9.1 Introduction

Uterine fibroids are the most common benign neoplasms of the female reproductive tract with an estimated incidence of 25–30% at reproductive age [1]. They are detected by ultrasound in about 70–80% of women by the age of menopause [2]. About 30% of fibroids produce symptoms such as abnormal uterine bleeding (AUB) which may result in anaemia, pain or pressure effects on contiguous structures such as urinary incontinence, urinary frequency, urinary outflow obstruction, hydronephrosis, constipation and tenesmus. Fibroids may also be associated with subfertility, and with adverse pregnancy outcomes such as miscarriage and fetal malpresentation [3]. The symptoms associated with fibroids are known to compromise quality of life [3].

9.2 Indications for Myomectomy

The surgical interventions for fibroids include myomectomy and hysterectomy, and these are considered when conservative management fails to control symptoms, when intractable bleeding induces iron deficiency anaemia or when quality of life is adversely affected [4]. The association between fibroid and subfertility, and the potential benefit of myomectomy for subfertility, continue to be a matter of debate. Systematic reviews on the effect of fibroids on reproductive outcome (both spontaneous and following medically assisted conception) suggest that submucosal and intramural fibroids are associated with adverse pregnancy outcomes and lower clinical pregnancy, and implantation rates with an increased rate of miscarriage, while subserosal fibroids do not seem to exert a detrimental effect on fertility or pregnancy outcome [5, 6]. Myomectomy is indicated when there is a desire to preserve the uterus.

Two systematic reviews examining the outcome of assisted reproductive techniques (ART) in the presence of fibroids demonstrated conflicting results. Sunkara et al., showed reduced clinical pregnancy and live birth rates in the presence of fibroids even when not distorting the cavity [7], while the Cochrane review by Metwally et al. demonstrated that presence of intramural fibroids did not appear to change live birth or miscarriage rates, although clinical pregnancy rates appeared to be lower in the presence of fibroids [8]. The role of myomectomy in otherwise asymptomatic women purely for purposes of fertility enhancement remains controversial. On the basis of current evidence, a lower threshold for treating certain fibroids, such as submucosal fibroids and intramural fibroids distorting the endometrial cavity, seems justifiable. At the other extreme, subserosal fibroids do not generally warrant treatment unless they are associated with symptoms such as menorrhagia or pain [3].

The approach for myomectomy is hysteroscopic for submucosal fibroids, open or laparoscopic for intramural and subserosal fibroids [9]. Laparoscopic myomectomy (LM) has been found to be associated with less postoperative pain, lower rates of post-operative fever and shorter hospital stay but longer operating times in comparison to traditional open myomectomy [10]. Other potential advantages of the laparoscopic approach include a quicker recovery time with a more rapid return to normal daily activities. Therefore LM is seen to be more advantageous to the patient than laparotomy.

9.3 Factors to Consider Prior to Surgery

Preoperative assessment and planning are crucial in choosing patients appropriately and minimizing risks of LM. Prior to considering LM, the number, size and location of fibroids must be mapped. This not only helps determine the feasibility of a laparoscopic approach over an open approach but also identifies submucosal fibroids which are generally better treated hysteroscopically [11, 12]. However, because of the potential for heavy bleeding and incomplete resection, some large submucosal myomas may be more effectively treated by the laparoscopic route, especially if resection is likely to result in significant endometrial loss/scarring or leave only a thin residual myometrial layer. A very thin myometrial layer may increase the risk of uterine rupture in subsequent pregnancy [12, 13].

There is no absolute restriction on the number and size of fibroids that can be removed laparoscopically, and this is often determined by the surgeon’s experience and expertise [13]. However, the risk of conversion to laparotomy, blood loss and surgical duration increase with fibroid size and number, and with accompanying adenomyosis [14]. Whilst there is no consensus, some authors consider LM to be appropriate for a maximum of three or four myomas whose sizes do not exceed 8 cm [14], whereas others believe in individual choice based on surgical skill [15].

