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Laparoscopic Myomectomy

Laparoscopic Myomectomy. ERTAN SARIDO Ğ AN Consultant in Reproductive Medicine and Minimal Access Surgery University College London Hospitals. Cumulative incidence of fibroids in black and white women Baird et al 2003. Age specific prevalence of clinically relevant fibroids Baird et al 2003.

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Laparoscopic Myomectomy

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  1. Laparoscopic Myomectomy ERTAN SARIDOĞAN Consultant in Reproductive Medicine and Minimal Access Surgery University College London Hospitals

  2. Cumulative incidence of fibroids in black and white womenBaird et al 2003

  3. Age specific prevalence of clinically relevant fibroids Baird et al 2003

  4. Myomectomy • Myomectomy • Amussat 1840 • Atlee 1844 • Laparoscopic myomectomy • Semm and Mettler 1977 • Laparoscopically assisted myomectomy • Nezhat et al 1994 • Laparoscopic assisted vaginal myomectomy • Pelosi & Pelosi 1997

  5. Advantages of Laparoscopic Approach • Shorter hospital stay • Shorter recovery • Less analgesia • Better cosmesis

  6. Laparoscopic vs open myomectomy

  7. Preoperative Assessment • Clinical examination • Ultrasound • MRI • Hysteroscopy

  8. Patient Selection • Uterine size • Number of fibroids • Size of fibroids • Location of fibroids ESTABLISH YOUR OWN CRITERIA ACCORDING TO YOUR OWN EXPERIENCE !

  9. Preoperative GnRHa Treatment • Reduced fibroid size • Reduced vascularity • Reduced blood loss • ?Difficult dissection • ?Increased conversion rate to laparotomy • ?Higher recurrence rates

  10. Preoperative GnRHa Treatment Zullo et al 1998 AJOG

  11. Surgical Technique • Vasopressin injection • Uterine incision • Enucleation of fibroid • Uterine repair • Extraction of fibroid

  12. Vasopressin Injection • 20 U in 10-40 ml saline • Subserosal • Into broad ligaments

  13. Serosal Incision • Horizontal vs Vertical • Tools • Monopolar • Laser • Harmonic scalpel

  14. Enucleation • Graspers • Myomectomy screws • Blunt probe • Diathermy hook • Harmonic scalpel

  15. Haemostasis • Bipolar forceps • Avoid indiscriminate, excessive coagulation • Suturing

  16. Uterine Repair • Multilayered repair • Use of curved needles • Synthetic absorbable sutures • Barbed sutures • Knots • Intracorporeal • Extracorporeal

  17. Extraction • Electric morcellator • Single use • Reusable • Posterior colpotomy

  18. Adhesion prevention • Interceed • Intercoat • Seprafilm • Icodextrin • Sepracoat • SprayGel • SprayShield

  19. Fertility after laparoscopic myomectomySeracchioli et al 2006

  20. Fertility after laparoscopic myomectomySizzi et al 2007

  21. Pregnancy outcome after laparoscopic myomectomySeracchioli et al 2006

  22. Obstetric outcome after laparoscopic myomectomySeracchioli et al 2006

  23. Myomectomy complications • Infection • Haemorrhage • Blood transfusion • Visceral injury • Thrombosis • Hysterectomy • Adhesions • Uterine dehiscence/rupture • Uterine fistula

  24. Uterine dehiscence/rupture • Use of excessive diathermy for haemostasis • Inadequate suturing • Inadequate number of layers • Use of straight needles • Use of inappropriate suture material

  25. Uterine rupture after laparoscopic myomectomySeracchioli et al 2006

  26. Complications after laparoscopic myomectomySizzi et al 2007

  27. Recurrence after laparoscopic myomectomyRosetti et al 2001 • n=81 • 40 months follow up with TVUS • Recurrence • Laparotomy 23% • Laparoscopy 27%

  28. Conclusions • Laparoscopic myomectomy is feasible in selected patients, but require considerable experience in advanced operative laparoscopy • Immediate complication rate, fertility and obstetric outcome appear to be similar to open myomectomy

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