Laparoscopic-assisted Myomectomy Research Articles

Laparoscopic-Assisted Myomectomy during the Second Trimester of Pregnancy

<h3>Study Objective</h3> Through this surgical video, we aim to review the literature, indications and a stepwise approach to performing a laparoscopic-assisted myomectomy safely in the second trimester of pregnancy. <h3>Design</h3> Surgical video - case report, laparoscopic technique education and literature review. <h3>Setting</h3> University teaching hospital. <h3>Patients or Participants</h3> Case report of single patient with indication for laparoscopic myomectomy in pregnancy. <h3>Interventions</h3> Surgical management of degenerated, necrotic fibroid in pregnancy. <h3>Measurements and Main Results</h3> Successful surgery and resolution of symptoms with ongoing pregnancy using the techniques described in this video. <h3>Conclusion</h3> Laparoscopic-assisted myomectomy has traditionally been avoided in pregnancy but has several indications and can be performed safely and effectively in select patients.

The choice of the X-ray endovascular method for the treatment of uterine fibroids and the possibility of prolonging the remission of the disease

Introduction. In the cohort prospective comparative study, the investigators examined the effectiveness of intraoperative administration of Antiadgesin and adjuvant therapy with Gynestril after laparoscopic-assisted myomectomy combined with temporary balloon occlusion of the internal iliac arteries and embolization of uterine arteries in the treatment of uterine fibroids.Objective. To achieve stable remission of the disease, improve reproductive outcomes after myomectomy.Materials and methods. 100 women who underwent organ-preserving treatment of uterine fibroids from January 1, 2015 to December 31, 2020 were enrolled in the study. The eligibility criteria were as follows: the age of 28–45 years (the mean age was 34 ± 4.5 years), organ-preserving treatment of uterine fibroids. The exclusion criteria from the study were as follows: the age of over 45 years; allergic reactions to mifepristone, Antiadgesin and contrast media; patients with contraindications for use of drugs, with aggravated medical history, with liver diseases, with endometrial hyperplastic processes (adenomyosis, endometrial hyperplasia).Conclusions. It has been shown that the continuous use of Gynestril at a dose of 50 mg/day for 3 months after surgical treatment due to proliferating uterine fibroids led to the absence of disease-recurrences within two years after discontinuation of the drug, and the occurrence of a relapse in one patient three years after treatment. The use of Gynestril after embolization of the uterine arteries made it possible to statistically reduce the size of the node by 25% within 12 months, 50% after 24 months and 70% – after 36 months. (p &lt;0.05). Intraoperative use of Antiadgesin made it possible to prevent adhesion and development of tubalperitoneal infertility.Conclusion. The combination treatment of uterine fibroids, including myomectomy and drug therapy with Antiadgesin and Gynestril, made it possible to implement reproductive function in 73.3% of patients, moreover, 40% of patients had undergone a natural delivery

Laparoscopic-assisted myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series

BackgroundNon-hysteroscopic myomectomy is infrequently performed in a freestanding ambulatory setting, in part due to risks of intraoperative hemorrhage. There are also concerns about increased surgical risks for morbidly obese patients in this setting. The purpose of this study is to report the surgical outcomes of a series of laparoscopic-assisted myomectomy (LAM) cases at a freestanding ambulatory surgery center (ASC), including a comparative analysis of outcomes in morbidly obese patients (BMI > 40 kg/m2).MethodsA retrospective comparative analysis was performed of 969 women, age 18 years or older, non-pregnant, who underwent LAM by one of two high volume, laparoscopic gynecologic surgical specialists at a freestanding ambulatory surgery center serving the Washington, DC area, between October 2013 and February 2019. Reversible occlusion was performed laparoscopically by placing a latex-based rubber catheter as a tourniquet around the isthmus of the uterus, causing a temporary occlusion of the bilateral uterine arteries. Permanent occlusion was performed laparoscopically via retroperitoneal dissection and uterine artery ligation at the origin of the anterior branch of the internal iliac artery. Minilaparotomy was performed for specimen removal in all cases. No power morcellation was used. Postoperative complications were graded using the Clavien-Dindo Classification system. Outcomes were compared across BMI categories using Pearson Chi-Square.ResultsAverage myoma weight and size were 422.7 g and 8.3 cm, respectively. Average estimated blood loss (EBL) was 192.1 mL; intraoperative and grade 3 postoperative complication rates were 1.4% and 1.6%, respectively. While EBL was significantly higher in obese and morbidly obese patients, this difference was not clinically meaningful, with no significant difference in blood transfusion rates. There were no statistically significant intraoperative or postoperative complication rates across BMI categories. There was a low rate of hospital transfers (0.7%) for all patients.ConclusionLaparoscopic-assisted myomectomy can be performed safely in a freestanding ambulatory surgery setting, including morbidly obese patients. This is especially important in the age of COVID-19, as elective surgeries have been postponed due to the 2020 pandemic, which may lead to a dramatic and permanent shift of outpatient surgery from the hospital to the ASC setting.

