INTRODUCTION

Uterine fibroids, also called uterine myomas, are the most common benign pelvic tumors in women worldwide, affecting between 12 and 25% of reproductive-age women with a prevalence of 80% of surgically excised uteri.¹

The most common indications for surgical treatment of myomas are symptoms such as persistent abnormal uterine bleeding (AUB) despite medical therapy, infertility related to endometrial cavity distortion from a myoma, bulk-related symptoms like pain, or critical bowel or urinary stenosis.²

In young women who wish to preserve their uterus and, therefore, in women seeking pregnancy, myomectomy is the first-choice surgical procedure for the removal of symptomatic uterine myomas.³

The preoperative workup needs a precise description also called “mapping” of the uterine myomas according to their location in the uterus. The International Federation of Gynecology and Obstetrics (FIGO) classification system for myoma location described eight types of uterine myomas from type 0 to 8 as follows (Figure 1):⁴ 

• Submucosal myomas (FIGO type 0, 1, 2): these myomas derive from myometrial cells just below the endometrium and protrude into the uterine cavity. The extent of this protrusion is then subclassified in type 0, completely within the endometrial cavity; type 1, extension less than 50% into the myometrium; type 2, extension 50% or more within the myometrium.
• Intramural myomas (FIGO type 3, 4, 5): these myomas are located within the uterine wall. They may enlarge sufficiently enough to distort the uterine cavity or serosal surface. Some myomas may be transmural and extend from the serosal to the mucosal surface.
• Subserosal myomas (FIGO type 6, 7): these myomas originate from the myometrium at the serosal surface of the uterus. They may have a broad or pedunculated base and may be infraligamentary (extending between the folds of the broad ligament).
• Cervical myomas (FIGO type 8): these leiomyomas are located in the cervix.

Minimally invasive myomectomy has several advantages compared to a laparotomic approach, such as lower postoperative pain, shorter hospital stay, faster physical recovery, better esthetic results, lower postoperative complications, and less postoperative adhesions.⁵

Contraindications for minimally invasive myomectomy include multiple lesions, very large myomas, although no guideline has ever clearly indicated the maximum number and the largest size to be able to perform a safe, effective minimally invasive myomectomy. High suspicion of malignancy at the preoperative workup should also discourage the use of the minimally invasive approach.⁶

Minimally invasive myomectomy is a very linear surgical procedure from a theoretical point of view but challenging for the surgeons and strictly related to their surgical skills in particular for the suturing and tissue extraction phases.⁷

The laparoscopic myomectomy technique is extremely operator dependent.

The most familiar technique regarding laparoscopic myomectomy used by the authors' working group is presented in this chapter, developed in an Italian setting over decades of experience.

SURGICAL INSIGHTS: PREOPERATIVE WORKUP AND PATIENT COUNSELING

Diagnostic procedures

The lack of a tactile feedback in laparoscopy can make finding myomas difficult (particularly in FIGO type 0–5) when the external uterine surface does not reveal their presence. For this reason, a correct preoperative ultrasound workup is essential to create a precise “mapping” that indicates the location and development of each myoma in the context of myometrium in order to facilitate the choice of the surgeon regarding the number, type and depth of uterine incisions to be performed. It has been demonstrated that the presence of multiple myomas makes it difficult to obtain both a preoperative ultrasound count and the mapping of myomas actually present during surgery, by the "masking" of smaller contiguous lesions due to the rear shadow cones.⁸ In some cases, it may therefore be a good option to repeat a preoperative magnetic resonance imaging (MRI) or an intraoperative transvaginal or transabdominal pelvic ultrasound, to identify “occult” myomas in order to perform the complete removal of each pathological lesion.

Informed consent

Due to the Food and Drug US Administration (FDA) alert on the risk of morcellation of malignant lesions and scientific evidence in subsequent steps from 2014 to date, it is considered appropriate to perform an “open” approach (and, in some cases, demolishing instead of conservative), rather than a laparoscopic approach, in cases where there is a strong suspicion of malignancy of myometrial lesions. The risk must be assessed by examining various anamnestic, clinical and instrumental criteria.

The preoperative ultrasound evaluation allows the exclusion of important alarm signals, in particular the presence of areas of non-homogeneity (indicative of necrosis) and/or intense central vascularization instead of a typically peripheral one, in the context of a uterine lesion.

Other factors that advise against the minimally invasive approach are a postmenopausal state, the large diameter of a myoma (usually greater than 10 cm), previous pelvic irradiation, the use of tamoxifen, high lactate dehydrogenase (LDH) values and the presence of persistent abnormal uterine bleeding.⁹ It is therefore essential to explain to the patient by the informed consent for surgical intervention, not only the potential complications linked to the laparoscopic approach and myomectomy surgery, but also the risks of possible tissue dissemination (benign in case of myomas, malignant in case of leiomyosarcoma) linked to an eventual morcellation and conservative approach.

