Fibroids and lap myomectomy

· Uncategorized
English: large subserosal leimyoma of the uter...

Image via Wikipedia

Diagram illustrating benign neoplasms, namely ...

Image via Wikipedia

English: laparoscopical myomectomy Deutsch: la...

Image via Wikipedia

fibroids or myomas

Laparoscopic myomectomy is done usually for the treatment of infertility.

Fibroids are the benign tumours of the smooth muscle of the uterus.They are very common in women during reproductive years and are the most common cause for the hysterectomy.They are oestrogen sensitive and grow slowly.

They are submucosal ,intramural ,subserosal or pedenculated.

fibroids

Symptoms

Menorrhagia
Intermenstrual bleeding
Dysmenorrhoea
Infertility

Diagnosis

It is based on
History
Clinical examination and
Ultrasound

Management

fibroids are usually asymptomatic, discovered accidentally on per vaginal examination or ultrasound.
If symptomatic, they are to be treated.
Menorrhagia can be controlled medically with tranexamic acid, mefenemic acid,progestogens, Mirena IUS and GnRh analouges.

Gynecologists prefer hysterectomy if woman is having troublesome symptoms and has completed her family.Hysterectomy gives higher satisfaction rate.
Myomectomy is the treatment for woman who wishes to conserve her uterus for the fertility.

Uterine artery embolisation is still subjected to clinical evaluation and is not as effective as hysterectomy as regarding the absence of menstrual symptoms.
Submucosal small sized fibroids can be removed with Hysteroscopic ablation using versapoint.

Laparoscopic Myomectomy

Some surgeons prefer to give GnRh analouges prior to fibroid surgery.They reduce the size of the myoma so reducing the intra operative blood loss.
Disadvantages are that sometimes they form a dense fibrous sheath around the fibroid. Its use has been reserved only for the very large myomas.
Consent explaining the risk due to excessive bleeding followed by laparotomy should be taken.

Placement of the ports

10mm trocar in the umbilicus and two 5mm in each iliac fossa under direct vision lateral to inferior epigastric arteries. further 10mm can be placed in the midline just above the fundus of the uterus or a 5mm at palmer’s point , depending upon the choice of the surgeon.
Piterssin (20 units in 20ml saline ) can be injected around the insertion of round ligament., 10ml on each side.It causes blanching of the uterus, but can produce severe hypertension.Deaths have been reported and in some countries it is banned.Anaesthetist must be aware of its use.
Most important part is planning of the incision.It is made using harmonic scalpel or diathermy armed scissors or needle electrode.
The serosa and myometrium is incised till the pseudocapsule is identified and then it is extended.Fibroid is manipulated using myoma screw, one designed by Dr Rakesh Sinha has a better tissue grip and better strength.The procedure is surprisingly bloodless even without pitressin if the surgeon is in the right plane.
Defect is repaired in 2 layers , interrupted 2/0 vicryl for the myometrium and 3/0 for the serosa is used. Knots can be tied extracorporeally or intracorporeally.
Dr Prakash Trivedi ties first one extra and the subsequent ones intracorporeally.

Removal of the fibroids from the peritoneal cavity

Morcellators are used for this purpose.They consist of two concentric cylindres with a motor drive causing the inner cylinder to rotate in relation to the outer one.
Antibiotics given are usually cefuroxime and metronidazole.

Complications are fever and fall in haemoglobin.

The procedure is demanding and needs mastery.
Myoma
Cutting of the capsule
Visible myoma after opening of cavity
Removal with morcellator

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: