Vasopressin during Laparoscopic Myomectomy: Does It Really Extend Its Limits?

Single-Incision Plus One Port Laparoscopic Surgery for Myomectomy: A Retrospective Study

BACKGROUND

The purpose of this study was to evaluate the effect of single-incision plus one port laparoscopic surgery (SILS + 1) for myomectomy.

METHODS

We retrospectively analyzed data from patients who underwent laparoendoscopic single-site myomectomy (LESS-M group, n = 40) and SILS + 1 (SILS + 1-M group, n = 40) for myomectomy at our hospital from October 2018 through December 2020. The patients' baseline demographic information and clinical data were compared between the two groups.

RESULTS

The results showed that no significant difference in basic characteristics or between the number, size, and location of uterine myomas between the two groups (p < 0.05). However, the surgery was more difficult and the total operating time was significantly longer in the LESS-M group compared to the SILS + 1-M group (83.5 ± 14.2 vs. 108.2 ± 18.1 min, p = 0.001). Moreover, the estimated intraoperative blood loss (113.4 ± 46.5 vs. 211.4 ± 60.3 ml, p = 0.001) and changes in hemoglobin level (13.1 ± 7.6 vs. 18.2 ± 6.0, p = 0.001) were significantly lower in the SILS + 1-M group compared to the LESS-M group. In addition, no serious intraoperative or postoperative complications occurred after surgery in either group. The clinical outcomes in the SILS + 1-M group were associated with a significant reduction in total surgical time compared to the LESS-M group (p < 0.05).

CONCLUSION

SILS + 1 for myomectomy is popular in clinics, with a satisfactory clinical effect.

The Effect of Intravenous Tranexamic Acid on Myomectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Myomectomy is the preferred surgical treatment for symptomatic women with uterine myomas who wish to preserve their fertility. The procedure may be associated with significant intraoperative blood loss, which predisposes to increased transfusion rates and morbidity. The objective of our systematic review and meta-analysis is to investigate whether intravenous (IV) use of tranexamic acid (TXA) may reduce blood loss during myomectomy. Three electronic databases were screened until June 2022. The eligible studies were assessed for risk of bias. Four randomized controlled trials that reported outcomes from a total of 310 women were finally included in the meta-analysis—155 patients received intravenous TXA while the remaining 155 received placebo injection with normal saline or water for injection. Total estimated blood loss was significantly lower in patients who received TXA before myomectomy compared to control (230 patients MD −227.09 mL 95% CI −426.26, −27.91, p = 0.03). This difference in favor of TXA group remained when intraoperative and postoperative blood loss was separately analyzed. Postoperative hematocrit values and hemoglobin levels did not differ among the two groups (180 patients MD 0.67% 95% CI −0.26, 1.59, p = 0.16 and 250 patients MD 0.17 mg/dL 95% CI 0.07, 0.41, p = 0.17, respectively). The number of patients that received blood transfusion was also not different (310 patients OR 0.46 95% CI −0.14, 1.49, p = 0.19). Total operative time was significantly prolonged in control group compared to TXA (310 patients MD −16.39 min 95% CI −31.44, −1.34 p = 0.03). Our data show that the IV use of TXA may significantly reduce intraoperative blood loss in patients undergoing myomectomy and contribute to reduced operative time.

The effect of temporary uterine artery ligation on laparoscopic myomectomy to reduce intraoperative blood loss: A retrospective case–control study

Objective

Study Design

Results

Conclusions

•

The surgical technique for laparoscopic myomectomy is introduced.

•

Temporary uterine artery ligation decreases the volume of intraoperative blood loss.

•

Temporary uterine artery ligation is less invasive than permanent occlusion.

•

Temporary uterine artery ligation does not require the use of any special devices, such as clips.

Strategies and Outcomes of Total Laparoscopic Hysterectomy for Large Uterine Cervical Fibroids

Background and Objectives:

To present the methods and outcomes of total laparoscopic hysterectomy with debulking surgery for large cervical fibroids.

