Other than laparoscopic suturing, the greatest challenge and often the most frustrating step in laparoscopic myomectomy is specimen removal. For multiple small myomas, the enucleated specimens can be placed in a specimen retrieval bag, brought up to the largest port site, morcellated in the bag at the skin line using an 11 scalpel blade or scissors. While the introduction of power morcellators, in the last decade, has revolutionized the laparoscopic myomectomy procedure, due to its ease of use, there have recently been serious concerns regarding the safety of its use. The most widely used devices in the US are made by Gynecare (Johnson & Johnson, Somerville, NJ), Karl Storz, WISAP, and Richard Wolf. Seeding of port sites with malignant cells or endometriosis is a well-known sequela of laparoscopic procedures. This may also occur with morcellated myoma tissue, as was shown in a case report by Ostrzenski [23]. Intra-abdominal seeding of benign leiomyoma could lead to parasitic leiomyomas that can become symptomatic or require further surgery [24, 25]. However, more concerning is the morcellation of an unsuspected leiomyosarcoma, that can lead to seeding of malignant tissue in the abdominal cavity, significantly altering the stage and prognosis of the disease [26]. Since there is no reliable test that could predict the presence of leiomyosarcoma in a leiomyomatous uterus, and based on recent reported cases of disseminated leiomyosarcoma following power morcellation [27], the US Food and Drug Administration (FDA) had issued a warning that discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for uterine fibroids, as of April 2014 (http://​www.​fda.​gov/​MedicalDevices/​Safety/​AlertsandNotices​/​ucm393576.​htm). This has followed same warning issued by multiple societies including the Society of Gynecologic Oncologists (SGO), the American Association of Gynecologic Laparoscopists (AAGL) and American College of Obstetrics and Gynecology (ACOG). As a result, multiple hospital systems throughout the United States have banned the use of power morcellators. However, there are multiple alternatives available to power morcellation. One alternative includes the removal of the specimen through a posterior and occasionally anterior colpotomy incision. The posterior colpotomy incision can be done vaginally below the cervix between the uterosacral ligaments. Once the peritoneum is opened, the myoma is grasped vaginally in a bag with a tenaculum or Leahy clamp and removed intact or progressively morcellated using a coring technique, while enclosed in a laparoscopic bag. Alternatively, the vagina can be identified laparoscopically with the help of the uterine manipulator, vaginal probe, or a sponge stick placed in the posterior fornix. An incision is then made laparoscopically using an electrosurgical needle, scissors, harmonic scalpel, or CO₂ laser. The disadvantage of this approach is that the pneumoperitoneum is rapidly lost, making it difficult to bring the myoma into the cul-de-sac. A wet lap pad or a surgical glove containing 2 wet sponges (also known as Ceana’s glove), may be placed in the vagina to restore the pneumoperitoneum and view the pelvis. Recently, the development of automatic insufflators, such as the AirSeal system (SurgiQuest, Connecticut), that re-fills the pneumoperitoneum when the vagina is open or gas leaks are present, make the procedure easier. Multiple small myomas can be removed with a specimen retrieval bag placed through the colpotomy incision. The colpotomy incision can be sutured laparoscopically or vaginally.

