Chapter 7.2 Conventional Laparoscopy Myomectomy. Operative Techniques

 Chapter 7.2 Conventional Laparoscopy Myomectomy

GENERAL PRINCIPLES

Definition

■ Uterine leiomyomas are the most common gynecologic tumor, with an

incidence approximating 20% to 25% in women aged 18 to 65 years.1

Uterine myomas are discreet, sharply circumscribed masses, and

histologically appear as whorled bundles of smooth muscle. Most

commonly, leiomyomas grow within the uterine corpus, but may also occur

within the uterine ligaments, uterine cervix, or on other abdominal

structures. Individual myomas are believed to be monoclonal and result

from somatic mutations yielding dysregulation of genes involved in growth

regulation. Growth of uterine leiomyomas lead to uterine enlargement,

which may yield symptoms such as abnormal uterine bleeding,

dysmenorrhea, dyspareunia, subfertility, pelvic pressure, urinary frequency,

or defecatory dysfunction. Uterine myomectomy is the preferred surgical

therapy for management of symptomatic uterine myomas in women who

desire future pregnancy or uterine preservation. Laparoscopic myomectomy

is a feasible, minimally invasive procedure and has been demonstrated to

yield less pain, shorter hospital stays, improved cosmesis, less blood loss,

and faster recovery compared to laparotomic procedures, and similar

surgical outcomes with less overall cost compared to robot-assisted

procedures.

Differential Diagnosis

■ Adenomyosis

■ Congenital uterine anomaly

■ Endometrial polyp

■ Hematometra

■ Pregnancy

■ Uterine leiomyosarcoma

■ Uterine carcinosarcoma

■ Endometrial carcinoma

■ Metastatic disease

■ Tubo-ovarian neoplasm

Nonoperative Management■ The goal of nonoperative management for uterine leiomyomas is to

decrease symptomatology and improve the quality of life. To maximize

patient satisfaction and compliance, therapies must be convenient for the

patient and with minimal deleterious side effects. From a surgical

perspective, medical therapies for uterine leiomyomas are frequently

employed to raise preoperative hemoglobin levels or to reduce uterine

volume to optimize a patient prior to surgical intervention.

■ Observation, which entails no immediate intervention, is reasonable for

patients who experience minimal symptoms or who elect not to receive

treatment. Watchful waiting is a practical option to select women who are

approaching menopause as uterine leiomyomas often regress as circulating

levels of estradiol and progesterone naturally.

■ Steroid hormones are commonly employed to manage bothersome

symptoms attributable to uterine myomas. A common first-line therapy for

management of abnormal uterine bleeding and dysmenorrhea is

combination oral contraceptive pills (OCPs). Although the efficacy of

combination OCPs for the treatment of symptomatic fibroids is uncertain

and scientific evidence is scarce,2 oral contraceptives may sufficiently

reduce the bothersome symptoms attributable to leiomyoma uteri in certain

women. The levonorgestrel intrauterine system (LNG-IUS) is another option

for management of abnormal uterine bleeding and has been shown to

decrease menstrual blood loss, reduce uterine volume, and lead to

improvement in hemoglobin levels.3 Of note, the presence of submucous

myomas that significantly distort the uterine cavity is a relative

contraindication for LNG-IUS.

■ Administration of GnRH agonists results in downregulation of hypothalamic

GnRH receptors, ultimately inducing a reversible hypogonadal state by 2

weeks. The GnRH agonist, leuprolide acetate, is approved by the Food and

Drug Administration (FDA) to increase hemoglobin levels and decrease

myoma size prior to myomectomy. Women who receive leuprolide acetate

therapy typically develop amenorrhea within 3 months. The expected mean

reduction in uterine volume is 36% by 3 months and 45% by 6 months

following initiation therapy. Patients treated with GnRH agonists may

experience menopausal symptoms such as hot flushes, vaginal dryness,

mood changes, and a reversible decrease in bone density. Hormonal addback therapy may be initiated to minimize side effects from GnRH agonists.

Of note, preoperative treatment with leuprolide acetate may not improve

blood loss during myomectomy.

■ GnRH antagonists compete with endogenous GnRH for pituitary binding

sites and have the advantage of a comparatively rapid onset of clinical

effects without certain side effects observed with GnRH agonists. Evidencesuggests that a 31.3% reduction in uterine leiomyoma size can be achieved

by 14 days of treatment.4 GnRH antagonists currently available in the

United States require daily injections, which may be an obstacle for many

patients.

