Laparoscopic Myomectomy and Myolysis for Fibroids

Laparoscopic myomectomy and myolysis are two more recent approaches to fibroids that offer a minimally invasive option for some women who previously would have needed major abdominal surgery. Both of these treatments deal best with subserosal fibroids (ones located closer to the outer surface of the uterus). A laparoscopic myomectomy removes the fibroid from the uterus and then repairs the normal myometrium by sewing (suturing) it back together. Myolysis uses a laser fiber or needles that deliver an electric current to destroy the fibroid in the uterus. In either procedure fibroids may recur, since the procedures target fibroids that are present but do not stop the process that is producing fibroids. In addition, one or two subserosal fibroids may be treated with this approach and others present at the time of surgery not treated.

Laparoscopic myomectomy was first used, and is still most widely used, for fibroids that are pedunculated, or on a stalk. For these fibroids, the removal is relatively easy, since the stalk can often be grasped, tied, or burned to control blood loss. The more challenging issue has been removing a large fibroid through a small incision.

Laparoscopic myomectomy is monitored with a laparoscope (similar to a telescope) that is inserted through a small incision at the belly button, just like in a laparoscopic tubal ligation (“having your tubes tied”). Instruments inserted into one or two smaller incisions lower on the abdominal wall are used to grasp the fibroid and uterus. Cautery or other cutting instruments separate the fibroid from the normal myometrium. The fibroid can then be removed. 

One of the earliest ways of removing the fibroid was to make an incision into the vagina (colpotomy) and remove the fibroid through that opening. This was a shorter procedure than trying to cut the fibroid into little pieces and remove them through the abdominal incisions. The introduction of electric morcellators, by which the fibroid can be rapidly processed into little pieces, was a major step forward. This advance made it possible to remove large fibroids in a minimally invasive fashion.

Surgeons with advanced skills can remove deeper or even multiple fibroids in this way. One issue with deeper fibroids is that it is more difficult to completely separate them from the underlying myometrium. Another is that the uterus must also be sutured, or stitched, back together.

The difference between regular suturing and laparoscopic suturing is similar to that between walking and walking on stilts. The princi-ples of laparoscopic suturing are the same as those of regular suturing, but a significant amount of practice is required to carry out the moves with the same precision and grace. The difficulty of laparoscopic suturing is one of the primary reasons some gynecologists have started to explore the possibility of using a surgical robot to perform laparoscopic myomectomy. 

In robotic myomectomy, the surgeon sits at a console, which can be in the operating room or can be thousands of miles away. From this console, the surgeon controls the robot, which duplicates the surgeon’s hand movements. With current robots, the surgeon can view the surgery in three dimensions. Not only is the view more like performing an open surgery than looking through a scope, but the robot allows the surgeon to use all the subtle, fine motions his or her hand can make that are impossible to perform with the stilt-like laparoscopic instruments. Finally, the console allows the surgeon to sit comfortably rather than standing in a specific position to perform the laparoscopy, resulting in less strain and more efficiency. The robotic arm controlled by the surgeon does require time to set up at the beginning of the case and a second surgeon to assist with conventional instruments.

For laparoscopic myomectomies, even with a skilled surgeon, sometimes the time under anesthesia can be significantly longer than for an open procedure. Although incisions are minimized and bleeding may be minimized, a significantly longer procedure can be a dis-advantage. Women should discuss with their surgeons typical times and outcomes for this procedure.

Finally, some uteruses are too large to allow fibroids to be removed laparoscopically. If the uterus rises above the belly button, a laparoscope placed in this region cannot easily monitor the procedure. Some physicians do place the laparoscope higher in the abdomen, but eventually the amount of space that is available for operating becomes limited. 

Myolysis does not require as much surgical skill as laparoscopic myomectomy. Generally, the probes (or needles) need to be inserted into the fibroid, but the uterus usually does not need to be sutured. 

Multiple punctures are required to treat even a small fibroid, and the serosal layer of the uterus is damaged by this technique, which may result in more scarring following surgery. The scarring can cause pain or problems for women trying for pregnancy.

The major controversy over laparoscopic myomectomy and myolysis has involved the group of women who want to have a future pregnancy, since when these procedures were relatively new, there were several reports of women who experienced uterine rupture at approximately 7 to 8 months of pregnancy. Uterine rupture occurs when the uterine wall gives way before labor. It can be a medical emergency for both the mother and the baby. In some of the cases of rupture after these procedures, both mother and baby did well after an emergency cesarean section, but some babies died as a result of the uterine rupture.

Significant controversy continues over this issue in the medical literature. Some authorities argue that inadequate surgical skill led to these early complications. While this concern may have some validity, there is also evidence that even superficial disruption of the serosal uterine lining may sometimes lead to uterine rupture. Although some surgeons have argued that removing the fibroid laparoscopically but making a bigger incision to repair the uterus directly is the solution, uterine ruptures have also occurred with this approach.  

Large studies of a significant number of women are beginning to be published which suggest that the rates of uterine rupture are less than 1 in 100 to 1 in several hundred. However, since uterine rupture is such a serious complication for both mother and baby, even a rate of rupture of 1 in several thousand may not be acceptable. Given the complexity of the process, best results will likely occur with surgeons who perform a high volume of these specialized procedures. Women who desire future fertility should discuss the issue of uterine rupture with their surgeon before undergoing a laparoscopic myomectomy.