9.4 Preoperative Imaging

Preoperative fibroid mapping is of paramount importance prior to LM. It is crucial to know the fibroid location during LM, as there is no opportunity to palpate the uterus intraoperatively.

9.5 Pretreatment with Medical Agents

The medical treatments that are used to reduce size of fibroids, increase feasibility of a laparoscopic approach and reduce operating time are gonadotrophin hormone-releasing hormone agonists (GnRHa), selective progesterone receptor modulators (SPRM) and aromatase inhibitors. Of these, GnRHa is most widely used. More recently, four SPRMs investigated in clinical trials are mifepristone, asoprisnil, ulipristal acetate (UPA) and telapristone acetate [20]. All were shown to decrease leiomyoma size and reduce uterine bleeding in a dose-dependent manner. Some follow-up studies have raised concerns about unopposed estrogenic activity and liver toxicity with mifepristone [21]. UPA has shown promising results in terms of efficiency and safety. UPA was compared to a placebo and to leuprolide acetate (a GnRH agonist) in two randomized trials [22, 23], which concluded that control of uterine bleeding in more than 90% of patients receiving a 3-month course of UPA, and the median times to control bleeding, were shorter in the UPA group (5–7 days) than in the GnRH agonist group (21 days).

Studies examining the use of the aromatase inhibitor letrozole have shown that the total operative time, the time required to close uterine incision and intraoperative blood loss significantly decrease after pre-operative treatment with letrozole [24].

There are pros and cons to the use of size-reducing agents prior to LM. The main advantages include correction of anaemia, attenuation of blood loss, reduced uterine and fibroid size, and less adhesion formation [25]. The reduction of fibroid size may increase the feasibility of laparoscopic surgery and also the retrieval of the fibroids. The downsides include added cost and side effects. In addition, these agents increase the difficulty in identifying surgical dissection planes, which may lead to increase in surgical time and risk of conversion to laparotomy [26]. Preoperative GnRH agonists have also been reported as a risk factor for fibroid recurrence, presumably because smaller fibroids shrink and are overlooked at surgery only to regrow when the analogue’s effects wear off [25].

Overall, given that medical therapies prior to surgery may increase the risk of recurrence, the routine use of these agents is not justified. This is especially so since other agents such as intraoperative vasopressin do not increase surgical intricacy and are of proven efficacy in reducing intraoperative bleeding [27, 28]. Therefore, the trade-off between reduction of volume and vascularity of fibroids and the ease of finding surgical planes must be considered prior to the use of GnRHa or UPA.

9.6 Correction of Anaemia

Anaemia is not uncommon in women having LM, owing to heavy menstrual bleeding (HMB). Preoperative intervention is required to resurrect the haemoglobin concentration to anaesthetically safe levels and to reduce postoperative morbidity. As already mentioned, GnRH analogues constitute one effective means for achieving this by temporarily avoiding heavy periods in the run-up to surgery. Some authors advocate recombinant erythropoietin, with evidence from an Italian prospective study showing a significant increase in haemoglobin concentrations before and after gynaecologic surgery (which included hysterectomy for large symptomatic fibroids) after using recombinant human erythropoietin for 8–16 days [29]. Women with borderline haemoglobin levels should also be advised on the use of oral iron therapy.

Regardless of the preoperative haemoglobin level, it should be ensured that cross-matched blood is readily accessible at the time of surgery.

9.7 Consent

The consent procedure for laparoscopic myomectomy should include discussion of the possibility of conversion to laparotomy and of the rare need for hysterectomy in addition to other standard complications associated with laparoscopic surgery. It is good practice to include a discussion on morcellation due to the additional risk of injury to vessels, bowel and other organs with the morcellator as well as the small risk of upstaging occult uterine sarcoma. According to a review carried out by the European Society for Gynaecological Endoscopy, prevalence of uterine sarcoma in fibroids is about 0.14% based on meta-analysis of retrospective trials [30]. It also appears to be age-related, with a lower risk in women <45 years [31]. However, current data on age and prevalence make it difficult to present an accurate risk.

