Clinical Review

2018 Update on minimally invasive gynecologic surgery

OBG Manag. 2018 November;30(11):35-36,38,41-44

References

Matchar DB, Myers ER, Barber MW, et al. Management of uterine fibroids: summary. AHRQ Evidence Report Summaries. Rockville, MD; Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E051.
Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100-107.
Stewart EA. Uterine fibroids. Lancet. 2001;357:293-298.
Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet. 2012;285:435-440.
Herrmann A, De Wilde RL. Laparoscopic myomectomy—the gold standard. Gynecol Minim Invasive Ther. 2014;3:31-38.
Stoica RA, Bistriceanu I, Sima R, et al. Laparoscopic myomectomy. J Med Life. 2014;7:522-524.
Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update. 2016;22:665-686.
Holub Z. Laparoscopic myomectomy: indications and limits. Ceska Gynekol. 2007;72:64-68.
Sinha R, Hegde A, Mahajan C, et al. Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol. 2008;15:292-300.
Aksoy H, Aydin T, Ozdamar O, et al. Successful use of laparoscopic myomectomy to remove a giant uterine myoma: a case report. J Med Case Rep. 2015;9:286.
Damiani A, Melgrati L, Marziali M, et al. Laparoscopic myomectomy for very large myomas using an isobaric (gasless) technique. JSLS. 2005;9:434-438.
Holzer A, Jirecek ST, Illievich UM, et al. Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain. Anesth Analg. 2006;102:1480-1484.
Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol. 1996;174:654-658.
Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14-21.
Pluchino N, Litta P, Freschi L, et al. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014;10:208-212.
Parker WH, Iacampo K, Long T. Uterine rupture after laparoscopic removal of a pedunculated myoma. J Minim Invasive Gynecol. 2007;14:362-364.
Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 2004;11:511-518.
Advincula AP, Xu X, Goudeau S 4th, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14:698-705.
Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet. 2012;285:435-440.
Mansour FW, Kives S, Urbach DR, et al. Robotically assisted laparoscopic myomectomy: a Canadian experience. J Obstet Gynaecol Canada. 2012;34:353-358.
Sangha R, Eisenstein D, George A, et al. Comparison of surgical outcomes for robotic assisted laparoscopic myomectomy compared to abdominal myomectomy (abstract 373). J Minim Invasive Gynecol. 2010;17(suppl):S90-S108.
Pundir J, Pundir V, Walavalkar R, et al. Robotic-assisted laparoscopic vs abdominal and laparoscopic myomectomy: systematic review and meta-analysis. J Minim Invasive Gynecol. 2013; 20:335–345.
Pitter MC, Srouji SS, Gargiulo AR, et al. Fertility and symptom relief following robot-assisted laparoscopic myomectomy. Obstet Gynecol Int. 2015. doi:10.1155/2015/967568.
Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod. 2013; 28:99-108.
Cela V, Freschi L, Simi G, et al. Fertility and endocrine outcome after robot-assisted laparoscopic myomectomy (RALM). Gynecol Endocrinol. 2013;29:79-82.
Kang SY, Jeung IC, Chung YJ, et al. Robot-assisted laparoscopic myomectomy for deep intramural myomas. Int J Med Robot. 2017;13. doi:10.1002/rcs.1742.
van den Haak L, Alleblas C, Nieboer TE, et al. Efficacy and safety of uterine manipulators in laparoscopic surgery: a review. Arch Gynecol Obstet. 2015;292:1003-1011.
Hickman LC, Kotlyar A, Shue S, et al. Hemostatic techniques for myomectomy: an evidence-based approach. J Minim Invasive Gynecol. 2016;23:497-504.
Tulandi T, Einarsson JI. The use of barbed suture for laparoscopic hysterectomy and myomectomy: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2014;21:210-216.
Alessandri F, Remorgida V, Venturini PL, et al. Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. J Minim Invasive Gynecol. 2010;17:725-729.
AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: morcellation during uterine tissue extraction. J Minim Invasive Gynecol. 2014;21:517-530.
Meurs EA, Brito LG, Ajao MO, et al. Comparison of morcellation techniques at the time of laparoscopic hysterectomy and myomectomy. J Minim Invasive Gynecol. 2017;24:843-849.

