Effective and Safe: Laparoscopic Myomectomy for Multiple Fibroids

Aaradhya Sharma

https://www.laparoscopyhospital.com/SERV01.HTM  Laparoscopic myomectomy is a minimally invasive surgical procedure performed to remove multiple fibroids from the uterus. The procedure involves making small incisions in the abdomen, through which a laparoscope and other surgical instruments are inserted. The laparoscope is a thin, flexible tube with a camera attached to it, which provides the surgeon with a clear view of the surgical site on a monitor.  The surgeon uses the surgical instruments to carefully cut and remove the fibroids from the uterus, while preserving the surrounding healthy tissue. The removed fibroids are then sent for further testing to confirm their nature and type.  Laparoscopic myomectomy offers several advantages over traditional open surgery, including less blood loss, less postoperative pain, shorter hospital stay, and quicker recovery time. The procedure is generally safe and effective, with low complication rates.  Patients who undergo laparoscopic myomectomy typically experience significant relief from symptoms such as heavy menstrual bleeding, pelvic pain, and pressure, and may also improve their chances of becoming pregnant in the future.  Overall, laparoscopic myomectomy is an advanced and minimally invasive surgical technique that offers patients a safe and effective option for the removal of multiple fibroids from the uterus.  Laparoscopic myomectomy offers several advantages over traditional open surgery for the removal of multiple fibroids. Some of these advantages include:  Minimally invasive: Laparoscopic myomectomy is a minimally invasive surgical procedure that involves making small incisions in the abdomen. This results in less blood loss, less pain, and a faster recovery time compared to traditional open surgery.  Shorter hospital stay: Since laparoscopic myomectomy is a minimally invasive procedure, patients typically spend less time in the hospital compared to open surgery.  Faster recovery time: Laparoscopic myomectomy patients can return to normal activities sooner than patients who undergo open surgery.  Preserves uterus and fertility: Laparoscopic myomectomy preserves the uterus and its function, which is important for women who wish to become pregnant in the future.  Reduced risk of complications: Laparoscopic myomectomy has a lower risk of complications compared to traditional open surgery, such as infection, bleeding, and injury to surrounding organs.  Improved cosmetic outcome: The small incisions used in laparoscopic myomectomy result in less scarring compared to open surgery, which can be important for some patients.  Overall, laparoscopic myomectomy is a safe and effective option for the removal of multiple fibroids, with several advantages over traditional open surgery.

Transcript

00:00Hello friends, this is a case of laparoscopic myomectomy for multiple fibroids.

00:06This patient has 5 fibroids and all are intramural fibroids.

00:12So one is very large as you can see here and the others are smaller.

00:20So one is approximately 15 cm, another one is 4 cm, 3 cm, 2 cm like that.

00:30So we are injecting the vasopressin for transient ischemia so that we can cut the seromuscular layer

00:38and we can start dissecting the layers to remove the fibroids.

00:43We can see transient ischemia is starting and approximately 100 ml of the vasopressin diluted

00:52with a normal saline is injected.

00:55Now this is oblique incision because it was an anterior valve fibroid with lateral right side lateral extension.

01:03So we will give oblique incision so that fallopian tube will not be involved in that incision.

01:09It is cutting the seromuscular layer of the fibroid.

01:12Now spreading the layers to expose the capsule of the fibroid.

01:24Now spreading the layers to expose the capsule of the fibroid.

01:30the fibroid and then there is a myoma screw which we will attach it and then

01:48enucleation is started this is a myoma rod which we have made ourself this is a

01:56stainless steel pure steel rod with the blunt tip that is a very good dissector

02:02because with the harmonic if you will try to push it it may bend and you will lose

02:07the harmony so we are using here myoma rod to separate the myoma and pushing and

02:14pulling technique will be used to separate the fibroid

02:18some of the muscle layer has to still cut so that you can get a proper plane and

02:32then removal will be easy

02:48so all around equally we have to do separation of the fabric one side more is not good to

03:16go and you should use combination of the blunt dissection as well as if the muscle is thick

03:23you can cut it with the harmonic

03:34as we can see here there are two fibroid which is attached together and that is making one