Another alternative method that we prefer is the use of laparoscopically assisted myomectomy/minilap myomectomy (LAM). This technique was first reported by Nezhat et al. in 1994 [28] and is less difficult and requires less time to complete than other modes of myomectomy. The decision to perform a LAM is usually made intraoperatively following completion of exploratory laparoscopy and treatment of other pelvic abnormalities. Cases most suitable for a LAM include a myoma greater than 8 cm, multiple myomas requiring extensive morcellation, a deep, large, intramural myoma that requires uterine repair in multiple layers. A combination of laparoscopy and a 2–4 cm abdominal incision may put laparoscopic myomectomy within the technical reach of more gynecologists. Better pelvic exposure during the laparoscopy allows the gynecologist to diagnose and treat associated endometriosis or adhesions, and the traditional access allows for fast morcellation and conventional suturing preserving myometrial integrity. In addition, LAM with morcellation and conventional suturing may reduce the mean operative time. Similar benefits may be seen with the introduction of barbed suture. Further support for the LAM technique is found in a study of in a study by Glasser that detailed 139 minilaparotomy myomectomies [29]. Out of the 139 cases presented, 66 underwent LAM, during which the laparoscope was used to identify and mark the incision site or to perform adhesiolysis. The authors concluded that myomectomy performed through a 3–6 cm minilaparotomy incision affords the advantage of same-day discharge as well as the ability to palpate the uterus and close the defect using a standard three-layered suturing technique. The most prominent myoma is injected at its base with 3–7 mL of diluted vasopressin. An incision is made over the uterine serosa at the surface of the tumor and extended until the capsule of the leiomyoma is reached. A corkscrew manipulator is inserted into the leiomyoma and used to elevate the uterus toward the midline suprapubic puncture. Alternatively a laparoscopic single tooth tenaculum can be used for the same purpose. With the trocar and manipulator attached to the myoma, a 4–6 cm transverse incision is made through skin and fascia and the rectus muscle separated in the midline. After opening the peritoneum transversely, an Alexis wound retractor (Applied medical) or a Mobius abdominal retractor (Cooper surgical) (Fig. 11.8) is introduced for better exposure. The leiomyoma is grasped with two Lahey tenacula (Fig. 11.9). The tumor is shelled and morcellated sequentially (Fig. 11.10), and after its complete removal, the uterine wall defect shows through the incision. When multiple leiomyomas are found, as many as possible are removed through one uterine incision if it can be accomplished without excessive tunneling. When other myomas are located and cannot be removed through the initial uterine incision, the 4-cm abdominal opening is approximated temporarily with two or three Allis clamps, or an inflated latex glove (placed over the self-retaining retractor while the insufflator is turned ON). The laparoscope is reintroduced, and the remaining myomas are identified, and brought to the incision and removed in a similar fashion. The uterus is then repaired in two to three layers (Fig. 11.11). The abdominal incision is then closed in routine fashion, ideally with a subcuticular skin closure. The laparoscope is used to evaluate hemostasis. The pelvis is observed to detect and treat endometriosis and adhesions that may have been obscured previously by myomas. Copious irrigation is used, blood clots are removed, and Interceed (Gynecare, Somerville, NJ) may be applied over the uterus to help prevent adhesions if the incision is completely dry. Nezhat and associates evaluated 143 charts from their practice [30], including those of patients who had myomectomy by laparotomy (15.3 %), laparoscopic myomectomy (44.7 %), or LAM (39.8 %). Mean operating times, estimated blood loss, hospital stay (after eliminating the first 15 LAM patients), and time to resume work or regular activities were the same for laparoscopic myomectomy and LAM despite larger myomas, difficult locations of intramural myomas, and adjunctive laparoscopy in the latter group. The leiomyoma weights were greater in the LAM group than in the laparoscopic myomectomy group (P ≤ 0.05). Time to 100 % recovery was slightly longer in the LAM group. Most patients are observed in an outpatient unit and discharged the morning after the operation, although some can leave the hospital on the afternoon or evening of the procedure.

