Laparoscopic myomectomy: methods to control bleeding.

Most of the surgeons find it difficult to perform myomectomy when it bleeds during the procedure as it becomes difficult to get into the correct plane of dissection. If this bleeding or blood staining of tissues is prevented it will be easier to get into the correct plane of dissection. In several studies, it is found that bilateral uterine artery ligation, at origin, does not interfere with future fertility as the end vessels and collaterals of the uterus are not interfered with. As no energy source is used to incise the myoma once Vasopressin has been used, the myomectomy scar integrity is better, as noted by various surgeons.

Since myomectomy was first performed by Washington and John Atlee, in 1844, it has come a long way, but even today, the biggest complication of myomectomy remains excessive blood loss during surgery, to the extent that most centers worldwide, take consent for hysterectomy at the time of myomectomy, if and when the need arises. Control of bleeding during myomectomy has multiple purposes.

Most of the surgeons find it difficult to perform myomectomy when it bleeds during the procedure as it becomes difficult to get into the correct plane of dissection. If this bleeding or blood staining of tissues is prevented it will be easier to get into the correct plane of dissection.

Suturing becomes difficult laparoscopically when the myoma bed keeps bleeding. If this can be controlled it becomes easier to suture the myoma bed.

If there is no bleeding then the use of energy sources is minimized and tissue necrosis is prevented, and this leads to better healing.

Small hematomas that can occur in the myoma bed lead to a weaker scar. This is considerably reduced if there is less bleeding and this leads to better scar integrity Several methods have thus been devised to decrease blood loss at myomectomy.

PREOPERATIVE METHODS

Gonadotropin-releasing hormone agonists

Most laparoscopic surgeons do not like to use Gonadotropin-releasing hormone (GNRH) agonists preoperatively because of the degeneration within the fibroid caused by the GNRH agonists, which interferes with the enucleation of the myoma.

INTRAOPERATIVE METHODS

Type of incision: The incision is placed according to the vascularity of the myometrium or as per the arrangement of the vessels. If it is a central fibroid, a midline vertical incision is preferred. If it is a lateral fibroid a transverse incision is preferred. In case of a broad ligament fibroid an anterior incision is preferred. Tunneling incisions are not preferred as they cause weakening of the myometrium and multiple hematomas. It is also difficult to suture these type of incisions.

Bilateral Uterine Artery Ligation at Origin: Under general anesthesia, after suitably painting and draping the patient, a direct trocar entry is made into the modified Palmer's Point (slightly more medial to the Palmer's Point), with a 10 mm trocar. We, then, use three accessory ports (5 mm), two of which are lateral to the inferior epigastric vessels on each side, and the third accessory port is then introduced suprapubically.

The dissection is started by lifting the peritoneum between the round ligament and the infundibulopelvic ligament [Figure 1]. This peritoneum is then incised with the use of a harmonic Scalpel / LigaSure / EnSeal (energy sources). Subsequently, the ureter is delinated and pushed medially. The anterior division of the internal iliac artery is then identified and the uterine artery is skeletonized at its origin from the internal iliac artery (the uterine artery can easily be identified by its tortousity from the beginning of its course)

Figure 1

Broad ligament dissection

The skeletonized uterine artery is then coagulated and cut using any of the above-mentioned energy sources. It is better if a 5 mm clip applicator is used to clip the vessel instead of cutting it [Figure 2]. Damage to the underlying vein has to be avoided during clipping. The procedure is then repeated on the opposite side.

Figure 2

Clip applied to uterine artery

In several studies, it is found that bilateral uterine artery ligation, at origin, does not interfere with future fertility as the end vessels and collaterals of the uterus are not interfered with.[12]

In multiple fibroid uterus, the very small myomas that are not tackled at the time of myomectomy, have been seen to shrink in size in the long-term studies, after uterine artery ligation.

It is also seen that this procedure prevents the recurrence of fibroids for a longer period than when myomectomy is done alone.

Vasopressin

The use of Vasopressin was first reported by Dillon in 1962, for open myomectomy. It has been available in India since 2003. Vasopressin is a synthetic anti-diuretic hormone, which induces local vasoconstriction lasting for approximately 30 minutes, and thus helps in the control of bleeding from the incised sites.

It has to be used with caution in patients suffering from cardiovascular diseases and hypertension as it can lead to a sudden increase in BP, and can also precipitate angina.

It is also associated with the adverse affect of water intoxication when used in very concentrated forms / inadvertent intravenous use.

The procedure

After the visual trocar is introduced into the modified Palmer's Point, three accessory trocars are introduced under vision as previously discussed.

A laparoscopic injection needle is then introduced through the left accessory port and inserted at the junction of the myoma and myometrium [Figure 3].

Figure 3

Vasopressin injection

Two hundred cubic centimeters of saline with 40 units of Vasopressin is then introduced through the laparoscopic injection needle, after first aspirating and ruling out accidental venous entry of the needle. Blanching of the myoma is then observed. The needle should not be removed from the first site of entry because if multiple sites of entry are created by the needle then the vasopressin and saline fluid will start leaking from the other sites. The purpose of this injection is not to create planes, but to reduce vascularity. The large amount of fluid injected also produces a compartment effect and helps to reduce bleeding. When the vasopressin saline solution is injected, care has to be taken that the needle does not penetrate so deep as to be inside the endometrial cavity. In such cases it is noticed that the pressure of injecting will be lesser than normal, the fluid will then leak through the vagina and there will be failure of the vasoconstricting effect of vasopressin.

In various studies, Vasopressin use is associated with a significant reduction of blood loss during laparoscopic myomectomy.

As no energy source is used to incise the myoma once Vasopressin has been used, the myomectomy scar integrity is better, as noted by various surgeons.

As a conclusion, in very large uteri (16 – 18 weeks or more) or in multiple fibroids, it is advisable to use a combination of both the above-mentioned methods to achieve satisfactory hemostasis [Table 1].

Table 1

Comparison of uterine artery ligation and vasopressin