Dr. J. B. Dubuisson began the great debated entitled Laparoscopic Myomectomy is a Safe Procedure by outlining the conditions under which laparoscopic myomectomy is a safe procedure.
Dr. Dubuisson stated that there is is a great demand from patients for minimally invasive surgery and it is important that the surgeon apply certain conditions to the selection of patients for successful treatment of leiomyomas by laparoscopy. Dr. Dubuisson said that the indications for a safe laparoscopic myomectomy include the following:
1. Subserous or intramural myomas with a maximum of 3 in number and an overall size less than 9 - 10 cm.
2. A contraindication to removal of a leiomyoma is the existence of significant adenomyosis.
3. In addition, the dissection must be performed without opening the uterine cavity and the defect closed with. If the defect cannot be sutured, a mini-laparotomy should be performed.
If these limitations are considered, the laparoscopic myomectomy is a safe procedure. Dr. Dubuisson defined laparoscopic myomectomy as a procedure which includes myoma enucleation, extraction of the myoma by morcellation or by enlargement of the abdominal port or by posterior colpotomy, concluding the procedure by laparoscopic suturing of the uterine defect. Laparoscopic assisted myomectomy utilizes a mini laparotomy for removal of the myoma and the suturing of the defect, but the enucleation is performed laparoscopically. The incision to enucleate the myoma can be made with monopolar electricity. Coagulation is performed with either bipolar or unipolar energy to control bleeding at the site of enucleation. Dr. Dubuisson has reported no complications with the use of monopolar energy, but stated the risk of burning bowel does exist, however small. Enucleation is performed with the use of forceps and corkscrew and dissection of the leiomyoma itself is performed with scissors. By limiting the damage to the myometrium by remaining within the capsule of the leiomyoma the effect on fertility and bleeding is limited. A cleavage plane can be found readily with most leiomyomas. It is necessary to close the incision well with 1 to 2 layers of Vicryl suture using an interrupted technique with intracorporeal knotting. There is a risk of adhesions with the use of suture whether performed by laparoscopy or laparotomy.
Dr. Dubuisson utilized an electric morcellator to remove the leiomyomas. He has reported on patients ranging in age from 19 to 64 with an average age of 39.8 years with primary indications of pain and infertility. The leiomyomas ranged in size from 5 to 9 cm and have been intramural, subserosal and pedunculated. 25% of patients who underwent a second look laparoscopy showed evidence of some adhesions. Adhesion barriers are recommended when it is possible to apply. There are risk factors for uterine rupture which include difficulties approximating the tissue, the wrong choice of suture, electrically caused necrosis, and technical failure because of inexperience. There have been five cases of uterine rupture reported after laparoscopic myomectomy, two cases of hysteroscopic myomectomy and one case of myolysis. In his particular series of 85 deliveries after laparoscopic myomectomy, there was one case (1.2%) of uterine rupture, 40% of all patients underwent cesarean section and 60% had vaginal deliveries. The risk of uterine rupture after a myomectomy by laparotomy approach is between 0 and 0.5%. There is no consensus regarding the major risk for uterine rupture. Cesarean section is indicated if there is a deep incision into the uterus, if there is a complicated postoperative course, and also if there is evidence of placenta accreta in the myoma scar. The extraction of uterine leiomyoma appears to improve fertility rates and therefore is recommended in selected cases.
Dr. Ray Garry presented a view that laparoscopic surgery for leiomyomas will not be accepted unless the significant complications of the laparoscopic approach can be avoided. As he points out, only the best of the best provide the surgical reports in the literature and in the hands of Professor Dubuisson laparoscopic myomectomy is a safe procedure. However, an evidence based surgical practice may not indicate the same results. An example of this is the hemorrhage rate found in the literature found for laparoscopic assisted vaginal hysterectomy, which is 56 per 1,000, whereas for abdominal hysterectomy it is less than 10 and vaginal hysterectomy less than 20 per 1,000. Ureteric damage is less experts than it is with the average gynecologic laparoscopic surgeons. The experts may demonstrate safety and efficiency in the performance of laparoscopic myomectomy but the same procedure may not be as effective or safe in the hands of the average laparoscopic surgeon.
Dr. Garry pointed out it is essential that complications of entry and exit be avoided as well as complications of the technique. Complications relating to damage to the bowel such as perforation has become the second most common claim against gynecologists in England. The entry technique itself is inherently flawed in that it is a blind procedure and until this procedure can be improved creates an unacceptable risk for the patient. A laparoscopic approach in fact treats best those who need it least. The indications for the procedure are that the individual must wish to retain the uterus and that the fibroid should be palpable and causing symptoms or bleeding and anemia. If the uterus is too large, then it is beyond the size which is considered safe by Dr. Dubuisson. In this case a hysterectomy may be the more appropriate procedure. A question exists as to whether the doctor should perform a risky and difficult procedure such as myomectomy simply because the patient requests that procedure when in fact a hysterectomy is more appropriate.
In fact, should this procedure be performed at all which results in an apparent four times greater risk of uterine rupture in the event of a pregnancy even in the hands of an expert operator if the patient wishes to retain the uterus for purposes of fertility.
Before a procedure is performed, the physician who is performing it should compare the performance of that procedure by laparoscopy and by laparotomy in his/her own hands. Surgery should be performed in the proliferative phase as the secretory phase can result in extensive bleeding. The physician must know how to suture in or to perform the procedure. Even with this approach any surgery that takes more than 2 ½ hours should be avoided.
Dr. Garry concluded that laparoscopic myomectomy must be considered a level 4 procedure and its performance perhaps should be restricted only those centers where a large number of these procedures are performed and therefore the physicians can develop substantial skill in the performance of the procedure.
Certain questions still exist with regard to the performance of laparoscopic myomectomy:
1. What is the appropriate energy source (electric versus ultrasonic energy)?
2. What is the role of GnRH agonists (would it be appropriate to use GnRH agonists to reduce size of a leiomyoma from 12 to 9 cm so that this procedure laparoscopically can be within Dr. Dubuisson's range for safety)?
3. Must closure be performed in an interrupted fashion as described, or is it possible to utilize continuous running suture?
4. What is the most appropriate suture material for closure.
5. Is the risk of uterine rupture with laparoscopic myomectomy truly four times as great as that with an open myomectomy?
6. Is it in fact necessary to arbitrarily establish a time limit of the procedure if the patient's recovery time and return to work are substantially improved by the performance of the laparoscopic approach?
7. What is the role of "pelvic embolization" or myolysis as a substitute for open or laparoscopic myomectomy?
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