Single layer suturing in intracapsular myomectomy of intramural myomas is sufficient for a normal wound healing

Study objectiveTo evaluate surgical outcomes of intracapsular single-layer myomectomy in terms of efficacy and safety as well as examine potential alterations based on kind of surgical approach. MethodsA prospective observational study was performed between January 2010 and December 2018. Women in reproductive age, affected by intramural or subserous myomas (FIGO type 3–6) of 4–14 cm diameter were enrolled. Primary outcomes included initial and final uterine incision length, time to wound healing and uterine rupture in subsequent pregnancies. Furthermore, a sub-analysis was also performed regarding surgical approach, namely laparoscopical or laparoscopically-assisted myomectomy, in order to confirm whether overall observations are similar for both potential surgical approaches. ResultsThere were finally 273 patients included in the present study. Overall mean uterine incision was initially 3.1 cm and was shortened to 2.2 cm at the end of operation, indicating a reduction of 29.1 %. Mean estimated blood loss was 154.2 mL and mean operative time was 82.1 min. No severe intraoperative and postoperative complications were presented. 121 of the studied women had pregnancy 3–36 months after myomectomy, without reporting any uterine rupture. When comparing LIM vs. LAIM, all outcomes were also favorable in the total of patients. ConclusionIntracapsular myomectomy either by LIM or LAIM is a safe and attractive alternative to abdominal myomectomy in setting of premenopausal patients with myomas up to 14 cm. A single-layer continuous suturing in intracapsular myomectomies is enough for a successful wound healing.

22: Laparoscopic-assisted myomectomy with uterine artery occlusion in morbidly obese patients at a freestanding ambulatory surgery center

22: Laparoscopic-assisted myomectomy with uterine artery occlusion in morbidly obese patients at a freestanding ambulatory surgery center

Pregnancy outcome after emergency uterine artery embolisation for management of intractable haemorrhage associated with laparoscopic-assisted myomectomy

The feasibility of emergency uterine artery embolisation (UAE) after diagnosis by three-dimensional computed tomographic angiography (CTA) for conservative management of intractable haemorrhage associated with laparoscopic-assisted myomectomy (LAM) was evaluated. In 764 women undergoing LAM, 12 cases were managed by emergency UAE to achieve haemostasis after evaluation by CTA. In two cases, bleeding was diagnosed in the postoperative period, while, in another 10 cases, bleeding was identified at the near-end stage of the surgical procedure. Uterine preservation was achieved in all cases. Among five women desiring child bearing, five spontaneous conceptions and one conception by assisted reproductive technology occurred. Five pregnancies resulted in live birth by caesarean section. Emergency UAE could be a useful minimally invasive option for the salvage of intractable haemorrhage associated with LAM to avoid exploratory laparotomy and/or hysterectomy. In women with fertility wish, pregnancy outcomes were favourable with high number of spontaneous pregnancy rate and without significant negative effects.Impact statementWhat is already known on this subject? Uterine myoma is the most common benign pelvic tumour in women. Myomectomy is indicated as the primary intervention for women with symptomatic myoma, who are of reproductive age and desire uterine preservation, since it can significantly improve symptoms and quality of life and, in some clinical situations, improve reproductive outcomes. Intractable haemorrhage associated with any forms of myomectomy is a potentially life-threatening condition with potential loss of future fertility. However, clear consensus on its management are not well known so far.What do the results of this study add? Emergency uterine artery embolisation after diagnosis by three-dimensional computed tomographic angiography has been effective in preserving the uterus with avoidance of laparotomy and/or life-saving hysterectomy as a salvage therapy for intractable haemorrhage associated with laparoscopic-assisted myomectomy. Significant adverse outcomes were not observed. Furthermore, in women desiring child bearing, a high rate of spontaneous conceptions with live birth by caesarean section was achieved after these combined interventions.What are the implications of these findings for clinical practice and/or further research? Endovascular embolisation could be considered as a minimally invasive alternative with favourable pregnancy outcome to treat intractable haemorrhage associated with myomectomy.

