A 6-Step Technique for Smooth Transvaginal Extraction of a Fibroid in Laparoscopic Myomectomy

Abstract

Study Objective In laparoscopic myomectomy (LM), it is necessary to devise a method to extract enucleated fibroids safely, easily, and minimally invasively. In our hospital, we don't use laparoscopic power morcellation. Before the surgery, we perform an MRI examination on all patients to rule out the possibility of malignancy. Only in cases that are considered benign, we extract enucleated fibroids via colpotomy of the posterior vaginal fornix, using scissors morcellation transvaginally. However, the poor surgical field sometimes makes extraction difficult. To counter these scenarios, we devised a technique for easy transvaginal extraction called the “Crisscross Method”, making a laparoscopic incision into fibroids with a long scalpel. Design Step-by-step demonstration of the technique. Setting General hospital in Japan. Patients or Participants N/A. Interventions We use a modified diamond trocar placement. After enucleating fibroids and suturing myometrium, we use the following 6-step-technique. 1: Grasp and pull the fibroid from the bilateral side and place in a vesicouterine pouch. 2: Remove the trocar from the center abdominal port site and insert a long scalpel. 3: Make several parallel cuts in a vertical direction to the long axis, like an accordion shape. Cut 2-3cm width and deeply into four-fifths. 4: Turn the fibroid over and cut deeply into four-fifths of the center in the long axis direction. 5: Cut the connecting parts alternately to make a long snake-like shape. 6: Perform the colpotomy of the posterior vaginal fornix. Grasp the end of the cut fibroid and feed it into the vagina for extraction. Measurements and Main Results By using this technique, we were able to extract fibroids easily, even in the cases of huge fibroids, without power morcellation. Conclusion This “Crisscross Method” is effective for transvaginal extraction of fibroids in LM. The important points are preoperative evaluation by MRI examination and preoperative explanations to patients about the risks and the benefits of this minimally invasive procedure. In laparoscopic myomectomy (LM), it is necessary to devise a method to extract enucleated fibroids safely, easily, and minimally invasively. In our hospital, we don't use laparoscopic power morcellation. Before the surgery, we perform an MRI examination on all patients to rule out the possibility of malignancy. Only in cases that are considered benign, we extract enucleated fibroids via colpotomy of the posterior vaginal fornix, using scissors morcellation transvaginally. However, the poor surgical field sometimes makes extraction difficult. To counter these scenarios, we devised a technique for easy transvaginal extraction called the “Crisscross Method”, making a laparoscopic incision into fibroids with a long scalpel. Step-by-step demonstration of the technique. General hospital in Japan. N/A. We use a modified diamond trocar placement. After enucleating fibroids and suturing myometrium, we use the following 6-step-technique. 1: Grasp and pull the fibroid from the bilateral side and place in a vesicouterine pouch. 2: Remove the trocar from the center abdominal port site and insert a long scalpel. 3: Make several parallel cuts in a vertical direction to the long axis, like an accordion shape. Cut 2-3cm width and deeply into four-fifths. 4: Turn the fibroid over and cut deeply into four-fifths of the center in the long axis direction. 5: Cut the connecting parts alternately to make a long snake-like shape. 6: Perform the colpotomy of the posterior vaginal fornix. Grasp the end of the cut fibroid and feed it into the vagina for extraction. By using this technique, we were able to extract fibroids easily, even in the cases of huge fibroids, without power morcellation. This “Crisscross Method” is effective for transvaginal extraction of fibroids in LM. The important points are preoperative evaluation by MRI examination and preoperative explanations to patients about the risks and the benefits of this minimally invasive procedure.