LEIOMYOMA UTERUS; Fibroids are benign monoclonal neoplasms of unclear etiology that arise from myometrial smooth muscle cells. Leiomyomas are the most common benign gynaecological tumours with an estimated incidence of 70 %to 80 % in women by the age of 50 years.

(1)Although fibroids maybe asymptomatic they are frequently associated with a number of clinical issues including abnormal uterine bleeding especially heavy menstrual bleeding, infertility, recurrent pregnancy loss, and complaints related to the impact of the enlarged uterus on adjacent structures in the pelvis which are referred  to as bulk symptoms.

(2)There are several reasons why embryo implantation may be unsuccessful in case fibroids leading to infertility and recurrent pregnancy loss. Firstly abnormal peristalisis is found in the myometrium surrounding the myoma ,which inhibits implantation .This abnormal peristalisis  gets corrected after myomectomy (3)also a diffuse inflammatory reaction is present surrounding a myoma which is found to get corrected following a myomectomy(4){5} .Overall several studies like a meta analysis by Somigliana (6)have shown an adverse effect of intramural fibroids on ART outcomes ,clinical pregnancy and live birth rates. In another systematic review and meta analysis by Pritts et al in 2009 (7)showed a higher miscarriage rate in association with intramural fibroids along with decreased implantation and live birth rate. Sunkara et al in a large study in 6087 Ivf cycles (8) associated with intramural fibroids found that even non cavity distorting intramural fibroids were associated with lower clinical pregnancy and live birth rates
PRE OPERATIVE PLANNING;

  1. The Myomectomy can be performed by the Hysteroscopic or the Laparoscopic routes depending on the location of the fibroids. While planning the route of the myomectomy we recommend that submucous fibroids larger than 4 cms or multiple submucous fibroids may be better approached by the laparoscopic route rather than the Hysteroscopic route ,as significant endometrial damage to the surrounding endometrium can occur while performing a hysteroscopic myomectomy leading to ashermanns syndrome subsequently. The Laparoscopic approach is thus preferred in these large submucous fibroids.
  2. b) Preoperative correction of anaemia with iron sucrose injections /Ferric carboxy maltose helps in avoiding/minimizing
    need for blood transfusion at the time of surgery and also helps in better healing and post operative recovery of the patient.

c)Preoperative Gnrh agonists or Selective Progesterone receptor Modulators like Ulipristal may be used to avoid menstrual bleeding and blood loss while the anaemia is being corrected with iron sucrose. Also additionally these agents decrease the size of the fibroids by causing hyaline degeneration and hydropic degeneration (9)making the fibroids softer but with a loss of planes which may be advantageous in hysteroscopy but is not desirable while performing a laparoscopic myomectomy. Additionally the Gnrh agonists cause adverse effects like menopausal hot flashes and trabecular bone loss making ulipristal a preffered choice by most surgeons.

HYSTEROSCOPIC MYOMECTOMY

Submucous myomas can be treated hysteroscopically by using either
a) Mechanical instruments like scissors and cold loops etc.
b)Electrocautery;Monopolar thermal loops or vapourizing electrodes or Bipolar loops may be used.
c) Laser fibres using the touch or non touch techniques.
d) intra uterine morcellation using hysteroscopic morcellators.
While using any of these methods other than monopolar cautery saline can be used as a distention medium minimizing the complications associated with the use of non electrolyte media like glycine. Complications like fluid overload and encephalopathy and pulmonary oedema are more commonly associated with use of glycine and non electrolyte media which have to be used if monopolar electocautery is being used for the hysteroscopic surgery.(as these media facilitate the passage of current which is not facilitated when
electrolyte media like saline are used.)

The Resectoscopic Slicing of the myoma with use of monopolar current still remains the most popular method of performing a hysteroscopic myomectomy.

Hysteroscopic myomectomy being carried out with a loop electrode and monopolar current.