2111 Case Series: Potential Link between the use of Celecoxib and Postoperative Hemorrhage Following Gynecological Surgery

Study Objective To report a potential link between the use of celecoxib and postoperative hemorrhage following gynecological surgery. Design Case Series. Setting Ambulatory Surgery Center. Patients or Participants Women >18 yrs old. Interventions Laparoscopic-assisted myomectomy. Measurements and Main Results After a general practice change from acetaminophen to celecoxib for perioperative pain, there was a significant increase in rate of postoperative hemorrhage. Six patients presented with signs of hemorrhage and acute anemia within 48 hours of surgery and were admitted to the hospital for hemoperitoneum and blood transfusions. Patients were prescribed the maximum recommended oral dose of 400 mg of celecoxib the day before surgery, and 200 mg daily on postoperative days 1-6. Patients were also given acetaminophen 1000 mg immediately before surgery, and oxycodone/acetaminophen 5/325 mg for postoperative pain. Intraoperative courses were unremarkable except for 2 cases in which extensive adhesiolysis between the uterus and sigmoid colon required repair of a serosal defect, and a rectal serosal defect in the other. Uterine artery occlusion via temporary tourniquet and permanent ligation were performed to control blood loss in all cases. Hemostasis was confirmed in all 6 cases at the end of the procedures, and patients were in stable condition at discharge. Conclusion Our experience echoes 1 other study on unexpected hemorrhage linked to celecoxib. As Stammschulte et al. (2014) noted, celecoxib and concomitant NSAIDs may lead to a relative overdose due to interactions or irregularities in the metabolism of the affected patients. Given the seriousness of the adverse events, caution is warranted when prescribing celecoxib for perioperative pain therapy. To report a potential link between the use of celecoxib and postoperative hemorrhage following gynecological surgery. Case Series. Ambulatory Surgery Center. Women >18 yrs old. Laparoscopic-assisted myomectomy. After a general practice change from acetaminophen to celecoxib for perioperative pain, there was a significant increase in rate of postoperative hemorrhage. Six patients presented with signs of hemorrhage and acute anemia within 48 hours of surgery and were admitted to the hospital for hemoperitoneum and blood transfusions. Patients were prescribed the maximum recommended oral dose of 400 mg of celecoxib the day before surgery, and 200 mg daily on postoperative days 1-6. Patients were also given acetaminophen 1000 mg immediately before surgery, and oxycodone/acetaminophen 5/325 mg for postoperative pain. Intraoperative courses were unremarkable except for 2 cases in which extensive adhesiolysis between the uterus and sigmoid colon required repair of a serosal defect, and a rectal serosal defect in the other. Uterine artery occlusion via temporary tourniquet and permanent ligation were performed to control blood loss in all cases. Hemostasis was confirmed in all 6 cases at the end of the procedures, and patients were in stable condition at discharge. Our experience echoes 1 other study on unexpected hemorrhage linked to celecoxib. As Stammschulte et al. (2014) noted, celecoxib and concomitant NSAIDs may lead to a relative overdose due to interactions or irregularities in the metabolism of the affected patients. Given the seriousness of the adverse events, caution is warranted when prescribing celecoxib for perioperative pain therapy.

Impact of safety protocol in an ambulatory surgical setting vs a hospital setting for laparoscopic-assisted myomectomy (LAM)