Methods:

This is a single-center study. Twenty-one women who underwent total laparoscopic hysterectomy between October 1, 2012 and November 30, 2020 for large cervical fibroids (diameter ≥10 cm) based on a diagnosis by magnetic resonance imagining were enrolled. Conventional total laparoscopic hysterectomy for large cervical fibroids was initially attempted. If this could not be completed, debulking surgery, such as enucleation of large cervical fibroids or cervical amputation, was performed during total laparoscopic hysterectomy.

Results:

Total laparoscopic hysterectomy could be completed in all 21 patients with large cervical fibroids without blood transfusion. Conventional total laparoscopic hysterectomy was performed in four patients (19%), and 17 patients (81%) required debulking surgery at the time of total laparoscopic hysterectomy. The median diameter of the major axis of the cervical fibroid, uterine weight, intraoperative blood loss, and operative time were 12 cm, 750 g, 100 mL, and 191 min, respectively.

Conclusion:

Total laparoscopic hysterectomy for large cervical fibroids, although minimally invasive, requires a high level of laparoscopic skill. However, our data suggests that total laparoscopic hysterectomy for large cervical fibroids can be feasible, with an acceptable level of blood loss, by performing debulking surgeries such as enucleation of large cervical fibroids or cervical amputation.

How to minimize bleeding in laparoscopic myomectomy

PURPOSE OF REVIEW

Laparoscopic myomectomy is a common surgical procedure for symptomatic myomas. However, bleeding control during surgery may pose a challenge. Therefore, the aim of this study was to review recent evidence regarding interventions to control bleeding during laparoscopic myomectomy.

RECENT FINDINGS

The use of vasopressin resulted in less blood loss compared to placebo. Barbed sutures reduced blood loss compared to conventional sutures. Intravenous infusion of tranexamic acid (TXA) in the intraoperative period of large myomectomies showed no significant difference compared to placebo. Uterine artery occlusion (UAO) and emergency uterine artery embolization were reported to be feasible and may reduce and treat bleeding before conversion to laparotomy.

SUMMARY

Several methods can control bleeding during laparoscopic myomectomy. Vasopressin and barbed sutures resulted in decreased blood loss, and TXA did not have an impact on bleeding control. The use of UAO and emergency embolization techniques can contribute to the control of bleeding; however, further studies are needed to prove the efficacy of these and other agents.

A Romanian study on the impact of glypressin in laparoscopic myomectomy

A major myomectomy-associated problem is excessive blood loss. The aim of the present study was to evaluate the effect of glypressin on blood loss during laparoscopic myomectomy (LM) in women with uterine myomas. A total of 188 women scheduled for LM for uterine myomas were divided into two groups. The one group of women (n=64) received a 5-ml intramyometrial injection of glypressin 0.2 mg/ml (glypressin group; group 1). The other group of women (n=124) (group 2) had an LM performed without any other method to reduce blood loss. The decrease in postoperative hemoglobin (Hb), hematocrit (Ht), morbidity and duration of hospital stay were assessed. The results revealed that Hb and Ht (as it was presumed) exhibited similar changes in our study. Statistically significant differences (P<0.05) were obtained between the two groups in terms of Hb and Ht; after LM both Hb and Ht were decreased. In conclusion, the impact of glypressin administration in hemorrhage control in uterine leiomyomas may establish new future perspectives, regarding its administration in gynecological hemorrhagic pathologies.

Assessment of the perioperative effect of vasopressin in patients undergoing laparoscopic myomectomy: A double-blind randomised study

Background and Aims:

Myomectomy is associated with perioperative bleeding. The aim of the study is to evaluate the effect of intramyometrial vasopressin on blood loss and the associated cardiovascular complications during myomectomy.

Methods:

The study included 194 patients classified into two groups- 1) Vasopressin group: the vasopressin was diluted as 0.1 unit/ml and 15 ml was injected by the surgeon in the plane between the myometrium and the myoma. 2) Control group: The patients received an equal amount of normal saline. The monitored parameters included the amount of blood loss, required blood transfusion, heart rate, mean arterial blood pressure, the incidence of hypertension, hypotension, bradycardia, tachycardia, electrocardiogram (ECG) changes and the blood troponin I level.

