Chapter 7.3 Robotic Myomectomy. Operative Techniques

 Chapter 7.3 Robotic Myomectomy

GENERAL PRINCIPLES

Definition

Uterine leiomyomas are one of the most common problems encountered by

the obstetrician/gynecologist with approximately 70% to 80% of

reproductive-aged women eventually developing these benign myometrial

tumors.1,2 The majority of leiomyomas do not cause any symptoms and are

often only noted incidentally on imaging or surgical pathology. However, as

they enlarge, uterine myomas can lead to bulk symptoms, abnormal uterine

bleeding, and dysmenorrhea. In a smaller percentage of cases, especially

when submucosal fibroids are identified, pregnancy loss and infertility can

occur.3

Differential Diagnosis

■ Uterine adenomyoma or adenomyosis

■ Pregnancy

■ Hematometra

■ Malignancy: uterine leiomyosarcoma or carcinosarcoma

■ Endometrial carcinoma or metastases from primary malignancy

■ Endometrioma

Anatomic Considerations

When planning a myomectomy, myoma location, number, and size are the

key anatomic factors used to determine the most appropriate surgical

approach. Uterine myomas are classified as being present just underneath the

serosal surface (subserosal), within the myometrium (intramural), or beneath

the endometrial lining (submucosal). Fibroids that are completely within the

uterine cavity with little intramural involvement are called intracavitary.

Submucous myomas can be further subclassified as type 0 (completely

intracavitary), type I (>50% of the myoma is intracavitary), and type II

(>50% of the myoma is intramural). For myomas that are type 0 or type 1, a

hysteroscopic approach is preferred. However, for type II myomas, a

nonhysteroscopic procedure is most appropriate.

Nonoperative Management

To treat uterine leiomyomas, multiple nonsurgical strategies are available andthese can at times be very successful. These nonsurgical options include

expectant management, medical management, uterine artery embolization,

and high-frequency magnetic resonance (MR)-guided ultrasonography. The

choice of the method is dependent upon judicious consideration of the

patient’s medical history, desire for future childbearing, risk of malignancy,

and the chance for successful outcome based on myoma characteristics.

Medical management typically relies on hormonal methods to reduce

abnormal uterine bleeding. Although many women obtain relief, especially

when heavy menstrual bleeding is the predominant symptom, the chance for

long-term treatment failure is relatively high. The first line in hormonal

agents is combined estrogen–progestin oral contraceptives. Although these

compounds will not restrict myoma growth or reduce uterine volume, in some

patients they can effectively reduce monthly blood loss. Despite the presence

of conflicting evidence, some studies have indicated that early exposure to

combined oral contraceptives may actually increase the risk of fibroids later

in life.4 Progestational compounds such as depo-medroxyprogesterone and the

levonorgestrel-containing IUD are also often used to manage symptomatic

uterine fibroids. Although the levonorgestrel IUD is FDA-approved for the

treatment of heavy menstrual bleeding, it is not indicated for the treatment of

uterine myomas, and in fact, having a myoma with any significant

intracavitary component is a relative contraindication to the placement of an

IUD. These agents are effective for mild symptoms and help reduce heavy

menstrual bleeding via endometrial and uterine atrophy. Lastly, a newer oral

nonhormonal formulation (tranexamic acid, an antifibrinolytic) has been used

successfully in women with myomas and can reduce the volume of monthly

blood loss by up to 30%.

Gonadotropin-releasing hormone (GnRH) agonists are a highly effective

treatment for both abnormal uterine bleeding related to myomas as well as

bulk symptoms. These agents lead to a hypogonadotropic state which results

in a substantial reduction in monthly blood loss within 3 months of

administration. It must be noted that following the administration of a GnRH

agonist, there is typically an initial increase (“flare”) in the release of

pituitary FSH and LH stores due to binding of the GnRH agonist to its

pituitary receptors. These pituitary receptors subsequently become

desensitized, with a resultant decline in FSH and LH secretion and clinical

symptoms resembling menopause within a few weeks. Local effects on

leiomyomas including direct inhibition of local aromatase p450 expression

leading to decreased conversion of androgens to estrogens, which are thought

to stimulate myoma growth. In addition, GnRH agonists can suppress myoma

cell proliferation and induce apoptosis, which likely underlies their capacity

to reduce myoma volume. A reduction in preoperative myoma size can make

a laparoscopic approach more feasible and avert the need for laparotomy.GnRH agonists can also be useful for the short-term correction of anemia

