Hemisection Technique for Laparoscopic Myomectomy

Article Information: Publication Date: 10/07/2005    Update Date: 10/07/2005   

More than ten years have passed by since we first performed a laparoscopic myomectomy in our Department using Semm’s technique.

As far as a subserous myoma is concerned, there are no particular problems; difficulties arise when dealing with intramural myomas.

Why have the most authoritative laparoscopic experts always advised not to go beyond certain limits? The main reasons are the dimension of myoma with the consequent increased blood loss and the extended length of the operation. 

A myoma with a diameter of ten centimeters fills a large part of the pelvis; therefore the traditional technique by Myoma-Drill or Grasping becomes extremely difficult in such a limited space.

When dealing with a large intramural myoma, whether developing in the anterior or posterior wall of the uterus, our technique consists in cutting the myoma down to the middle, thereby dividing it into two equal portions, making traction with clamps on both edges of the myoma and continuing the incision to the base. This is facilitated by the spontaneous expulsion of the myoma from the uterus.

At this point we find ourselves with two myomas, each of them approximately five centimeters in diameter, with minor risk of damage to the uterine cavity.

One of the two mid parts is now grasped and held with a five millimeter clamp and then, with bipolar forceps and scissors, enucleated: the second portion will follow with the same technique.

The entire procedure is performed under direct visual control which is very important because it allows constant verification and examination of the hemostasis. 
Access routes to the myoma depend on its volume.
The incision of the myoma can be made using both a simple laparoscopic scalpel and a monopolar or ultrasonic hook.
After having removed the myoma the breach is sutured with introflexing stitches, according to Tompkins method, with monofilament PDS 2-0 suture swaged to a 3/8 or ½ circle, conical, smooth-edged point needle of a suitable diameter ( CT 1, CT 2 ).
The myoma is then removed with a Semm electric morcellator. 
We have removed 80 myomas with this technique, myomas with a diameter ranging from 5 to 12 cm. The average hemoglobin drop was 1.5 gr/ml. Only in one case the hemoglobin fells of 3 points.

References:

References

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Dubuisso JB, Fauconnier A, Babaki-Fard K, Chapron C. Laparoscopic myomectomy: a current view. Hum Reprod Update. 2000 Nov-Dec;6(6):588-94. Review. (Medline)

Semm K. New methods of pelviscopy (gynecologic laparoscopy) for myomectomy, ovariectomy, tubectomy and adnectomy. Endoscopy. 1979 May;11(2):85-93. (Medline)

Shushan A, Mohamed H, Magos AL. How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies. Hum Reprod. 1999 Jan;14(1):39-43. (Medline)