16: Validation of a hybrid technique for minimally invasive myomectomy

Abstract

Laparoscopic myomectomy (LM) is considered the gold standard for surgical management of uterine leiomyoma; however, when compared to abdominal myomectomy, it is associated with prolonged operative time (OT), higher cost, risk of leiomyoma recurrence and weaker uterine defect repair. The purpose of this study is to compare surgical outcomes of commonly performed myomectomy techniques with laparoscopically assisted abdominal myomectomy (LAAM), a hybrid approach combining both laparoscopic and abdominal techniques using an ultra-minilaparotomy incision and bilateral uterine artery occlusion to control blood loss. A retrospective chart review of 1380 patients undergoing myomectomy for benign indications at a community hospital from 2011 to 2013. Myomectomies performed via abdominal, conventional laparoscopic (CLM), robotic-assisted (RAM), and LAAM approaches were included in the study. Data collected included patient & leiomyoma characteristics, and surgical outcomes such as EBL, operating time (OT), length of stay (LOS), conversions to laparotomy and complications. Nonparametric Kruskal-Wallis tests were used to compare surgical outcomes across myomectomy techniques. Post hoc comparisons between LAAM and each of the other myomectomy approaches were performed using Bonferroni-adjusted Wilcoxon rank sum test. Patient characteristics were equally distributed among surgical groups. Average aggregate leiomyoma weight removed via LAAM technique was 389 gm, significantly larger than leiomyomas removed via CLM and RAM at 223 gm and 269 gm respectively (p < 0.001). When controlling for leiomyoma weight, LAAM had lowest average EBL among all surgical routes, 162 ml vs 181 ml for CLM, 166 ml for RAM, and 266 ml for abdominal approach. LAAM had the shortest OT with a mean of 73.9 min (p < 0.001) vs 101.6 min for CLM, 145.6 min for RAM and 96.8 min for abdominal. LAAM also had the shortest LOS at 0.4 days compared to 0.9 days for combined laparoscopic modalities and 2.5 days for abdominal (p < 0.001). The rate of conversion to mini-lap was highest for CLM at 20.9% vs 17.3% for RAM. Rate of conversion to laparotomy was also highest for CLM at 16.6% followed by RAM at 6.4% and lowest for LAAM at 0.6% (p < 0.001). Despite removal of higher leiomyoma volume in LAAM group, no difference in overall complication rates were noted between LAAM and combined LM approaches, but a statistically significant difference was noted between LAAM (10.0%) and abdominal group (19.9%, p < 0.015). LAAM also had the lowest direct hospital costs, which were primarily driven by operating room times and LOS. A second analysis examining only cases performed by high-volume surgeons revealed similar results. LAAM approach had higher total specimen weight removed, lower average EBL, shorter operating time, and comparable or lower complication rates when compared to other myomectomy techniques. LAAM as a cost effective minimally invasive technique overcomes the inherent technical challenges associated with laparoscopic myomectomy such as the inability to palpate small leiomyoma, limitation in tissue removal and uterine defect repair by combining the best benefits of abdominal and laparoscopic myomectomies.