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Abdominal myomectomy

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  1. 1. Abdominal Myomectomy Prof Aboubakr elnashar Benha university Hospital, Egypt
  2. 2. A. The normal uterine blood supply is represented diagrammatically. B. The uterine vascular patterns are altered by multiple myomas.
  3. 3. Indications in infertility 1. Distorting the uterine cavity  Submucous: interfere with fertility and should be removed in infertile patients, regardless of the size or presence of symptoms (Gambadauro,2012).  Intramural: distorting: reduce the chances of conception not distorting: controversial results.  Subserosal: No evidence supports removal in asymptomatic, infertile 3. >5-7cm 4. Multiple >3 (3-5 cm) (Bajekal & Li, 2000)
  4. 4. Contraindications. 1. No longer desire fertility or uterine preservation. 2. Endometrial cancer or uterine sarcoma. 3. Pregnant. 4. Asymptomatic: No evidence supports prophylactic myomectomy for decreasing the risk of any adverse outcome later in life.
  5. 5. Relative contraindications 1. Strong possibility that a functional uterus could not be reconstructed {numerous small F, very large F, adenomyosis} 2. Fibroid located in the region of the uterine vessels or broad ligament
  6. 6. Contents  Myomectomy of uterine body fibroids Preoperative Operative Postoperative  Myomectomy of cervical fibroids  Myomectomy of broad ligament fibroids
  7. 7. Preoperative
  8. 8. I. Patient Evaluation 1. U. S:  Confirm diagnosis  Locate F. • TAS: uteri >12 w {Beyond the reach of the TVS}. •TVS: Accurate in excluding endometrial hyperplasia Inaccurate in dd SM fibroids & polyps.  DD: adenomyoma from F (Bromley et al (2000) 2 or more :1.Mottled heterogeneous myometrial texture. 2.Globular uterus 3.Small myometrial lucent areas. 4. Shaggy” indistinct endometrial strips. When doubts persist: MRI
  9. 9. 2. HSG: Distortion of the fallopian tubes or uterine cavity: 1. Planning the technique of myomectomy. 2. Predicting fertility. If the tubes are occluded: myomectomy is not contraindicated. If the uterine cavity is normal: no need for hysteroscopy
  10. 10. 3. Endometrial biopsy: Indication: Irregular or intermenstrual bleeding. Abnormal endometrial thickening on TVS
  11. 11. 4. MRI: Indication DD: F from diffuse and localized adenomyosis Uncommon presentations. Uncertain location after TVS & SIS When the number of lesions >5: precise F mapping and characterization
  12. 12. 1. Route: Submucous: hysteroscopically intramural and serosal: laparotomy 2. Counseling Multiple large Broad ligament Cornual Cervical : conversion to hysterectomy 3. Determine small and buried F within the myometrium: ensures complete excision.
  13. 13. II. Consent Risk: 1. Bleeding and transfusion. 25% 2. Conversion to hysterectomy 1-2% (Iverson, 1996; LaMorte, 1993; Sawin, 2000). All patients should be warned of this possibility. 3. Adhesion post wall incisions: 90% ant wall incisions: 50% 4. Recurrence 50% in 5 y
  14. 14. III. Patient Preparation 1. Hematologic Status Anemia: oral iron therapy GnRHa
  15. 15. 2. GnRHa Advantages: 1. Control of preoperative menorrhagia 2. Decrease uterine volume: less invasive surgical procedure: smaller laparotomy incision 3. Diminish F vascularity and uterine blood flow 4. Decrease adhesion.
