To the Editor:
We read with interest the article entitled “Surgical management of uterine fibroids in Hesse, Germany, between 1998 and 2004” by Hesse et al (1). In doing so, we wonder how the authors identified the specific surgical route used for myomectomy and hysterectomy. Did the authors review operative reports from 34,814 surgeries? Or did the investigators use their medical system’s equivalent to our current procedural terminology (CPT) codes in order to categorize the techniques employed in treating uterine myomas? From the current report, is it possible to track the use of laparoscopic-assisted myomectomy (LAM)? This technique, distinct from laparoscopy with conversion to laparotomy, gives the benefits of both laparoscopy and laparotomy (2-6). If the authors were indeed able to include information regarding the use of this technique, why did they not do so?
Whereas laparoscopic techniques in general offer several advantages over conventional laparotomy (i.e., improved visualization, shorter recovery period, less post-operative pain, and decreased adhesion formation) (4,6), laparoscopic-assisted myomectomy offers advantages even over conventional laparoscopy in selected cases. This technique may facilitate multi-layer uterine closure in cases of very large or multiple myomas. LAM could enable the majority of surgeons to reduce the risks associated with inadequate laparoscopic closure of the uterus (2,5). LAM also makes minimally invasive myomectomy accessible to more practitioners, simplifying the procedure by facilitating suturing and reducing operative time (5,6). In contrast to conventional laparoscopy, LAM allows palpation so that the surgeon can identify small intramural myomas with his or her fingers, an advantage not present in conventional laparoscopy (5). This technique also avoids extensive use of thermal energy to achieve hemostasis laparoscopically, which may compromise uterine tissue (5).
Another benefit conferred by LAM is minimization of adhesions. This can be achieved when thorough laparoscopic pelvic irrigation is used to remove blood closts and debris that one may not ordinarily have the opportunity to remove during laparotomy. Lastly, and perhaps most significantly, laparoscopic assisted myomectomy allows treatment of concomitant disorders, such as endometriosis, which are amenable to laparocopic diagnosis and treatment but often missed during laparotomy (2-4). This is especially true of lesions located in the posterior cul-de-sac or underneath the ovaries, where visualization at laparotomy is inadequate.
While the current study certainly presents interesting results, it would be intriguing to look into what specific types of techniques the surgeons actually employed.
Linda M. Nicoll, MD
Jian Qun Huang, MD
Lisa Bhagan, MD
Center for Special Minimally Invasive Surgery
Stanford University Hospital and Clinics
Palo Alto, CA
1. Hackethal A, Bruggeman D, Leis A, Langde S, Stillger R, Munstedt K. Surgical management of uterine fibroids in Hesse, Germany, between 1998 and 2004. Fert Stert 2009: 91(3); 862-8.
2. Nezhat C, Nezhat F, Bess O, Nezhat CH, Mashiach R. Laparoscopically assisted myomectomy: A report of a new technique in 57 cases. Int J Fertil 1994: 39(1); 39-44.
3. Nezhat F, Seidman DS, Nezhat C, Nezhat CH. Laparoscopic myomectomy today; Why, when, and for whom? Hum Reprod 1996: 11(5); 933-4.
4. Nezhat C, Nezhat F, Silfen SL, Schaffer N, Evans D. Laparoscopic myomectomy. Int J Fertil. 1991; 36(5):275-80.
5. Prapas Y, Kalogiannidis I, Prapas N. Laparoscopy vs. laparoscopically assisted myomectomy in the management of uterine myomas: a prospective study. Am J Obstet Gynecol. 2009; 200(2):144e1-6.
6. Agdi M, Tulandi T. Endoscopic management of uterine fibroids. Best Pract Res Clin Obstet Gynaecol. 2008; 22(4):707-16.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.05.079
The Authors Respond:
In our report, it was clearly stated that we presented data from the mandatory statewide survey on surgical data in the field of gynecology (the GQH survey).
Regarding myomectomies the instrument assessed the approaches 1) laparotomy, 2) laparoscopy, 3) conversion from laparoscopy to laparotomy, and 4) others (e.g., hysteroresectoscopy). We are aware of the shortcomings of the presented data because we could not assess the size and the localization of the fibroids, the reasons behind the decision why the surgeon chose either operative surgical approach (including LAM), and the qualification of the surgeon. It would have been interesting to assess the mentioned aspects but unfortunately that was not the main intention of the quality assurance (GQH) study.
We agree that the intended conversion from laparoscopy to laparotomy (LAM) may be beneficial for a limited number of patients.
However, the LAM technique has considerable drawbacks: increased surgical trauma due to the additional trocar lesions, longer operation time and an increased risk for intraabdominal adhesions. As is well understood, every additional peritoneal trauma and mesothelial injury may result in adhesions. Furthermore, compared to primary laparotomy, the operating expenses are much higher with the combined approach.
In summary, the LAM technique may be beneficial if the surgeon is not confident that he can close the uterotomy adequately. In patients in whom there is a suspicion of endometriosis or additional intra-abdominal disease, the laparoscopic evaluation might be beneficial as well .
Generally speaking, not the surgical approach but rather the atraumatic, adequate surgery and skillful wound adaption for the patients benefit should be the surgeon’s main concern.
Andreas Hackethal, MD
Department of Obstetrics and Gynecology
Justus-Liebig-University of Giessen
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.05.080