prior to surgery, as indicated by a Cochrane database review.5 However,

long-term use is not recommended due to the significant side effects of the

hypoestrogenic state, such as bothersome hot flushes, and possible osteopenia

and osteoporosis. It is not recommended to use these agents for longer than 6

months.6

The remaining nonsurgical options, as with medical options, can offer some

relief but do also have associated limitations. Uterine artery embolization

(UAE) or uterine fibroid embolization (UFE) is the first of these approaches.

These methods involve instillation of occlusive material bilaterally into the

arteries feeding the myoma beds.7 This technique is not recommended for

women who desire future childbearing as the effects on fertility and ovarian

reserve are unclear. A newer method is the use of magnetic resonance

imaging-guided focused ultrasound (MRGUS). Using MRI guidance, multiple

ultrasound waves are focused to induce local tissue destruction. The latter

method is best suited when the leiomyoma cannot be resected via other

surgical methods.6 MRGUS has been associated with complications such as

skin burns, fibroid expulsion, and persistent neuropathy; it is not currently

widely used.8

IMAGING AND OTHER DIAGNOSTICS

As with the evaluation of many forms of pelvic pathology, transvaginal

ultrasound is often the initial basic imaging study obtained. Pelvic ultrasound

allows for the basic identification and localization of leiomyomas (Fig. 7.3.1).

Myomas typically appear as enlarged hypoechoic and/or heterogeneous

masses with lobular contours. The amount of fibrous tissue versus smooth

muscle tissue determines the degree of hypoechogenicity. Due to mass effects,

myomas tend to compress the surrounding myometrial tissue, creating a

pseudocapsule and a defined myoma border (Fig. 7.3.2). Due to myoma

degeneration and necrosis, internal calcifications can cause shadowing and a

“venetian blind” effect with ultrasound waves. Characterization of submucosal

and intramural myomas can be further enhanced with the use of threedimensional (3D) ultrasound; however, the utility of this feature is dependent

on sonographer experience.

Figure 7.3.1. Transvaginal pelvic ultrasound demonstrating 4 to 5 cm posterior myoma

displacing the endometrium anteriorly.

Figure 7.3.2. Transvaginal pelvic ultrasound with visualization of posterior myoma but

indistinct margins and unclear cavity involvement.

To evaluate the uterine cavity, saline infusion sonohysterography (SIS) can

be used to determine the degree to which the uterine cavity is occupied or

impinged upon by a submucosal myoma. Knowing the degree of penetrance

of a myoma can influence the choice of operative approach. SIS has a greatersensitivity and specificity than transvaginal ultrasound (85.4% and 98.2% for

SIS, respectively).9

Magnetic resonance imaging (MRI) is an additional imaging modality to

complement the aforementioned ultrasonographic techniques and is routinely

used at our institution to assist in preoperative planning for myomectomy.

MRI relies on the use of a magnetic field to change the spin of hydrogen

atoms present in tissue and measures the radiofrequency waves emitted by

those atoms. The strength of the signal is affected by the number of hydrogen

atoms (i.e., the water content of a particular tissue). Water content will affect

the tissue’s appearance on T1- and T2-weighted images, with tissues with high

water content appearing brighter on T2-weighted imaging. T1-weighted

images better depict fat and areas of hemorrhage. Myomas classically appear

as dark, well-circumscribed areas on T2-weighted images. Cystic

degeneration, however, leads to increased brightness in this image sequence.

Figure 7.3.3. T2-weighted MRI images provide excellent fibroid “mapping” in

preparation for a robotic approach. The endometrial cavity is well visualized using this

technique and can be more easily avoided in the interest of future fertility.