  16. 16. Disadvantages. 1. Can provoke hyaline or hydropic degeneration: obliterate the pseudocapsule connective tissue interface between F and the myometrium: tedious and lengthy enucleation (Deligdish, 1997). 2. Higher rates of recurrence (Fedele, 1990; Vercellini, 2003). {shrink in volume: ±missed during surgery} GnRHa should not be used routinely  High priority on type of surgery, incision, duration of recovery. Allow 1. Transverse rather than a vertical incision 2. laparoscopic rather than abdominal
  17. 17. 3. Antibiotic Prophylaxis 1 g 1st or 2nd generation cephalosporin (Iverson, 1996, Periti, 1988, Sawin, 2000). 4. Bowel Preparation not required unless extensive adhesions are anticipated. 5. Vaginal preparation If risk of conversion to hysterectomy is present 6. Timing Immediate postmenstrual
  18. 18. IV. Instruments Gynaecological general set  2 other valuable items: 1. Myoma screw 2. Bonney’s myomectomy clamp applied across the base of the uterus at the junction of the body and cervix uteri, softly occluding uterine arteries as they pass up the lateral side of the uterus.
  19. 19. Intraoperative
  20. 20. Surgical Steps Anesthesia and Patient Positioning. General or regional anesthesia. Supine Vagina and abdomen are surgically prepped  Foley catheter  Steps 1. Incision 2. Identification 3. Reduction 4. Incision 5. Enucleation 6. Closure 7. Closure 8. Prevention
  21. 21. 1. Skin incision. Depend on a. Size b. Location Pfannenstiel: ut: ≤14-16 w Vertical midline: -ut: ≥ 16 w -Br lig fibroid {dissection in the pelvic sidewall with subsequent unroofing of the ureter}
  22. 22. 2. Fibroid identification. Inspect the serosal surface to identify F Firm palpation of the myometrium before and during the surgery {identify seedling intramural or submucous F} Plan the uterine incision based on the number and location of F.
  23. 23. 3. Reduce blood loss: I. To compress the uterine arteries: uterine tourniquet Bilateral windows are created in the leaves of the broad lig at the level of the internal cervical os Foley catheter is threaded through the opening to encircle the uterine isthmus. Once in place, the ends are clamped to compress the uterine vessels. II. To compress ovarian arteries: Ring forceps Tourniquet
  24. 24. Tourniquet should not be left in position ≥20 min. If necessary, after its temporary release, it can be reapplied following compression of the uterus in a hot towel { accumulation of histamine-like substances: suddenly released into the general circulation in large quantities after the clamp is removed}.
  25. 25. Tourniquet Safe: soft plastic tubes are quite atraumatic. No injuries Inexpensive Beneficial: large or multiple intramural F. Not necessary for every myomectomy, Especially: small or pedunculated. Large cervical or broad ligament F prevents placement of the tourniquets: tumor should be removed first defects repaired when feasible tourniquets applied for the remainder of F
  26. 26. How to decrease blood loss Before operation 1.Surgery in immediate postmenstrual 2.GnRha During operation I. Mechanical: 1. Tourniquet 2. Permanent ligation of the uterine arteries (Liu, 2004; Taylor, 2005). 3. Bonney’s myomectomy clamp
  27. 27. II. Medical: 1. Ergometrine: IV 0.25mg: At opening abdomen: uterine contractions in the nonpregnant as well as the pregnant uterus: reduces the vascularity so completely that a clamp is often not required. Not oxytocin (Grade 1B). 2. Misoprostol: vaginal 3. Epinephrine: intramyometrial 4. Vasopressin (Pitressin): intramyometrial (20 U in 50-100 mL normal saline) contraindicated: epilepsy, migraine, asthma, heart failure, and nephritis 5. Controlled hypotensive anesthesia
  28. 28. Cochrane sys review, 2011 significant reductions in blood loss with 1. vaginal misoprostol 2. intramyometrial vasopressin 3. intramyometrial bupivacaine plus epinephrine 4. tranexamic acid 5. peri-cervical tourniquet 6. gelatin-thrombin matrix No evidence of an effect on blood loss with oxytocin or F enucleation by morcellation. Bupivacaine plus epinephrine has limited clinical importance compared with other interventions as the clinical impact was small.
