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IN THE NAME OF GOD

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• Hysterocopic myomectomy • Nezhats video assisted and

Robotic-Assisted Laparoscopy and Hysteroscopy.2013

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Hysterocopic myomectomy

• Uterine leiomyomas are the most common benign tumors in women.

• Submucos and intracavitary myomas are frequent causes of menorrhagia -Anormal uterine bleeding - recurrent pregnancy loss –

pain and infertility.• Dilation and curettage will commonly miss these lesions.• Diagnostic hysteroscopy should be performed as part of

the evaluation of a patient suffering from the above symptoms.

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Patient Selection

• Appropriate candidates for hysteroscopic Myomectomy are woman with symptomatic uterine fibroids which can be removed hysterocopically and in whom another surgical approach is not required to remove additional fibroids or treat other pathology.

• Before operating for a submucosal myoma other causes of bleeding must first be explored.

• Not all submucosal myomas cause AUB.

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• Working up and medically treating other causes are prudent first steps before proceeding to surgery.

• Patients over 40years of age/ or with a history of untreated AUB for a period>1year /should have an endometrial biopsy to rule out cancer.

• If AUB caused by a structural defect such as a submucosal myoma does not respond to medical therapy then it requires surgery.

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Indications for hysteroscopic removal of fibroids

• Menorrhagia• AUB• Recurrent pregnancy loss• Infertility• Dysmenorrhea• Necrotic leiomyoma following uterine fibroid

embolization• Histologic evaluation of intra cavitary lesions with

uncertain finding on pelvic imaging.

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Contraindicatins

• Hysteroscopic myomectomy is contra indicated in women in whom hysterscopic surgery is contraindicated.

• When it is not feasible to remove the myoma hysteroscopically.

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Feasibility of fibroid removal

• As a rule it is feasible to remove fibroids by hysteroscope that have an intra cavitary component.

• Removal of large fibroids that penetrate into the myometrium takes longer/increased complications: fliud absorption/uterine perforation/incomplete fibroid resection.

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Myometrial penetration

• The European Society for Gynecological Endoscopy(ESGE):

• Type0 _fibroids are those which are completely within the endometrial cavity

• Type 1 _fibroids are those which extend less than 50%into the myometrium.

• Type 2 _ fibroids are those which extend 50%or more within the myometrium.

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Clinical success rates according to fibroid type

Type Complete resection rate

Volume of fliud absorbed

0 96-97% 450

1 86-90% 957

2 61-83% 1682

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Leiomyoma size

• Hart et al; examined the effect of fibroid size in a prospective study of 122 women.

• They found that ,the risk of subsequent fibroid related surgery within 4years, was significantly lower in women with fibroids that were <3cm 10% versus 4cm<fibriods 60%

• Multiple fibroids or those >3cm require special consideration and possibility of two stage procedure.

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The Lasmar classification for submucous fibroids

0 1 2size Largest

fibroid<=2cmLargest fibroid 2.1-5cm

Largest fibroid >=5cm

Topography Fibroid located in Lower third of the uterus

Middle third Upper third

Extension Fibroid cover<1/3 of wall

1/3-2/3 Fibroid cover >2/3

penetration Fibroid completely in cavity

<50%in myometrial wall

>50%in myometrial wall

wall Add 1point if fibroid is in lateral wall

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• When total score/0-4 hysteroscopic myomectomy is considered low complexity

• Total score 5-6 the procedure is high complexity /consider GnRH agonist or two step procedure

• Total score 7-9 procedure is too complex /consider alternatives to the hysteroscopic methods.

• All fibroids with score <=4(group 1)that underwent hysteroscopic myomectomy were completely removed.

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Preoperative evaluation and preparation

• Should not differ from other hysteroscopic procedures except:

• It is critical to perform an endometrial biopsy in any woman with AUB at risk of endometrial hyperplasia or cancer.

• This includes any woman over the age of 40with abnormal bleeding.

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Informed consent

• Consultation regarding other treatment options is mandatory.

• Medical treatment/hysterectomy/other routs of myomectomy/uterine artery embolization should be discussed.

• Woman should be counseled about potential complications of the procedure/ excessive fluid absorption and hemorrhage/recurrence of fibroids or symptoms/second procedure /only intracavitary fibroids would be treated and other left in place.

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Evaluation of the uterus

• Knowledge of fibriod characteristics as well as other pathologies(adenomyosis-endometrial polyp)prior to surgery is crucial.

• Some authors suggest saline infusion sonography to evaluate relationship of a leiomyoma to both the endometrial cavity and the myometrium.

• Others use a combination of office based diagnostic hysteroscopy and HSG.

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Evaluation of the uterus

• We evaluate the uterus using hysteroscopy and transvaginal ultrasound.

