Author Information
Parulekar SV
Abstract
Citation
Parulekar SV. Myomectomy: lateral
extraperitoneal Approach. JPGO 2014 Volume 1 Number 2 Available from: http://www.jpgo.org/2014/02/myomectomy-lateral-extraperitoneal.html
Parulekar SV
(Professor
and Head, Department of Obstetrics and Gynaecology, Seth
G.S. Medical
College and K.E.M
Hospital, Mumbai, India.)
Abstract
Myomectomy is
operative removal of uterine leiomyoma and reconstructing the uterus.
Conventionally the uterine incision is made in its anterior or posterior wall.
These incisions are through peritoneal covering of the uterus, which can lead
to development of adhesions and related morbidity. A novel approach of incision
on lateral (extraperitoneal) surface of the uterus is presented. A review of
the world literature reveals that this is the first time this approach has been
described.
Introduction
The bulk of the myometrium is in the
anterior and posterior walls of the uterus, and leiomyomas develop there.[1,2]
Conventionally myomectomy is done by making an incision on the uterine wall
over the leiomyoma, usually in midline, and making additional tunnelling
incisions in the leiomyoma bed for removing other leiomyomas lying on the side.[3,4,5]
An incision is made directly over the leiomyoma too if required. [3,4,5]
But the anterior and posterior surfaces of the uterus are covered by visceral
peritoneum and any incision on them produces a scar to which bowel and/or
omentum can get adherent. Such adhesions can lead to infertility, retroverted
fixed uterus, chronic abdominal and pelvic pain and intestinal obstruction.[6,7]
An incision on the extraperitoneal surface of the uterus would avoid such a
scar and all the related complications. A novel approach of incision on lateral
(extraperitoneal) surface of the uterus is presented.
Operative Technique
The abdomen is opened through
infraumbilical vertical or transverse incision. The uterus and pelvic structures
are examined. Lateral approach to the leiomyoma is possible if the leiomyoma is
large, is in the upper segment of the uterus, and has grown radially in all
directions. The bowel and omentum are packed away into the upper abdominal
cavity. Any technique used for reducing blood loss during myomectomy can be
used, such as use of Bonney’s myomectomy clamp, Rubin’s technique of rubber
tourniquet, and injection of diluted vasopressin around the uterine vessels.[8]
If the leiomyoma is exactly in the midline and expanding equally in all
directions, either right or left lateral approach can be used. If it is
anterolateral, then that side is used in which direction it has grown. The
round ligament on that side is divided between two clamps, and the clamps are
replaced by ligatures. The broad ligament is opened further in downwards
direction. It is separated from the underlying uterine surface by gentle blunt
dissection. The position of the uterine vessels is noted. They are located
posteriorly if the leiomyoma is in the anterior uterine wall, and anteriorly if
the leiomyoma is in the posterior uterine wall. A longitudinal incision is made
in the lateral uterine wall over the bulge produced by the leiomyoma, away from
the uterine vessels. It is deepened in the coronal plane until the
pseudocapsule of the leiomyoma is cut. The leiomyoma is held with an instrument
like a tenaculum, bulldog vulsellum, Allis forceps or Bonney’s myoma screw. It
is enucleated by blunt and if necessary, sharp dissection. A downward extension
of the incision is prevented by applying an Allis’ forceps there and by
exercising due care. If the uterine incision is found to inadequate for removal
of the leiomyoma, it is enlarged by making horizontal cuts in its center
anteriorly and posteriorly, still restricting them to the extraperitoneal
portion of the uterine surface and remaining away from the uterine vessels. A
leiomyoma too large to be removed through the uterine incision is removed by
morcellation. Any other leiomyomas present are removed through tunnelling
incisions as have been described conventionally. Hemostasis is achieved in its
bed by ligatures, sutures and electrocauterization as appropriate. Its cavity
is closed by a series of interrupted sutures of No. 1 delayed absorbable
sutures. The cut end of the round ligament are approximated. The defect in the
broad ligament is sutured with a continuous suture of No.1-0 delayed absorbable
suture. A drain may be left in the broad ligament, though it is usually not
required. The abdomen is closed in layers.
Figure 1. Left lateral view of the uterus
with anterior wall leiomyoma (M). Arrow: left round ligament; Hollow arrow:
left fallopian tube.
Figure 2. The left round ligament is
divided (arrows) and left broad ligament is opened.
Figure 3. The pseudocapsule of the
leiomyoma is cut.
Figure 4. The leiomyoma is enucleated by
dissection.
Figure 5. The bed of the leiomyoma is seen
(arrows).