  29. 29. Video: 7
  30. 30. 4. Uterine incision. Site: The lower the incision, the stronger will be the subsequent scar. {It is a useful to mobilize the peritoneum of the uterovesical fold: reflect the bladder down in the mid-line: low incision peritoneal fold which at the end of the operation can be used to cover the incision}.
  31. 31. Midline vertical: {removal of the greatest number of F through the fewest incisions}.
  32. 32. On the anterior wall: {Adhesions after post wall incisions: 90% ant wall incisions: 50%} Posterior wall F: 1. Deep Intra cavitary 2. Subserous Incisions in the posterior uterine wall
  33. 33. 3. Fundal: Bonney hood Transverse posterior fundal incision Enucleation of F. interrupted sutures in layers are used to close the dead space Extra serosa is sutured with fine suture to the anterior surface of the uterus: functional anterior incision. Posterior approach but avoids a posterior defect. Functional anterior uterine incision out of a posterior incision.
  34. 34. Number: Minimize the number To reach lateral tumors: tunneling create lateral myometrial incisions within the initial central incision Length should accommodate diameter of the largest F. Avoid 3 vital structures: ureters, uterine vessels, cornua Depth incising through the pseudocapsule of F: F clearly bulges into the incision.
  35. 35. Video: 8
  36. 36. 5. Tumor Enucleation.  Grasp F with Lahey or single-toothed tenaculum leiomyoma screw Traction and create tissue tension between the myometrium and F. Dissection
  37. 37.  An Allis clamp is applied to one edge of the incision, and the incision is elevated. A finger or hemostatic forceps is used to sweep the myometrium off the F.
  38. 38. Dissection •Sharp: knife Mayo scissors electrocoagulation •Blunt: handle of the scalpel finger hemostatic forceps Small bleeding points in the base of the cavity are individually tied or diathermied.
  39. 39. Approximately two to four main arteries feed each F and enter the tumor at unpredictable sites: ligate them prior to transection when possible Be ready to grasp them immediately with hemostats for ligation or fulgaration if they are lacerated during tumor excision No large blood vessels enter F, and there is no vascular pedicle
  40. 40. ± Myometrial Incision. Smaller internal incisions into the myometrium may be required to excise all F.
  41. 41. Video: 9
  42. 42. 6. Myometrial Closure Obliterating the cavity If excessive myometrium and serosa are present: trim away. If the endometrial cavity is entered: close with a running suture of 4-0 or 5-0 delayed- absorbable suture. •Not necessary to close the mucosa as a separate layer. If smaller internal myometrial incisions: close first with delayed- absorbable suture
  43. 43. The myometrium then is closed in layers {improve hemostasis and prevent hematoma formation}. 0 to 2-0.
  44. 44. Circular mattress Figure of 8 Continuous locked large, full-thickness through-and-through Layered interrupted sutures are time consuming but provide the best opportunity at tissue coaptation.
  45. 45. 7. Serosal Closure. Vicryl: material of choice 4-0 or 5-0 Running baseball  Continuous  interrupted.
  46. 46. Video: 10
  47. 47. 8. Adhesion prevention i. Barriers a. absorbable barrier Interceed (oxidized regenerated cellulose) can be placed over the uterine corpus to protect the tubes and ovaries from denuded peritoneal surfaces and uterine incision. b. non-absorbable barrier, Gore-Tex (polytetrafluoroethylene surgical membrane), can be sutured over the uterine incisions with 7- 0 absorbable minimal reactive sutures.
  48. 48. c. Seprafilm (HAL-F) Bioresorbable Membrane (sodium hyaluronate and carboxymethylcellulose) d. SprayGel 65% reduction in adhesions ii. Make sure that the uterus is left in a well anteverted position round lig should be shortened where necessary The adhesion barrier Seprafilm is teased out of its paper protection onto the incision in the uterus. The Seprafilm will dissolve within 2 weeks, after the uterine incision has started to heal.