03:39big so now little ligature will be used because sometime if you feel that you are reaching

03:46through the feeding vessels and muscle are little potential to bleed then those particles of the

03:51muscles you can catch with the ligature

04:21so once you reach to the base you should be little more careful and you should be little

04:29more gentle to tackle with the vessels because abrupt evasion can open the cavity and you can

04:35evolve the endometrial linings as well so we should be looking careful once you reach to the base

04:44and proper hemostasis also should be achieved in that ligature is a better instrument to achieve this hemostasis

04:50so now maya maya maya screw is relocated at appropriate site and we can see that this is the larger fibroid

05:01right up to me it is almost going to come out

05:20so larger one is almost out and now we will go for the another fibroids but before that we have to suture it because the larger one

05:32so larger one is almost out and now we will go for the another fibroids but before that

05:44we have to suture it because the larger one it was more vascular and it may bleed so we

05:50will enter into the muscle layer through the cirrhosa and then we will repair it in two

05:55layers the first layer will be the muscle layer and after that we will return back with the

06:02cirrus layer so this is the first layer continuing that is muscle layer and the deep bite on the

06:09muscles will be taken and that is required to stop bleeding as well if you will do faster suturing

06:17and you close the muscle then bleeding automatically stops

06:25most of the myomectomy we do only by three ports

06:28so we don't use any assistance to hold the uterus or to help in suturing

06:38so we can see muscles are approximating and that will minimize immediately the bleeding will stop

06:45deep muscular bite has to be taken and in this bite cirrhosa should never be taken

06:50and this is continuous suturing which will continue to the other end

07:08suture itself will act as a retractor so you can keep on holding the suture to pull the muscle and to take

07:14it deep bite

07:31so after reaching to the another end we can exit to the cirrus layer

07:36so this is exit to the healthy cirrus layer and then we will start returning back

07:49to close the cirrus layer as you can see breathing is already stopped and now cirrhosa will be closed

07:59in the second layer these are the iliac vessels so you have to be careful

08:03this is externally a carter and vein as you can see

08:08and now this is returning back and in that we will go to the margin so that margin will get inverted

08:16so if you will do the bite little margin will be inverted then you have the minimum chances of addition

08:23the margin so now the second layer it is returning back

08:31and we are keep on taking the cirrhosa with the deep inversion of the margins

08:37so you will enter into cirrhosa and come out with the cirrhosa and that way you can invert it

08:44you may use the baseball suturing also but if you will invert the cirrhosa continuous suturing is also equally good

08:52so

08:59so

09:01so

09:05so

09:11So this is a running suture.

09:41There it is.

10:10Again, tail end also you can pull it further after reaching to the other end to make the

10:15first layer even more tighter.

10:17So this is the last bite.

10:24So this is the last bite of the serous layer when tightening all the layers.

10:33So this is the last bite of the serous layer when tightening all the layers, pulling the

10:55tail end to make the first layer even more tighter.

10:59And then you can terminate it by the serous knot.

11:02So first time double wrap followed by two opposite alternating wraps.

11:09So this is over.

11:28And then you can cut the suture and remove it out.

11:35And then you can cut the suture and remove it out.

11:56Now I will go for the second fibroid.

11:58This is sub-serous and it can be easily removed with one cut easily you can get it out.

12:09So it is almost pedunculated and it will be hardly few seconds you can remove it.

12:16Now this is third one which is a round ligament fibroid.

12:20You can see it is over the round ligament and that also you can remove it easily.

12:27You can cut parallel and then you can separate this fibroid.

12:33After opening the layers, you can use my hammer screw to just attach it.

12:41This is my hammer screw which is attached.

12:46And then you can remove it out.

13:06After that you have fourth fibroid that is posterior valve.

13:10This is just near the cervix.

13:14And this also is removed, this is posterior valve fibroid.

13:21My hammer screw is again attached.

13:25And then slowly you can remove it out.

13:42So you have to be careful that the tube should not be attached.

13:47So here we are holding the round ligament to give the traction.

13:51Here we have not used the uterine manipulator.