9.8 Surgical Technique

9.8.2 Trocar Placement

Trocar placement is at the surgeon’s discretion and should facilitate fibroid enucleation and suturing. The choice of pneumoperitoneum depends on surgeon’s preference. With large fibroids, a Palmer’s point entry may be preferred with the 10 mm trocar placed under vision. This may sometimes be better when placed higher than the umbilicus for improved vision of large fibroids. The Palmer’s point entry may also be preferred where periumbilical adhesions are anticipated as a result of prior surgery [32]. The authors’ preference is to use three further ports: two 5 mm high lateral ports placed lateral to the epigastric vessels and a 11–12 mm suprapubic port (Figure 9.1a and b). The suprapubic port facilitates insertion of needles, sutures and 10 mm claw graspers or myomectomy screws. This port is later enlarged for the morcellator. Surgeons who perform ipsilateral suturing will place both 5 mm ports ipsilaterally.

Figure 9.1

(a) Port placement for laparoscopic myomectomy.

(b) Use of ports for contralateral suturing.

As an initial step, it is important to carefully survey the pelvis and reassess whether the laparoscopic approach remains feasible. For deeper sited fibroids, that may not be readily evident on inspection. Sometimes, an intraoperative ultrasound evaluation may compensate for the lack of tactile evaluation, but the pneumoperitoneum may pose a challenge to image quality [33].

9.8.3 Minimizing Intraoperative Bleeding

Before the serosa is incised, a dilute solution of Pitressin^® (20 U/mL; Goldshield Pharmaceuticals, Croydon, UK), a synthetic vasopressin, is injected. We dilute 20 U of Pitressin^® (Argipressin) in 20 mL of saline and administer it using an 18-gauge spinal needle placed directly through the abdominal wall. Pitressin^® is instilled bilaterally into the broad ligament just inferior to the round ligaments and subserosally over the fibroid in the plane that allows the solution to ‘spread’ over the fibroid (Video 9.1), accompanied by blanching (Figure 9.2a and b). Vasopressin causes rapid constriction of vascular smooth muscle and may cause untoward cardiovascular complications, making it important to forewarn the anaesthetist prior to its instillation. Pitressin^® use in myomectomy is an off-label use of the drug. A recent meta-analysis affirms the efficacy of vasopressin in reducing intraoperative bleeding during myomectomies. Other agents used to reduce intraoperative bleeding are vaginal misoprostol, intravenous tranexamic acid or a combination of 0.25% bupivacaine and adrenaline [27, 28].

Video 9.1 Initial assessment and argipressin injection.

Figure 9.2

(a) An enlarged uterus due to fundal/anterior wall fibroids.

(b) Blanching of the uterus after argipressin injection.

9.8.5 Fibroid Dissection and Enucleation

Identification of the correct plane helps fibroid extraction. The incision is carried through the serosa, the myometrium, the pseudocapsule and into the myoma itself. So-called onion-skinning allows the myometrium to retract and the fibroid to progressively become extruded, thereby allowing the correct plane to declare itself. This plane, which tends to be avascular, is often deeper than is commonly recognized (Video 9.2).

Primary traction on the exposed fibroid is applied with a claw grasper or myoma screw placed through the 11–12 mm suprapubic port. A blunt probe along with a grasper such as a Manhes forceps to hold the myometrial/serosal edge via the paraumbilical ports is used to push the myometrial edge off the fibroid. This enables the space along the pseudocapsule to be gradually extended circumferentially. Tension on the fibroid by use of the suprapubic 10 mm claw forceps with simultaneous counter-traction from the blunt probe and/or Manhes forceps and the uterine manipulator, aided by division of more stubborn bands using the energy device, progressively coaxes the fibroid from its uterine bed. Once removed, the fibroid can be placed in the pouch of Douglas. Larger fibroids may be placed in the upper abdomen, but it would be better to keep smaller fibroids in the pelvis to avoid difficulty in locating them later in the upper abdomen among the loops of bowel and the omentum (Figure 9.3a–d).

Figure 9.3

(a) Enucleation of an intramural fibroid through an anterior wall oblique incision.

(b) Removal of two further smaller fibroids located deep in myometrium.

(c) Removal of a fourth fibroid.

(d) The myometrial defect after enucleation of fibroids.

9.8.6 Haemostasis and Repair of the Myometrial Defect

It is often felt that a distinct primary vascular pedicle will be found at the fibroid base. However, this is not supported by vascular studies which demonstrate that the vascular supply completely surrounds the fibroid as a dense vascular capsule [37]. Electrocautery to wide areas should be avoided. Individual bleeding vessels should be isolated and cauterized to limit thermal spread and tissue charring. Extensive cautery leads to poor healing of tissue and is implicated in the risk of uterine rupture [38]. Use of a vasoconstrictor may maintain a bloodless field to allow prompt suturing without recourse to diathermy. Two studies have reported on pregnancies following LM during which electrocoagulation was avoided and haemostasis secured by suturing; no uterine ruptures were observed in 111 deliveries in one study [39] and 106 deliveries in the other [40].

Difficulty encountered with suturing is a major cause of conversions to laparotomy [41]. The uterine defect can be closed using conventional laparoscopic needle drivers and delayed absorbable sutures. Knot tying may be either intra- or extracorporeal. Care should be taken to identify any breach of the endometrial cavity. If the endometrial cavity is breached, the endometrium should be closed separately with interrupted 3-0 monofilament polyglactin. The myometrium is closed using large curved needles swaged to 1-0 or 0 polyglactin in one or two continuous running layers depending on the depth of fibroid invasion and the thickness of myometrium to be approximated. Continuous sutures are associated with a significantly smaller drop in haemoglobin levels [42]. Suturing is made more convenient with an anchoring suture placed on the proximal end of the defect on which the assistant exerts traction so as to bring the target into a favourable position for placing the running suture, which is commenced at the distal end. A separate layer of 0 or 2-0 monofilament polyglactin is used to close the serosa.

Technological innovations such as self-righting needle drivers that snap the needle into place with the correct orientation and barbed sutures that obviate the need for knot tying may simplify suturing and make the procedure expeditious [43, 44] (Video 9.3). The barbs in barbed sutures face either in one direction with a needle swaged to one end (V-Loc™ Device; Covidien, MA, USA; Stratafix™, Johnson & Johnson, USA) or in opposite directions from the midpoint with needles at either end (Quill™ SRS; Angiotech Pharmaceuticals, Inc. Vancouver BC, Canada). The barbed suture distributes tension more uniformly along the length of the uterine incision and self-anchors (Figure 9.4).

Video 9.3 Suturing of the myometrial defect.

Figure 9.4

(a) Uterine incision after the first layer myometrial repair.

(b) Serosal closure.

9.8.7 Fibroid Removal and Anti-adhesion Agents

The fibroid is usually removed using a single-use or reusable electromechanical morcellator. The 10 mm suprapubic trocar is removed and the skin incision extended to accommodate a 12 or 15 mm morcellator. The fibroid is drawn into the morcellator via a heavy grasper and the morcellator is activated, taking extreme care that its tip is free of the abdominal wall and in a pocket of pneumoperitoneum having proper 360-degree clearance from bowel and adjacent structures to minimize potential risk of damage to vessels and organs. The morcellator blade is kept retracted except when actively morcellating the fibroid. Morcellation injuries, if they happen, can be fatal. After the main bulk of the fibroid is removed, meticulous inspection of the abdominopelvic cavity and removal of fibroid fragments is imperative, as morcellated fragments of fibroid have been implicated in the development of disseminated peritoneal leiomyomatosis [45].