Ambulatory surgery center (ASC) for major gynecological surgery improves efficiency and decreases cost compared to a hospital setting. Protocols to ensure safety when performing major gynecologic surgeries are critical in the ASC setting. The objective of this study is to assess whether protocols do ensure safety when performing major gynecological surgeries such as laparoscopic-assisted myomectomy (LAM) in a high-volume ASC and compare it with protocols and outcomes in a hospital setting. This is a descriptive / retrospective study. This paper descriptively outlines the similarities and differences of a surgical safety protocol in an ambulatory surgical center compared to a hospital setting. Furthermore there is retrospective analysis of LAM outcomes that are commonly considered as safety standards in both settings including intraoperative and postoperative complications. The protocols were similar with regards to preoperative patient selection and checklist, surgical precautions including prevention of retained surgical items, DVT prophylaxis, infection control, surgical wound classification, vaginal and genital antisepsis for the surgical patient, postoperative care in PACU and discharge criteria for surgical management. The major preoperative differences from hospital protocol were transfusion criteria preoperatively. In the ASC, a cut-off of 9.0 g/dl was used, and a cut-off of < 7.5 g/dl was used in the hospital setting. LAM cases are only scheduled as morning cases. 23 hour observation is available at ASC. Additionally myomectomy patients at the ASC have ISTAT (blood analysis system to check Hemoglobin/Hematocrit) prior to procedure and at 1 and 2 hours after the procedure in the PACU to detect any signs of bleeding. Any patients that did require blood transfusion postoperatively were transferred to the local hospital from the ASC. There were 588 patients that underwent LAM at the ASC compared to 228 patients at the hospital. There was no significant difference in case complexity factors between settings including BMI, number of previous abdominal and pelvic surgeries or other comorbidities. Intraoperative complication rate was 3.4% (95% CI 1.8-5.0) at the ASC compared to 4.9% (95% CI 1.7-8.1) , p = 0.4430. There were no significant differences in postoperative complications between the ASC and the hospital setting including infections and thromboembolic events. Blood transfusion was required in 1.7% of the cases at ASC compared to 8.8% at the hospital setting. The estimated blood loss and average fibroid weight were not statistically different between the two groups. The LAM safety protocol at a free-standing ASC allows for patient complication outcomes that are comparable to an in-hospital setting without apparent limitations in patient complexity.

70: Laparoscopic-assisted myomectomy with reversible uterine artery occlusion: outcomes from a series of 404 cases

70: Laparoscopic-assisted myomectomy with reversible uterine artery occlusion: outcomes from a series of 404 cases

67: Laparoscopic-assisted myomectomy with uterine artery ligation at the origin: outcomes from a series of 184 cases

To present our experience with laparoscopic-assisted myomectomy (LAM) with uterine artery ligation. A retrospective review was conducted of 184 patients who underwent LAM with uterine artery ligation between 2013 and 2017. All cases were performed by one of two surgeons at a single practice in freestanding ambulatory surgery center. The practice consists of two minimally invasive gynecologic surgical specialists, who individually performed all the procedures. All women in this case series were 18 years or older, non-pregnant, with benign indications for surgery. The study was deemed exempt according to 45 CFR 46.101(b) by IntegReview IRB, an independent institutional review board. The type of myomectomy performed in all cases was LAM, with retroperitoneal dissection, uterine artery ligation at the origin at the anterior branch of the internal iliac artery, and a mini-laparotomy for specimen removal. A total of 184 consecutive LAM cases were analyzed. Mean myoma weight removed was 546 g (11-2800 g). Mean operative time and estimated blood loss were 68 minutes (15-180 minutes) and 264 mL (10-1400 mL), respectively. Rate of blood transfusion was 4.9%. Rate of intraoperative and postoperative complications (including major and minor) was 6.5% and 7.6%, respectively. The types of myoma removed were subserosal (21%), intramural (41%), and submucosal (28%). No power morcellation was used in any cases. Laparoscopic-assisted myomectomy with early uterine artery ligation at the origin is safe and effective procedure for removal of all types of uterine myoma, with ability to control blood loss and remove a significant tumor load.

Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation

Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss. Retrospective chart review (Canadian Task Force classification II-1). Suburban community hospital. Women age ≥18 years with nonmalignant indications. A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013. Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups. LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.

Identification of Leiomyoma Cell Sheets in Peritoneal Washings Retrieved by an Intraoperative Red Blood Cell Salvage Device during Laparoscopic-Assisted Myomectomy with in-Bag Manual Tissue Extraction: A Pilot Study

