag technology use a deployable rigid bag opening that probably will help to overcome this difficult step. Pulling the bag up through a port site or cannula requires an incision in the range of 30 mm – larger than the incision currently employed in many laparoscopic operations. The larger incision is likely associated with more pain and greater time to full postoperative recovery.

Calcified fibroids are very difficult to morcellate. Preferably, they should be extracted through a posterior colpotomy or via a min-laparotomy incision. Coring during extraction will require frequent changes of scalpel blades, which dull quickly on these myomas.

Natural orifice morcellation. Transvaginal placement of an Alexis retractor (Applied Medical, Rancho Santa Margarita, CA) can facilitate the process of vaginal coring, as reported by Kho et al. [53]. Coring or bivalving the large uterus has a small risk of spreading small bits of tissue into the vagina and near the vaginal apex, but this is much less than the risk of open power morcellation of a uterine tumour because the uterine serosa is pulled tightly against the vagina, reducing the spread of tissue into the peritoneal cavity.

Favero and colleagues have an alternative approach that involves placement of the fibroid within a bag and bringing the opening of the bag out through the vagina and performing hand morcellation of the tumour in the bag via the vagina [54]. A polyurethane bag with polypropylene draw strings (Lapsac, Cook Medical, Bloomington, IA) is inserted into the abdominal cavity through the vagina. The specimen is inserted into the bag and the drawstrings are pulled to close the bag. The surgeon pulls the strings and opening of the bag out to the vaginal introitus. The bag is opened and two narrow retractors are placed in the vagina to protect the vaginal tissue, urethra, bladder and rectum. Lahey clamps are placed on the uterine cervix and the uterus is morcellated using a cold-knife. Bivalving a small uterus will facilitate its removal through the vagina. Coring of the uterus may be preferred for very large uterine tumours.

This method is a modification of the original laparoscopic-assisted vaginal myomectomy reported by Pelosi and Pelosi [55] and later by Goldfarb and Fanarjian [56]. Their technique is best for posterior wall fibroids and greatly depends on a wide patulous vagina to pull down the uterus and enucleate, then sew the defect. Goldfarb considers this better than mini-laparotomy since the acute angulation of uterine blood vessels affords minimal blood loss.

Laparoscopic-assisted Myomectomy. First reported by Nezhat et al. in 1994 [57], this method enables conventional multi-layer suturing. After laparoscopic myomectomy, a mini-laparotomy can be made either suprapubically or by widening the umbilical port and the uterus or uterine tumour can be pulled up to the skin surface and removed by coring the tissue with a scalpel. An Alexis retractor (Applied Medical) is usually inserted. As with vaginal coring, although the process does not occur in a bag, the risk of spreading tumour tissue into the abdominal cavity is reduced compared with open power morcellation. However, using this technique, tissue may be spread into the abdominal incision, resulting in the postoperative growth of small nodules of endometrium or fibroids in the incision. But a plus to this technique is that proper suturing of the uterine myoma bed can be done through the mini-lap incision.