13:53Uterine manipulator is not good because it will perforate the uterus.

13:58Now this is the fifth fibroid which is also intramural.

14:04And this also has to be separated.

14:06So this is not very deep.

14:11Again, my hammer screw is attached.

14:32Again, my hammer screw is attached.

14:43And slowly you can separate it.

14:47So laparoscopic myomectomy is a very interesting surgery.

14:55It is not difficult to perform if you have a good suturing skill.

15:01And if you use little advanced instrument like harmonic or ligature then it is very safe.

15:08And you can repair it as good as in open surgery.

15:13So this is the last one.

15:16The fifth one which also needs suturing because it is muscle extension was there.

15:22This fabric is also separated.

15:32After that this one need to be suturing because this was a little deeper so it need to be closed.

15:51This need only single layer suturing.

15:58And three, four bytes we will take and then we will return back to close with the same tail.

16:20Now we should try a knot.

16:23And with the same tail it is closed.

16:37Sometimes the tail is big you can hold the tail also to take a wrap.

16:43Then you can pull the needle end.

16:44Then you can pull the needle end.

16:45Holding suture near the needle you can pull the needle out.

16:50So now we can cut the suture.

16:57And then we will cover the entire this area with the interseed.

17:06We can see there is no bleeding everything is dry.

17:10And then we are using reoxygenated cellulose.

17:13This is a large size interseed.

17:15And we will cover all around the uterus.

17:18Interior as well as posterior.

17:20So that there will be no any adhesion.

17:23This is posterior.

17:24And the posterior fabric area also is covered with the interseed.

17:29And anterior fabric area also we should cover it.

17:32Round ligament area also will be covered.

17:35And then we can put some saline so that it will stick and it will remain.

17:39This is round ligament area that is also covered with the interseed.

17:44So there is no bleeding.

17:48Now just to start working the interseed.

17:51It is better to put some saline over interseed.

17:54So that it will stick and it will not displace easily.

17:58After that morselation will start.

18:04And all these five fibroids we can see it is nearer.

18:08And one by one you can morselate all of them.

18:11Here we are using the Storch Morselator.

18:13This is a quite young person.

18:15She has infertility problem.

18:17And she is hardly 25 year old.

18:20So there is no any risk of malignancy.

18:22So we will not use morseef endobag.

18:25Directly we will pull all of the fibroids.

18:27And we will morselate.

18:29Storch Morselator has a very sharp blade.

18:31Which doesn't have a saw shaped.

18:33So it doesn't green the fibroids.

18:35It does not disperse the tissue.

18:37So generally it cuts without any dispersion of the fragment.

18:41Because some of the morselator has saw shaped.

18:45They green the tissue.

18:46And they make it fragment.

18:48But in Storch it is a sharp blade.

18:51So fragmentation doesn't happen.

18:53So this all is one by one taken.

18:56And this is the large one also it will be taken.

18:59So this is the morselation.

19:02And we will not show you entire morselation.

19:05Because morselation is a time taking procedure.

19:08So it will be morselated same way.

19:11So thank you friends.

19:14This was just a simple case of.

19:17Laparoscopic myomectomy.

19:19Where we have.

19:20Demonstrated how to perform the multiple fibroid surgery.

19:24By laparoscopy.

19:25Laparoscopic myomectomy is a very easy procedure to perform.

19:29And if you have a good quality morselator.

19:32And little good suturing skill.

19:34Then any size of the myoma.

19:36And any place of the myoma.

19:38You can remove.

19:39Giving the advantage of the percent of the faster recovery.

19:42Minimal hospital stay.

19:44Less chances of post-operative incisional hernia.

19:48Less chances of infection.

19:50And maintain the immunity.

19:52And the less adhesion also.

19:54So we should must give this advantage to all our patients.

19:58And we should try to perform the myomectomy.

20:01As much as possible.

20:03And it is a very good procedure.

20:05In my opinion it is the gold standard for laparoscopy.

20:08So thank you very much for watching this video.

20:11Have a nice day.

20:14And have a very good future.

20:17Thank you very much.

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