Laparoscopic removal of myomas must be performed in selected cases of subserous and interstitial myomas. The operation is performed based on specific criteria. The indications for laparoscopic myomectomy have been increased in the past decade, as its advantages over traditional laparotomy have been recognized.
Myomas are generally benign tumours of the uterus and appear during the reproductive age of a women at a 20% rate. They may be single or numerous, while their size ranges from a few mm to several cm. Depending on their localization, they are classified as interstitial, subserous or submucosal, with or without a stem.
The number, size, localization, the raletion to the wall, the absence of projection in the uterine cavity, and the absence of degeneration are some of the criteria for laparoscopic ablation. Pediculated and large subserous myomas are easily removed laparoscopically. Very large, multiple myomas at a difficult location or near large vessels, the ureter, the oviduct and those that due to size occupy the wall and project into the cavity, are difficult to remove laparoscopically. For myomas situated in the broad ligament the surgeon must be experienced.
Submucosal myomas can be treated with hysteroscopic surgery (see relative section). Interstitial and subserous myomas, which are the majority of myomas, laparoscopic surgery has good results.
Careful preoperative examination is necessary to decide which patients should undergo laparoscopic myomectomy, because it is impossible to pulpate the uterine wall completely. Preoperative examination includes transvaginal anf pelvic ultrasound, examination of the intrauterine cavity using hysteroscopy or hysterosalpingography, and general blood test including hematocrit measurement. Ultrasound examination includes measurement of uterine size, number, size and location of myomas and their type.
Also, it is very useful to count the distance between myoma and endometrium, and the exclusion of the presence of adenomyoma. The adenomyoma is difficult to remove from the myometrium and therefore laparoscopic surgery is not recommended. Diagnosis of adenomyomas is mainly pathoanatomical, but can also be performed using ultrasound, colour doppler or MRI.
Hysterosalpingography is useful for the evaluation of the size of the uterine cavity and state of the oviducts is cases of infertility. Basic hormone tests (FSH, LH, PRL, Ε2, TSH on the 3rd day of the cycle) to identify the biological age of the ovaries, and semen analysis complement the infertility investigation. Indications for laparoscopy are related to the number, size and type of myomas. A metaanalysis suggests maximal diameter 5 cm and maximal number 2 myomas per patient.
According to J. Dubuisson is that laparoscopic myomectomy should not be performed if 2-3 myomas are identified using ultrasound, or if the diameter exceeds 8-10 cm.
The localization of the myoma may cause some difficulties. The presence of interstitial myoma of 4-7 cm in diamater, which project in the uterine cavity, causes questions regarding its laparoscopic ablation.
An incision is perfomed over the myoma using laser CO2 and the myoma is removed according to the principles of atraumatic microsurgery, avoiding bleeding. The cavity is closed using special endoscopic sutures. The myoma is removed following its fragmentation using a special laparoscopic tool (morsellator). The operation end with careful washing of the peritoneal cavity with saline.