■ Mifepristone is a weak progesterone receptor agonist that has been

demonstrated to reduce heavy menstrual bleeding and improve myomaspecific quality of life. Treatment with mifepristone yields a reduction of

uterine volume by 26% to 74% in women with leiomyomas.5 At present,

mifepristone is not FDA-approved in the United States for the treatment of

uterine leiomyomas.

■ Ulipristal acetate (UPA) is an orally administered selective progesterone

receptor modulator that inhibits proliferation of leiomyoma cells, but not in

normal myometrial cells.6 UPA has been shown to significantly reduce

fibroid volume, decrease abdominal pressure, and decrease myoma-related

pain. UPA has stimulatory effects on the endometrium and its progesterone

antagonist action could result in an increased risk for endometrial

hyperplasia and endometrial carcinoma. However, studies have

demonstrated that the incidence of endometrial hyperplasia and malignancy

after treatment with UPA appears to be low. Pregnancies after UPA

administration have been reported without maternal complications related

to leiomyomas.

■ Magnetic resonance–guided focused ultrasound surgery (MRgFUS) is an

outpatient treatment option for uterine leiomyomas in premenopausal

women. MRgFUS is a noninvasive, thermoablative technique in which

waves of ultrasound energy converge on a small volume of tissue, which

leads to the thermal destruction, coagulative necrosis, and reduction of

leiomyoma of volume.7 Pregnancies have been described after MRgFUS

with no specific pattern of complications.

■ Uterine fibroid embolization (UFE) reduces uterine arterial blood flow and

results irreversible infarction of leiomyomas. The leiomyomas eventually

decrease in size and bothersome myoma-related symptoms improve. Most

commonly, the approach to percutaneous embolization is via the right or

left femoral artery under local anesthesia. UFE may reduce menstrual loss

by 85% and the mean dominant fibroid volume by 30% to 46%.8 The safety

of pregnancy after UFE has not been established to date; however,

pregnancies after UFE have been reported.9

IMAGING AND OTHER DIAGNOSTICS

■ Multiple imaging modalities are available for the evaluation of suspected

uterine myomas, each with relative strengths and weaknesses. In addition

to documenting the number and size of any myomas present, a primaryobjective of pelvic imaging prior to laparoscopic myomectomy is to rule

out other pathologies such as adenomyosis and gynecologic malignancy.

■ Pelvic ultrasound provides high-quality imaging of the uterus and adnexa

and is oftentimes the primary imaging modality for the evaluation of

patients with suspected uterine myomas (Fig. 7.2.1). Pelvic ultrasound is

widely available, with advantages that include relatively low cost, high

diagnostic accuracy, and lack of ionizing radiation. Ultrasound of the pelvis

is performed using both transabdominal and transvaginal techniques to

ensure the best-quality anatomic survey is obtained. It is important to note

that, although effective at evaluating total endometrial thickness,

transvaginal ultrasound has low sensitivity for detecting intracavitary

masses and determining the type of submucous myomas. Saline-infused

sonography (SIS) differs from nonenhanced transvaginal ultrasound in that

saline is employed to distend the uterine cavity, which serves as a contrast

medium and allows for detailed examination of the endometrium.

Figure 7.2.1. Pelvic ultrasound for evaluation fundal, subserosal myoma.

■ Magnetic resonance imaging (MRI) of the uterus is the preferred imaging

method for evaluating uterine myomas prior to laparoscopic myomectomy

(Fig. 7.2.2). MRI allows for efficient, comprehensive evaluation of the

uterus and clearly demonstrates the size and location of myomas present.

Compared to SIS, MRI is superior at accurately estimating the degree of

submucosal myoma ingrowth into the endometrial cavity, which is crucial

for preoperative planning, as a surgeon may choose to excise certain

submucous myomas in hysteroscopic fashion. MRI allows for assessment of

the junctional zone, which is important for identifying adenomyosis.Compared to computed tomography and pelvic ultrasound, MRI is superior

at differentiating benign uterine leiomyomas from uterine

leiomyosarcomas.

PREOPERATIVE PLANNING

■ Appropriate preoperative patient counseling is important to define a

patient’s goals from surgery and to establish reasonable expectations

following laparoscopic myomectomy. In general, the intent of uterine

myomectomy is to improve, not necessarily eliminate, bothersome

symptoms attributed to uterine myomas. The risks of laparoscopic

myomectomy should be emphasized, including perioperative blood loss

possibly necessitating transfusion, postoperative adhesion formation which

may yield pain or subfertility, and the rare need for hysterectomy if

unexpected pathology or uncontrollable bleeding is encountered.

