LAPAROSCOPIC UTERINE ARTERY LIGATION IN LAPAROSCOPIC MYOMECTOMY
LAPAROSCOPIC UTERINE ARTERY LIGATION (LUAL) performed at the time of Lap Myomectomy is compared with Lap Myomectomy alone. In our experience, we found several advantages of LUAL + LM compared to Lap Myomectomy alone.
- Decreased blood loss at the time of LM.
- Regression of small fibroids that were not removed at Myomectomy.
- Reduction in the recurrence of fibroids in a follow up period of 24months.
- No Adverse affects on pregnancy outcomes after LUAL + LM.
The prevalence of fibroids is 20-40% among women of reproductive age group and it increases with age especially after 35 years of age. Hence pregnancy and its outcome after LUAL and LM are extremely important end points to the success of LM.
Also since fibroids recurs in almost 15-20% women after Myomectomy alone more and more methods are now being looked at to prevent the recurrence of fibroids.
VASCULAR CONCEPTS OF THE UTERUS:
The basis of using LUAL at Lap Myomectomy is that “Fibroids derive their blood supply exclusively from the uterine arteries whereas the uterine Myometrium derives its blood supply from several named vessels ovarian Inf mesenteric, Lumbar, Inf epigastric, Sacroiliac, Circumflex iliac, femoral etc and unnamed collaterals.
Hence the ischemia caused by LUAL affects the fibroid with little or no effect on the normal uterine Myometrium.
COMPARISON OF LUAL WITH UAE (UTERINE ARTERY EMBOLISATION):
During UAE embolic agents like polyvinyl alcohol or trisacryl gel spheres are injected into the uterine arteries using angiographic catheters. These embolic agents enter into the small 2-6mm diameter uterine end arterioles and also into the utero ovarian collaterals and can hence lead to non target embolisation of ovarian vesselsls leading to premature ovarian failure.
Also pregnancy outcomes after UAE assessed by evidence from several trials showed increased risk of miscarriages, more preterm deliveries, malpresentations FER and PPH (Increased incidence of placenta accreta also) after UAE. Hence the interventional radiological society of Europe considered the desire to maintain child bearing to be a relative contraindication to UAE.
- Direct trocar insertion of the visual port is done at the modified palmers point (2cms medial and below palmers point). This visual port (10mm) position is preferred by us at Lap Myomectomy compared to the umbilical Trocar as an operating distance can be maintained from the myoma and uterus better visualization can thus be attained.
- 3 (5mm) Trocar are then inserted under vision according to the size of the fibroid(Higher insertion for bigger fibroids)
(Visual Trocars inserted in the spinoumbilical lines laterally & medially from the suprapubic area to umbilicus)
- The myoma spiral is then inserted into the fibroid for uterine manipulation and for creating a stretch on the broad ligament fold.
- The Peritoneum between the round ligament and Infundibulopelvic ligament is opened (Usually with Harmonic scalpel it our centre)
- The ureter is then identified and kept medial.
- The Int iliac is then dissected out and the uterine artery identified by its characteristic colour and tortuosity from its beginning.
- The uterine artery is then tackled with Harmonic scalpel/ or clipped with 5mm ligaclip(Beware of the uterine vein which may accidentally get injured with the clip). The entire procedure is then repeated on the other side. Lap Myomectomy is then carried out as usual.
OUTCOME AFTER LUAL + LAP MYOMECTOMY
- We have found that LUAL is an extremely useful procedure to achieve haemostasis before commencing Lap Myomectomy is very large/ Multiple fibroids.
- In multiple fibroids where in the myometrium may be compromised by attempting to remove all the fibroids. It may be advisable to remove the large fibroids and perform a LUAL as it has been observed that the smaller fibroids shrink on their own after LUAL.
- Recurrence of fibroid is minimal (Less than 2%) in women previously treated with LUAL.
- Pregnancy outcomes: Remain the same as those seen after a Lap Myomectomy and unlike UAE there is no increase in the incidence of miscarriages, PTL, PPH, etc after LUAL.
- Day Baird D, Dunson DB, Hill MC
High Cumulative incidence of uterine leio myoma in Black and White women ultrasound evidence.
Am J Obstet Gynecol 2003:188
- Rakesh Sinha Hayden Homer/ Ertan Saridogan
- Pregnancy outcomes after uterine artery embolisation for fibroids. The Obstetrician Gynaecologist pg 265 No4 2009
- Alborzi et al Fert sterility 2009
- Goldberg J Pereira L, :Pregnancy outcomes after treatment for fibromyomata : uterine artery embolisation versus Laparoscopic Myomectomy
AM J Obstet Gynaecology 2004:191
- Walkar WJ, MC Dowell SJ: Pregnancy after uterine artery embolisation a series of 56 completed pregnancies Am J Obstet Gynaecol 2006:195
- Hirst A, Dutton S, The HOPEFUL Study Health Technol Assess 2008 12 1-248