MRI is useful for surgical planning, especially if a laparoscopic or robotic

myomectomy is desired (Fig. 7.3.3). The advantages of MRI over TVUS is

greater sensitivity (80% vs. 40%, respectively), especially when four or more

myomas are present. Disadvantages include possible nonidentification of verysmall myomas (typically less than 0.5 cm3) and significantly increased cost

compared to ultrasound. Computed tomography is typically not used to image

myomas given the inferior soft tissue contrast relative to MRI and TVUS.

However, it may be useful in identifying ureteric compression if this is a

concern.10

PREOPERATIVE PLANNING

Prior to performing any type of myomectomy, the surgeon must first address

several issues:

■ The most common preoperative issue is anemia resulting from heavy

menstrual or abnormal uterine bleeding. Given the known bleeding

dysfunction associated with uterine leiomyomas, the most common form

identified is iron deficiency anemia. Milder forms of anemia can be treated

with supplemental iron either in oral or IV form.

■ As a second step in preoperative planning, treatment with a GnRH agonist

such as leuprolide acetate can be considered for 3 months prior the

procedure. This is used either to decrease uterine or myoma volume, or to

reduce ongoing abnormal uterine bleeding and anemia.

■ Ruling out malignancy is essential prior to performing any myomectomy.

Women with risk factors (e.g., greater than 6 months of irregular menstrual

cycles or known anovulation, polycystic ovarian syndrome, obesity or

insulin resistance, or thickened endometrium) should be sampled to rule out

endometrial cancer. This is typically done using office endometrial biopsy

to detect any underlying endometrial hyperplasia or cancer.

■ It is also essential to obtain appropriate imaging procedures to delineate

the dimensions of the uterus and the number, size, and location of myomas,

and other pelvic pathology. As outlined above, SIS or MRI is preferred

versus traditional transvaginal ultrasonography.

SURGICAL MANAGEMENT

The decision to proceed with surgical treatment for uterine leiomyomas is

based upon several factors. These include:

1. Any associated abnormal uterine bleeding or heavy menstrual bleeding that

is not responsive to conservative measures

2. Ongoing growth following menopause or any suspicion of malignancy

3. Infertility secondary to distortion of the endometrial cavity or fallopian

tubes

4. Recurrent pregnancy loss (especially with known distortion of the

endometrial cavity)

5. Diminished quality of life due to pain or pressure symptoms6. Chronic blood loss leading to ongoing iron deficiency anemia

In choosing robotic myomectomy versus other techniques, multiple factors

must be considered as outlined in Table 7.3.1.

Table 7.3.1 Comparison of Myomectomy Techniques

It is imperative to map the location, size, and relative proximity to the

cavity for all uterine myomas. Robotic myomectomy is best suited for

patients with subserosal, intramural, fundal, or pedunculated fibroids. It is

also most appropriate when the patient has any single myoma less than 15

cm, and if there are five or fewer myomas present in the uterus. The main

advantage of robotic myomectomy is the availability of a 3D view of the

operative field and ease of instrument maneuvering and suturing. This is

especially important for less-experienced surgeons who may find a total

laparoscopic approach prohibitive, but who would still prefer to perform the

surgery in a minimally invasive fashion. Robotic myomectomy, like other

forms of minimally invasive approaches, provides the opportunity for

decreased postoperative pain, faster return of bowel function, decreased

length of hospital stay, and enhanced cosmesis versus an abdominal

approach.11

Once the decision has been made to perform the myomectomy in a

robotically assisted fashion, the patient is considered for pretreatment with a

GnRH agonist. This pretreatment, as for laparoscopic, abdominal, and

hysteroscopic approaches, is indicated when it is necessary to correct anemiaand/or reduce uterine or myoma volume, but can also be associated with

more difficult dissections and poor tissue definition, which can sometimes

make a minimally invasive approach more challenging. We do not routinely

use GnRH agonists in the absence of anemia when minimally invasive surgery

is planned for the above reasons. Surgeons should always consent patients for

a possible laparotomy due to bleeding or other intraoperative complications

should the need arise.

Positioning

In preparation for a robotic myomectomy, standard laparoscopic equipment is

required along with the addition of the patient-side robot, the vision cart, and

the robot–operator console.

The patient is positioned as for a conventional laparoscopic case, i.e., in

dorsal lithotomy with Allen or yellowfin stirrups with arms tucked at the

sides in a neutral position and all bony prominences appropriately padded. A

gel pad or other cushioning device is placed underneath the patient to prevent

the patient from sliding cephalad along the table while in Trendelenburg.

Chest straps can also help in preventing patient drift during the case.

Although some texts recommend routine use of maximum Trendelenburg

position (as the table cannot be readjusted once the robot is docked if

visualization is suboptimal), our experience is to use only as much

Trendelenburg positioning as needed to perform the procedure.

Approach

Multiple robotic approaches have been described, including the use of

parallel, between the legs, and side docking for gynecologic procedures

(which is thought to provide improved access to the uterine manipulator).

Our preference is to side dock the robot. In addition, there are various

strategies for port placement, with the camera positioned intra-, infra-, or

supraumbilical depending on uterine size and surgeon preference. Our

preference is to place the robotic camera intra- or slightly infraumbilically.

The use of accessory ports is similarly a matter of surgeon preference and

ease of the procedure. Our approach is described below. The most important

factor is to determine prior to the procedure what the preferred approach will

be, as there is some difficulty in placing additional ports or changing

configuration once the robot is docked. Again, imaging and examination is

key in preparing these steps.Procedures and Techniques (Video 7.3)

Since the application of the daVinci robotic surgery system for use in myomectomy,

multiple variations in technique have developed. In this section, we will discuss the

methods typically used at our institution.

Uterine manipulator insertion

Once the patient has been prepped and draped as for a conventional laparoscopic

myomectomy, the uterine manipulator is inserted. This is done to optimize exposure

for myoma enucleation as well as to provide a conduit for instilling dye into the

uterus to define and avoid the endometrial cavity during close dissection.

We typically place a uterine manipulator such as a RUMI (Cooper Surgical)

manipulator. Once the Foley catheter is placed and the cervix is visualized with

either a bivalve speculum or Spaniard–Auvard weighted speculum, a single-tooth

tenaculum is placed on the upper lip of the cervix for traction and the uterine

manipulator is inserted.

To insert the RUMI uterine manipulator, one first sounds the uterus. Then the

balloon tip of the RUMI uterine manipulator is inserted through the cervix into the

cavity. Once the full length of the balloon tip is inside the endometrial cavity, the

balloon is inflated with approximately 7 mL of normal saline. Once the balloon is in

place, the uterine manipulator is checked to confirm that it is secure (Tech Fig. 7.3.1).

Tech Figure 7.3.1. RUMI and RUMI insertion.

Trocar placement and docking of the daVinci Robot

Trocar sites are placed as depicted in Tech Figure 7.3.2. Prior to insertion of each

trocar, 0.25% bupivacaine is injected subcutaneously and an infraumbilical skin

incision is made with a size-11 scalpel to allow placement of the umbilical trocar,

which will ultimately accommodate the robotic camera. We typically start with a 5-

mm trocar to survey laparoscopically and ensure the procedure is appropriate for

the surgical robot. Once the initial infraumbilical incision has been made, an optical

trocar such as the Xcel trocar (Ethicon) is used to enter the abdomen. If the survey

confirms the pelvis is suitable for a robotic approach, we then exchange the 5-mm

for a 12-mm trocar which can accommodate the robotic camera.

In addition, two to three 8-mm robotic trocars are placed at an angle

approximately 15 degrees inferiorly and 8 to 12 cm lateral to the umbilical port site.

An assistant port was then typically placed in the right lower quadrant and it is

through this port that needles can be introduced and extracted with direct

visualization (Tech Fig. 7.3.2). This arrangement was more prevalent when power

morcellation was used for removal of the fibroid. However, given the recentcontroversy regarding morcellator use, we now place a GelPOINT suprapubically

and forego the right lower quadrant accessory port so that the GelPOINT can be

used to both pass needles and for tissue extraction at the conclusion of the case. If

a suprapubic incision is not desirable, the right lower quadrant accessory port can

be used to pass needles and the GelPOINT can be placed into the larger umbilical

incision for tissue extraction at the conclusion of the case (Tech Fig. 7.3.3).