Additionally, the patient should be informed of the possibilities of future

myoma recurrence and of intrapartum uterine rupture. The patient should

understand that any procedure that begins laparoscopically may require

laparotomy to complete.

Figure 7.2.2. Pelvic MRI for evaluation of fundal, subserosal myoma.

■ Favorable surgical outcomes require that medical comorbidities are

optimized prior to laparoscopic myomectomy. Commonly, patients with

abnormal uterine bleeding have iron deficiency anemia, which should be

corrected prior to surgery to minimize risk of perioperative transfusion andmaximize wound healing potential. Options for iron repletion include oral

iron therapy and intravenous iron infusions. Oftentimes, concomitant

medical therapy is required to reduce abnormal uterine bleeding in order to

achieve a net increase in hemoglobin. Pre-existing cardiopulmonary disease

may lead to difficulty with ventilation or tolerance of Trendelenburg

position and should be addressed prior to laparoscopic surgery. Poorly

controlled diabetes mellitus may lead to poor wound healing and increased

risk of perioperative infection.

SURGICAL MANAGEMENT

■ Laparoscopic myomectomy should be avoided in patients with suspected

gynecologic malignancy and contraindications to pneumoperitoneum or

Trendelenburg positioning. Other limitations to laparoscopic myomectomy

include the size and number of myomas to be excised and a surgeon’s

ability to efficiently perform laparoscopic suturing. In many instances, it is

more difficult to remove numerous small myomas as opposed to fewer,

larger myomas.

Positioning (Figs. 7.2.1 and 7.2.3)

■ The patient is placed in dorsal lithotomy position with their legs in stirrups

and their arms tucked in neutral positions at their sides. As Trendelenburg

positioning will eventually be necessary for the completion of the surgery,

it is prudent to take the opportunity to place the patient in Trendelenburg

position prior to surgical preparation to ensure that patient does not shift

on the operative table. Beanbag or foam egg crate mattress covers are

effective measures to ensure the patient’s position does not change during

Trendelenburg positioning. Following surgical preparation of the abdomen

and vagina, the patient is draped, a Foley catheter is introduced into the

bladder, and a uterine manipulator is placed. We prefer to use a uterine

manipulator through which fluid can be introduced into the uterine cavity

and allow performance of chromopertubation.

■ Placement of laparoscopic cannulas is dependent on the size and position of

the myomas. In general, we place laparoscopic cannulas at the umbilicus,

within the left and right epigastrum at the level of the umbilicus, and in the

left lower quadrant to facilitate laparoscopic suturing in an ipsilateral

approach from the patient’s left side (Fig. 7.2.3). As total uterine length

increases, port placement may need to shift cephalad, but the overall

geometry of the port placement need not change. The diameter of each port

depends on surgeon preference, myoma size, and quality of the

laparoscopic instruments.

Figure 7.2.3. Typical port configuration for laparoscopic myomectomy.Procedures and Techniques (Video 7.2)

Techniques to minimize perioperative blood loss

■ Laparoscopic myomectomy can be associated with significant intraoperative

blood loss, which may necessitate the perioperative transfusion of blood

products. The knowledge of the various agents and techniques that reduce

bleeding during laparoscopic myomectomy is essential to enhancing patient

safety and surgical outcomes. Several pharmacologic agents have been found to

reduce intraoperative blood loss during myomectomy. Preoperative

administration of uterotonics such as methylergonovine, misoprostol, and

prostaglandin E2 has been shown to decrease intraoperative blood loss by

evoking myometrial contractions.10 The intramyometrial injection of vasopressin

leads to reduction of intraoperative blood loss by evoking local vasoconstriction.

In our practice, 20 units of vasopressin are mixed with 100 mL of normal saline

and injected to form a wheal over the underlying leiomyoma. The half-life of

intramuscular vasopressin is 10 to 20 minutes and a surgeon should appreciate

that the safe maximal dosage of vasopressin has not been established. Care

should be taken to avoid intravascular injection, as there are rare cases in which

injection of vasopressin evoked cardiovascular collapse. Intravenous

administration of tranexamic acid (TXA) competitively inhibits the conversion of

plasminogen to plasmin, thereby minimizing intraoperative blood loss during

myomectomy by exerting an antifibrinolytic effect.11 Of note, the use of

intravenous oxytocin and locally injected bupivacaine with epinephrine have not

been demonstrated to decrease blood loss during myomectomy.12 Use of cell

salvage devices decreases the need for perioperative allogeneic blood

transfusion. Interventions that decrease blood flow to the uterus, such as uterine

artery embolization, application of a pericervical tourniquet, and temporary

clamping of the uterine artery, have been described with varying levels of

efficacy.