Following the concerns of morcellation of undiagnosed leiomyosarcoma, two statements by the FDA (United States Food and Drug Administration) in April and November 2014 discouraged the use of electro-mechanical morcellation in the majority of women due to the potential risk of spreading occult uterine sarcoma. Morcellation in a bag has been proposed to diminish the risk of vessel and organ injury, prevent scattering of the fragments and also minimize upstaging occult uterine sarcoma. Several techniques of in-bag morcellation of fibroids have been proposed to avoid many of the reported morcellation complications (Video 9.4). However, not all risks have been addressed such as spillage from the content of the bag in the abdomen, especially if the bag is punctured. Small series of in-bag morcellation have been published with good results [46, 47]. Vaginal morcellation in a bag has been also been described [48]. Possible drawbacks are the need for a sufficient vaginal entry and the fact that only hysterectomy specimens are suitable for this technique. There is insufficient evidence for concrete recommendations on fibroid morcellation, but in-bag morcellation appears to be an option that requires further evaluation.

Video 9.4 Morcellation of the fibroid in a containment bag.

Another option for fibroid removal is via a colpotomy incision, which may be faster than morcellation [34]. However, colpotomy leaves the woman with a vaginal incision, may increase the risk of infection and cannot be used for very large fibroids unless the fibroids are reduced.

After removal of the fibroid, the uterus is irrigated and haemostasis confirmed.

Barriers to adhesion may be used upon completion of suturing (Figure 9.5 and Video 9.5). A Cochrane review found that oxidized regenerated cellulose (Interceed^®; Johnson & Johnson, New Brunswick, NJ, USA) reduces adhesions following laparoscopy and that expanded polytetrafluoroethylene (Gore-Tex^®; WL Gore and Associates, Newark, DE, USA) surgical membrane may be superior to Interceed^®, although its usefulness is limited by the need for suturing and later removal [49]. No evidence of effectiveness for sodium hyaluronate/carboxymethylcellulose (Seprafilm^®; Genzyme, Cambridge, MA, USA) and Fibrin sheet (Tacho Comb, Tokyo, Japan) in preventing adhesion formation was found [49]. As yet, however, there is no substantial evidence that any of these agents improve fertility, reduce pain or decrease the incidence of postoperative bowel obstruction [50].

Figure 9.5 Uterine incision covered with a barrier anti-adhesion measure after the repair.

Video 9.5 Application of barrier anti-adhesion measure (Interceed^®)

Finally, when closing the abdominal wall incisions, it is important to repair the rectus sheath defect within the 15 mm suprapubic incision to avoid later herniation. Closure can be effected with either a J-shaped needle or a suture passer needle.

9.9 Complications

Surgeons require training and appropriate skills to perform laparoscopic myomectomy. Initial concern about increased risk of complications has been replaced by the focus on early recovery [14, 51–53]. In 2007, a large prospective study of 2050 LM procedures undertaken in four Italian referral centres reported an overall complication rate of 11.1%, of which 9.1% were considered minor and 2% major [15]. Intraoperative bleeding occurred in 0.68% of women and serious secondary haemorrhage in 0.1%. One of these required laparoscopic hysterectomy. Failure to complete the planned surgery occurred in 0.34% of instances; conversion to laparotomy occurred in the other seven women (one due to bleeding, three due to anaesthetic problems, one because of a suspected sarcoma and two women because of insufficient space limiting mobilization for very large myomas). In this series, only one woman suffered a bowel injury. One woman had an unrecognized episode of prolonged hypotension resulting in acute kidney failure, which resolved after 2 days of dialysis, and two women had an unexpected sarcoma. Among 386 women who became pregnant, one woman had uterine rupture at week 33 of gestation; this woman had had an 8 cm adenomyoma.

The most common complications included unexplained transient pyrexia (105 of 2050 women; 5.1%) and urinary tract infections (70 of 2050 women; 3.4%). There were 12 (0.6%) episodes of uterine manipulator injury. Overall, the mean drop in haemoglobin was approximately 1.6 g/dL and hospital stay was about 2 days [15].

