https://www.laparoscopyhospital.com/SERV01.HTM
Laparoscopic myomectomy for large, soft myomas, often encountered after Gonadotropin-Releasing Hormone (GnRH) agonist therapy, presents a unique set of challenges. GnRH treatment is frequently employed to reduce myoma size and soften its texture preoperatively, but these changes can complicate tissue handling and require specialized techniques. This article outlines a case-based approach, detailing optimal surgical techniques, the instrumentation used, and considerations for managing large, softened myomas laparoscopically.
Myomas, or fibroids, are a common concern in gynecological practice, often requiring surgical intervention. Large myomas can lead to significant symptoms such as pelvic pain, menorrhagia, and reproductive issues. GnRH agonist therapy is widely employed to shrink and soften myomas preoperatively, but it also alters the myoma's consistency, posing unique surgical challenges. When fibroids become soft and vascular post-treatment, handling, and resection require enhanced expertise and specific laparoscopic tools to ensure safe and efficient removal.
Preparation:
Complete blood work, including hemoglobin and hematocrit levels, to anticipate intraoperative blood loss.
Counseling on potential risks, especially regarding myometrial integrity and possible conversion to laparotomy.
Surgical Technique
Port Placement and Access
Supraumbilical Port Placement: For large myomas, a supraumbilical primary port facilitates an improved field of view and working space.
Accessory Ports: Placement should account for ergonomic access to the uterus's position and the surgeon’s dominant hand. Often, three to four ports are adequate.
Instrumentation
Harmonic Scalpel: Ideal for precise dissection with minimized thermal spread, especially critical in soft tissue.
Ligasure or Advanced Bipolar Devices: These provide excellent hemostasis, particularly in the vascularized environment post-GnRH therapy.
Myoma Screw or Grasper: Essential for manipulating and stabilizing the softened myoma.
Stepwise Surgical Approach
Identifying and Isolating the Myoma:
The softened myoma may blend with the myometrium. Gentle dissection to define the myoma capsule is crucial.
The use of a myoma screw can assist in maneuvering the myoma without undue force.
