Surgical Techniques for Mini-Laparotomy Myomectomy

Abstract

<h3>Study Objective</h3> Demonstrate techniques for optimizing the use of mini-laparotomy as a complement or alternative to laparoscopic myomectomy. <h3>Design</h3> Surgical technique video. <h3>Setting</h3> Operating room. The patient is positioned in low lithotomy, a uterine manipulator is placed and 10mL of dilute methylene blue is injected into the endometrial cavity. A traditional laparoscopic setup is utilized in addition to a mini-laparotomy tray. A medium-size wound protector is needed. <h3>Patients or Participants</h3> Single case of a patient with symptomatic uterine myomas requiring surgical management. <h3>Interventions</h3> Minimally invasive myomectomy. <h3>Measurements and Main Results</h3> For this video demonstration, the patient is lying supine in low lithotomy. A 3.5cm transverse mini-laparotomy incision has been created three finger breaths above the pubic symphysis. Measures to decrease blood loss during the procedure are taken. These include injection of dilute vasopressin 20u in 100cc of saline at the hysterotomy site, 600mcg of misoprostol administered per rectum at the time of prep in addition to infusing 1g of tranexamic acid before skin incision. The potential benefits of this modality include the ability to palpate myomas, in situ debulking and morcellation, use of a single hysterotomy for multiple myomectomies, and the conversion of the mini-laparotomy to a port site. Surgical techniques for tissue extraction, endometrial cavity defect repair, fibroid enucleation, and hysterotomy closure are also described. <h3>Conclusion</h3> Mini-laparotomy myomectomy may be an alternative or complement to laparoscopic myomectomy, allowing the surgeon the ability to palpate leiomyomas, morcellate in situ and minimize hysterotomy size that can potentially lead to decreased operating time and blood loss.