Description
Laparoscopic myomectomy is a minimally invasive surgical procedure performed to remove uterine fibroids, which are non-cancerous growths that develop in the uterus. During a laparoscopic myomectomy, the surgeon makes small incisions in the abdomen and inserts a laparoscope, a thin tube with a camera and light, to visualize the uterus and fibroids. The surgeon then uses specialized surgical instruments to remove the fibroids while preserving the healthy tissue of the uterus. Benefits of laparoscopic myomectomy include smaller incisions, less pain and scarring, shorter hospital stays, and quicker recovery times compared to traditional open surgery. However, not all women are candidates for laparoscopic myomectomy, and the procedure may not be appropriate for large or numerous fibroids or certain locations within the uterus.
Résumé
- A 32-year-old woman with six years of infertility and a previous failed IVF cycle presented with a fibroid (4x4.5 cm) distorting her endometrial cavity, leading to suspected implantation failures. Her AMH was 2.3, and she had bilateral tubal blocks.
- Laparoscopic myomectomy was planned due to the fibroid's location. Pre-operative preparation included a GnRH agonist depot injection to minimize blood loss. The myoma was enucleated through a transverse serosal incision, with the endometrial cavity remaining unopened. Meticulous suturing was performed to minimize adhesions.
- Three months post-surgery, the patient underwent IVF, resulting in the retrieval of 12 oocytes. The IVF cycle led to a successful pregnancy with two live intrauterine fetuses. She delivered two female children at 34 weeks via LSCS, without complications during surgery or pregnancy.
- A 28-year-old female with three years of infertility, dysmenorrhea, and a previous spontaneous abortion was found to have a subserosal fibroid (3.4x3.3 cm) distorting the endometrial cavity, as well as PCO. She was planned for laparoscopic myomectomy.
- During surgery, accidental opening of the endometrial cavity occurred, which was repaired. HSG confirmed tube patency after the fibroid was removed. Ovulation induction and IUI were then performed, resulting in a successful pregnancy.
- This case highlights that opening the endometrial cavity during fibroid removal isn't necessarily detrimental. Proper repair can still lead to successful conception and pregnancy. The patient conceived in an IUI cycle and delivered a male child at 36 weeks via LSCS.
- Fibroids can cause infertility by hindering sperm travel, obstructing tubal openings, distorting the uterine cavity, causing vascular changes, disrupting uterine contractions, and impairing implantation and endometrial maturation. The FIGO classification categorizes fibroids based on their location and relationship to the uterine layers.
- Indications for myomectomy in infertile women include failure of three IUI cycles, recurrent implantation failure, intramural myomas larger than 5 cm, and intramural myomas with submucous extension. Hysteroscopic myomectomy is preferred for submucous myomas, while laparoscopic approaches are considered for multiple or larger submucous myomas, or those extending to the uterine serosa.
- Hysteroscopic myomectomy is limited to FIGO types 0 and 1. A pelvic MRI with contrast is recommended to determine the feasibility of hysteroscopic resection. Hysteroscopic resection should be avoided if the myoma is within 1 cm of the serosa edge to prevent uterine perforation. Intrauterine pressure should be maintained at 70-80 mmHg to reduce intravasation risk.
- Laparoscopic myomectomy, though potentially longer in operative time, is associated with less blood loss, fewer complications, reduced postoperative pain, and faster recovery. Pre-operative counseling is essential to define patient goals and establish realistic expectations. Patients should understand the potential for future myoma recurrence, intrauterine rupture, and the need for hysterectomy in rare cases.
- Preoperative management for patients with menorrhagia includes intravenous iron, GnRH agonists, or ulipristol to improve hemoglobin levels. Misoprostol and tranexamic acid can also be used to reduce bleeding during surgery. Vasopressin injections during surgery constrict blood vessels. Consider temporary clipping of the uterine arteries.
- Ensure gentle tissue handling, meticulous hemostasis, and irrigation to prevent serosal drying. Minimize electrocautery use. Anti-adhesion agents, such as oxidized regenerated cellulose or Seprafilm, can further reduce adhesion formation. Solutions like crystalloids or hyaluronic acid gels can also be used. Despite potential drawbacks, laparoscopic myomectomy remains a valuable and widely used minimally invasive technique.
Exemple de certificat
À propos des intervenants
Dr Richika Sahay
Director at India IVF Clinic Head Fertility specialist and Gynec-Laparoscopic surgeon at Fortis Hospital
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