Developments in Techniques for Laparoscopic Myomectomy

ABSTRACT Objectives: Conflicting opinions about laparoscopicmyomectomy (LM) are still present regarding indicationsand risks related to reproductive outcome. We reviewedour 13-year experience (1) to identify risk factors orchanges in methods that have improved our myomectomytechnique and (2) to evaluate how the learning curve andimproved surgical devices influenced our procedures, and(3) to study the myomectomy scar with a power colorDoppler ultrasound (US). Methods: From January 1991 to December 2003, we stud-ied332patientswhounderwentlaparoscopicmyomectomy.We analyzed, as the learning curve, how the introduction ofthe Steiner morcellator, the use of vasoconstrictive agents,and different techniques of suturing have influenced param-eters such as operating time and blood loss. Results: We performed 332 single or multiple myomec-tomies for symptomatic myomas. Most patients (47%) hadmore than one myoma, with a maximum of 8 per patient(average myomas removed for patients: 2.23, range 1 to8). Myoma size ranged from 1cm to 20 cm (mean,60.20 SD27.1 mm). Myomas 4cm were removed duringmyomectomy for larger ones. The conversion rate to lap-arotomy was 1.51%. The average drop in hemoglobinconcentration was 1.06 SD0.86 g/100 mL (range, 0.7 to2.2 g/100 mL). No blood transfusions were required. Nomajor intraoperative complications occurred. The dura-tion of the procedure ranged from 30 minutes to 360minutes (mean, 124 SD52.6). The dimensions of the my-omas removed increased with experience (4.91 SD2.2cm of the earlier cases to 6.76 SD2.7 of the latest group,P 0.000). The learning curve positively influenced thelength of the procedures in the first cases. The introduc-tion of electromechanical morcellation in 1996 reducedthe procedure time. Data showed significantly reducedHb drop after the introduction in 1998 of vasoconstrictiveagents ( Hb 1.62 g/100 mL versus 0.95; P 0.001). Therunning suture offered few advantages in terms of proce-dure time. However, the drop in hemoglobin was advan-tageous ( Hb 1.1 g/100mL vs 0.61, P 0.01). The overallrate of intrauterine pregnancy following LM was 65.5%.No uterine ruptures occurred. We had 2 serious postop-erative complications: