Using the wristed robotic tenaculum (or an assistant using a laparoscopic tenaculum or corkscrew), grasp and elevate the myoma away from the fixed uterus (FIGURE 1). This step is not intended to enucleate the myoma through force, but to apply traction and position the fibroid to best delineate and present the leading edge of the pseudocapsule that lies between the myoma and the myometrium. Dissection then can proceed using a “push and spread” technique, bluntly separating the natural plane between the fibroid and the myometrium. Occasionally, fibrous attachments of the pseudocapsule can be transected sharply using the bipolar forceps and monopolar scissors.
Again, we encourage the intermittent use of minimal thermal energy to facilitate this process and achieve temporary hemostasis. As the dissection progresses, the fibroid can be regrasped closer to its leading edge, causing the myoma to be rolled out (VIDEO 3 and VIDEO 4).
Close the myometrium We advocate multilayer closure with reapproximation of the myometrium and serosal edges to achieve hemostasis and prevent hematoma (VIDEO 5).
The half-life of vasopressin ranges from 20 to 40 minutes. By this point of the procedure, assuming that the use of thermal energy has been minimal, the myometrial edges should be bleeding slightly, demonstrating adequate reperfusion. The myometrial defect then can be repaired using delayed absorbable suture, such as 2-0 V-Loc 180 (Covidien, Mansfield, Massachusetts).
Barbed suture has revolutionized laparoscopy and minimally invasive surgery, eliminating the need for endoscopic knot-tying. Quill suture (Angiotech, Vancouver, British Columbia, Canada) and V-Loc suture are used safely throughout gynecology, myomectomy included.8,9 However, when the endometrial cavity has been entered, avoid using barbed suture to reapproximate this initial layer to prevent synechiae.
No closure technique has been shown to prevent uterine rupture. Uterine rupture during pregnancy is one of the most serious potential complications following myomectomy. The precise risk of rupture after laparoscopic or robot-assisted laparoscopic myomectomy has not been determined.
Parker and colleagues evaluated case reports of uterine rupture after laparoscopic myomectomy in an attempt to identify a common causal risk factor. In their review of 19 uterine ruptures, however, they were unable to identify a single plausible risk factor. Uterine rupture has occurred in cases involving three-layer closure, removal of pedunculated fibroids, removal of fibroids as small as 1 cm, and in cases where no thermal energy was used.10
Pregnancy rates and outcomes have not been well-established because of confounding variables, such as a high prevalence of infertility and difficulty with long-term follow-up. One of the largest retrospective case studies on this topic involved 872 women who underwent robot-assisted myomectomy.11 Preterm delivery was correlated with the number of myomas removed and an anterior location of the largest incision.11
Undock the robot for morcellation
We strongly recommend that fibroids be morcellated using the 5-mm laparoscope while the robot is undocked, for several reasons. First, we advocate use of the robotic camera port site for morcellation. In the umbilicus, or midline, patients generally experience less pain. And with insufflation, the camera port site is the highest point on the abdomen, allowing greater distance between the morcellator and the iliac vessels and other major structures.
Second, the 12-mm robotic camera is heavy and cumbersome, easily causing fatigue when held separately. The robotic arms and patient side cart are bulky and can be limiting, physically impeding the range of motion necessary to morcellate safely, effectively, and efficiently.
After undocking the robot, remove the midline camera port to introduce the morcellator with the aid of a 5-mm laparoscope through a lateral port. We recommend taking the patient out of a steep Trendelenberg position and placing her in minimal Trendelenberg during morcellation to keep the specimen and fragments from falling to the upper abdomen.
Perfect the art of morcellation
A number of morcellators use electrical or mechanical energy. Blades ranging in diameter from 12 to 20 mm also are available. We favor the reusable MOREsolution tissue-extraction system (Blue Endo, Lenexa, Kansas) with a disposable 20-mm blade, particularly for large or multiple myomas.
The art of morcellation can be learned (VIDEO 6 and VIDEO 7). We recommend the following strategies:
- Slower morcellation speeds cause less fragmentation but may prolong the surgery significantly when the myomas are large. For such myomas, as well as cases that involve significant calcification, we recommend morcellation speeds of at least 600 rpm.
- A beveled trocar is preferred because it allows for longer continuous morcellation along the surface of the myoma and less fragmentation and coring.
- As morcellation nears completion and the specimen begins to fragment more, use short bursts of activation with increased traction, and ask the assistant to help stabilize the end pieces. This approach will help minimize the dissemination of fragments throughout the entire abdominal and pelvic cavity.
- Reapproximate the fascia for all trocar sites larger than 10 mm to prevent incisional hernias. When you exchange the robotic camera port with the morcellator, only one port site will require fascial closure because all other trocar sites typically are 8 mm or smaller.