Laparoscopic Myomectomy; Certain Principles need to be adhered to while performing a laparoscopic myomectomy. The ultimate aim of these principles is to achieve a good scar after myomectomy which can withstand subsequent pregnancy .
In order to achieve a good and strong post myomectomy scar it is important that
the healing of the myoma bed wound happen by primary intention and not by secondary intention (producing a big ragged scar unable to withstand subsequent pregnancy.)
The principles to achieve a good scar are as follows;
a)Intracapsular myomectomy;All Myomectomies should be performed keeping the pseudocapsule of the myoma intact by the intracapsular method.As the neurovascular bundles run across this pseudocapsule meticulous dissection and less use of electrocautery on the pseudocapsule is advantageous over the extracapsular approach ,in terms of blood loss ,operational time,and proper hysterotomy wound healing.(10).

b)Meticulous Haemostasis and avoidance of haematoma formation in the myomectomy scar is mandatory for a good myomectomy scar formation. Haematomas can form if some bleeders are left in the myoma bed after fibroid enucleation. Haematomas can also form if the myoma beds are not sutured adequately and dead space is left behind in the myoma bed .To avoid dead spaces being left  in the myoma bed multilayer closure of the myoma bed may be required for deep seated fibroids. Also the use of Barbed sutures helps in proper approximation and adequate dispersal of uniform tension throught the stitch line when used,which in turn prevents haematoma formation. Haematomas when formed can get infected easily forming micro/macroabscess leading to formation of an even weaker scar.

c)Less use of Electrocautery; Whenever possible the use of Electrocautery over the myoma bed should be avoided as necrosis and ischaemia caused by the electrocautery can lead to the formation of a weak scar.

Intraoperative Tips and Tricks;
a)Operating Distance;The primary visual port should be placed higher than usual in the Palmers or Lee Huang point (11) in most myomectomies as the myoma screw during enucleation will pull the myoma cephalad bringing the myoma closer to the visual port and hence will obstruct the vision if the visual port if low,especially in very large fibroids.

b)Haemostasis is a major concern at myomectomy and several methods are now available to reduce bleeding at the time of myomectomy.
Impact of medical interventions on hemostasis during myomectomy

Method Effect on Haemostasis.
Prostaglandin/Oxytocin +++
Vasopressin +++
Tranexemic Acid +/-
Gelatin Matrix Thrombin(Floseal) ++
Fibrin Sealant Suture(Tisseal) ++
LUAL(laparoscopic uterine artery ligation ) +++

 

In a study by Lisa Hickmann et al [12]an evidence based evaluation of the various methods used to control haemostasis showed that drugs like tranexemic acid are ineffective in controlling bleeding at myomectomy. Whereas   Oxytocin which were previously thought to be effective on the pregnant   uterus only has been found to be effective in non pregnant cases as well hence is now used effectively as a 40 units  I.V infusion during myomectomy.
Vasopressin has been found to extremely useful during myomectomy it should be injected in a diluted dose at a single point into the uterus (and not into the fibroid) to avoid it leaking from another area. Although uncommon, several studies have reported severe cardiopulmonary complications in healthy individuals, including hypotension, bradycardia, cardiac arrest and pulmonary oedema at doses ranging from .2 to.6 units/ml. Hence, vasopressin should be diluted to a concentration of 0.05 to .3 units per mL.

Surgical methods like LUAL (Laparoscopic uterine artery ligation from origin bilaterally) are extremely effective not only to control bleeding at the time of myomectomy but is also effective in preventing the recurrence of fibroids later in life. Several studies have shown that future fertility and pregnancy outcome (in

terms of Fetal growth restriction or placenta accreta) remain unaffected after Lual
compared to UAE(uterine artery embolization wherein subsequent pregnancy is not advisable as the polyvinyl alcohol particles block the complete blood supply including the collateral circulation of the uterus.)
LUAL can be performed by the lateral or posterior window technique.
In the lateral window technique, the broad ligament in opened in the avascular plane between the round ligament and the infundibulopelvic ligament and the uterine artery is clipped at its origin from the internal iliac artery bilaterally.

Vasopressin being injected into the uterus.

Uterine artery being clipped at origin.

