Laparoscopic myomectomy with clipping of uterine arteries, barbed suture and no morcellator: an original case

Some surgical techniques and devices are shown in this uncommon myomectomy case. The procedure is begun with transitory clipping of uterine arteries and infundibulopelvic (IP) ligaments to avoid massive bleeding. Once the myomectomy has been performed, the uterine serosa is closed using the V-Loc™ barbed suture. The myoma is then morcellated with the Chardonnens cold knife, and finally the specimen is extracted vaginally through a culdotomy, which is partially closed using the EndoStitch® device.

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Laparoscopic myomectomy with clipping of uterine arteries, barbed suture and no morcellator: an original case

Authors

A Wattiez, S Maia, A Vázquez Rodriguez

Abstract

Some surgical techniques and devices are shown in this uncommon myomectomy case. The procedure is begun with transitory clipping of uterine arteries and infundibulopelvic (IP) ligaments to avoid massive bleeding. Once the myomectomy has been performed, the uterine serosa is closed using the V-Loc™ barbed suture. The myoma is then morcellated with the Chardonnens cold knife, and finally the specimen is extracted vaginally through a culdotomy, which is partially closed using the EndoStitch® device.

Classification

live recorded

Keywords

Laparoscopic myomectomy, clipping, uterine arteries, barbed suture, morcellator

Media type

Surgical video

Duration

14'20''

Publication

2011-04

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E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3248.htm

Laparoscopic myomectomy with clipping of uterine arteries, barbed suture and no morcellator: an original case

1. Exposure and anatomical landmarks 00'18''

The procedure is started with an appropriate view of the peritoneal cavity. The preoperative diagnosis of an anterior intramural myoma is confirmed, and the surgical strategy is then planned. Anatomical landmarks such as ureters and umbilical arteries must be identified before the transitory clipping technique of uterine arteries is performed. To facilitate this technique, both ovaries are suspended to the abdominal wall, which gives the assistant an enhanced freedom of movement. The suspension is carried out without too much tension because its main objective is to put the ovaries out of the surgical field.

2. Clipping of uterine arteries and infundibulopelvic vessels 01'38''

Massive bleeding is the most important and frequent complication of this procedure. Different techniques have been described to minimize blood loss. The transitory clipping of uterine arteries and infundibulopelvic ligaments is a very efficient method, since it is associated with less blood loss during myomectomy and a decreased recurrence rate according to the literature. The technique consists in opening the parietal peritoneum of the pelvic side wall in order to identify the uterine artery between the ureter and the umbilical artery and to clip it temporarily. The technique is completed by clipping the infundibulopelvic vessels on both sides.

3. Myomectomy 03'19''

This part of the surgery is begun with the uterine incision. The orientation of the incision is determined by many factors such as size, number, and location of fibroids, as well as their proximity to the uterine tubes and vessels. The best incision is the one that gives the best results, making the suturing more efficient and ergonomic. In this case, a transverse incision was performed using the monopolar hook. Next, the myoma is enucleated. For that purpose, the myoma must be grasped for better manipulation, usually by means of a corkscrew placed through the central trocar. Once the cleavage plane between the leiomyoma and the surrounding myometrium has been determined, the leiomyoma is enucleated using traction and counter-traction. Other options to grasp the myoma include the Pozzi, Manhes, or Museux graspers. A good hemostasis should be preserved throughout the procedure, especially at the level of the myoma’s pedicle.

4. Closure 05'47''

Closure is probably the most important part of the surgery. One or multiple layers must be used so as not to leave any dead space and thus minimize the risk of hematoma formation. Interrupted sutures, continuous sutures, intracorporeal or extracorporeal knots can be used for closing the surgical defect. The closure is performed in two layers. The first layer is performed with two separate stitches using both an intracorporeal and an extracorporeal knotting technique. The second layer is tailored to approximate the uterine serosa. For this purpose, a continuous V-Loc™ barbed suture is used.

5. Removal of clips and morcellation of myoma with cold knife 08'41''

Before proceeding to the myoma’s morcellation, clips are removed by gentle traction using a flat fenestrated grasper in order to check any eventual bleeding after morcellation. If electrical morcellation is not available, a Chardonnens cold knife can be used for morcellation.

6. Extraction of the myoma by posterior culdotomy 10'38''

Once the myoma has been morcellated, a posterior culdotomy is performed for specimen extraction. The vaginal closure is carried out using the EndoStitch®. The procedure is completed with adequate hemostasis and profuse lavage.