Following trocar placement, the daVinci robot is docked. As described earlier,

the patient should be placed in deep to maximum tolerated Trendelenburg position.

The robot may be placed either in between the patient legs, between each of the

stirrups, or on the patient’s side. As the robot is advanced toward the patient, each

arm is extended at the most proximal joint away from the center of the robot. This

provides adequate room in between each arm to allow for independent and

unhindered movement for each instrument. Once all of the robotic arms are

docked, the robotic camera and instruments are inserted into their respective

trocars. Our preferred set of instruments include the tenaculum forceps, Maryland

bipolar forceps connected to cautery, harmonic shears, and two needle drivers. In

our experience, the third arm is rarely needed, especially if a skilled assistant is

available to assist using the accessory port (Tech Fig. 7.3.4).

Tech Figure 7.3.2. Trocar placement: From the central 12 mm camera port, accessory

robotic ports are placed 8 to 12 cm away to minimize the risk of interference between

the camera and the robotic arms.

Tech Figure 7.3.3. GelPOINT placement: Note the placement of the GelPOINT in the

midline suprapubic position.

Tech Figure 7.3.4. Picture of robotic ports and placement of robotic arm over trocar.

Hysterotomy

Before making the hysterotomy, a solution of dilute vasopressin (20 units in 200 mL

of normal saline) is injected into the serosa and myometrium surrounding the

myoma. This is done by using a laparoscopic needle tip device attached to asyringe containing the vasopressin (Tech Fig. 7.3.5). Blanching will be noted if the

correct planes are achieved. It should be noted that severe cardiopulmonary

complications have been noted in healthy individuals such as cardiopulmonary

arrest, hypotension, and pulmonary edema when using vasopressin, especially in

more concentrated solutions. To further enhance the effect of the vasopressin,

ligation of the vascular pedicle during the myoma enucleation can also be

performed.12

Just as in open and laparoscopic myomectomies, it is key for the surgeon to be

aware of the relationship of the myomas to the fallopian tubes and uterine arteries.

To further limit bleeding, the uterine arteries can be temporarily occluded using

laparoscopic Satinsky clamps. Techniques that have been successfully used are

preoperative misoprostol, injection of bupivacaine with epinephrine, preoperative

tranexamic acid, and the use of uterine tourniquets.

After injection of dilute vasopressin, one can proceed with the hysterotomy. A

harmonic device is first applied with the “cut” setting to make the hysterotomy

through the serosa and myometrium until the capsule of the fibroid is opened. The

hysterotomy should be made in a horizontal fashion if possible, although suturing

can be performed in a vertical plane if needed owing to increased maneuverability

of the robotic instruments versus traditional laparoscopy (Tech Fig. 7.3.6). It is key to

ensure that the hysterotomy not extend to the uterine vessels or fallopian tubes.

Maintaining hemostasis is also critical throughout this procedure and bipolar

electrosurgery can be used to control any acute bleeding.

Tech Figure 7.3.5. Injection of vasopressin: A 1:10 dilution of vasopressin is injected in

to the myoma bed, note the blanching which arises when injection is performed in the

proper plane.

Tech Figure 7.3.6. A–B: In making the hysterotomy, a harmonic scalpel is used to cut

the serosa and further dissect down to the myoma.

Myoma removal

Once the hysterotomy has been performed and the capsule is entered (exposing

the smooth white myoma fibers), a robotic tenaculum is anchored into the myoma.