Figure 6. The bed of the leiomyoma is
closed with interrupted sutures of No. 1 polyglactin.
Figure 7. The bed of the leiomyoma is
nearly closed.
Figure 8. The suture line in the anterior
broad ligament after its closure (arrows).
A posterior wall leiomyoma can be
approached through the posterior leaf of the adjacent broad ligament, which is
stretched over the leiomyoma. The incision is made close to the uterus. The
serosa is loosely attached to the leiomyoma and is easily separable. The
remaining steps of the operation are as described for an anterior wall
leiomyoma.
Figure 9. Right lateral view of the uterus
with posterior wall leiomyoma (M). The left broad ligament has been opened by a
longitudinal incision (arrows). The ovary (O) lies anterior to the incision.
Figure 10. The leiomyoma (arrows) is
exposed by making an incision in its pseudocapsule.
Figure 11. The leiomyoma (M) is separated
by dissection.
Figure 12. The leiomyoma (M) is bisected.
It shows partial cystic degeneration.
Figure 13. The leiomyoma is removed
piecemeal by morcellation.
Figure 14. The bed of the leiomyoma is seen
(arrows).
Figure 15. The bed of the leiomyoma is
closed with interrupted sutures of No. 1 polyglactin.
Figure 16. The incision in the broad
ligament is closed with a continuous suture of No. 1-0 polyglactin. The suture
line gets covered by the ovary when it falls back in place.
Discussion
Making an incision in the posterior wall of
the uterus is considered the worst option because the postoperative scar would
be exposed to the general peritoneal cavity and would invite adhesions with
bowel and/or omentum.[5,6,7] Unless the uterus is anteverted by
plication of the round ligaments, it would get retroverted and perhaps get
adherent to the rectum. An upper segment posterior uterine incision is managed
by an elaborate and cumbersome technique called Bonney’s hood operation.[5,8]
A low posterior uterine incision leaves behind a posterior scar which can
result in a retroverted fixed uterus due to adhesions with the rectum. An
anterior wall incision is less risky, because the scar would be somewhat
covered when the round ligaments are shortened by plication. Still it is
associated with the risk of adhesion to the lower anterior abdominal wall and
sometimes the urinary bladder. [6,7]
An incision in the lateral wall of the
uterus would avoid all such complications. This surface lies in the broad
ligament and is extraperitoneal. As a result the scar would get covered by
peritoneum when the broad ligament is sutured back. The lateral uterine wall is
no more vascular than the anterior and posterior walls despite the proximity of
the uterine vessels.[1] Hence a lateral incision is not associated
with any increase in uterine bleeding during the operation. A leiomyoma which
grows radially in all directions expands the lateral uterine walls sufficiently
to permit placement of the uterine incision away from the uterine vessels. Thus
there is no risk of injury to the uterine vessels. There is no risk of injury
to the ureter as it lies below the level of the uterine vessels. The uterine
myometrium is similar in all of its walls, and healing of a lateral wall
incision is as good as that of an anterior or posterior wall incision. This is
seen in the healing of the cesarean section incision, the lateral ends of which
have sometimes to be extended into the lateral uterine wall. Blood supply of the
uterus in the area of the incision is not impaired by a lateral incision any
more than with anterior or posterior incisions, owing to the rich anastomoses
between the vessels of the right and the lest sides, and between the uterine
and ovarian vessels of each side.[9,10] This is supported by the
fact that lateral uterine wall incisions made for removal of lateral wall
leiomyomas heal as well as anterior or posterior wall incisions.
Lateral approach to myomectomy is not
applicable if there are leiomyomas which are small and restricted to the
anterior or posterior uterine walls away from the lateral walls, or if they are
in the cervix. This approach should be applicable to laparoscopic myomectomy as
well. In fact it could be easier than the conventional anterior or posterior
approaches owing to the use of the lateral ports. However this author has no
experience with laparoscopic myomectomy. Work needs to be done on that by a
laparoscopic surgeon.
It is possible to use conventional anterior
and posterior incisions and prevent postoperative adhesions by using oxidized
regenerated cellulose barrier, polytetrafluoroethylene membrane, or
bioresorbable membrane (sodium hyaluronate and carboxymethylcellulose).[11]
However these substances are expensive, not readily available, and unnecessary
when a lateral extraperitoneal uterine incision is used.
Conclusion
Lateral incision on the extraperitoneal
part of the uterus for removal of large leiomyomas in the upper segment which
grow radially is a technique that is easy, satisfactory and associated with
absence of complications of adhesions of the intraperitoneal structures to the
scar seen with anterior and posterior uterine wall incisions.
References
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