Hysterotomy

■ Hysterotomy planning is important. The planned incision must be of adequate

length to allow for efficient enucleation of the myoma, but without undue trauma to

healthy uterine tissue. The surgeon must ensure that vital structures such as the

fallopian tubes and ascending uterine vessels are not at risk for injury (Tech Fig.

7.2.1). Transverse uterine incision facilitates ipsilateral laparoscopic suturing.

However, some myomas in the inferior aspects of the uterus may require a

vertical or oblique incision to facilitate enucleation and hysterorrhaphy. Multiple

myomas can be enucleated through a single hysterotomy when possible.

Tech Figure 7.2.1. Hysterotomy planning.

■ Vasopressin (20 units mixed with 100 cc normal saline) is injected into the

myometrium surrounding the myoma (Tech Fig. 7.2.2). Depending on the depth of

the myoma, tissue blanching and wheal formation may be observed. Hysterotomy

is performed using either a monopolar radiofrequency (RF) instrument or an

ultrasonic scalpel. For both classes of instruments, the surgical goal is to rapidly

incise tissue with the aim of minimizing unintended thermal injury. When using a

monopolar instrument, the electrosurgical unit is set to output a low-voltage,

continuous (“cut”) waveform. The uterine tissue is incised by linear vaporization, a

nontouch technique in which RF energy arcs from the tip of the active electrode

to the target tissue, leading to rapid tissue division with minimal thermal spread.

When using an ultrasonic scalpel, the device’s maximum blade excursion setting

should be used and care taken to minimize dwell time at the surgical site (Tech

Fig. 7.2.3). Incidental bleeding from the serosa and myometrium can be controlled

by judicious use of RF or ultrasonic energy. In general, excessive use of energy

devices to control myometrial bleeding is ill advised due to the possibility of

tissue necrosis and poor wound healing. If significant bleeding is encountered,

hemostasis may be achieved by suture ligation or pressure application.

Hysterotomy proceeds until the capsule of the myoma is observed (Tech Fig.

7.2.4).

Tech Figure 7.2.2. Injection of dilute vasopressin solution into myometrium surrounding

the myoma.

Tech Figure 7.2.3. Hysterotomy performed with ultrasonic scalpel.

Tech Figure 7.2.4. Exposure of the myoma capsule following hysterotomy.

Enucleation of myoma

■ The capsule of the myoma is incised (Tech Fig. 7.2.5) and dissection proceeds

between the inner capsule and myoma edge (Tech Fig. 7.2.6). If developing the

appropriate plane proves difficult, one can make a shallow incision in the myoma

itself, which may help distinguish myoma from capsule. Application of traction on

the myoma and countertraction on the capsule provides surgical exposure and

aids in the enucleation of the myoma. Once excised, the myoma is placed in the

posterior cul-de-sac for later retrieval (Tech Fig. 7.2.7). It is important for the

surgical team to keep an accurate count of the number of myomas excised to

ensure all specimens are extracted from the abdomen at the end of the

procedure. The myoma capsule need not be excised. Additionally, incising the

endometrium should be avoided if possible. However, entering the cavity is

unavoidable in the case of certain submucous myomas. If breach of the

endometrial cavity is in question, a solution of methylene blue may be introduced

into the endometrium through the uterine manipulator and any defects identified.

Tech Figure 7.2.5. Exposure of myoma following incision of myoma capsule.

Tech Figure 7.2.6. Enucleation of myoma by dividing tissue investments between

myoma and myoma capsule.

Tech Figure 7.2.7. Stowage of myoma in posterior cul-de-sac for later retrieval.

