Laparoscopic Myomectomy - Brigham and Women's Hospital

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SCOTT BODELL FOR OBG MANAGEMENT Laparoscopic myomectomy: 8 Pearls Jon I. Einarsson, MD, MPH Dr. Einarsson is Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School and Chief of the Division of Minimally Invasive Gynecology at Brigham and Women’s Hospital in Boston. The author reports no financial relationships relevant to this article. ›› SHARE YOUR EXPERIENCE! How do you select patients for laparoscopic myomectomy? E-MAIL obg@qhc.com FAX 973-206-9251 SURGICAL TECHNIQUES From preoperative imaging to postoperative analgesia, the choices you make determine the ease of the procedure and the quality of the outcome Myomectomy is the surgery of choice for women who have symptomatic fibroids and who wish to retain their uterus. And laparoscopic myomectomy is preferable to the abdominal approach in many ways, offering: 1-4 • faster recovery • a shorter hospital stay • diminished blood loss • decreased adhesion formation • a comparable or higher rate of pregnancy. Nevertheless, laparoscopic myomectomy is a technically challenging procedure with surgeon-specific limitations. The biggest challenge: appropriately suturing the hysterotomy site. In this article, I share my experience with laparoscopic myomectomy and offer 8 pearls that may contribute to a successful outcome. Don’t settle on 1. laparoscopy prematurely Given its advantages over the abdominal route, laparoscopic myomectomy should be the preferred approach in the treatment of symptomatic uterine fibroids (FIGURE 1, page 50). However, not all patients are appropriate candidates for laparoscopy. Several guidelines have recommended a maximum number and size of fibroids for laparoscopic removal, but practice varies widely, and experienced surgeons successfully take on cases that are well beyond the limits set by most published guidelines. 5-7 IN THIS ARTICLE When and how to treat uterine fibroids page 50 How MRI can guide treatment: 3 cases page 53 Should you worry about uterine rupture in postmyomectomy pregnancy? page 58 Watch the author remove a fibroid at obgmanagement.com CONTINUED ON PAGE 50 obgmanagement.com Vol. 22 No. 3 | March 2010 | OBG Management 49
SURGICAL TECHNIQUES / LAPAROSCOPIC MYOMECTOMY FIGURE 1 When and how to treat uterine fibroids 50 YES Hysteroscopic or laparoscopic fibroid resection Hysterectomy Medications Pro No surgery Infertility with submuscosal fibroid? Submucosal Hysteroscopic fibroid resection Cons Limited data and experience Potential side effects with long-term therapy NO No treatment needed Cons Not suitable for all fibroids High recurrence rate on short-term follow-up NO Cons Surgery Unknown long-term reoperation rate OBG Management | March 2010 | Vol. 22 No. 3 Uterine fibroids Symptoms? YES Future pregnancy possible or desired? NO YES Location of fibroids? NO MRI-guided focused ultrasound Pro No surgery Intramural or subserosal Desires uterine preservation? YES Laparoscopic uterine artery occlusion Pro Allows for concomitant removal of uterine fibroids and other pathology Submucosal Hysteroscopic fibroid resection Uterine fibroid embolization Pro No surgery Location of fibroids? Cons 20%-25% reoperation rate Small risk of premature ovarian failure Intramural or subserosal Myomectomy Myomectomy Pros Allows for future fertility Excellent for bulk symptoms Cons 15%-20% reoperation rate General anesthesia CONTINUED ON PAGE 52
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Laparoscopic Myomectomy - Brigham and Women's Hospital

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