• although MRI is a better imaging it is too expensive

• Recently virtual hysteroscopy has received some attention as noninvasive technique provides accurate information about uterine cavity.

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Preoperative medication

• As with other hysteroscopic operation antibiotics are not indicated during myomectomy.

• Endomtrium should be in early proliferative phase for any hysteroscopy.

• To schedule the procedure with the endometrium in appropriate state prolonged progesterone treatment as found in depo medroxy progesterone acetate frequently leads to endometrial atrophy which allows for greater visualization during the procedure.

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GnRH agonists

• Decrease fibroid size but make dissection difficult.

• Many surgeons use for large fibroids>3cm.• We use them for temporary cessation of

menses in patient with sever anemia that may preclude surgery or in whom intravenous iron therapy is contraindicated.

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Vasopressin

• Vasopressin intravascular injection or absorption has been associated with profound HTN/bradycardia/intra operative mortality.

• 20u vasopressin are mixed in 100ml of normal saline injected into cervical stroma in 5ml in each of 4qudrants of cervix.

• Taking care to avoid cervical arteries at 3 and9 oclock.

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It can be given every 30-45 min if bleeding is encoutered or the procedure is prolonged.Vaso reduce : blood loss,distentionfliud intravasation.operative time during laparascopy.Although statistically significant the clinical value of these findings is questionable.

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Treated(vasopressin) Conrol(placebo)

Intraoperative blood loss 20.3ml 33.4ml

Distention fluid intravasation

448.5ml 819,1ml

Operative time 31.1min 34.1min

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Instrumentation

• New technologies such as vaporization electrodes and hysteroscopic morcellators have been introduced.

• Vaporization electrode operate at a higher power density(120-220W vs60-120W with a monopolar electrode)and vaporize the tissue.

• This eleminates accumulation of tissue fragment that can occlude the view.

• It also prohibits evaluation of the tissue for pathology.

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Vaporization electrode

• The vaporization technique should be avoided at the cornua and isthmus,since these anatomical regions are thinner and at increased risk of Perforation,bowel burns,intraperitoneal injuries.

• Because of the higher power setting used,two dispersive pads should be placed to ground the patient.

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HYSTEROSCOPIC MORCELLATOR

• Has a rotatory blade for resection and suction tubing to remove tissue fragments.

• Comperative studies have reported that myomectomy duration was 8-26 min shorter with the intra uterine morcellatore versus a resectoscope.

• The disadvantage for the hysteroscopic morcellatore :

• Can not cauterize bleeding vessels ,is not designed to treat deeper myoma .

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• It is limited to woman with hysteroscopic type 0 leiomyomas.

• Since leiomyomas that appear to be type 0 upon preoperative evaluation may sink deeper into the myometrium,the optimal situation is for a surgeon to have access to both the wire loop and morcellator.

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Tissue removal and fluid control

• Use of a hysteroscopic with a continuous flow operative sheath is necessary in order to clear blood from the uterine cavity and improve visualization.

• Some operative sheaths aspirate pieces of tissue from the uterine cavity to remove debris or retrieve specimens for pathologic evaluation.

• Hysteroscopic myomectomy has risk of excessive absorption of distending fluid.Automated fluid pump and monitoring systems are preferable to manual technique.

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Technical pearls

• Monopolar resectoscope should be set to a cutting current of 80-120W.

• The wire loop should easily pass through the tissue ,if it does not the power setting is increased to prevent tissue adherence to the wire loop.

• Resection should be performed from the far end of the fibroid towords the surgeon,and be always visible.

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• Small fibroids are cut by retracting the thumb and using the spring mechanism.

• While incising a large fibroid the thumb should be retracted half away.The rest of the incision is performed by retracting the whole resectoscope .

• The initial incision into the fibroid should be at the midline ,as the edges of fibroid tend to fall inward,creating a panoramic view.

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• Pedunculated fibroids that are smaller than uterine cervix should be cut at the base.

• Larger ones should be first cut to small pieces and then detached from the base.

• Evacuation of the chips can be performed using vacuum,tissue forceps,curette,or as we prefer by using the wireloop.

• We avoid pulling un-detached fibroids using tissue forceps for fear of perforation.

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• Hamou has suggested that uterine contractions could be used to push the myoma into the cavity,hydromassage through electronic suction irrigation device, deflating uterine cavity for several minuets,use of protaglandines we seldom use this prepration it can result severe diarrhea&difficult uterine distention.

• Uterine massage via bimanual examination has also be discribed to help to extrude the remaining portion of a fibroid.

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• The need to use concomitant intraoperative laparascopy is debatable.

• A retrospective cohort study of 126 patients reported that complete fibroid resection was more likely with sonographic versus laparascopic guidance .