Study ObjectiveTo examine whether peritoneal washings during laparoscopic-assisted myomectomy with in-bag manual tissue extraction can contain spilled leiomyoma cell sheets. DesignRetrospective observational study (Canadian Task Force classification II-2). SettingDepartments of Obstetrics and Gynecology and Diagnostic Pathology at a general hospital. PatientsTwenty-four women. InterventionsHysterotomy followed by complete enucleation by blunt and sharp dissection was performed. Enucleated myomas were placed into a retriever bag and extracted through a suprapubic or umbilical mini-laparotomic incision by manual morcellation with a surgical scalpel. A histological examination was performed to identify the dispersed leiomyoma cell sheets in trapped tissues on the surface of a defoaming sponge equipped in the reservoir of an intraoperative red blood cell salvage device, which was used to collect peritoneal washing fluid along with blood. Measurements and Main ResultsBag rupture was not observed in any case; however, apparent leiomyoma cell sheets were identified in 20 of 24 cases (83.3%). No devices or procedures that were used for myomectomy could completely prevent leiomyoma cells from appearing in the peritoneal washing fluid. ConclusionEven when careful in-bag tissue extraction of myomas was performed in laparoscopic-assisted myomectomy, dispersion of leiomyoma cell was identified in most cases. Further study is needed to show that the feasibility of rigorous washing to reduce the potential risk of leiomyoma cell dissemination.

Size, Type, and Location of Myoma as Predictors for Successful Laparoscopic Myomectomy: A Tertiary Government Hospital Experience.

Background:Laparoscopic myomectomy (LM) is a preferred alternative to abdominal myomectomy due to shorter hospitalization, faster recovery, and decreased intraoperative adhesions. The criteria, however, which constitute proper selection of patients for LM, are still a matter of debate. Since conversion to either laparoscopic-assisted myomectomy (LAM) or laparotomy (EL) entails longer time and increased costs compared to performing an open procedure from the outset, this research aims to evaluate size, location, and type of myoma as predictors for LM.Methodology:Inpatient medical records of all women who underwent LM from January 2014 to August 2016 were retrieved and reviewed. Demographic data, intraoperative records, and postoperative course were obtained. The association of size, type, and location of myomas to the procedure performed was analyzed.Results:There was no significant association between the size of the myoma or its location to the procedure performed. However, intramural and subserous myomas were associated with successful LM, while submucous myomas were associated with conversion to either LAM or EL (P = 0.010).Conclusion:LM is a difficult procedure that challenges even the most skilled laparoscopic surgeon. Proper patient selection lessens complications and decreases the risk of conversion. In this study, type of myoma may be a good predictor for successful LM; however, this conclusion may be limited by the small sample size. A large-scale multicentric prospective study is necessary to validate the role of the proposed predictors to prevent unplanned conversion to an open procedure and reduce cost and increase safety of LM.

Portomesenteric Vein Thrombosis After Excision of Parasitic Peritoneal Myomas

An enlargement of multiple asymptomatic pelvic masses was detected during a regular checkup of a 39-year-old woman. Twelve years earlier, she had undergone laparoscopic-assisted myomectomy, at which time an uncontained manual extraction of a posterior intramural myoma was performed. This was followed by 2 uneventful cesarean deliveries after spontaneous conceptions. Diagnostic imaging revealed at least 3 abdominal masses, 1 of which received its major blood supply from the inferior mesenteric artery. Gasless single-port laparoscopic excision of the peritoneal masses, was performed along with laparoscopic-assisted vaginal hysterectomy and bilateral salpingo- oophorectomy. The masses were histopathologically diagnosed as parasitic peritoneal myomas. The patient's immediate postoperative course was uneventful; however, on day 6 after surgery, she complained of severe periumbilical abdominal pain and vomiting. Anticoagulant therapy was initiated after hematologic examination revealed an elevated D-dimer level and dynamic computed tomography angiography showed portomesenteric vein thrombosis. Vaginal stump bleeding, which occurred 17 days after the initiation of anticoagulant therapy, was managed conservatively, and there was no recurrence of venous thrombosis in the year after surgery. To avoid significant morbidities and potential mortality when parasitic peritoneal myomas with aberrant neovascularization are excised, attention should be given to the perioperative development of venous thromboembolic events in rare locations.

In-Bag Manual Extraction of Excised Myomas by Surgical Scalpel through Suprapubic Mini-Laparotomic Incision in Laparoscopic-Assisted Myomectomy