Pre-treatment with GnRH agonists before myomectomy remains controversial. In a systematic review of randomized controlled trials of the use of GnRH analogues before hysterectomy and myomectomy, it was found that pre- and postoperative blood counts were improved, uterine and myoma volume decreased, and operative time and blood loss reduced by GnRH agonist therapy [31]. Reduction in leiomyoma size makes the procedure less time-consuming because a smaller uterine incision can be made and less morcellation is required. The individual myomas, however, are softer, which often results in the clamps tearing through the tissue, resulting in the loss of upward traction, which is counterproductive and may result in increased bleeding. Thus, although GnRH agonist treatment may soften the myoma (facilitating morcellation) and shorten operative times, it also may increase the duration of laparoscopic or minilaparotomy myomectomy [32]. For anemic patients, preoperative GnRH treatment may enable restoration of a normal hematocrit, decrease the size of the myoma, and reduce the need for transfusion [33]. However, not all studies have shown the benefits described above. Increased difficulty in identifying and dissecting the cleavage planes and shrinking small myomas to the point at which they cannot be seen or palpated may increase recurrence [34]. In a recent meta-analysis by Chen et al. looking at the effect of preoperative GnRH use prior to laparoscopic myomectomy, GnRH agonist did not reduce operative time [35]. However, intraoperative blood loss was statistically lowered (mean difference, 60 mL; 95 % confidence interval [CI], 39–82). Statistical difference was also observed in postoperative hemoglobin concentration (mean difference, 1.15 g/dL; [95 % CI, 0.46–1.83]) and red blood cell count (mean difference, 0.65 × 10(6) cells/mL; [95 % CI, 0.16–1.14]) but not serum iron concentration. In our practice, we do not use routinely preoperative GnRH agonists, unless the patient is anemic.

Post-myomectomy adhesions have long been thought to possibly compromise fertility, although sound data is lacking. Single, vertical, anterior and midline uterine incisions may cause fewer adhesions. Although sutures predispose patients to adhesions [36] they are necessary to close the uterine defect. Both Seprafilm [37] (HAL-F) bioresorbable membrane (Genzyme Corporation, Cambridge, MA) and Interceed (oxidized regenerated cellulose) [38], have been shown to reduce postoperative adhesions in this setting. However, the impact on fertility was not assessed in these studies, and their routine use cannot be advocated for this purpose [39, 40]. Regardless of the adhesion prevention material used, most are ineffective in the absence of hemostasis. This was shown very early in a study on animal models by Linsky and associates [41]. Using an imbricating baseball-type closure on the uterine serosa is both hemostatic and minimizes the presence of raw edges, which could possibly predispose to adhesion formation.

Spontaneous uterine rupture of the gravid uterus following laparoscopic myomectomy has been reported in all types of leiomyomas including pedunculated, subserosal or intramural types, mainly in the 2nd and 3rd trimesters of pregnancy [42, 43]. In a review of 19 case reports of uterine rupture following laparoscopic myomectomy, published between 1992 and 2004 [42], looking at risk factors for uterine rupture, the authors concluded that in order to decrease the risk of this complication surgeons need to adhere to techniques developed for abdominal myomectomy including limited use of electrosurgery and multilayered closure of the myometrium. The necessity for complete closure of the defect cannot be emphasized enough. It is inadequate to place two or three large through-and through interrupted sutures in a deep myometrial defect if the patient plans future childbearing. Other reports of uterine rupture following laparoscopic myomectomy emphasize the importance of adequate closure of the myometrial defect [44–46]. A recent study reported the appearance of myomectomy scars in 15 women undergoing elective cesarean delivery because of previous myomectomy [47]. The scars in the five women who had myomectomies performed laparoscopically were all described as “strained with thinned tissue and illdefined edges” despite being sutured. In the 10 women who had their myomectomy performed by laparotomy, the majority of scars were symmetric, with the tissue being of uniform thickness compared with the surrounding myometrium. Certainly the liberal use of electrocautery for hemostasis might be the etiologic factor in uterine rupture. In summary, patients must be thoroughly counseled about the possibility of uterine rupture at any time during the gestation, and made aware of the possibility of fetal loss and even hysterectomy, if hemorrhage cannot be controlled. During pregnancy, these patients should be followed carefully and all complaints of abdominal pain addressed immediately. Despite the lack of evidence, the most common practice among obstetricians is to recommend cesarean delivery in future pregnancies for patients with a history of myomectomy regardless of the approach, especially if the uterine cavity has been penetrated during the myomectomy [48]. In our practice, we recommend cesarean delivery when there is deep myometrial invasion, regardless whether or not the uterine cavity was entered.