Tips for Safe Laparoscopic Multiple Myomectomy.

STUDY OBJECTIVE: To demonstrate key steps in performing safe laparoscopic multiple myomectomy.

DESIGN: Video focuses on stepwise description of all major steps of the surgical technique.

PATIENT: Twenty-seven-year-old woman. Informed consent was taken from the subject, and the institutional review board approved this research.

INTERVENTION: Laparoscopic multiple myomectomy with morcellation in bag.

MEASUREMENTS AND MAIN RESULTS: About one-third of women with fibroids present with symptoms severe enough to warrant treatment. We demonstrate a case of a 27-year-old woman with complaints of secondary infertility and menorrhagia. On examination the uterus was enlarged up to 24 weeks size. Ultrasonography mapping located 7 myomas ranging in size from of 3 to 10 cm and classified as International Federation of Gynecology and Obstetrics classes 2, 3, 4, 5, 6, and 7. Generally, laparotomy or laparoscopy and mini-laparotomy is performed for such cases of multiple myomas. However, the total laparoscopic approach can confer benefits if performed following safe steps and within good time. The following were the key steps of surgery: (1) Higher port position using Lee Huang point for primary port, (2) intermittent vasopressin use for each myomectomy, (3) cold technique of myomectomy, (4) myoma lace creation, (5) multiple layer suturing using double-ended barbed sutures, (6) myoma garland creation, and (7) morcellation in a stomach-shaped bag.

CONCLUSION: The intermittent use of vasopressin is effective in reducing blood loss. Suturing using barbed sutures is less time consuming. Creating lace of myomas by passing a thread through each myoma, prevents losing them in the abdominal cavity and creating garland of myomas by tying two free ends of the lace helps in easier bagging. Morcellation in bag prevents dissemination of bits of myoma and visceral injury. These steps help in performing laparoscopic multiple myomectomy safely. However, this technique should be reserved for selected cases and should be performed by surgical teams with the required expertise and experience.