It is also necessary to report, in the explanation process, the risk of an unplanned hysterectomy, specifying its risk in the informed consent.¹⁰

SURGICAL INSIGHTS: LAPAROSCOPIC MYOMECTOMY SURGICAL STEPS

Patient positioning, uterine manipulator and trocar placement

The patient is generally placed supine in the classic lithotomy position with arms stretched along the sides. The cervix is clamped with a tenaculum and a uterine manipulator is inserted, after local disinfection. A Foley catheter is inserted into the bladder, after local disinfection.

After laparoscopic umbilical access (or supra-umbilical access in cases of large uteri, 3–4 cm above the transverse umbilical line) for the video-optical system, the abdomen is insufflated with CO₂ until an intra-abdominal pressure of 12 mmHg is reached. The ancillary ports positioning and sizes can differ and be tailored to each patient’s characteristics, such as uterine size, intrabdominal adhesions, myoma location and according to the surgeon’s preference. We suggest the most frequent setting used by the author’s working group (Figure 2).

An exploration of the upper abdomen is performed before obtaining the Trendelenburg position.

Once the Trendelenburg position has been obtained, the intestine and the omentum are moved to the upper part of the abdomen.

Two 5-mm ancillaries trocars are usually positioned under directed vision into the right iliac fossa and into the left iliac fossa, lateral to the deep inferior epigastric vessels, and a 12-mm port is inserted into the suprapubic region.

Preventive bleeding reduction measures (optional)

Once the myoma has been identified, a 22-mm gage needle is introduced abdominally from the suprapubic region and injected at the subserous uterine level in correspondence with the myoma to be removed with a vasoconstrictor solution based on vasopressin. The use of vasoconstrictor agents via intramyometrial injection has been proven to be an effective means of prevention of intraoperative bleeding, reducing the need for blood transfusions after laparoscopic myomectomy. These pharmacological agents allow a more rapid and easier enucleation, reduce the use of bipolar energy vascular synthesis instruments for selective hemostasis and promote clear vision and a clean operating area. However, due to the possible side-effects (bronchoconstriction, urticaria, anaphylactic reaction and myocardial infarction, pulmonary edema, arterial hypertension, hemorrhage late postoperative), the use of vasoconstrictors needs to be agreed on with the anesthetist.

Uterine incision

The uterine incision is usually performed by monopolar hook (or crochet) in correspondence with the uterine myoma and must be linear, deep and clear. The incision must, in fact, expose the myoma below its pseudocapsule.

The hysterotomy can be linear, oblique (preferable in the case of an anterior myoma) or elliptical (preferable in the case of a large myoma, multiple or pedunculated myomas).

In the case of a linear incision, even if the arteries and arterioles of the myometrium have a transverse course, it is preferable to make a sagittal incision since the subsequent suturing will be more effective and easier to perform.

During the hysterotomy and exposure of the myoma, it is important to minimize the coagulation, to avoid damaging the surrounding myometrium to prevent the subsequent risk of rupture of the pregnant uterus.

In the case of multiple uterine myomas, it is advisable to remove the larger uterine myomas first, to allow easier mobilization of the uterus. In the case of myomas in both the anterior and posterior uterine walls, it is advisable to proceed with the removal of anterior myomas first, as they are more accessible and can be an obstacle to the correct exposure of the posterior myomas.

Myoma enucleation

For a correct enucleation, it is necessary to identify the cleavage plane between the myoma and its pseudocapsule. An enucleation which follows the correct cleavage plane, in fact, drastically reduces intraoperative blood loss.

This phase requires the use of:

• A tenaculum for the traction of the myoma;
• Bipolar forceps to perform a selective hemostasis and to eliminate the fibro-connective bridges between the pseudocapsule and myoma;
• Grasping forceps (controlled by the right hand of the first assistant);
• A uterine manipulator (controlled by the second assistant) for the countertraction maneuvers on the uterus.

It is important that the tenaculum is applied to the myoma in an eccentric position to promote a correct, easy dislocation of the lesion during the traction and countertraction maneuvers and that its position varies progressively in relation to the myoma’s gradual enucleation.

Bipolar electrosurgery must be applied selectively to the blood vessels of the fibro-connective bridges between the myoma and pseudocapsule, sparing the anatomical and functional integrity of the healthy myometrium. Hemostasis should preferably be achieved via the suturing step to avoid iatrogenic thermal injuries, predisposing a risk of rupture of the pregnant uterus.

To avoid the formation of intrauterine synechiae and iatrogenic adenomyosis, attention should be paid to keep the uterine cavity as intact as possible in case of transmural lesions.

Suture

This step has a fundamental role in restoring good myometrial integrity to minimize the risk of future uterine rupture during pregnancy or childbirth. The wall defect subsequent to the myoma’s removal can be repaired in single or multiple layers depending on the depth of the incision. Although the risk of obstetric complications is much higher in cases of multiple, voluminous and intramural or transmural lesions, a careful suture of the uterine incision is also essential in the case of removal of subserous myomas, even if pedunculated, because the incision still interrupts the continuity of the uterine serosa.