Using blunt dissection, countertraction with the tenaculum, and judicious use of

harmonic energy, the myoma is completely enucleated taking care at the base not

to approach the endometrium. Once removed, the myomas can either be

immediately removed or set aside in the posterior cul-de-sac or paracolic gutters if

additional myomas need to be collected (Tech Figs. 7.3.7 to 7.3.9). It is essential that

a written account of all the myomas removed be maintained by the surgical team to

avoid any retained specimens in the abdomen at the conclusion of the case. It is

not unusual that small myomas can roll cephalad and be lost behind the liver or

under bowel loops. Discrete areas of myometrial or serosal bleeding can be

coagulated using short bursts of bipolar current. Electrosurgery should be limited

since excessive coagulation can compromise the integrity of the myometrium and

hinder closure of the hysterotomy. It is also possible that excessive electrosurgery

in myomectomy repair can relate to subsequent uterine rupture risk with pregnancy.

Hemostatic methods that do not rely on cautery are products such as Floseal

(Baxter, Deerfield, IL) or Surgiflo (Ethicon, Inc), which are frequently used by our

group. These can be used as needed to maintain optimal hemostasis.

Pedunculated myomas are managed in a similar way. However, instead of

subserosal injection of vasopressin, this injection is done into the stalk avoiding

direct intravascular injection of vasopressin as much as possible. The myoma is

removed by transecting the stalk using any number of methods of coagulation; our

preference is to use the Ligasure device (Covidien) in such cases. Additionally, the

remaining vascular pedicle can be oversewn at the conclusion to ensure

hemostasis.

Tech Figure 7.3.7. During enucleation, traction is placed on the myoma using a

laparoscopic tenaculum placed through the GelPOINT port.

Tech Figure 7.3.8. A–C: Further enucleation using traction and countertractions.

Hemostasis is maintained using the harmonic scalpel and bipolar electrosurgery.

Tech Figure 7.3.9. Note the almost completely enucleated myoma with only a single

pedicle of tissue remaining.

Deep intramural myomas and myomas of the broad ligament require the greatest

amount of laparoscopic skill and especially skills at laparoscopic suturing.

Furthermore, with myomas of the broad ligament, it is essential to maintain

awareness of the position of the ureter and uterine vessels. Preoperative MRI can

identify these myomas and these should be approached by surgeons skilled in

advanced robotics, pelvic anatomy, and minimally invasive surgery.

Hysterotomy closure

Quick closure of the hysterotomy is essential for limiting blood loss during a

myomectomy procedure. In this context, robotic surgery may offer advantages over

the conventional laparoscopic approach given the increased ease and speed of

suturing. This is especially important for surgeons with less experience in

laparoscopic suturing and knot tying. Hysterotomy closure can be further facilitated

via the use of barbed or quilled absorbable suture materials such as V-LocTM

(Covidien, Mansfield, MA) and QuillTM SRS (Angiotech Pharmaceuticals Inc.,

Vancouver, BC, Canada). These barbed sutures eliminate the need for the surgeon

to tie knots and the barbs help distributed tension along the whole length of the

suture (Tech Figs. 7.3.10 to 7.3.12).13

Regardless of the suture being used, hysterotomy closure is done in a manner

similar to that of an open myomectomy. The closure is performed in several layers.

If not using barbed suture, the deep layer is performed with either an interrupted or

a running, locked technique using 0-polyglactin. Additional layers are placed as

needed for approximation of tissue and strength. Once the uterus is well reapproximated, the uterine serosa is then closed using a running stitch of 2-0 or 3-0

polydioxanone. All sutures are initially introduced using the accessory port for

suture passage. To help reduce the likelihood of adhesions, we typically placeInterceed over the serosal defect if the incision line is completely hemostatic.

Floseal or Surgiflo may also be used at this point in the case if there is ongoing

diffuse oozing, but in those cases Interceed is not advised as it can increase

adhesion formation in the setting of blood.

Tech Figure 7.3.10. A Myoma bed following complete enucleation and prior to suturing.

B Start of hysterotomy closure with first layer using a single V-Loc suture. This initial

layer is placed in a running, locked fashion.

Tech Figure 7.3.11. Serosal closure is achieved using an additional V-Loc suture

placed in a running, but unlocked fashion.

Tech Figure 7.3.12. Complete serosal stitch and completion of hysterotomy closure.

Myoma morcellation

Prior to a moratorium placed by the FDA on power morcellation in 2014, this

technique was commonly used for tissue extraction at the conclusion of the case.