Study ObjectiveTo evaluate the safety and feasibility of in-bag manual extraction for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. DesignRetrospective comparative study (Canadian Task Force classification II-2). SettingDepartments of obstetrics and gynecology and diagnostic pathology at a general hospital. PatientsTwenty-six patients undergoing open manual extraction and 26 patients undergoing in-bag manual extraction by surgical scalpel for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy. InterventionsIn patients with open manual extraction, myoma tissues were directly morcellated in an uncontained setting, whereas in patients managed by in-bag manual extraction, enucleated myomas were put into a retriever bag and then were morcellated by a surgical scalpel while monitoring bag damage by the leakage of indigo carmine dye filled in a bag. The patient demographics and surgical outcome measures were compared between the 2 groups. In the initial 15 patients with in-bag manual extraction, the macroscopic myoma fragments retained in the bag were collected and removed after completion of myoma extraction. Then, the bag contents were washed with normal saline and spilled microscopic tissues salvaged by centrifugation. A histologic examination was performed for collected tissue materials to identify the microscopic myoma fragments. Measurements and Main ResultsIn patient demographics and surgical outcomes, which include excised tissue weight, surgical duration, and estimated intraoperative blood loss, no significant differences could be identified between the 2 groups. Bag rupture as monitored by the leakage of indigo carmine dye in vivo and ex vivo was not observed. In all patients managed by in-bag manual extraction, spilled macroscopic myoma fragments were identified in the bag. Furthermore, histologic examinations of collected bag contents detected microscopic myoma tissues in 53.3% of patients. These results suggest that without closed conditions, these microscopic myoma particles, which could be difficult to completely remove even by rigorous washing of the peritoneal cavity under laparoscopic vision, might be dispersed in the peritoneal cavity and potentially form iatrogenic peritoneal parasitic myomas if they survive and grow. ConclusionIn-bag manual extraction of myoma tissues through a suprapubic mini-laparotomic incision by a surgical scalpel is a feasible alternative to prevent the dispersion of microscopic myoma fragments and to avoid the potential risk of spreading occult malignancy in 2-port laparoscopic-assisted myomectomy.

Strong Association Between Endometriosis and Symptomatic Leiomyomas.

Background and Objectives:The relationship between leiomyoma and endometriosis is poorly understood. Both contribute to considerable pain and may cause subfertility or infertility in women. We conducted this retrospective study to assess the rate of coexistence of endometriosis in women with symptomatic leiomyoma. The primary outcome measured was the coexistence of histology-proven endometriosis in women with symptomatic leiomyoma.Methods:This is a retrospective review of a data-based collection of medical records of 244 patients treated at a tertiary medical center, who were evaluated for symptomatic leiomyoma from March 2011 through December 2015. Of those, 208 patients underwent laparoscopic or laparoscopic-assisted myomectomy or hysterectomy. All patients provided consent for possible concomitant diagnosis and treatment of endometriosis. The remaining 36 patients underwent medical therapy and were excluded from the study. All patients who had myomectomy or supracervical hysterectomy underwent minilaparotomy for extracorporeal morcellation and specimen removal beginning in April 2012.Results:Of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis, whereas 27 had leiomyoma. Of the 27 patients, 9 also had adenomyosis. Patients with only fibroid tumors were, on average, 4.0 years older than those with endometriosis and fibroids (mean age, 44 vs 40 ± SD). Patients with both pathologies were also more likely to present with pelvic pain and nulliparity than those with fibroid tumors alone.Conclusions:In our patient population, 87.1% of patients with a chief concern of symptomatic fibroids also had a diagnosis of histology-proven endometriosis, which affirms the need for concomitant diagnosis and intraoperative treatment of both conditions. Overlooking the coexistence of endometriosis in women with symptomatic leiomyoma may lead to suboptimal treatment of fertility and persistent pelvic pain. It is important for physicians to be aware of the possibility of this association and to thoroughly evaluate the abdomen and pelvis for endometriosis at the time of myomectomy or hysterectomy in an effort to avoid the need for reoperation.

電動モルセレータを使用しない2孔式腹腔鏡補助下子宮筋腫核出術の導入

Objective: This study aimed to investigate the utility and safety of 2-port laparoscopic-assisted myomectomy (2P-LAM), performed without a morcellator, in comparison with conventional laparoscopic-assisted myomectomy (C-LAM).

