Challenges of uterine fibroids - focus: endoscopic and hysteroscopic enucleation
Epublication WebSurg.com, Mar 2012;12(03). URL: http://websurg.com/doi/lt03enmettler001
25 to 30% of women are diagnosed with uterine myomas worldwide. Laparoscopic myomectomy has remarkable advantages for patients with less postoperative pain and shorter recovery time. The fibroid resection technique varies depending on the myoma’s size and position. Pedunculated fibroids: The myoma’s pedicle is cauterized by means of the bipolar forceps and divided after loop placement. Subserous and intramural myomas: An incision extended until the pseudo-capsule is made vertically or horizontally at the site of the underlying myoma. The dissection is performed strictly within the pseudo-capsule plane with the help of two pairs of grasping forceps using traction and counter-traction. After myoma enucleation, the uterus is sutured along a seromuscular plane using one or two layers of separate polydioxanon suture (PDS) stitches with extracorporeal or intracorporeal knots. Continuous suction and irrigation is performed to minimize adhesion formation. The myomas are then extracted by morcellation using an electric morcellator; an alternative method is to take it out by colpotomy, or to cut it in case of smaller pieces. Cervical myomas: These can be easily reached and enucleated transvaginally. Adenomyosis uteri: In case of dysmenorrhea resulting from well-discernible adenomyotic lesions, a careful resection is recommended by hysteroscopy or laparoscopy. Adenomatoid tumors: They resemble fibroids with no clear cleavage plane. The exclusion from malignancy is only possible by histology which account for their necessary removal; they can also turn into malignancy. Submucous myomas: They are located within the uterine cavity; their resection is performed hysteroscopically with the resectoscopic loop in a slicing manner with bipolar or monopolar current. Attention must be paid regarding resection if the distance between the myoma and the uterine serosa is less than 8mm. The laparotomic approach is preferably performed if the myoma is bigger than 20cm in diameter, located at very critical points, suspected of being a sarcoma, or if there are more than 10 fibroids. In any case when surgery is indicated, laparoscopic or hysteroscopic myomectomy is the primary choice according to the location. The results of many international series demonstrate the feasibility of laparoscopic and hysteroscopic myomectomy as a technique leading to a remission of symptoms with a low rate of complications and leading to an increased rate of fertility.