Hand Assisted Laparoscopic Myomectomy

Abstract

<h3>Study Objective</h3> To demonstrate the utility of using hand assisted laparoscopic surgery (HALS) for myomectomy of large uterine fibroids in carefully selected patients. <h3>Design</h3> Case series on hand assisted laparoscopic surgery for myomectomy. <h3>Setting</h3> Tertiary Gynecology Hospital in Sydney Australia. <h3>Patients or Participants</h3> Two patients. 1. 37-year-old G1P1 (BMI 20) with a 20 cm FIGO type 7 posterior fundal leiomyoma with pressure symptoms. 2. 41-year-old G4P4 (NVD with BMI 28 with a 13cm FIGO type 3 fibroid with heavy menstrual bleeding. Both patients desired uterine preservation and proceeded with HALS myomectomy. Both patients had Pelvic MRI with no suspicious features. <h3>Interventions</h3> Preoperative misoprostol and intraoperative vasopressin was used to minimise blood loss. Following laparoscopic entry, a pelvic assessment was performed to confirm the decision to proceed with 5cm suprapubic incision for the HAL port. Myomectomy was facilitated via the HAL port which enabled sharp and blunt dissection under laparoscopic vision. Following myomectomy, fibroids were manually morcellated in bag via the HAL port. [Pictures illustrating the operative procedure and steps]. <h3>Measurements and Main Results</h3> HALS was successfully used in both cases to perform a myomectomy of extremely large uterine fibroids that would have otherwise required midline laparotomy. Access and visualisation of the entire pelvis was enhanced by the presence of a pneumoperitoneum and laparoscopic magnification. Use of the HAL port improved exposure, and traction. Blunt dissection was optimised due to the feedback of tactile sensation with the surgeon's hand enabling faster dissection and enucleation of the fibroids minimising blood loss and reducing operative time. <h3>Conclusion</h3> Conventional laparoscopic surgery can be unsuitable for patients with some large myomoas. Use of HALS has been limited in gynaecological surgery (as opposed to other specialities such as urology and colorectal). This case series demonstrates the benefits of using HALS in carefully selected patients for minimally invasive myomectomy.