Baseball suturing done with Barbed sutures.

Barbed sutures are routinely in a baseball manner where the suture is passed inside out on both sides of the wound. Suturing in this manner has two main advantages i.e the myoma bed is closed with most of the suture buried inside and hence less suture exposed minimizes the chances of bowel going and getting adherent on the barbs. Secondly baseball suturing ensures that the dead space of the myoma bed is completely obliterated.

c) Intra abdominal adhesions occur more frequently after open surgery compared to after laparoscopy. Gentle tissue handling with maintainence of the peritoneal surfaces ,and good haemostasis with no blood collections and less use of cautery  and minimal raw surface exposure  are the usual rules to be followed to avoid post operative adhesions. Adhesion prevention barriers like 4%icodextrin, auto cross-linked hyaluronic acid, oxidized regenerated cellulose, polytetrafluroethylene have been shown to reduce adhesion development with varying results.(13,14)
Inadequately sutured myoma beds can lead to pelvic abscess formation in a haematoma .One such case was referred to us.

Another complication that can arise due to poor healing of a myomectomy scar is the implantation of a pregnancy in the weak myomectomy scar. One such case was referred to us.

Ectopic pregnancy in a myomectomy scar.

REFERENCES
[1} J Minim Invasive Gynecol. 2012 Mar-Apr;19(2):152-71.

AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas.

 

[2]Myomas and Adenomyosis: Impact on Reproductive Outcome

Nikos F. Vlahos, 1 Theodoros D. Theodoridis, 2 and George A. Partsinevelos 3Biomed Res Int. 2017; 2017: 5926470

[3]Myomectomy Decreases abnormal uterine peristalsis and increases pregnancy rate ;Yoshina,Osamy Nishi et al ;JMIG 2012 ,19

[4]Decreased pregnancy rate linked to abnormal uterine peristalsis caused by intramural fibroids ;Human Reproduction 2010.

[5] Differential infiltration of macrophages and prostaglandin production by different uterine myomas . Seiyou Midura et al Human Reproduction 2008 ,21.

[6)  Somigliana E., Vercellini P., Daguati R., et al. Fibroids and female reproduction: A critical analysis of the evidence. Human Reproduction Update. 2007;13(5):465–476

[7] Pritts E. A., Parker W. H., Olive D. L. Fibroids and infertility: an updated systematic review of the evidence. Fertility and Sterility. 2009;91(4):1215–1223.

[8]  Sunkara S. K., Khairy M., El-Toukhy T., Khalaf Y., Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis. Human Reproduction. 2010;25(2):41

[9]  Sankaran S., Manyonda I. T. Medical management of fibroids. Best Practice and Research: Clinical Obstetrics and Gynaecology. 2008;22(4):655–676.

( 10)  Tinelli A., Malvasi A., Hurst B. S., et al. Surgical Management of Neurovascular Bundle in Uterine Fibroid Pseudocapsule. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2012;16(1):119–129.

(11)Lee-Huang point 20 years on;Kuan-Gen Huang,Chyi-Long Lee ;Gynaecology and Minimally Invasive Therapy ;Nov 2013,Vol 2 ,Issue 4,pages 103-104.
[12] Hemostatic Techniques for Myomectomy: An Evidence-Based Approach

Lisa Caronia Hickman, MD*, Alexander Kotlyar, MD, Shirley Shue, BS, and

Tommaso Falcone, MD Journal of Minimally Invasive Gynecology (2016) 23, 497–504

(13) Mais V., Cirronis M. G., Peiretti M., Ferrucci G., Cossu E., Melis G. B. Efficacy of auto-crosslinked hyaluronan gel for adhesion prevention in laparoscopy and hysteroscopy: A systematic review and meta-analysis of randomized controlled trials. European Journal of Obstetrics Gynecology and Reproductive Biology. 2012;160(1):1–5.

(14) Ahmad G., O’Flynn H., Hindocha A., Watson A. Barrier agents for adhesion prevention after gynaecological surgery. The Cochrane database of systematic reviews. 2015;4:p. CD000475.