Complications correlate positively with fibroid number and size [54]. It should be remembered that compared with open myomectomy, LM is a relatively new procedure that is still evolving. Furthermore, some of the skills needed for LM are not readily transferable from more routinely performed procedures as might be the case for open myomectomy. As such, many operators are still on their learning curve and as their repertoire of laparoscopic skills continues to be honed, complication rates will undoubtedly fall. Furthermore, new innovations in laparoscopic equipment to aid suturing and fibroid removal have made LM easier. In a very insightful study, some of these authors appraised their own practice over a 13-year period. They found that as their dexterity improved and they supplemented their practice with electromechanical morcellation and vasoconstrictive agents, they could cope with considerably larger fibroids while at the same time decreasing their operating times and blood loss [55]. Our own case series of 514 LMs reported successful completion of the procedure in 512 women with 18/514 (3.5%) women suffering significant complications: blood loss >1000 mL (n = 15), bowel injury (n = 1), bladder injury (n = 1), small bowel obstruction secondary to port site hernia (n = 1). Two cases were converted to open surgery, one because of suspected uterine malignancy and another due to bowel injury at initial entry, and there were no cases of undiagnosed uterine malignancies following morcellation of fibroids [56].

9.10 Laparoscopic Myomectomy versus Open Myomectomy

Reduced pain and bleeding are consistent features after laparoscopy, identified in several studies. Randomized controlled data from two studies also support reduced febrile morbidity following laparoscopy and a shorter duration of postoperative ileus [55, 60]. Although the lack of a tactile component during laparoscopy could possibly allow smaller fibroids to be missed, this does not seem to be of any clinical consequence [60].

Owing to the technical challenges of laparoscopic suturing and the time taken for removal of fibroids from the abdominal cavity, laparoscopic myomectomy would be expected to be a longer procedure. However, major differences in operating times are not consistently apparent from RCTs. Increasingly acceptable operating times for LM probably reflect refinement of laparoscopic skills along with access to better surgical equipment. The large Italian multicentre study reported a mean operating time of 107.7 minutes for 2050 LM procedures [15].

One of the major criticisms levelled against LM has been that the integrity of uterine repair is inferior to that attainable following open myomectomy; however, in many instances, suboptimal operative technique may have contributed to poor outcome. It is hard to establish how the risk of uterine rupture following LM compares with that following open surgery. It is clear from recent series that when good surgical discipline is maintained, dehiscence rates well below 1% can be expected [15].

The outcomes in terms of cumulative pregnancy, live birth and miscarriage rates among the women with unexplained infertility were similar regardless of the surgical approach used [40]. Interestingly, however, reproductive parameters were significantly better following LM among women with symptomatic fibroids. As a group, women having LM had significantly higher pregnancy and live births per cycle and a shorter time to first conception [40]. Thus, there is a suggestion that fertility prospects might improve with the laparoscopic approach. One mechanism by which LM could be advantageous to fertility is through reduced adhesion formation [50].

9.11 Conclusions

Modern LM is the result of years of refinement, often in response to weaknesses highlighted by adverse effects, combined with key advances such as the development of intraoperative vasoconstrictors, barbed sutures and electromechanical morcellation. The end result is a technique with impressive efficacy and safety profiles. Although there are no preset restrictions, surgeons must be pragmatic in matching their skill to fibroid burden, opting for a laparotomy approach when fibroids are too many or too large. In such circumstances, laparoscopic-assisted myomectomy (LAM) may be of value. Compared with conventional myomectomy, apart from its obvious aesthetic superiority, LM is consistently associated with reduced rates of pain, bleeding, febrile morbidity and ileus, shorter hospital stay and faster recovery. Importantly, recent evidence indicates that with careful attention to surgical detail, the rate of uterine rupture in pregnancy following LM is low and operating times are not dissimilar to open surgery. Moreover, in terms of reproductive outcome in subsequent pregnancy LM is superior to uterine artery embolization and may offer advantages over the open approach.