Robotically Assisted Laparoscopic Myomectomy
BS was a 38-year-old patient with lower abdominal and pelvic pain, pressure on her bladder and bowels, and heavy menstrual periods. She had been aware of numerous fibroids starting at age 25 and had tried unsuccessfully to conceive since age 26. Her symptoms persisted despite the traditional methods attempted by her OB/GYNs.
At age 28, BS had undergone an abdominal myomectomy (AM) which required a transfusion, left her with a 10 inch scar and culminated in a 3 day hospital stay and 8 week home recovery period. Her symptoms abated only to return five years later, resulting in the same diagnosis. At age 36, BS had undergone a uterine fibroid embolization (UFE). Despite it being an outpatient procedure she was admitted several days later for pain management and infection of embolized fibroids which resulted in a week long hospital stay. Although the pain was treated the symptoms themselves did not improve.
BS still hoped to conceive and so a hysterectomy was out of the question. Furthermore, she wanted to avoid the severe pain, hospitalization and blood transfusion associated with another AM or UFE. After examination at AMIGS Surgery Center she was diagnosed with an “18 week” size fibroid uterus. After a pelvic MRI demonstrated several fibroids, BS underwent a Robotically Assisted Laparoscopic Myomectomy.
Patient Results and Benefits of Minimally Invasive Robotically Assisted Laparoscopic Myomectomy
The procedure involved 5 tiny incisions ranging from ¼ to ½ inches and ultimately removed 6 fibroids that ranged from 2 to 5 inches in diameter and weighed 660 grams (1.5 pounds) total. Following the successful surgery, BS returned home the same day and within 3 weeks had resumed her normal routine with a regular quality of life, standard menstrual periods and no abdominopelvic pressure or discomfort.
Proper recognition and understanding of surgical anatomy is paramount to successful and safe completion of any surgery, including RALM. Correct tissue handling and “prophylactic” hemostasis are equally important. These principles need to be followed regardless of the myomectomy route. Employment of Robotic and/or Laparoscopic instrumentation can’t “miraculously” replace or even enhance these principles.
Preoperative MRI is important to identify the uterine (submucosal, intramural, subserosal, pedunculated) and pelvic (anterior, posterior, lateral, inferior, superior, fundal, cornual) spatial location of leiomyoma/s. Hysterotomy/ies need to avoid injury to uteroovarian and/or uterine vessels. Dissection of leiomyoma/s needs to be done with judicial hemostasis avoiding excessive devascularization of myometrium. Hysterotomy and leiomyoma excision site repair need to be performed in several layers.
Large leiomyoma, usually more than 7-8 centimeters (250-400 grams) size, has to be morcellated with 20 millimeter diameter blade which greatly fascilitate morcellation.