Multiple Myomectomy Research Articles

Laparoscopic myomectomy and myolysis

The indications for operative laparoscopy have expanded greatly over the past decade as its many advantages over laparotomy have become recognized. Laparoscopic myomectomy as a technique is now clearly described. A monopolar hook is used for the uterine incision. After atraumatic enucleation of the myoma, the myometrium and serosa are usually sutured, especially if the incision is deep or more than 2 cm long. Myomas can be removed by posterior colpotomy. However, the development of an electrical cutting device permits easier and quicker removal of the myoma through the suprapubic puncture site. Only complicated myomas or those which give rise to persistent symptoms despite properly prescribed medical treatment, together with those which grow rapidly, require surgery. These satisfactory preliminary results must not mask the fact that laparoscopic myomectomy is lengthy and difficult, reserved for experienced surgeons with a thorough familiarity with endoscopic sutures. Under these conditions, laparoscopic myomectomy is possible, even for large myomas (5 cm and over) located purely intramurally. However, there are limits, and it is preferable to schedule myomas measuring over 8 cm and multiple myomectomy (over two) for laparotomy. Although the preliminary results are encouraging, the risk of adhesiogenesis on the uterine scar, the quality of the uterine suture and the fertility results need to be assessed in the near future.

6 Laparoscopic myomectomy and myolysis

The indications for operative laparoscopy have increased greatly over the past decades as its many advantages over laparotomy have become recognized. Laparoscopic myomectomy as a technique is now clearly described. A monopolar hook is used for the uterine incision. After atraumatic enucleation of the myoma, myometrium and serosa are usually sutured particularly if the incision is deep or more than 2 cm long. Myomas can be removed by posterior colpotomy. However, the development of an electrical cutting device permits an easier and quicker removal of the myoma through the suprapubic puncture site. Only complicated myomas and/or those which give rise to persistent symptoms despite properly prescribed medical treatment, together with those which grow rapidly, require surgery. In our experience of ablation of myomas measuring 5 cm and over the results were satisfactory in all 71 patients with more than one year of follow-up. In two cases (2.7%) we were obliged to convert to laparotomy. We were confronted with no serious per-operative or post-operative complications. These satisfactory results must not mask the fact that the technique is lengthy and difficult and should be carried out by experienced surgeons thoroughly familiar with endoscopic sutures. Under these conditions, laparoscopic myomectomy is possible, for large myomas (5 cm and over) even if they are located completely intramurally. However, there are limits and it is preferable to use laparotomy for myomas measuring over 10 cm and for multiple myomectomy (over 3). Finally, the risk of causing adhesions and the quality of the uterine suture need to be assessed in the near future.

Disseminated intravascular coagulation, hemolytic anemia and acute renal failure associated with extensive multiple myomectomy

Disseminated intravascular coagulation (DIC) and acute renal failure are uncommon complications of multiple myomectomy. We report a case of DIC, microangiopathic hemolytic anemia, myoglobinemia, and acute renal failure following the removal of 52 uterine fibroids. We postulate that extensive myometrial dissection and the administration of hetastarch favored the development of DIC and microangiopathic hemolytic anemia. Acute renal failure ensued, necessitating hemodialysis. Proposed mechanisms and recommendations for future prevention are discussed.

Human blastocyst grown in vitro in ovulation cervical mucus.

An ovum was taken from a 34-year-old patient undergoing laparotomy for fibromyomata on Day 14 of a regular 28-day menstrual cycle and kept in follicular fluid at body temperature while 1.2 ml of cervical mucus was aspirated from the patients midcervical canal. The ovum and follicular fluid was expressed into the mucus in a sterile Petri dish. A drop of semen from the husband was added to the preparation and finally small pieces of the fimbriae bimbriae were added. The dish was covered and kept in a moist chamber at 37 degrees C with 20% oxygen. After 5 days the ovum in the blastocyst stage was transferred to a slide and photographed in phase contrast which revealed approximately 100 cells. Since the patient had just undergone multiple myomectomies the blastocyst was not transferred in utero. It was concluded that this technique may be useful for patients with ligated or excised fallopian tubes who may want a child.

Multiple myomectomy

Although multiple myomectomy is seldom used in current gynecologic practice, it is a procedure that has definite value, especially for young women who desire children. Three case summaries have been presented to show that the operation can be used successfully in patients with numerous large fibroids, even when degeneration of some tumors is present. The technique and applicability of this procedure are then considered in some detail. Pregnancy can be expected in about 40 per cent of the patients who have undergone myomectomy, and in most cases is carried to a successful conclusion.

Progress in myomectomy: Surgical measures and diagnostic aids favoring lower morbidity and mortality

Myomectomy was begun a little over one hundred years ago as a bold surgical venture for the removal of a pedunculated tumor which was erroneously believed to spring from the ovary. If there were other similar embedded tumors they were considered inoperable. The operation has gradually developed technically so that today multiple myomectomy is done as a conservative plastic operation upon the uterus with the specific object of not only removing all of the fibroids but of conserving the uterus with retention of menstruation and possible reproduction.Three dangers attending the operation to an appreciable degree, namely, hemorrhage, postoperative morbidity, and mortality, were gradually reduced by improvements in surgical technique. Hemorrhage has been controlled by temporary constriction of the uterine vessels by the fingers of an assistant, by rubber covered clamps, and finally by use of an elastic rubber tourniquet circumscribing the cervix and constricting the uterine vessels on either side. This elastic tourniquet has made possible the bloodless removal of many fibroids which previously would have indicated hysterectomy.The reduction of morbidity and mortality was further brought about by careful planning of the uterine incisions which were placed mostly on the anterior and superior surface of the uterus and removing as many fibroids as possible through one incision. By providing adequate peritoneal protection of the wound, covering them with vesicouterine peritoneum, anterior parietal peritoneum, sigmoid epiploica and omentum according to the requirements of the conditions met in the individual cases, intestinal agglutinations, intestinal adhesions, postoperative distress, and morbidity were further reduced. The mortality has been reduced in fairly large series of cases to 1 per cent and below, comparing favorably with the best statistics on hysterectomy.The complete planning of myomectomy includes diagnostic measures by which to exclude or demonstrate the presence of intrauterine lesions, chiefly, retained products of conception in incomplete abortion, submucous myoma, polyps, and carcinoma. These can be diagnosed by exploratory curettage done before the myomectomy. Practically all intrauterine lesions are amenable to demonstration by means of radiopaque media injected into the uterine cavity. A viscous soluble crystalloid iodine solution has been found useful and safe and may replace diagnostic curettage. Uterine polyps may be removed by curettage and the polyp forceps, and submucous myomas may be removed by vaginal or abdominal hysterotomy at the same time as other fibroids are removed. If the operation is designed to relieve sterility the uterine incision and suture should guard against implicating the insertion of the Fallopian tubes.Recurrences are relatively rare and arise from seedling fibroids overlooked at the time of operation or escaping inspection because of their embedded location. The choice of a second myomectomy is left in such cases to the patient, provided she is young enough and still desires children or resort may be had to hysterectomy or radiotherapy. In from 25 to 35 per cent of the cases, myomectomy has been followed by pregnaney. This would appear to justify the pains taken by the surgeon in conserving the uterus.Myomectomy is the ideal and at present the only conservative treatment for uterine fibroids which preserves menstruation and the possibility of reproduction.