MYOMAS and MYOMECTOMY MYOMAS and MYOMECTOMY JeanJean--Bernard Dubuisson, M.D.Bernard Dubuisson, M.D.

ClinicalClinical ProfessorProfessorChairman of the Chairman of the DepartmentDepartment of of ObstetricsObstetrics and and GynaecologyGynaecology

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UniversityUniversity HospitalHospital of Geneva (CH)of Geneva (CH)

CLERMONT CLERMONT 20112011

MYOMECTOMY SUTURINGMYOMECTOMY SUTURINGJeanJean--Bernard Dubuisson, M.D.Bernard Dubuisson, M.D.

Clinical Professor Clinical Professor Chairman of the Department of Obstetrics and Gynaecology Chairman of the Department of Obstetrics and Gynaecology

University Hospital of Geneva (CH)University Hospital of Geneva (CH)

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LEARNIG OBJECTIVESLEARNIG OBJECTIVES1.Select the indications of Laparoscopic myomectomy1.Select the indications of Laparoscopic myomectomy

2.Learn how to avoid the bleeding of the uterine incision2.Learn how to avoid the bleeding of the uterine incision3.Learn the principles of myomectomy suturing3.Learn the principles of myomectomy suturing

«« A MYOMECTOMY IS AN INJURY FOR THE A MYOMECTOMY IS AN INJURY FOR THE UTERUS, SO WE HAVE TO LIMIT THE TRAUMA UTERUS, SO WE HAVE TO LIMIT THE TRAUMA USING AN EXCELLENT TECHNIQUEUSING AN EXCELLENT TECHNIQUE »:»:

HYSTEROSCOPY: HYSTEROSCOPY:

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NO MYOMETRIUM INCISIONNO MYOMETRIUM INCISION

LAPAROSCOPY, LAPAROSCOPY, ATRAUMATIC INCISION, ATRAUMATIC INCISION, GOOD MYOMECTOMY SUTURINGGOOD MYOMECTOMY SUTURING

Before any operation, it is necessary to precise:Before any operation, it is necessary to precise:

1) the right diagnosis 1) the right diagnosis (avoid the classical diagnostic laparoscopy) and (avoid the classical diagnostic laparoscopy) and

2) the right access 2) the right access (laparoscopy, hysteroscopy, laparotomy, vaginal access)(laparoscopy, hysteroscopy, laparotomy, vaginal access)

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SymptomsSymptomsClinical examination: uterine size/mobilityClinical examination: uterine size/mobilityBiology: anaemia ?Biology: anaemia ?Imaging: EchoImaging: Echo--Doppler or IRMIDoppler or IRMI

ECHOECHO--DOPPLER or RMIDOPPLER or RMIMyomas: Myomas:

number, size, type, situation, number, size, type, situation, vascularization from which arteries ?vascularization from which arteries ?aspect of necrobiosisaspect of necrobiosis

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Adenomyosis associated ?Adenomyosis associated ?Suspicion of sarcoma ? Total incidence of sarcoma : Suspicion of sarcoma ? Total incidence of sarcoma :

Among women operated for myomas sarcoma is noted on Among women operated for myomas sarcoma is noted on 0.23%.0.23%.

When performing conservative surgery ?When performing conservative surgery ?

Young women < 45 yearsYoung women < 45 yearsD i fD i f

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Desire of pregnancy Desire of pregnancy Women who do not want a hysterectomy Women who do not want a hysterectomy When myomectomy easier than a hysterectomy : unique When myomectomy easier than a hysterectomy : unique pedunculated myoma (laparoscopy), submucous myoma pedunculated myoma (laparoscopy), submucous myoma (hysteroscopy)(hysteroscopy)

Which conservative surgery ?Which conservative surgery ?

In young women or in women desiring a pregnancy, the In young women or in women desiring a pregnancy, the myomectomy is the best +++ whatever the number, the myomectomy is the best +++ whatever the number, the size size

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If no desire of pregnancy, the occlusions of all the uterine If no desire of pregnancy, the occlusions of all the uterine arteries by laparoscopy may be performed (round arteries by laparoscopy may be performed (round ligaments, uterine arteries, infundibulopelvic ligaments, ligaments, uterine arteries, infundibulopelvic ligaments, +/+/-- hysteroscopic resection of myomas) hysteroscopic resection of myomas)

Uterine embolization ?Uterine embolization ?

Which access ?Which access ?