Benefits after RALM over time

Long-term benefits from RALM, such as symptom recurrence rates and fertility outcomes, have been demonstrated. In 2015, Pitter and colleagues published the first paper on symptom recurrence after RALM.²³In this retrospective survey, 426 women underwent RALM for symptom relief or infertility across 3 practice sites; 62.9% reported being symptom free after 3 years. In addition, 80% of symptom-free women who had undergone RALM to improve fertility outcomes conceived after 3 years. The mean (SD) time to pregnancy was 7.9 (9.4) months. Overall, pregnancy rates improved and symptom recurrence increased with the interval of time since surgery.²³

In another study, Pitter and colleagues reported on pregnancy outcomes in greater detail.²⁴They evaluated 872 women who underwent RALM between October 2005 and November 2010 at 3 centers. Of these women, 107 conceived, resulting in 127 pregnancies and 92 deliveries through 2011. The means (SD) for age at myomectomy, number of myomas removed, and myoma size were 34.8 (4.5) years, 3.9 (3.2), and 7.5 (3.0) cm (weight, 191.7 [144.8] g), respectively. Overall, the pregnancy outcomes in this study were comparable to those reported in the literature for conventional LM.

Cela and colleagues reported similar outcomes based on their review of 48 patients who underwent RALM between 2007 and 2011.²⁵ Seven women became pregnant (8 pregnancies). There were no spontaneous abortions or uterine ruptures. Following suit, Kang and colleagues reported outcomes in 100 women who underwent RALM for deep intramural fibroids (FIGO type 2 to 5).26 The average (SD) number of fibroids was 3.8 (3.5) with a mean (SD) size of 7.5 (2.1) cm. All patients recovered without major complications, and 75% of those pursuing pregnancy conceived.

The importance of LM and RALM

After this brief review of the data on conventional LM and RALM, it is fair to conclude that both surgical options are a game changer for the minimally invasive management of uterine fibroids. Despite strong evidence that suggests laparoscopy is superior to laparotomy for myomectomy, the technical demands required for performing conventional LM may explain why it is underutilized and why the advantages of robotic surgery—with its 3-dimensional imaging and articulated instruments—make this approach an attractive alternative.

The myomectomy technique we prefer at our institution

At our medical center, we approach the majority of abdominal myomectomies via conventional LM or RALM. We carefully select candidates with the goal of ensuring a successful procedure and minimizing the risk of conversion. When selecting candidates, we consider these factors:

size, number, location, and consistency of the fibroids
patient’s body habitus, and
relative size of the uterus to the length of the patient’s torso.

Additionally, any concerns raised during the preoperative workup regarding a suspected risk of occult leiomyosarcoma preclude a minimally invasive approach. Otherwise, deciding between
conventional LM and RALM is based on surgeon preference.

Watch how it’s done

View these surgical techniques on the multimedia channel

Robot-assisted laparoscopic myomectomy

Arnold P. Advincula, MD, Victoria M. Fratto, MD, and Caroline Key
A systematic approach to surgery in a 39-year-old woman with heavy menstrual bleeding who desires future fertility. Features include robot-specific techniques that facilitate fibroid enucleation and hysterotomy repair and demonstration of the ExCITE technique for tissue extraction.

Laparoscopic myomectomy technique

William H. Parker, MD
A step-by-step demonstration of the laparoscopic myomectomy technique used to resect a 7-cm posterior fibroid in a 44-year-old woman.

Laparoscopic myomectomy with enclosed transvaginal tissue extraction

Ceana Nezhat, MD, and Erica Dun, MD, MPH
A surgical case of a 41-yearold woman with radiating lower abdominal pain and menorrhagia who desired removal of symptomatic myomas. Preoperative transvaginal ultrasonography revealed a 4-cm posterior pedunculated myoma and a 5-cm fundal intramural myoma.