  49. 49. Postoperative
  50. 50. 1. Hospitalization: 1 to 4 days {return of normal bowel function and febrile morbidity usually dictate this course} 2. Postoperative activity can be individualized vigorous exercise: delayed until 4 to 6 weeks after surgery.
  51. 51. 3. Subsequent Pregnancy No clear guidelines Darwish et al (2005) •wound healing usually is completed within 3 months. •Local methods of contraception (diaphragm, condoms, and spermicidal jelly or foam) for at least 3 months
  52. 52. I. Intraoperative 1. Hemorrhage  Average blood loss Abdominal myomectomy: 200 to 800 mL (460 mL) laparoscopic myomectomy: 80 to 250 ml. depending on the size and location of F.  Risk of blood transfusion 25%.
  53. 53. 2. Convert a myomectomy to a hysterectomy  1-2% (Iverson, 1996; LaMorte, 1993; Sawin, 2000). Loss all chance of a pregnancy: all patients should be warned of this possibility. Causes: 1. Failure of attempts to achieve haemostasis: to control bleeding 2. Failure of reconstructing the uterus {many defects left by the removal of multiple small fibroids or a single large fibroid}. 3. Visceral damage
  54. 54. II. Postoperative 1. Fever 15%: 38.5°C 48 h postoperatively (Darwish, 2005; Iverson, 1996; LaMorte, 1993). Causes 1. Atelectasis 2. myometrial incisional hematomas 3. release of unknown pyrogenic factors during the myoma dissection
  55. 55. 2. Pelvic infection not common (2%) 3. Thromboembolism.
  56. 56. III. Long term complications 1. Menorrhagia Incidence: 65% Causes: 1. Submucous F missed at operation 2. Endometrial hyperplasia, 3. Coincidental DUB.
  57. 57. 2. Recurrence US: 50% over 5y (Fedele et al, 1995) Asymptomatic recurrence is not relevant outcome. Lower recurrence rates 1. Uterine size < 10 w 2. Single F 3. Subsequent childbirth.
  58. 58. 3. Repeat surgery 5-10%. 35% after endoscopic procedures. Risk factors. 1. Removal of multiple myomas 2. Weight gain ≥30 pounds since age 18 y. Decreased risk 1. Uterus ≥12 w 2. Pregnancy after myomectomy: protective. over 10 y following myomectomy 15% of patients achieving pregnancy and 30% of patients not achieving pregnancy required repeat surgery (Candiani et al, 1991) (Stewart et al, 2002)
  59. 59. 4. Uterine rupture during pregnancy. Quite rare most likely to occur in labor. CS 1. large defects in the active segment of the uterus 2. Endometrial cavity is entered
  60. 60. Cervical Fibroid Incidence: rare 5% of all F. Relations close bladder, ureter, and rectum: approach needs to be modified.
  61. 61. Types: According to the location Intracervical Extracervical 1. Anterior arising from the superficial muscle of the anterior lip of the cervix bulges forwards and undermines the bladder.
  62. 62. 2. Posterior F of the posterior part of the cervix Intracervical posterior type Longitudinal incision made with a monopolar electrode in the posterior uterine wall.
  63. 63. MRI (T2 sagittal). (A) Intracervical type. (B) Extracervical type (anterior uterine wall
  64. 64. MRI (T2 sagittal). (C) Extracervical type (posterior uterine wall). Arrow 5 myoma nuclei.
  65. 65. 3. Lateral starting on the side of the cervix burrows out into the broad ligament and expands it. Relation to the ureter is most important. -Most commonly: ureter is underneath F and to the lateral side. -Very rarely: when F begins to develop under the ureter, it may be lifted onto the upper surface of the tumour. However, wherever the ureter and uterine artery may be in relation to F, they will always be extracapsular. A knowledge and appreciation of the importance of this fact will turn a potentially dangerous procedure into a relatively safe and easy operation.