The best :The best :hysteroscopy for submucous myomashysteroscopy for submucous myomasl f b d i t titi ll f b d i t titi l

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laparoscopy for subserous and interstitial myomas laparoscopy for subserous and interstitial myomas The necessity if contraindication to endoscopy :The necessity if contraindication to endoscopy :laparotomylaparotomyUnfrequently :Unfrequently :vaginal access (for posterior myomas ) vaginal access (for posterior myomas )

Follow the guidelines (for security):the indications of Laparoscopic Myomectomy are :

1) Solitary myoma with size ≤ 8-10 cm≤ 3/4 myomas when D1 + D2 + D3 …< 14 cm

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y2) But it depends of the uterine mobility, the morphology of the woman

(pelvic size)

Dubuisson JB et al (1996),Serrachioli R et al (2000),Mais V et al (1996)

Adenomyosis and myomectomyAdenomyosis and myomectomy

confirmation with US or MRI : confirmation with US or MRI :

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Associated adenomyosis of the myometrium around the Associated adenomyosis of the myometrium around the myoma myoma Adenomyoma and not a myomaAdenomyoma and not a myoma

= relative contra= relative contra--indications to laparoscopy because noindications to laparoscopy because nocleavage plane is very often observed cleavage plane is very often observed

Haemorrhage and myomectomy :Haemorrhage and myomectomy :How to avoid the bleeding ? How to avoid the bleeding ? 1)1) Preoperative use of GnRh but myomectomy may be technically Preoperative use of GnRh but myomectomy may be technically

more difficult : the cleavage plane is not easily identified making the more difficult : the cleavage plane is not easily identified making the enucleation of the myoma more hemorrhagicenucleation of the myoma more hemorrhagic

Y Beyth Fertil Steril, 53, 1, 187-188, 1990myoma to soft, difficult to grip with a forceps

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myoma to soft, difficult to grip with a forceps2) During operation2) During operationEvaluate the vessels of the myoma, appreciate which kind of uterine Evaluate the vessels of the myoma, appreciate which kind of uterine

incision to doincision to doAppreciate the rapidity of the hysterotomy and of the closure you will do Appreciate the rapidity of the hysterotomy and of the closure you will do

(instruments, bipolar, monopolar, aspiration and washing, sutures (instruments, bipolar, monopolar, aspiration and washing, sutures ready)ready)

Discuss pre hysterotomy uterine arteries occlusion Discuss pre hysterotomy uterine arteries occlusion

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Uterine artery occlusion sitex

Uterine artery occlusionUterine artery occlusion

>> Unilateral occlusion if the biggest myoma is lateral :>> Unilateral occlusion if the biggest myoma is lateral :right myoma = right artery …right myoma = right artery …

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>> Bilateral occlusion if the myoma is vascularized by>> Bilateral occlusion if the myoma is vascularized by

both arteriesboth arteries

Operative technique of laparoscopic myomectomyOperative technique of laparoscopic myomectomy

1)Uterine canulation for exposure : posterior myoma= anteversion of1)Uterine canulation for exposure : posterior myoma= anteversion ofthe uterusthe uterus

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2)Hysterotomy should be made as close to the midline as possible.2)Hysterotomy should be made as close to the midline as possible.Vertical incision can eliminate the need to incise vascular areas,Vertical incision can eliminate the need to incise vascular areas,and avoid the injury of the interstitial portion of the falloppian tubeand avoid the injury of the interstitial portion of the falloppian tube

Incise until the capsula using monopolar needleIncise until the capsula using monopolar needle

Operative technique of laparoscopic myomectomyOperative technique of laparoscopic myomectomy

3) Identify the plane between the myoma and the myometrium3) Identify the plane between the myoma and the myometriumby dissecting with the scissors and the monopolar needleby dissecting with the scissors and the monopolar needle

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by dissecting with the scissors and the monopolar needleby dissecting with the scissors and the monopolar needle

4) Hemostasis is achieved once the myoma is removed using4) Hemostasis is achieved once the myoma is removed using

bipolar coagulationbipolar coagulation

Operative technique of laparoscopic myomectomyOperative technique of laparoscopic myomectomy5) The myoma bed is closed in layers of interrupted absorbable suture5) The myoma bed is closed in layers of interrupted absorbable suture

material Identify the plane between the myoma and the myometriummaterial Identify the plane between the myoma and the myometriumby dissecting with the scissors and the monopolar needleby dissecting with the scissors and the monopolar needle

6) Hemostasis is achieved once the myoma is removed using bipolar6) Hemostasis is achieved once the myoma is removed using bipolarcoagulationcoagulation

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ggThe absence of bleeding after the enucleation makes the sutureThe absence of bleeding after the enucleation makes the sutureof the hysterotomy easier: of the hysterotomy easier: The edges of the incision are well seen. The target of the curvedThe edges of the incision are well seen. The target of the curvedneedle is more precise.needle is more precise.The better conditions offers the possibility of performing two layersThe better conditions offers the possibility of performing two layerswhen it is needed.when it is needed.