Continue to: Preoperative MRI guides surgical approach

References

Matchar DB, Myers ER, Barber MW, et al. Management of uterine fibroids: summary. AHRQ Evidence Report Summaries. Rockville, MD; Agency for Healthcare Research and Quality; 2001. AHRQ Publication No. 01-E051.
Baird DD, Dunson DB, Hill MC, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003;188:100-107.
Stewart EA. Uterine fibroids. Lancet. 2001;357:293-298.
Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet. 2012;285:435-440.
Herrmann A, De Wilde RL. Laparoscopic myomectomy—the gold standard. Gynecol Minim Invasive Ther. 2014;3:31-38.
Stoica RA, Bistriceanu I, Sima R, et al. Laparoscopic myomectomy. J Med Life. 2014;7:522-524.
Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update. 2016;22:665-686.
Holub Z. Laparoscopic myomectomy: indications and limits. Ceska Gynekol. 2007;72:64-68.
Sinha R, Hegde A, Mahajan C, et al. Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol. 2008;15:292-300.
Aksoy H, Aydin T, Ozdamar O, et al. Successful use of laparoscopic myomectomy to remove a giant uterine myoma: a case report. J Med Case Rep. 2015;9:286.
Damiani A, Melgrati L, Marziali M, et al. Laparoscopic myomectomy for very large myomas using an isobaric (gasless) technique. JSLS. 2005;9:434-438.
Holzer A, Jirecek ST, Illievich UM, et al. Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain. Anesth Analg. 2006;102:1480-1484.
Mais V, Ajossa S, Guerriero S, et al. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol. 1996;174:654-658.
Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—a meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145:14-21.
Pluchino N, Litta P, Freschi L, et al. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014;10:208-212.
Parker WH, Iacampo K, Long T. Uterine rupture after laparoscopic removal of a pedunculated myoma. J Minim Invasive Gynecol. 2007;14:362-364.
Advincula AP, Song A, Burke W, et al. Preliminary experience with robot-assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 2004;11:511-518.
Advincula AP, Xu X, Goudeau S 4th, et al. Robot-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short-term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14:698-705.
Nash K, Feinglass J, Zei C, et al. Robotic-assisted laparoscopic myomectomy versus abdominal myomectomy: a comparative analysis of surgical outcomes and costs. Arch Gynecol Obstet. 2012;285:435-440.
Mansour FW, Kives S, Urbach DR, et al. Robotically assisted laparoscopic myomectomy: a Canadian experience. J Obstet Gynaecol Canada. 2012;34:353-358.
Sangha R, Eisenstein D, George A, et al. Comparison of surgical outcomes for robotic assisted laparoscopic myomectomy compared to abdominal myomectomy (abstract 373). J Minim Invasive Gynecol. 2010;17(suppl):S90-S108.
Pundir J, Pundir V, Walavalkar R, et al. Robotic-assisted laparoscopic vs abdominal and laparoscopic myomectomy: systematic review and meta-analysis. J Minim Invasive Gynecol. 2013; 20:335–345.
Pitter MC, Srouji SS, Gargiulo AR, et al. Fertility and symptom relief following robot-assisted laparoscopic myomectomy. Obstet Gynecol Int. 2015. doi:10.1155/2015/967568.
Pitter MC, Gargiulo AR, Bonaventura LM, et al. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod. 2013; 28:99-108.
Cela V, Freschi L, Simi G, et al. Fertility and endocrine outcome after robot-assisted laparoscopic myomectomy (RALM). Gynecol Endocrinol. 2013;29:79-82.
Kang SY, Jeung IC, Chung YJ, et al. Robot-assisted laparoscopic myomectomy for deep intramural myomas. Int J Med Robot. 2017;13. doi:10.1002/rcs.1742.
van den Haak L, Alleblas C, Nieboer TE, et al. Efficacy and safety of uterine manipulators in laparoscopic surgery: a review. Arch Gynecol Obstet. 2015;292:1003-1011.
Hickman LC, Kotlyar A, Shue S, et al. Hemostatic techniques for myomectomy: an evidence-based approach. J Minim Invasive Gynecol. 2016;23:497-504.
Tulandi T, Einarsson JI. The use of barbed suture for laparoscopic hysterectomy and myomectomy: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2014;21:210-216.
Alessandri F, Remorgida V, Venturini PL, et al. Unidirectional barbed suture versus continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study. J Minim Invasive Gynecol. 2010;17:725-729.
AAGL Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: morcellation during uterine tissue extraction. J Minim Invasive Gynecol. 2014;21:517-530.
Meurs EA, Brito LG, Ajao MO, et al. Comparison of morcellation techniques at the time of laparoscopic hysterectomy and myomectomy. J Minim Invasive Gynecol. 2017;24:843-849.

VTE risk after gynecologic surgery lower with laparoscopic procedures

2018 Update on minimally invasive gynecologic surgery

References

Benefits after RALM over time

The importance of LM and RALM

The myomectomy technique we prefer at our institution

<img style="width: 250px; height: 150px;" class="media-element file-medstat-image-full-text" data-delta="10" typeof="foaf:Image" src="https://cdn-uat.mdedge.com/files/s3fs-public/Image/November-2018/obgm03011035_side_fig1.jpg" width="500" height="300" alt="" title="" />

Robot-assisted laparoscopic myomectomy

Laparoscopic myomectomy technique

Laparoscopic myomectomy with enclosed transvaginal tissue extraction

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