Hysterorrhaphy

■ Using laparoscopic suturing techniques, the myometrium is approximated in

multiple layers using 0 or 2-0 gauge, delayed absorbable suture in running or

figure-of-eight fashion. Studies have established that the use of barbed suture is

safe and effective for hysterotomy closure, with overall less time required for

hysterorrhaphy (Tech Fig. 7.2.8).13 Care must be taken to effectively approximate

tissue and achieve hemostasis, without undue tension being placed on the

myometrium which may lead to tissue strangulation. The serosa is approximated

using either 2-0 delayed absorbable conventional or barbed suture in simple

running or baseball stitch fashion. If the uterine cavity is entered during

enucleation of a submucous myoma, the endometrium should be approximated

with 3-0 delayed-absorbable, monofilament suture in simple running fashion.

Chromopertubation, if indicated, may be performed after hysterorrhaphy

completion (Tech Fig. 7.2.9).

Tech Figure 7.2.8. Hysterorrhaphy using delayed-absorbable barbed suture.

Tech Figure 7.2.9. Completion of hysterorrhaphy.

Myoma extraction

■ The FDA has discouraged tissue extraction by laparoscopic power morcellation

due to the risk of spreading unsuspected cancer during the process. Multiple

groups are evaluating the potential utility of contained electromechanical

morcellation, but data are sparse at present. However, other methods are

available for extracting myomas following laparoscopic myomectomy.

■ Minilaparotomy is efficient and effective for tissue extraction in most cases.

Following hysterorrhaphy, the myomas are placed securely in a laparoscopic

specimen bag (Tech Fig. 7.2.10). Depending on the patient’s anatomy, myoma

size, and prior surgical incisions, minilaparotomy is performed either through a

transverse Pfannenstiel incision or an extended umbilical incision. Thelaparoscopic bag is brought through the incision and the myomas are removed

(Tech Fig. 7.2.11). Again, it is important to confirm the number of myomas

removed matches the number of myomas enucleated. For larger myomas,

contained morcellation with a scalpel is feasible and can be facilitated by

placement of a self-retaining wound retractor.

■ Posterior colpotomy is a reasonable approach for extracting moderate-sized

myomas in appropriately selected patients. Again, myomas are carefully placed

within a laparoscopic retrieval bag. A posterior colpotomy is made from the

medial aspect of one uterosacral ligament to the medial aspect of the

contralateral uterosacral ligament using either a monopolar RF or an ultrasonic

device. Posterior colpotomy is facilitated by elevating the posterior vaginal fornix

cephalad, either by employing a uterine manipulator with a pericervical cup or an

assistant with a Breisky retractor placed within the posterior fornix (Tech Fig.

7.2.12). Ring forceps are introduced through the colpotomy and the string of the

laparoscopic retrieval bag grasped (Tech Fig. 7.2.13). The myomas counted to

confirm all specimens are extracted. The posterior colpotomy is repaired using

2-0 delayed-absorbable suture is running or figure-of-eight fashion using either

laparoscopic or transvaginal suturing technique.

Tech Figure 7.2.10. Collection of myoma in laparoscopic retrieval bag in anticipation of

contained transabdominal tissue extraction.

Tech Figure 7.2.11. Extraction of myoma through transverse mini-Pfannenstiel incision.

Tech Figure 7.2.12. Posterior colpotomy along pericervical cup.

Tech Figure 7.2.13. Extraction of myoma tissue through posterior colpotomy.

Adhesion prevention

■ Following tissue extraction, the pelvis is inspected laparoscopically. Meticulous

hemostasis is achieved by holding pressure, use of RF energy, suture ligation, or

hemostatic agent. An adhesion barrier such as oxidized regenerated cellulose is

placed over each hysterotomy to decrease incidence of postoperative pelvic

adhesion formation (Tech Fig. 7.2.14).

Tech Figure 7.2.14. Oxidized regenerated cellulose placed over hysterorrhaphy site for

adhesion prevention.PEARLS AND PITFALLS

CASE SELECTION

Laparoscopic myomectomy is associated with a learning curve and perioperative

outcomes are dependent on multiple factors. A surgeon should individualize their

surgical approach for myomectomy based on factors including myoma size, number

of myomas present, and their personal experience and skill level.

BARBED SUTURE

The use of barbed suture facilitates efficient hysterotomy closure and can reduce the

length of surgery in some cases.

UNDETECTED UTERINE PATHOLOGY

MRI for preoperative evaluation of uterine fibroids is most likely to detect the

presence of pathologies such as adenomyosis and sarcoma compared to other

imaging modalities and is the preferred method for evaluating a patient considering

surgical myomectomy.

