武功密笈

小黃藏書

? Symptomatic:

Excessive uterine bleeding, pelvic pain, recurrent pregnancy loss, infertility, etc.

‚ Not expected to go into menopause soon

ƒ Wishing to preserve their fertility for childbearing or for personal reasons

Preoperative Treatment:

v LHRHa:

? Leuprolide acetate:

Ÿ Usually continued for 3 months

Ÿ At least 26% reduction in uterine volume

(38% of these subjects experienced more than 50% shrinkage.)

‚ Goserelin acetate:

Ÿ Goserelin acetate combined with iron treatment was found to be more effective

than iron alone.

Gosereline and iron group:

Uterine volume decreased by 37% to 40%

Myoma size decreased by 44% to 47%

Less blood loss during surgery

v Advantages:

? To allow time to improve patient hematologic status

‚ Reduction in the amount of blood loss during myomectomy as a result of a decrease

in the size of the myoma and it vascularity and easier removal of smaller myoma

v Disadvantages:

? Approximately 10% of myomas do not respond to LHRHa.

‚ Loss of cleavage planes, leading to a more difficult dissection of the tumor

ƒ Because of the initial stimulatory effects of LHGHa, bleeding may be more

excessive in the first treatment cycle

　

　

v Contraindications:

Ÿ Any medical condition that worsens with abdominal distention and a Trendelenberg position for a

prolonged period of time

Ÿ Diffuse leiomyomata

Ÿ More than three myomas ³ 5 cm

Ÿ Uterine size greater than 16 weeks’ gestation

Ÿ A myoma > 15 cm

Ÿ Patients who have completed childbearing and who desire hysterectomy

v Technique:

? Pedunculated myoma:

Ÿ Coagulating the pedicle with a bipolar forceps

Ÿ Excision

‚ Intramural myoma:

Ÿ Injection of vasopressin (0.2 U/mL) into the myometrium adjacent to the myoma

Ÿ Incising the myometrium over the myoma until the myoma is seen

Ÿ Enucleation of myoma using a laparoscopic scissors and blunt dissection

(Blood vessels encountered during the dissection should be coagulated.)

Ÿ Removal of myoma by using a 20-mm serrated edge macromorcellator

Ÿ Repair of uterine incision

2-0 polydioxanone suture for the deep myometrial layer

4-0 polydioxanone for the superficial layer

v Results:

Ÿ Benefits:

A shorter hospital stay, shorter recovery, and less blood loss

Ÿ Complications:

? Time-consuming

‚ Inadequate multilayered uterine closure,

leading to the weakness of the uterine wall

ƒ Postmyomectomy adhesion formation

Ÿ Myomectomy and reproductive outcome:

- Despite the risk of adhesion formation, myomectomy seems to enhance reproductive

outcome.

- The pregnancy rate after laparoscopic myomectomy seems to be similar to that after

abdominal myomectomy.

　

　

v Procedures:

Ÿ Partially enucleate the myoma by laparoscopy.

Ÿ Grasp the partially enucleated myoma with instrument inserted suprapubically via a 10-mm trocar.

Ÿ Enlarge the abdominal incision transversely enough to accommodate the myoma.

Ÿ Deliver myoma from the abdominal cavity.

Ÿ Continue enucleation and then repair the uterine defect extracorporeally.

Ÿ Replace the uterus into the abdominal cavity.

Ÿ Close the abdominal incision.

Ÿ Resume the laparoscopy and perform the ligation.

v Main advantage compared with laparoscopic myomectomy:

A proper multilayered uterine closure can be performed more easily, and without prolonging the

duration of surgery.

　

v Mechanism: reduction of myoma size by coagulating its blood supply.

v Methods: Nd:YAG laser or bipolar needle electrode.

v Use of various devices for mechanically elevating the anterior abdominal wall, obviating

the need for pneumoperitoneum

v Advantages:

avoidance of risks of peumoperitoneum,

and the ability to use conventional laparotomy instruments

　

Hysteroscopic Myomectomy: ~ for submucous myoma

v Indications:

Ÿ Women with abnormal uterine bleeding

Ÿ Women with recurrent pregnancy wastage

Ÿ Women with reproductive failure attributed to the presence of a myoma

v Contraindications:

Ÿ Large uterine cavity of more than 12 cm in depth that cannot be distended adequately

by medium

Ÿ Suspicion of endometrial hyperplasia or carcinoma

Ÿ Upper genital tract infection

Ÿ Patient with severe liver, renal, or cardiac disease placing the patient at increased risk

for fluid overload

Ÿ Suspected leiomyosarcoma

v Preoperative Treatment:

Ÿ Hematologic evaluation

Ÿ LHRHa is recommended in women with large submucous myomas (³ 4 cm)

and in those with severe anemia

v Technique:

Ÿ Cervical dilatation up to 9 cm

Ÿ Insertion of operative hysteroscope into the uterine cavity under direct vision via a vidio camera

Ÿ Myomectomy by resectoscope, Nd:YAG laser, or hysteroscopic scissors

¬ Fluid balance should be monitored carefully during surgery. A negative balance of greater than

1500 mL can be associated with electrolyte imbalance, hyponatremia, and secondary pulmonary

and brain edema.

v Results:

? Menorrhagia is usually corrected in most patients.

‚ Myomas with an extensive intramural component may need a two-step procedure.

ƒ The failure rate is high in patients with multiple myomas.

v Complications:

Ÿ Immediate complications:

cervical tears, uterine perforation, thermal injury to the bowel or the bladder,

bleeding, and fluid overload.

Ÿ Late complications:

infection, intrauterine adhesions, uterine repture during future

pregnancy, recurrence

　

v Hysterectomy should be offered to symptomatic women who have completed

childbearing.

v When proper technique and patient selection criteria are used, laparoscopic myomectomy

is as effective as abdominal myomectomy.

v The procedure should be performed similar to laparotomy, including multilayered uterine

closure.

v The safety and efficacy of newer procedures including myoma coagulation and

cryosurgery remain to be determined.

v Women with submucous myomas are best treated by hysteroscopy.

Endoscopic Myomectomy, Laparoscopy and Hysteroscopy; Togas Tulandi, MD, and Sundus Al-Took, MD.; Obstetrics and Gynecology Clinics of North America 26(1):135-148, March 1999