Abstract
Overview: Laparoscopic myomectomy has become increasingly popular in Sri Lanka due to its favorable long term outcome. Purpose of this study is to evaluate not only laparoscopic myomectomy technique but also operative time, blood loss depending on site, size and number of fibroid. Method: In this retrospective study we have analyzed data from 432 women who had undergone laparoscopic myomectomy at Colombo South Teaching Hospital, Sri Lanka during the period from 2011 January to 2021 January. Data were collected from patient database, hospital records and histopathology data base. Data were collected according to demographical details including age, BMI, parity and past surgical histories, myoma details including size, type, site and number, intraoperative details and postoperative data. Results: Mean age of patients undergone laparoscopic myomectomy are 35.5 years (SD 6.083) Majority of the population (67%) were nulliparous. Indication wise 192 patients (44.4%) had pressure symptoms,137 patients (31.7%) presented with heavy menstrual bleeding and 103 patients (23.8%) had subfertility history. Regarding fibroids characteristics, single fibroid found in 168 patients (38.9%), fibroids between 2-4 found in 199 patients (46.1%) and fibroids 5-10 found in 65 patients (15%). Considering the location of fibroid, 192 patients (44.4%) had anterior wall, posterior wall in 125 (28.9%), fundal in 87 (20.1%), broad ligament in 21 (4.1%) and other locations in 7 patients (1.6%). Regard to type of the fibroids intramural fibroids identified in 196 patients (45.4%), sub serosal in 136 (31.5%), submucosal in 75 (17.4%) and pedunculated in 22 patients (5.1%). Mean blood loss was 159.4 +/- 68.03 ml while mean operative time was 124 +/- 49.6 minutes. But those differs with number and size and site of the fibroids. Mean blood loss and operative time increased when fibroids number and size increased. Mean operative time is 92.23 minute for fibroid size less than 8cm vs 178.9 minute for fibroid more than 12cm. Mean blood loss is 115.25ml for fibroid less than 8cm vs 238.27ml for fibroid size more than 12cm. Mean operative time for single fibroid is 90.8 minute vs 179.5 minute for fibroids 5-10. Mean operative time and blood loss are increased with posterior wall and broad ligament fibroids. However, it is not statistically significant (P Value 0.006 and 0.008 respectively). Prolonged operative time did not impact on surgical outcomes in terms of hospital stay and blood transfusion. Conclusion: In experienced and expert hand, laparoscopic myomectomy is a safe procedure with good surgical outcomes and low complication rate. Operative time and blood loss are mainly associated with the size of largest fibroid and number of fibroids. Open myomectomy may be of benefit for number of fibroids > 10 when considering completeness of surgery. Hand morcellation through suprapubic port is a safe and effective method of specimen retrieval in laparoscopic myomectomy.
Highlights
Laparoscopic myomectomy is a challenging yet rewarding gynaecological surgery conducted worldwide by skilled laparoscopic surgeons
Colombo-South Teaching Hospital (CSTH) is the centre of excellence in gynaecology laparoscopic surgeries in Sri Lanka and lead by an experienced surgeon who has got more than 15 years of hands-on advanced gynaecological laparoscopic surgeries in Sri Lanka
There are limitations associated with laparoscopic approach such as prolonged operative time, risk of convertion to laparotomy, risk of reopening and complications related to specimen retrieval . 11-14 Mais et al[15] shows that there is no significant difference in between open myomectomy and laparoscopic myomectomy in terms of bleeding and operative time
Summary
Laparoscopic myomectomy is a challenging yet rewarding gynaecological surgery conducted worldwide by skilled laparoscopic surgeons. Fibroids can significantly affect their quality of lives due to abnormal uterine bleeding, pelvic pain, pressure symptoms leading to bladder and bowel symptoms, and subfertility. In his case series of uterine myomectomy has illustrated, pressure symptoms that negatively affect patient’s quality of life, heavy uterine bleeding with failed medical therapy, infertility, rapid growth, and suspected sarcomas as indications for surgical management of fibroids[3]. Even though there were many limitations for laparoscopic myomectomy in the past including the limitations caused by size and location of the fibroid, vascularity, and risk of intra-operative bleeding[6,7], with advancing technology and skilled surgeons there are virtually nil boundaries for the scope of laparoscopic approach in the contemporary
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