Laparoscopic Myomectomy

Laparoscopic Myomectomy Treatment in Jaipur

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Benign diseases of the uterus are found commonly in gynecologic patients and account for most laparotomies and hysterectomies. Myomas are the most common uterine neoplasm, affecting approximately 20 to 25% of women of reproductive age. They can develop in any area where there are smooth muscle cells of mullerian origin, such as the fallopian tubes, uterine corpus, and cervix. They arise from the benign transformation and proliferation of smooth muscle cells. Increased estrogen stimulation alone or in concert with growth hormone or human placental lactogen are the major growth regulators. Progesterone appears to inhibit the growth of myomas but under certain conditions may promote their growth.

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In laparoscopic or robotic myomectomy, minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.

Laparoscopic myomectomy. Your surgeon makes a small incision in or near your bellybutton. Then he or she inserts a laparoscope ― a narrow tube fitted with a camera ― into your abdomen. Your surgeon performs the surgery with instruments inserted through other small incisions in your abdominal wall.
Robotic myomectomy. Instruments are inserted through small incisions similar to those in a laparoscopic myomectomy, and the surgeon controls movement of instruments from a separate console.

Sometimes, the fibroid is cut into pieces and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).

Laparoscopic and robotic surgery use smaller incisions than a myomectomy, or laparotomy, does. This means you may have less pain, lose less blood and return to normal activities more quickly than with a laparotomy.

Symptoms

The severity and type of symptoms associated with uterine leiomyomas are dependent on their number, size, and location. Common symptoms are abnormal uterine bleeding, abdominal pressure, urinary frequency, and constipation. Although they are seldom the only cause of infertility, data from several studies show a link between myomas, fetal wastage, and premature delivery.Indications for treatment are summarized. Factors such as the size, number, and location of the myomas influence the choice of the operation.

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Preoperative Evaluation and Treatment

In patients with leiomyomas who complain of menorrhagia, the hematocrit is used to assess the degree of anemia. For anemic patients, preoperative suppressive therapies such as danazol or gonadotropic-releasing hormone agonists (GnRH), may enable restoration of a normal hematocrit, decrease the size of myomas,4  and reduce the need for transfusion.1 However, studies that examined the effects of GnRH agonists on intraoperative blood loss have revealed conflicting results.5,6  GnRH agonists have negative side effects as well such as the development of a pseudo-menopausal hypoestrogenic state, and are associated with a possible increased risk of myoma recurrence.4  In addition, studies have also shown that agonist therapy can soften myomas, obscuring the cleavage plane between the fibroid and the pseudocapsule, making the surgery more difficult with increased bleeding.7

The presence of large broad ligament myomas may necessitate the performance of an intravenous pyelogram to search for ureteral obstruction. Periodic pelvic and ultrasound examinations aid in monitoring the growth rate of asymptomatic myomas. Submucous myomas can be detected by pelvic ultrasound, hysterosonogram, or hysteroscopy. Since small interstitial myomas palpated during laparotomy can be missed at laparoscopy, a vaginal ultrasound should be done preoperatively, and can also be performed intraoperatively to aid in myoma identification and localization.4,5

Depending on the myoma’s size and location, preoperative autologous blood donation may be suggested. Patients are counseled regarding the potential for intra- and post-operative bleeding and the possible need for a laparotomy as well as blood transfusion. Although myomectomy may rarely result in hysterectomy, patients should be informed of this possibility.

Laparoscopic Myomectomy

Women who have large intramural fibroids should be managed laparoscopically only if the surgeon is capable of meticulous repair of the uterus which can be difficult.  Nezhat et al. reported the results of  myomectomies performed on 137 women from whom 196 myomas were removed.8 The fibroids ranged in size from 2 to 14 cm. The operative time ranged from 50 to 160 minutes (mean: 116 minutes). Estimated blood loss was between 10 and 600 mL, and two women received blood transfusions because of intraoperative blood loss. The hospital stays ranged from 7 to 48 hours, with a mean of 19.6 hours.

In 114 women undergoing laparoscopic myomectomy (LM) who desired future pregnancy, the average number of myomas removed was 3.0 +/- 2.9 and the mean size was 5.9 +/- 3.0 cm.9 In 52.4% of the cases, the most deeply infiltrating myoma was intramural, in 42.9% subserosal, and in 4.7% pedunculated. Thirty-one pregnancies occurred in 29 women.  Of the 26 that could be followed, 5 had vaginal deliveries at term. Cesarean sections were done for 14 patients: 9 at term, 1 at 26 weeks, and 4 at unknown gestational ages. Six women miscarried in the first trimester, and one had an ectopic pregnancy. No spontaneous uterine ruptures were noted. Compared with women with ectopic pregnancies, miscarriages, and preterm deliveries, those who delivered at term were younger (33.1 +/- 1.9 versus 36.6 +/- 4.8 years, < 0.005) and had fewer myomas at surgery (1.9 +/- 2.0 versus 4.8 +/- 3.0, < 0.05). Those who had intramural myomas were most likely to develop complications during pregnancy. In another study, 28 infertile patients with at least one uterine leiomyoma of > 5cm in diameter underwent laparoscopic myomectomy.10 The average size of the myomas removed was 6 cm (range: 4 to 13.3 cm). The postoperative intrauterine pregnancy rate was 64.3% (= 18), including one of two patients who underwent concomitant hysteroscopic myomectomy. Four patients had spontaneous abortions, and 14 delivered viable term neonates. Six patients had a vaginal delivery without complications, and 8 had a cesarean delivery.