  66. 66. 4. Central interstitial or submucous origin, expands the cervix equally in all directions. Upon opening the abdominal cavity, a central cervical myoma can be recognized at once {cavity of the pelvis is more or less filled by a tumour, elevated on top of which is the uterus like ‘the lantern on the top of St Paul’s’.}
  67. 67. 5 Multiple cervical fibroids lateral F present on both sides, or anterior F coexistent with a posterior tumour, or lateral F may complicate either an anterior or a posterior one.
  68. 68. Myomectomy • More difficult 1. Anatomic location and displacement of surrounding organs: close bladder, ureter, and rectum 2. Bleeding is excessive 3. Closure of cavity is difficult
  69. 69. Myomectomy Differ according to the type and location Anterior cervical F: well suited for enucleation Posterior cervical F much more inaccessible the bed which remains after their removal may be difficult to reach. Central cervical F usually enucleate very readily leaves an immensely elongated supravaginal cervix: more difficult to deal with satisfactorily.
  70. 70. Surgical recommendations (Bonney , 2003; Matsuoka et al, 2010) 1. Determining the positional relationship between F and surrounding organs: Intravenous urography 2. Preoperative GnRHa 3. During myomectomy: vasopressin; 20 U/mL diluted in 200 mL of saline injected in the layer between the myoma and the serosa 4. Huge cervical F: bilateral uterine artery ligation opening the broad ligament at round ligament identification and ligation at its origin from the internal iliac artery through retrograde umbilical ligament tracking.
  71. 71. 5. Incision Anterior cervical F: Transverse incision is made in the uterovesical pouch and peritoneum, to perform a blunt dissection of the bladder. Posterior cervical F midline vertical incision {avoid injuring the vessels and to stay at a safe distance from the ureters}.
  72. 72. 6. The course of the ureter is confirmed with special attention given to the sacral uterine ligament attachments, to determine the displacement in the relative position of the uterine arteries or ureter. 7. Enucleation Simultaneous complete homeostasis is achieved along with dissection {avoid post enucleation difficulties due to retracted capillaries}. After enculation: wound should be pulled up by the forceps for suturing to avoid making dead space.
  73. 73. Broad ligament myomas  Extremely rare. Types: 1. True springs from the muscle fibres normally found in the mesometrium At least three situations: a. In the round ligament. b. In the ovariouterine ligament. of small size, and can be enucleated
  74. 74. c. In the connective tissue surrounding the ovarian or uterine vessels: frequently attain a large size: distend the broad ligament: fallopian tube is stretched and lies sessile on their upper surface Relations 1. entirely separate from the uterus, which they displace but do not deform. 2. uterine artery: beneath and on the inner side of the tumour 3. Ureter: displaced inwards, and will be found running in the posterior peritoneal layer of the broad ligament, after which it courses under the tumour to reach the bladder.
  75. 75. Huge Broad Ligament Degenerated Myoma finger is pointing to her Rt ovary which was displaced by a big fibroid in the right broad ligament, pushing everything normal into the left lower quadrant. Beneath the finger is the normal looking uterus.
  76. 76. Treatment 1. Enucleated 2. Hysterectomy If the tumour is very large, vascular or adherent, principally {controlling the haemorrhage easily}.
  77. 77. 2.False’. Tumour springs from the lateral wall of the uterine body or of the cervix, and bulges outwards between the layers of the broad ligament: uterus is an integral part of the tumour. distend the broad ligament, raise the lateral pelvic peritoneum and invade the mesocolon.
  78. 78. DD from true: 1. its relation to the uterus 2. it displaces the uterine artery outwards and upwards: in extreme cases the uterine and ovarian vessels are approximated and run parallel on the top of the tumour. 3. The ureter: displaced outwards to the pelvic wall and, as a rule, lies under the tumour In rare lateral cervical myomas together with the lateral angle of the bladder, ureter may be undermined by the tumour and elevated on its upper surface.  These tumours can be enucleated,
  79. 79. Intravenous urography is also necessary to look for any displacement or obstruction to the ureter. True left B lig Fibroid
  80. 80. Thank you