The technique of closure of the uterus :The technique of closure of the uterus :

When the myoma is subserous and the bed of the incision is not When the myoma is subserous and the bed of the incision is not deep, the closure is mandatory but only one layer is needed.deep, the closure is mandatory but only one layer is needed.

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May be performed :May be performed :Separate single sutures of absorbable suture material:Separate single sutures of absorbable suture material:Vicryl (0,or 00) with always good reapproximation of the edges. Vicryl (0,or 00) with always good reapproximation of the edges. Separate figure of eight when the bleeding is predominant Separate figure of eight when the bleeding is predominant Running sutures are possibleRunning sutures are possible

The technique of closure of the uterus after interstitial myomectomy : The technique of closure of the uterus after interstitial myomectomy : When the patient is young, with infertility or desire of pregnancy, the When the patient is young, with infertility or desire of pregnancy, the technique must be excellent to avoid bleeding and to decrease the risk technique must be excellent to avoid bleeding and to decrease the risk of dehiscence during the future pregnancy. The medicolegal of dehiscence during the future pregnancy. The medicolegal i li ti f th d h t b ki li ti f th d h t b k

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implications of the procedure have to be known.implications of the procedure have to be known.When the patient is forty or more, without desire of pregnancy, theWhen the patient is forty or more, without desire of pregnancy, thetechnique must be efficient to perform the hemostasis and avoid the technique must be efficient to perform the hemostasis and avoid the bleeding. The solidity of the uterus is not the priority.bleeding. The solidity of the uterus is not the priority.

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-- The technique of closure of the uterus : The technique of closure of the uterus : 1) When the myoma is interstitial and the bed of the incision is deep, the 1) When the myoma is interstitial and the bed of the incision is deep, the

closure is mandatory. two layers are needed.closure is mandatory. two layers are needed.May be performed:May be performed:Separate single sutures of absorbable suture material: Vicryl (0,or 00) Separate single sutures of absorbable suture material: Vicryl (0,or 00) with always good reapproximation of the edges. with always good reapproximation of the edges. S fi f i h h h bl di i d iS fi f i h h h bl di i d i

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Separate figure of eight when the bleeding is predominant Separate figure of eight when the bleeding is predominant Running sutures are possibleRunning sutures are possible

2) Laparoscopic suturing in the vertical zone:2) Laparoscopic suturing in the vertical zone:The C.H. Koh technique:The C.H. Koh technique:First layer continous closure (2First layer continous closure (2--0 PDS) 0 PDS) Second layer myometrial suturing using the same suture going back Second layer myometrial suturing using the same suture going back towards the first knot where it is tiedtowards the first knot where it is tiedSubserous/seromuscular layer (4Subserous/seromuscular layer (4--0 PDS0 PDS

--Uterine artery occlusion :Uterine artery occlusion :

--Incision of the broad ligament Incision of the broad ligament --Visualisation of the umbilical artery Visualisation of the umbilical artery

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--Dissection under visual control of the ureter Dissection under visual control of the ureter --Visualisation and dissection of the uterine artery close to the ureterVisualisation and dissection of the uterine artery close to the ureter

and occlusion with a CLIPand occlusion with a CLIP

The revascularization of the uterus and of the scar is The revascularization of the uterus and of the scar is observed in the following hours by the numerous arteries observed in the following hours by the numerous arteries (cervicolvaginal, vaginal, utero(cervicolvaginal, vaginal, utero--ovarian, broad ligament) ovarian, broad ligament) and their anastomosis…and their anastomosis…After uterine artery occlusion, even bilateral, the healing of After uterine artery occlusion, even bilateral, the healing of the hysterotomy is of good quality (post operative US + the hysterotomy is of good quality (post operative US +

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Doppler, deliveries) …Doppler, deliveries) …In young women desiring pregnancy, unilateral uterine In young women desiring pregnancy, unilateral uterine artery occlusion has no consequences, bilateral occlusion artery occlusion has no consequences, bilateral occlusion has also probably no consequences, but it must be has also probably no consequences, but it must be evaluated in long series. evaluated in long series.