• When to offer the patient a two step operation:multiple, large ,broad-based or intra deep penetrating fibroids are seen during avaluation.

• After 2-4months we visit the patient if fibroid related symptoms persist ,schedule the second operation.

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• When fertility is important we avoid resecting fibroids located the anterior and posterior walls.(opposite fibroids .)such concomitant resection can lead to intrauterine adhesions,two step operation is preferable.

• FOLLOW UP:Discharged a few hours after.We recommend 3days of rest although patients can resume normal activity (other than bathing in pools&sea,sexual intercourse,aerobic sport)24h after

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• The patient should be on pelvic rest for 4-6w.• Follow up visit:4-6w• in two large studies :Complication rate 0.8-

2.6%respectively.lower in single ,small,intracavitary fibroids versus multiple,large,intrauterine fibroids.

• The most frequent and dangerous are:uterine perforation,fluid imbalance.

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Uterine perforation

• A dilator, hysteroscope ,surgical instrument may perforate uterus.extensive resection and deep myometrial invasion increase the risk.

• There is no data to suggest that laparoscopic or sonographic guidelines decrease the frequency of uterine perforation.

• If electrosurgical energy,morcellation,suction curettage were utilized and perforation is suspected the potential for visceral injury (bowel.bladder)is increased.immediate laparoscopic abdominal exploration should be performed.

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• Fundal perforation without energy can be managed by careful observation:BP/PR/monitor pain and abdominal distention/u/o/CBC+fib baseline,2h,6h,24h.

• In uterine perforation Avoid placing an intrauterine balloon for 2reasons:it may extend the tear more damage to tissue.it may conceal bleeding behind the balloon.

• Althuogh small tears measuring less than 5mm can be left to heal themselves unless they are actively bleeding,authours recommend a HSG to ensure the integrity of the uterine wall after perforation prior to pregnancy

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• Damage to bowel is rare,studies have not shown any change in outcome with primary closure of the bowel injury versus colostomy.

• Overall, young healthy patients with bowel injury from hysteroscopy, tend to do very well.

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Intravasation and electrolitic imbalanced

• Extensive endometrial or myometrial resection increase the risk of absorption of distention fluid resulting:pulmonary edema,hyponatremia,heart failure,cerebral edema,even death.

Non electrolyte fluid-plan termination---750cc fluid intravasation.Immediately stop---1000 some authors---1500,2000.The greatest risk with hypotonic solution is hyponatremia,

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• The greatest the uterine pressure the higher the rate of fluid absorption

• Visualization adequate for surgery can usually be achieved with pressure 75-100.

• Any additional pressure will usually not add to visibility but will only increase the rate of fluid absorption.

• Serum Na decrease by 10mmol/l for every liter of hypotonic solution absorption.

• If serumNa level is increasing and the initial serumNa was at least 125 it is safe to discharge the patient.

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• Symptoms&signs of hyponatremia :initial bradycardia /HTN/nausea, vomiting ,seizure, pulmonary edema/cardiac abnormalities ,cerebral edema herniation, coma and death.

• If significant hyponatremia is suspected diuretic such as furosemide should be given immediately.

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Excessive peri-operative bleeding

• The most common cause:uterine perforation.• Hemorrhage can be controlled:uterine artery

ligation.• Bakri balloon can be placed for tamponade

but is not recommonded if patient has perforation.once balloon is placed it is left for 24-48h then slowly decompressed

• In life threatening hemorrhage hysterectomy.

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Intra uterine adhesions

• Intra uterine adhesions represent the major long term complication of hysteroscopic myomectomy.

• An early second look hysteroscopy is an effective preventive and therapeutic strategy.

• many studies and surgeons report high patient satisfaction ,resolutionof AUB with success rate 70-99%.

• Rate of myoma incomplete resection 5-17%.about half of these will have to undergo another operation.

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Reproductive outcomes

• Submucouse fibroids reduce reproductive outcome.&increase RPL therefore should be removed.

• Intra mural fibroids may cause a detrimental effect on conceiving and reaching vaibility with a pregnancy

• It is not known whether hysteroscopic myomectomy affects placentation in subsequent pregnancies.

• Fibroids are a well known risk factor for placenta previa/placenta abruption.

• There have been no case of uterine rupture after hysterocopic myomectomy.

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• Patients over 40years of age/ or with a history of untreated AUB for a period>1year /should have an endometrial biopsy to rule out cancer.• We avoid pulling undetached

fibroids using tissue forceps for fear of perforation. Uterine massage via bimanual examination has also be discribed to help to extrude the remaining portion of a fibroid.

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• Althuogh small tears measuring less than 5mm can be left to heal themselves unless they are actively bleeding,authours recommend a HSG to ensure the integrity of the uterine wall after perforation prior to pregnancy

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