www.rfay.com.au

Dr Roger McMaster-Fay

Gynaecologist and Endoscopic Surgeon - Clinical Lecturer, Sydney University



Fibroid removal explained...


Total Laparoscopic Hysterectomy for Large Uterine Fibroid Masses
In a nutshell

Endoscopic hysterectomy has a faster recovery than open (abdominal) hysterectomy but most uterine fibroid masses are removed by the open procedure. Laparoscopic hysterectomy, with ligation of the uterine vessels using staples then endoscopic debulking by morcellation, was attempted on 31 consecutive patients with large uterine fibroid masses. The operation was performed successfully in 30 cases with one converted to abdominal hysterectomy. For laparoscopic cases the mean operating time was 202 minutes and mean postoperative stay 2.1 days. There were no major complications. Many uterine fibroid masses can be removed safely by this endoscopic technique with fast patient recovery.

Dr Roger A. McMaster-Fay     [Gynecol Surg 2004; 1: 195-197.]

Introduction: ”Uterine leiomyomas (fibroids or myomas), benign tumours of the human uterus, are the single most common indication for hysterectomy” (Lancet 2001; 357: 293-98). This review of fibroids did not describe the endoscopic techniques of performing such surgery, despite there being three previous publications1-3. Of a total of 56 cases reported in these studies, 42 had laparoscopically assisted vaginal hysterectomies (LAVH) where the uterine vessels are ligated vaginally, nine (16%) had laparoscopic hysterectomies (LH) where the uterine vessels are ligated laparoscopically and five were converted to abdominal hysterectomies. When the uterine vessels were ligated laparoscopically (LH) it was done using bipolar coagulation1,3 or by laparoscopic suture ligation2. In each series morcellation was used in some cases to assist debulking the uterine mass, mainly via the trans-vaginal route except in two cases where it was performed transabdominally through one of the laparoscopic ports3.

O’Shea et al.4 improved on these figures and removed 19 of their 21 uterine fibroid masses by laparoscopic hysterectomy using bipolar diathermy on uterine vessels. Morcellation was performed laparoscopically in three cases. Wattiez et al5 removed 34 consecutive large uterine fibroid masses (mean weight 617g) by total laparoscopic hysterectomy. They used bipolar coagulation to secure the uterine vessels in 28 but resorted to laparoscopic suture ligation in six cases. They had one ureteric coagulation (thermal) injury and mean hospital stay was 3.6 days. They did not use laparoscopic morcellation.

The initial experience with cutter-stapling devices when ligating uterine vessels was complicated by reports of ureteric injuries but subsequently the author reported a safe technique of using these devices through the umbilical port (5th Annual Scientific Meeting of Australian Gynaecological Endoscopic Society; 1995 Nov 23-25; Melbourne, Australia).

Fibroid operation

Materials & Methods: In the last five years 31 large uterine fibroid masses have been removed, 30 totally endoscopically using the same technique: Transvaginally the cervico-vaginal reflection is incised and the utero-vaginal space is opened mobilizing the bladder off the uterus. The vagina is sutured closed. A Sairges uterine elevator (R.WOLF) is inserted into the uterus. A four-port laparoscopy is then performed. The ovarian and uterine vessels are occluded and divided using a disposable EndoGIA cutter-stapling device (United States Surgical Corporation, a division of TYCO Healthcare Group L.P.). For the uterine vessels the device is inserted through the umbilical port. It is opened and placed over the skeletonised uterine vessels, parallel and adjacent to the cervix, after the bladder pillars have been divided. The device is so placed that its distal end goes down to the vaginal suture line (see Fig. 1). The assistant exerts negative traction from below via the uterine manipulator, which ensures that the uterus is mobilized well away from the ureters and only then is the device closed. The anatomy is rechecked and then the device is fired occluding and dividing the uterine vessels.

Operating tools

All uteri were debulked transabdominally using the S.E.M.M. Moto-Drive 15mm mechanical morcellator (WISAP) through the left hand port. The mass is pulled onto the rotating serrated edge cylindrical hollow blade of the morcellator with grasping forceps inserted through the middle (see Fig. 2). The cylindrical pieces are removed through the left port. When adequately debulked the remaining uterine fibroid mass collapses and can then be removed through the vagina. The vagina is then sutured with the EndoStitch (TYCO) laparoscopically under direct vision.

Results: One case was converted to an abdominal hysterectomy because of dense pelvic adhesions, this was also the largest mass in the series (1,280g). For the 30 totally endoscopic procedures the mean operating time was 202 minutes (range: 135-300), the mean specimen weight was 598g (range: 285-1,255) and the mean postoperative hospital stay was 2.1 days (range: 1-4). No injuries, reoperations or blood transfusions occurred, with the lowest postoperative haemoglobin being 82g/dL.

Discussion: “The main challenge is securing the uterine vessels”5. Bipolar coagulation is the commonly used method of ligating uterine vessels endoscopically. Bipolar coagulators are usually reusable devices giving them a cost advantage over disposable cutter-stapling devices. The disadvantage is that the blood vessels associated with uterine fibroid masses are usually considerably enlarged and thus high amounts of heat energy may be required to coagulate them with the concern about collateral spread of the heat energy that may result in thermal ureteric injury. With these large masses surgical access is limited and surgeons are forced to work closer to the pelvic sidewalls thus increasing the risk of ureteric injury. In these cases some endoscopic surgeons prefer to ligate the uterine vessels trans-vaginally (LAVH), whilst others opt for an open procedure.

This series of uncomplicated endoscopic ligations of large uterine vessels using a cutter-stapling device, confirms the efficacy of the described technique. This is the first series to use transabdominal endoscopic morcellation to debulk every uterine fibroid mass. Operating times remain longer for laparoscopic hysterectomy than for abdominal hysterectomy but in this series a single Gynaecologist performed all operations with a generalist assisting. Longer operating times did not have any adverse effect on patient wellbeing here but a team approach with at least two Gynaecologists operating together may be preferable and could reduce operating times. Shorter hospital stay may contribute to the procedures overall acceptance. Presented here is a safe technique for removing most large uterine fibroid masses totally endoscopically with fast patient recovery. The numbers in this study are small and further studies are required to confirm the suitability of this technique both from patient safety and cost perspectives.

More information on Fibroids and Cancer:

See William H Parker's "Fibroids and Cancer" (US) website.

References:

  1. Pelosi MD, Kadar N. Laparoscopically assisted hysterectomy for uteri weighing 500g or more. J Am Assoc Gynecol Laparosc 1994; 1: 405-9.
  2. Salmanli N, Maher P. Laparoscopically-assisted vaginal hysterectomy for fibroid uteri weighing at least 500 grammes. Aust J Obstet Gynaecol 1999; 39: 182-4.
  3. Clayton RD, Hawe JA, Garry R. Laparoscopically assisted hysterectomy for the large uterus. Gynaecol Endoscopy 1999; 8: 219-23.
  4. O’Shea RT, Cook JR, Seman EI. Total laparoscopic hysterectomy: a new option for removal of the large myomatous uterus. Aust J Obstet Gynaecol 2002; 42: 282-4.
  5. Wattiez A, Soriano D, Fiaccavento A, et al. Total laparoscopic hysterectomy for very enlarged uteri. J Am Assoc Gynecol Laparosc 2002; 9: 125-30.