The moratorium was placed based upon the risk of occult leiomyosarcoma in a

morcellated specimen (which is approximately 1/300 to 1/500). Our current

approach is to completely avoid power morcellation and use a suprapubically

placed GelPOINT device for tissue extraction (Applied Medical, Rancho Santa

Margarita, CA). Once all of the myomas have been removed from the uterus, themyomas are extracted either intact or via morcellation using a scalpel at the level of

the skin incision where the GelPOINT device was placed. It should be noted that

this incision is limited to 2 to 3 cm, so it is not a large additional incision and it is

placed in a cosmetic location within the natural hairline (Tech Fig. 7.3.13). Some

surgeons are performing this type of morcellation contained in a tissue extraction

bag. There is no data as to whether these techniques alter the prognosis of a

leiomyosarcoma once diagnosed.

Tech Figure 7.3.13. A–C Contained manual morcellation of the specimen within a bag

at the level of the minilaparotomy site.

Robot undocking and closure

Once all the myomas have been removed and adequate hemostasis has been

achieved, the rocked can be undocked. This is done by unlocking each of the

robotic arms from each trocar by unclasping the distal arm knobs shown previously.

Once each arm has been freed, the robot can be pulled away from the patient and

each trocar can be removed under visual guidance. For any port larger than 10 mm,we typically close the fascia using a Carter–Thomason (Cooper Surgical) port

closure device. Subcutaneous closure of the port sites is performed with

interrupted stitches of 2-0 Polysorb. Skin closure can be performed with 4-0 or 5-0

absorbable suture, steri-strips, or surgical glue per the preference of the individual

surgeon.PEARLS AND PITFALLS

Address the patient’s anemia prior to surgery. Anemia and uterine bulk can be

minimized by administering a GnRH agonist 3 months prior to the myomectomy.

If more than five fibroids are present or if there is a single myoma greater than 12 to

15 cm, consider an alternative to robotic myomectomy for all but the most skilled

surgeons.

Most surgeons should only consider robotic myomectomy for a patient with a limited

number of fibroids that are only subserosal, pedunculated, or intramural.

Avoid power morcellation given the risk of malignancy and current FDA moratorium.

Limit operative blood loss using dilute vasopressin injection prior to hysterotomy.

Consider cost and OR time when suggesting a robotic myomectomy and compare

costs within your institution.

Use barbed suture such as a V-Loc to evenly distribute the tension on the suture and

close the hysterotomy more quickly without the need to tie knots.

To remove the fibroids, perform a suprapubic minilaparotomy using a GelPOINT

wound retractor which can double as an assistant port.

Beware excessive use of cautery on the incision; instead select hemostatic agents

such as FloSeal.

POSTOPERATIVE CARE

Postoperative treatment is identical for that of laparoscopic myomectomies.

The main goal remains early mobilization and likely discharge later on the

day of surgery or the following morning. During the follow-up appointment,

it should be reviewed that due to her myomectomy, she may be at increased

risk for uterine rupture. In counseling patients on their reproductive futures, a

discussion should be initiated regarding potential recommendations for

cesarean section depending on the extent of the dissection and disruption of

myometrium. Recommendations should be made in the operative report for

obstetricians to review.

OUTCOMES

Overall robotic myomectomy has favorable outcomes in comparison to

laparoscopic myomectomy and especially to abdominal myomectomy. In our

center’s published experience, robotic myomectomy led to decreased blood

loss compared with conventional laparoscopy and abdominal myomectomy,

albeit with an increased surgical time.14 Multiple studies have shown

increased cost associated with the robotic approach; however, robotic surgery

may afford opportunities for minimally invasive myomectomy to surgeonswho otherwise would require an open procedure to complete the case. Longterm outcomes such as recurrence, fertility, and obstetric endpoints have yet

to be determined.

COMPLICATIONS

In general, robotic myomectomy has a highly favorable complication profile.

This is owing to the minimally invasive approach underlying this surgery. In

our experience, operative blood loss is lower than for laparoscopic

myomectomy and especially when compared with abdominal myomectomy.

KEY REFERENCES