Tips and Tricks for Laparoscopic Myomectomy: A Video Presentation

OBJECTIVE This video presentation demonstrates an evidence-based approach on the surgical steps of a laparoscopic myomectomy for a multi-fibroid uterus. DESIGN We are presenting a video demonstrating the steps of the surgery and the technique with narration. PATIENT We are presenting a case of a 34-year-old nulliparous patient with a history of primary infertility. The patient had a history of three unsuccessful embryo transfers. She was otherwise medically fit and well and had no previous surgeries. Her magnetic resonance imaging pelvis showed three uterine fibroids. The dominant fibroid was 6.5 cm × 6.9 cm in size, arising from the posterior wall of the uterus. There were two intramural fibroids at the fundal area with the largest measuring 3.1 cm × 3.3 cm Figure 1. The evidence for myomectomy before In-Vitro-Fertilisation (IVF) treatment was discussed, and the patient was counseled that surgery for intramural fibroids, not distorting the endometrial cavity, might not improve the chance of live birth.1,2 However, given her history of recurrent implantation failure and the patient's wish, it was agreed to proceed to surgery.Figure 1: Pelvic magnetic resonance imaging demonstrating the fibroids/Traction-counter traction maneuver with myomectomy screw http://www.apagemit.com/page/video/show.aspx?num=1370&kind=2&page=1INTERVENTIONS Laparoscopic myomectomy is safe and efficient, offering a quicker recovery, comparing to open approach, without increasing the risk of complications.3 Following standard insertion of a 10 mm intraumbilical, a 5 mm right iliac fossa, a 10 mm and a 5 mm left iliac fossa laparoscopic ports, diluted argipressin was injected beneath the fibroid pseudocapsules. The uterine blanching due to vasoconstriction is observed, achieving adequate hemostasis.4,5 Uterine artery ligation is not needed in this case.6 An ultrasonic scalpel is used for the fibroid enucleation, aiming to reduce blood loss.7 Careful dissection is employed to avoid breaching the endometrial cavity. Three fibroids are enucleated with traction and counter-traction maneuvers through two uterine incisions, using a myomectomy screw and claw graspers Figure 1. The use of barbed sutures to close the uterine bed facilitates a shorter operating time and reduces blood loss.8 In-bag power morcellation (LiNA Xcise™ and Espiner ECO-T Containment Bag) through the left iliac fossa, incision is used to retrieve the specimens reducing the risk of developing parasitic fibroids9 and offering protection in the rare event of an undiagnosed sarcoma.10-13 Hyaluronic acid gel is applied on the uterine incisions to prevent intra-abdominal adhesions.14-16 Three fibroids were removed with a total weight of 154 g. The procedure lasted approximately 2 hours. The patient was discharged the next day. There is insufficient data to advise a minimal time interval between myomectomy and conception.17 The patient was advised to delay conception for a minimum of 3 months. CONCLUSION This video emphasizes that laparoscopic myomectomy is a safe and effective option for women who wish to retain fertility, with advantages such as shorter recovery time, less pain, and better cosmetic results than open surgery. Laparoscopic myomectomy surgical and fertility outcomes are comparative with robotic and superior to abdominal myomectomy.18 The use of vasoconstrictive agents, ultrasonic scalpel, myoma screw, barbed sutures, and in-bag power morcellation is recommended to facilitate a successful procedure. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author contributions D.M., T.M. and N.T. Conceived the idea and jointly performed the surgery. All authors contributed to the video editing and writing the manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.