Results:

The heart rate decreased significantly in both groups, but the decrease was lower with vasopressin than the control group through the time points T3 to T5 (P < 0.05) The mean arterial blood pressure increased significantly in both groups, but the increase was higher with vasopressin than the control group through T3 to T5 (P < 0.05). The amount of blood loss decreased significantly with vasopressin than the control groups (P = 0.001). The number of transfused packed red blood cells was lower with vasopressin than the control group (P = 0.001). The incidence of hypertension, bradycardia and atrial extrasystole was higher with vasopressin than the control group (P = 0.005, P = 0.012, P = 0.033, respectively).

Conclusion:

Intramyometrial vasopressin decreases blood loss and blood transfusion, but it is associated with cardiovascular complications that may be serious as reported in other studies. Therefore, anaesthesiologists and gynaecologists must follow the precautions to avoid and minimise the incidence of complications with intramyometrial vasopressin.

Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.

Misoprostol vs vasopressin as a single hemostatic agent in laparoscopic myomectomy: Comparable, or just better than nothing?

AIM

Laparoscopic myomectomy may be associated with considerable blood loss, especially in patients in whom no specific hemostatic measures are used. We conducted this retrospective comparative study to investigate whether misoprosol is an effective and safe alternative to vasopressin when used as single hemostatic agent in laparoscopic myomectomy.

METHODS

Two hundred cases undergoing laparoscopic myomectomy (-ies), were included. Of these, 50 pre-treated with vaginal misoprostol 400mcg 1 h before surgery (group 1), were compared with two historic consecutive groups: 100 patients treated with intraoperative intra-myometrial injection of dilute vasopressin (20 IU/100 mL normal saline) (group 2), and 50 treated without use of any hemostatic agent (group3).

RESULTS

Mean procedure length did not differ significantly between the three groups (127.9 vs 100.6 vs 130.8 min). Mean estimated blood loss (EBL) was 179.7 ± 200.0 mL in group 1, compared with 147.8 ± 171.8 mL in group 2 (P = 0.793) and 321.8 ± 246.0 mL in group 3, respectively (P < 0.001). EBL was lower in group 2 in most of the study's subgroups of patients stratified according to size and number of fibroids compared with group 1, with the exception of patients with ≥4 fibroids, and ≥7 cm in size. In these subgroups, misoprostol appeared more effective. Neither agent was associated with serious adverse events.

CONCLUSION

Vaginal misoprostol can be effective in reducing blood loss during laparoscopic myomectomy. Although rates of EBL are, in general, higher compared with those obtained with vasopressin, they are significantly reduced compared with those observed when no hemostatic agent is used. In extended procedures, vaginal misoprostol, due to its prolonged uterotonic action, may be associated with reduced blood loss compared with vasopressin.

Robotic myomectomy for large uterine myomas

OBJECTIVE

To evaluate surgical outcomes and feasibility of robotic myomectomy in large uterine myomas.

MATERIALS AND METHODS

This is a retrospective study for robotic myomectomies performed from October 2012 to August 2017 by a single surgeon in a tertiary care referral hospital. Demographics, diagnosis, perioperative variables, operative outcomes and complications were recorded. Large uterine myoma was defined as the estimated diameter of dominant myoma equal to or larger than 10 cm by sonography.

RESULTS

Seventy-four patients were included and 32 (43.2%) patients had large uterine myoma. Patients with myoma larger than 10 cm showed significantly heavier myoma weight (446.5 ± 206.2 mg vs. 288.1 ± 147.5, p < 0.001), similar blood loss (309.4 ± 190.3 mL vs. 200.9 ± 285.9 mL, p = 0.06), and longer operative time (263.4 ± 83.7 min vs. 219.1 ± 75.7 min, p = 0.02) compared with patients with myoma <10 cm. The largest myoma removed was 20 cm in diameter. Perioperative complications were rare.

CONCLUSION

Robotic myomectomy is feasible for managing large uterine myomas. It is a safe procedure with acceptable longer operative time.