Effects of laparoscopic uterine artery occlusion assisted myomectomy for ovarian

Objective To study the laparoscopic uterine artery occlusion effect of assisted myomectomy for ovarian function. Methods 90 cases of existing operation indications of uterine leiomyoma patients were selected as the research objects and divided into 45 cases of the control group and 45 cases of the study group. The control group received laparoscopic uterine myomectomy, the study group received laparoscopic uterine artery occlusion assisted laparoscopic myomectomy comparison between the two groups, the curative effects of the patients with operation and influence on ovarian function and sexual function. Results In the control group, the operation time(72.03±13.53)min was longer than that of the study group(60.05±10.32)min(t=4.722,P 0.05)the time of hospitalization and postoperative(t=0.466,P>0.05)showed no significant differences. The control group after 3 months of follicle stimulating hormone(FSH),estradiol(E2)were(6.08±1.35)U/L,(80.31±5.36)pmol/L, the study group after 3 months of FSH,E2 were(6.85±1.42)U/L,(72.39±5.35)pmol/L, the difference between the two groups was statistically significant(t=2.636,t=7.015,P 0.05). Conclusion Laparoscopic uterine artery blocking effects of laparoscopic assisted myomectomy in patients with ovarian function can recover quickly, safely and reliably. Key words: Abdominoscopy; Uterine artery; Uterine fibroid; Ovary

Conservative management of uterine artery pseudoaneurysm after laparoscopic-assisted myomectomy and subsequent pregnancy outcome: case series and review of the literature

ObjectiveUterine artery pseudoaneurysm is a rare potentially life-threatening complication after myomectomy. Its clinical characteristics and management, and the outcomes of subsequent pregnancy, are not well understood. The purpose of this study was to clarify these important issues. Study designRetrospective analysis of a case series of uterine artery pseudoaneurysm detected after laparoscopic-assisted myomectomy (LAM) in a single center over a 13-year period. During the early postoperative course, gray scale ultrasonographic evaluation was carried out routinely by searching for an anechoic or hypoechoic well-defined cystic structure in the post-myomectomy scar. In suspicious cases, further evaluation was performed by color Doppler flow analysis and three-dimensional computerized tomographic angiography. After finally confirming the diagnosis by digital subtraction angiography, uterine artery pseudoaneurysm was conservatively managed by angiographic intervention. In cases achieving successful conception, cesarean delivery was chosen and the uterine scar was evaluated. ResultsUterine artery pseudoaneurysm was diagnosed in 9 out of 854 cases of LAM. One case was undiagnosed until massive uterine hemorrhage occurred in the late postoperative period, while the other eight cases were diagnosed in the early postoperative course without hemorrhagic complication. Eight cases were managed by uterine artery embolization, but spontaneous resolution of pseudoaneurysm was observed in one case during a difficult prolonged attempt to superselect the offending branch of the uterine artery. Postembolization course was uneventful, except in a 41-year-old woman who developed oligomenorrhea. Among five women desiring preserved fertility, three women including one after spontaneous miscarriage achieved live birth by cesarean section. One woman experienced spontaneous miscarriage and one did not become pregnant by fertility treatment. In a case with elective cesarean delivery, severe early postpartum hemorrhage occurred from the placental bed and was conservatively managed by emergency uterine artery embolization. ConclusionThe development of uterine artery pseudoaneurysm after myomectomy may be more common than previously considered, and should be carefully monitored to avoid potentially life-threatening hemorrhage and loss of fertility. Although spontaneous resolution may occur, conservative management by angiographic intervention could be a feasible management option for future fertility preservation, once a diagnosis has been made.

腹腔鏡下子宮筋腫核出術における子宮筋腫の搬出法について

Objective: To determine the present status of morcellation during a laparoscopic myomectomy via a multicenter questionnaire.Design: Postal questionnaire survey. Setting: 180 member hospitals of the Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy (JSGOE).Patients: NoneInterventions: None.Main outcome measures: Common clinical practices.Results: In order to determine the safest procedure, the author submitted a multicenter questionnaire to gynecologic laparoscopists who were certified by the JSGOE. We received 107 completed surveys (60% response rate). Some differences were found between electric morcellation and extraction via an incision in the posterior vaginal fornix. Difficulties were encountered with electrical morcellation in regard to the size and hardness of the leiomyomas; in addition, the cost of the device was a factor. When difficulty is encountered with electrical morcellation, the surgeon should consider conversion to a laparoscopic assisted myomectomy, crushing with an ultrasonic incision apparatus, use of a scalpel, and extraction from the vaginal fornix or abdominal incision. Rare complications associated with either approach were reported, including bladder and bowel injury. Maintaining an adequate field of view and an appropriate position of the morcellator to avoid squeezing it into the abdominal cavity is important.Conclusions: The result of the questionnaire revealed that methods are available that can reduce complications with a laparoscopic myomectomy; these methods evolve with the surgeon's experience. This paper might aid laparoscopists in the development of appropriate methods for morcellation during a laparoscopic myomectomy; thus, increasing the safety of the procedure.