POSTOPERATIVE CARE

■ Patients who undergo laparoscopic myomectomy can typically be

discharged home the same day. Common clinical scenarios that necessitate

inpatient management include pain not controlled by oral pain medications,

persistent nausea or vomiting, or for perioperative management of

comorbidities. Patients are prescribed a narcotic pain medication, stool

softener, antiemetic, and nonsteroidal anti-inflammatory medication.

Patients are instructed to ambulate as tolerated, but refrain from strenuous

activity for 2 weeks. Patients with tissue extraction via posterior colpotomy

are instructed to refrain from vaginal intercourse for 6 weeks. Patients are

counseled to expect mild uterine cramping and light bleeding per vagina.

They are instructed to seek medical attention should they experience

intractable pain, unrelenting nausea, fever greater than 38.3°C, excessive

vaginal bleeding, lightheadedness, shortness of breath, or syncope. Patients

are typically examined at 6 weeks following surgery. We advise patients to

not conceive for 3 to 6 months following laparoscopic myomectomy.

OUTCOMES

■ Studies report a steady increase in the cumulative recurrence rate of uterine

myomas following laparoscopic myomectomy, specifically 11%, 36%, 53%,

and 84% at 1, 3, 5, and 8 years, respectively.14 However, recurrence doesnot always require further treatment. A study of 114 patients noted that at

a 27-month interval after laparoscopic myomectomy, 33% of patients had

recurrent leiomyomas; however, only 37% of the patients required

additional surgical management.15

COMPLICATIONS

■ Laparoscopic myomectomy has clear advantages over abdominal

myomectomy by avoiding risks associated with laparotomy. A metaanalysis found that mean operative times were 13 minutes longer in the

laparoscopic myomectomy group,16 but the lengths of hospital stay and

time required for recovery are significantly lower in laparoscopic

myomectomies compared to laparotomic myomectomies. A multicenter

study including 2,050 patients reported the total complication rate of

laparoscopic myomectomy to be 11.1% with minor complications

accounting for 9.1% and major complications for 2.02%.17 The most serious

reported complications were perioperative hemorrhage in 0.68% and

postoperative hematomas in 0.48%.17 A known complication of

myomectomy is intra- and postoperative bleeding, and blood loss has been

shown to be significantly less in laparoscopic myomectomy compared to

abdominal myomectomy.18

■ The formation of adhesions is a frequently encountered complication

following myomectomy. Studies, in which a second-look laparoscopy was

performed following laparoscopic myomectomy, have reported intraabdominal adhesions to be present in up to 66% of women.19 Adhesion

prevention at time of myomectomy should be considered a priority and

multiple agents have been found to reduce the rate of adhesion formation,

such as oxidized regenerated cellulose, which was noted to significantly

decrease the rate of adhesion formation to 12% at the time of second-look

laparoscopy, compared to 60% without use of adhesion barrier.20

■ Intrapartum uterine rupture is a rare and potentially life-threatening

pregnancy complication after myomectomy and manifests with symptoms

of vaginal bleeding, fetal distress on cardiotocographs, increased uterine

contractions, pain, and loss of fetal station. Breach of the endometrium

during myomectomy may increase this risk and, as such, women may be

offered elective cesarean delivery of a subsequent pregnancy to minimize

this risk. Expert opinion suggests that a multilayered uterine closure and

avoidance of excessive use of RF energy on the myometrium are

appropriate measures to reduce the risk of subsequent uterine rupture after

myomectomy.21 A study evaluated 359 women after laparoscopic

myomectomy and 72 women became pregnant resulting in 76 pregnancies

in which no case of uterine rupture or dehiscence occurred.22 The authorssupposed that their favorable results may be explained by the meticulous

hemostasis that was obtained and by a layered closure of hysterotomies, as

well the avoidance of excessive cautery. The true incidence of uterine

rupture after myomectomy, whether laparoscopic or abdominal, is

unknown. No data suggest that one suturing technique or material is

superior in minimizing this risk of uterine rupture.23

■ A significant complication associated with minimally invasive myomectomy

is dissemination of uterine tissue during enucleation and tissue extraction.

Iatrogenic, parasitic myoma formation is a rare complication following

myomectomy and has been observed in patients who underwent manual or

electromechanical morcellation techniques. The enucleation and extraction

of an unsuspected uterine sarcoma may lead to intra-abdominal spread of

cancerous tissue and worsen a patient’s long-term survival. Presently, the

FDA warns that an estimated 1 in 350 women undergoing hysterectomy or

myomectomy for treatment of uterine myomas are found to have an

unsuspected uterine sarcoma. Patients should