Endoscopic loops for laparoscopic myomectomy

12 11 2010

To the Editor:

We have read with interest the recent paper by Zhao et al., describing laparoscopic myomectomy with vasopressin and loop ligation of the surgical base of fibroids’ pseudocapsule (1).

This combined approach was effective in reducing bleeding during myomectomy for large fibroids. A double technique was needed because the pseudo-capsule globally surrounds the fibroids with its peri-myomatous vessels. Therefore, the loop at the surgical base of the fibroid deals with the vessels there located, while those overlying the fibroid, the first ones to be incised by the surgeon, are pharmacologically ligated by the vasopressin. Unfortunately, the intramyometrial injection of vasopressin implies risks due to potential intravasation and serious complications have been reported with its use (2).

Nevertheless, the described technique shows various additional advantages on which we would like to comment.

For submucous fibroids, Zhao and colleagues describe the advantage of avoiding the opening of the uterine cavity. This is certainly beneficial, although further studies might be needed to confirm that a submucosal Roeder knot with Polyglactine might be a better choice for those patients who wish to retain their fertility.

We also acknowledge a further clear advantage of the described technique, which is the understandable reduction in need of diathermy, since extensive use of electrocoagulation could induce myometrial necrosis, postoperative fistulae and, eventually, uterine rupture (3).

It will certainly be interesting to read about the reproductive outcomes following this operation, although we argue that the Authors’ recommendation to wait for conception for at least two to three years, in a patient group with a mean age of 37-38 years old, would represent an important confounding factor. Age is a major determinant of conception following myomectomy (4).

We like the Authors’ idea, but we would also like to highlight the existence of other techniques that effectively apply the same concept of endoscopic loops, but do not require the support of potentially dangerous vasopressin.

For instance, commercial loops can successfully be used directly on the serosa and myometrium surrounding the base of subserosal fibroids (5). The application of such loops before the incision on the serosa, and their progressive tightening, reduces blood loss from peri-myomatous vessels globally, and also facilitates the enucleation thanks to a “squeezing” effect on the myometrium. Commercial loops can be easily replaced by custom made ones with a Roeder knot.

Other loop-based techniques have been described for the laparoscopic enucleation of deeper intramural fibroids which also dispense with the need for vasoconstrictors. For instance, a triple tourniquet approach (one of them pericervical and two on the infundibulo-pelvic ligaments) can render the uterus temporarily avascular for surgery (6).

Laparoscopic myomectomy is challenging, and bleeding represents one of its main limits.
We agree that the use of endoscopic loops is an additional, useful tool in the armamentary of surgeons performing laparoscopic myomectomy, but we also believe that one of its main advantages is a reduction in the need for other, risky interventions, such as vasopressin injections or extensive diathermy.

Pietro Gambadauro, M.D.
Centre for Reproduction
Department of Obstetrics and Gynaecology
Uppsala University Hospital
Uppsala, Sweden

Adam Magos, M.D.
Minimally Invasive Therapy Unit & Endoscopy Training Centre
University Department of Obstetrics and Gynaecology
Royal Free Hospital
London, United Kingdom

References
1. Zhao F, Jiao Y, Guo Z, Hou R, Wang M. Evaluation of loop ligation of larger myoma pseudocapsule combined with vasopressin on laparoscopic myomectomy. Fertil Steril, In Press, DOI:10.1016/j.fertnstert.2010.08.059

2. Hobo R, Netsu S, Koyasu Y, Tsutsumi O. Bradycardia and cardiac arrest caused by intramyometrial injection of vasopressin during a laparoscopically assisted myomectomy. Obstet Gynecol 2009;113:484–6

3. Pelosi M, Pelosi MA. Spontaneous uterine rupture at thirtythree weeks subsequent to previous superficial laparoscopic myomectomy. Am J Obstet Gynecol 1997;177:1547–9

4. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur J Obstet Gynecol Reprod Biol. 2003;110:215-9.

5. Gambadauro P, Campo V, Campo S. Laparoscopic myomectomy using endoscopic loops under progressive tension. Gynecological Surgery, In Press, DOI: 10.1007/s10397-010-0573-4

6. Taylor A, Sharma M, Buck L, Mastrogamvrakis G, Di Spezio SA, Magos A. The use of triple tourniquets for laparoscopic myomectomy. J Gynecol Surg 2005;21:65–72

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.11.042

The Authors Respond:

I have read the letter to the editor from Drs. Gambadauro and Magos carefully. I would like to answer their comments about our paper.

Regarding the use of vasopressin during laparoscopic myomectomy: The use of vasopressin during myomectomy (including laparoscopic and laparotomy) is a very common method in our department and in many other hospitals in China. In our opinion, the use of vasopressin is a safe method to reduce myometrial bleeding. Each patient had an electrocardiogram (ECG), pulsed Doppler echocardiography and blood pressure check prior to surgery, and only when the results of these examinations were normal was the vasopressin used. Additionally, before injecting the vasopressin, we always confirmed that the needle was not in blood vessel, so that intravasation could be avoided.

Regarding the conception time after operation: We are currently conducting a study on the pregnancy results after laparoscopic myomectomy in a larger population sample. In this study, we want to compare the results of pregnancies when patients were pregnant one year, one and half years and more than two years after laparoscopic myomectomy. This is why we recommend that the relatively young patients can be pregnant over two years after operation. We also obtained each patient’s agreement for this study.

FuJie Zhao, M.D., Ph.D.
Obstetrics and Gynecology Department
Shengjing Hospital
China Medical University
Shen Yang City, People’s Republic of China

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.11.043

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