The uterine suture can be continuous or through detached stitches according to the surgeon's preference.

The authors' working group usually use a continuous barbed suture in several layers with a final introflecting layer, entering and exiting with the needle at the level of the serosa with the so-called “far-near and near-far” suture to allow adequate juxtaposition of the suture margins.

The use of a continuous "barbed" (or self-locking) suture allows a knot-free suture, ensuring a fast, safe and effective closure. A recent meta-analysis has shown that the use of a “barbed” suture, compared to “smooth” ones, allows the suturing time to be reduced drastically and, consequently, the total operating time, intraoperative blood loss, length of hospitalization and perioperative complications.

Some cases of obstruction and intestinal volvulus have been described in the literature following the use of barbed sutures, it is therefore necessary to remember to cut the tail of the suture very short without letting it protrude outside the uterus.¹²

Tissue extraction

Morcellation of myomas greater than 2 cm is a mandatory surgical step to remove lesions via laparoscopic ports (Figure 3).

Morcellation, in fact, indicates the reduction of a sample of solid tissue into smaller sized parts, to allow its extraction through small incisions or cavities.

There are two types of morcellation: manual with scalpel (vaginally or mini-laparotomy) and electromechanically intraperitoneal (power morcellation).

Electromechanical morcellators represent a relatively recent mode of morcellation (FDA approved their use in the early 1990s), where the tissue is cored using a rotary blade or an electrosurgical unit.

Some recommendations should be applied for the correct, safe use of electromechanical morcellators:

• Correct vision of the operating field is required, which must be free of intestinal loops;
• Incorporate an adequate portion of the myoma removed by the tenaculum forceps to have a correct seal on it during the core drilling maneuver;
• Apply progressive tension to the myoma to avoid continued fragmentation in the abdomen and allow the formation of tissue fragments of a suitable length in order to reduce the surgical time;
• Do not push the blade into the abdominal cavity so as to avoid iatrogenic visceral or vascular injuries.

There are some risks associated with the use of electromechanical morcellators:

• Visceral lesions (intestinal, urogenital);
• Vascular lesions;
• Satellite (or parasitic) myomas (incidence of 1.4%);
• Iatrogenic endometriosis (0.9% incidence).

However, the rate of intraoperative complications associated with power morcellation is relatively low, estimated to be 0.02–0.007%.¹³

FDA warning and guidelines about morcellation

In 2014 power morcellation was banned due to a highly publicized event concerning a patient undergoing laparoscopic hysterectomy with final diagnosis of leiomyosarcoma misdiagnosed at the pre- and intraoperative findings. A subsequent communication from the FDA estimated a prevalence of undiagnosed sarcoma to be 1 case out of 352 women undergoing hysterectomy or myomectomy for presumed fibroids (and, in particular, one case of leiomyosarcoma out of 498) and highlighted the need for a review of uterine tissue extraction techniques. In the alert, the FDA discouraged the use of electric morcellators because, in the case of sarcomas, they may lead to neoplasia dissemination at a pelvic and abdominal level, with consequently reduced survival, and complicating diagnosis and staging of the disease.

These data have been debated and contested by the main national and international scientific societies. A more extensive and recent review of literature, in fact, highlighted how the risk of an undiagnosed sarcoma should be greatly reduced, attesting to the prevalence of leiomyosarcoma in patients undergoing surgery for suspected benign pathology to 1 in 1550 patients submitted to surgery (0.06%).¹⁴ It also did not highlight the significant reduction in overall survival following electromechanical core drilling, whether in the case of en bloc removal of the malignant tumor pathology (hysterectomy) or in the case of manual coring with scalpel.¹⁵

Many international gynecological societies have published position statements about power morcellation, such as the American College of Obstetricians and Gynecologists (ACOG),¹⁶ the American Association of Gynecologic Laparoscopists (AAGL)¹⁷ and the International Society for Gynecologic Endoscopy.¹⁸

The Italian Society of Gynecological Endoscopy (SEGI) conducted a review of the clinical and scientific evidence for correct, responsible management of uterine diseases. In the document “Recommendations for laparoscopic morcellation of the uterus and leiomyomas”, published in April 2015, the SEGI authorizes the use of morcellation, subject to prior approval and with the exclusion of patients with suspected cervical or endometrial neoplasia, of those with uterine myomas with suspect malignancy at a preoperative diagnostic evaluation and those with a positive history of retinoblastoma or family history of polyneoplastic syndromes (Lynch syndrome, hereditary leiomyomatosis, kidney tumors).¹⁹

When the preoperative patient’s evaluation suggests a malignant lesion, a laparotomic approach should be preferred and, in the case of patients aged between 40 and 45 years with a uterine mass of uncertain nature, their desire for childbearing must be truly investigated and evaluated in order to establish whether a conservative strategy (myomectomy instead of hysterectomy) is really appropriate.

In conclusion, the recent FDA recommendations impose a careful preoperative evaluation and patient’s counseling regarding the use of power morcellation.

PRACTICE RECOMMENDATIONS