Handling cervical myomas.

Compared to myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified, as the organs that have to be considered differ depending on the location of the myoma. Surgical difficulties associated with these cases are, poor access to the operative field, difficulty in suturing the repairs, increased blood loss, and distortion of the anatomy of the vital neighboring structures in the pelvic cavity.

Uterine myoma is a common gynecological disorder occurring in 20 – 50% of women, of late reproductive age. A majority of myomas are associated with uterine corpus. Cervical myomas (CM) account for less than 5% of uterine myomas.

Laparoscopic Myomectomy and Hysterectomy have been advocated over traditional laparotomy for various benefits in case of uterine leiomyoma.[1] With the advances in laparoscopic techniques, almost all uterine myomas in the uterine corpus can be treated using laparoscopic myomectomy. However, the treatment of cervical myoma by laparoscopic operation remains crucial. It is essential to establish techniques for safety in operative laparoscopy, for different types of cervical myomas.[2] Compared to myomas that occur in the uterine corpus, cervical myomas are closer to other organs such as the bladder, ureter, and rectum, and the approach needs to be modified, as the organs that have to be considered differ depending on the location of the myoma. Surgical difficulties associated with these cases are, poor access to the operative field, difficulty in suturing the repairs, increased blood loss, and distortion of the anatomy of the vital neighboring structures in the pelvic cavity.[3]

Cervical myomas are divided into two types according to the location, comprising of the intracervical and extracervical types. Surgical steps differ according to the type and location, either anterior or posterior.

OPERATIVE STEPS FOR LAPAROSCOPIC MYOMECTOMY IN CERVICAL MYOMA

A uterine manipulator is normally inserted through the cervix into the uterus before surgery, which sometimes is not possible in patients with a myoma bulging out of the external os of the uterus into the vagina.[4]

The standard surgical steps of operative laparoscopy are followed. Pneumoperitoneum can be obtained by the closed method. The primary 10 mm trocar may be inserted at a point 2-3 cm above the umbilicus or in the palmer's area in such cases. We prefer three 5 mm trocars (one midline and two lateral) in the lower abdominal region.

A step worth considering in huge cervical myomas is bilateral uterine artery ligation before Myomectomy or Hysterectomy. The Uterine can be approached by opening the broad ligament at round ligament and identification and ligation at its origin from the internal iliac artery through retrograde umbilical ligament tracking.

An average of 20 U/mL diluted in 200 mL of saline can be laparoscopically injected into the myoma in the presence of a posterior uterine wall myoma and in the layer between the myoma and the serosa, in an attempt to reduce operative blood loss.

The course of the ureter is confirmed with special attention given to the sacral uterine ligament attachments, to determine the displacement in the relative position of the uterine arteries or ureter. At times when the myoma is large and boundaries difficult to confirm, the broad ligament is opened with an anterior approach to delineate the myoma.

In case of an anterior wall type, a transverse incision is made in the uterovesical pouch and peritoneum, to perform a blunt dissection of the bladder. When performing traction and enucleation with a laparoscopic myomectomy screw, the base of the wound is held with a bipolar grasping forceps and simultaneous complete homeostasis is achieved along with dissection to avoid post enucleation difficulties due to retracted capillaries.

In case of posterior myomas we prefer a midline vertical incision to avoid injuring the vessels and to stay at a safe distance from the ureters [Figure 1].

Figure 1

Posterior myomas we prefer a midline vertical incision to avoid injuring the vessels and to stay at a safe distance from the ureters

After the Cervical Myoma is completely enucleated, morcellation is performed. If complete enucleation is difficult with large myomas and there is limited pelvic space for traction, the myoma is sometimes morcellated when it is still attached to the uterus. The approach should be varied according to the size and location of the myoma.

The most difficult part of cervical myomectomy is suturing the base of the wound following enucleation. Complete dissection of the surrounding organs such as the bladder and ureter, near the base of the wound, is difficult. Bleeding makes it difficult to maintain the visual field, thereby increasing the possibility of damage during suturing. A bottom-up procedure makes it possible to perform suturing safely by providing a complete visual field [Figure 2].

Figure 2

Saturing of resultant defect

The resultant defect is sutured at intervals of about 1 cm with 1/0 or 2/0 absorbable suture material. For the second layer, continuous sutures of the muscle layer can be made with 1/0 sutures for the first layer of cervical mucosa. It is recommended to close the peritoneum also with sutures, to restore the anatomy.

OPERATIVE STEPS TO BE CONSIDERED FOR LAPAROSCOPIC HYSTERECTOMY IN CERVICAL MYOMA

An additional difficulty may be the introduction of conventional manipulators during total Laparoscopic Hysterectomy, where a myoma screw with additional port may be utilized, to manipulate the uterus.

A reasonable option is to perform myomectomy and correct the distortion of the anatomy before proceeding to the hysterectomy, in selected cases.

When performing hysterectomy with myoma in situ, approach the broad ligament on the side with less distortion first and try to tackle the uterine simultaneously on that side. After release of the uterosacrals on the less affected side, normally, reasonable mobility of the uterus is gained so as to be at a safe distance from the vital pelvic organs on the contralateral side (where myoma is projecting) when performing the dissection and coagulation.[5]

Prior identification of the ureters with either retroperitoneal dissection or pre-procedure cystoscopic ureteric stenting may be of help in selected cases of very large cervical myomas with lateral projection. In cases of anterior myomas, prior bladder dissection helps in reaching the uterines. Thus, after considering the location of the myoma, cervical myomectomy or hysterectomy can be performed safely by developing a uniform strategy that uses a fixed operative procedure, if sufficient attention is paid to the following points [Figure 3a and b]:

Figure 3

(a) Uterus with cervical myoma, (b) Bladder dissection

Reducing the size of the myoma with preoperative GnRH

Determining the positional relationship between the myoma and the surrounding organs

Optional blocking of the uterine artery blood flow temporarily

Suppressing bleeding during myomectomy with the use of vasopressin

Minimizing the risk of damaging the surrounding organs by properly positioning the incision in the myometrium

Suturing the bottom of the wound after grasping with the forceps, to avoid making a dead space

Prior myomectomy before attempting definitive steps for hysterectomy