Laparoscopic multiple myomectomy with temporary clipping of uterine and infundibulopelvic vessels

This video presents a multiple laparoscopic myomectomy in a 31-year-old patient with chronic pelvic pain and metrorrhagia. Myomectomy starts after intraoperative temporary clipping of the uterine artery and infundibulopelvic vessels. This simple method allows for the prevention of massive bleeding during the excision of the myomas. Once all myomas have been enucleated, they are extracted by morcellation.

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Laparoscopic multiple myomectomy with temporary clipping of uterine and infundibulopelvic vessels

Authors

A Wattiez, P Messori, E Faller, J Albornoz

Abstract

This video presents a multiple laparoscopic myomectomy in a 31-year-old patient with chronic pelvic pain and metrorrhagia. Myomectomy starts after intraoperative temporary clipping of the uterine artery and infundibulopelvic vessels. This simple method allows for the prevention of massive bleeding during the excision of the myomas. Once all myomas have been enucleated, they are extracted by morcellation.

Classification

live recorded

Keywords

Laparoscopic myomectomy, intraoperative temporary clipping, uterine arteries, barbed suture, morcellation

Media type

Surgical video

Duration

20'32''

Publication

2012-02

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E-publication

WeBSurg.com, Feb 2012;12(02).
URL: http://www.websurg.com/doi-vd01en3576.htm

Laparoscopic multiple myomectomy with temporary clipping of uterine and infundibulopelvic vessels

1. Exploration 00'05''

The procedure starts with the evaluation of the uterine myomas and MRI images. Several myomas are found, and in particular a large intramural myoma at the apex of the uterus. MRI shows that this large myoma is very close to the uterine cavity, although there are still a few millimeters of safety margin.

2. Anatomical landmarks and clipping of right uterine artery 00'48''

Anatomical landmarks such as ureters and umbilical arteries must be identified before uterine arteries are temporarily clipped. Ureter identification begins at the pelvic brim. On the right side of the pelvis, the ureter crosses the external iliac artery, so the right ureter has the bifurcation of the common iliac artery medially. The ureter is followed until it crosses the umbilical artery. The technique consists in opening the parietal peritoneum of the pelvic side wall in order to identify the uterine artery between the ureter and the umbilical artery and to clip it temporarily.

3. Anatomical landmarks and clipping of left uterine artery 02'40''

Ureter identification starts at the pelvic brim. On the left side of the pelvis the ureter crosses the common iliac artery so the left ureter has the bifurcation of the common iliac artery laterally. The ureter is followed until it crosses the umbilical artery. The peritoneum is opened at the junction between the ureter and the umbilical artery. This artery can be identified when upward traction is placed on the abdominal wall. After identification of the uterine artery parallel to the ureter between the ureter and umbilical artery, it is clipped temporarily.

4. Clipping of infundibulopelvic vessels 05'13''

The technique is completed by clipping the infundibulopelvic vessels on both sides.

5. Myomectomies 05'33''

The orientation of the incision is determined by many factors such as size, number, and location of fibroids, as well as their proximity to the uterine tubes and vessels. The best incision is also the one which makes suturing easy. In this case, different incisions are performed with the monopolar hook until the capsula of the myomas. Several myomas are enucleated using a corkscrew and a Museux forceps. Traction has to be applied along with tissue dissection in order to free the myomas. Thanks to the clipping, bleeding is controlled and the sutures can be made at the end of the myomectomies.

6. Closure 14'03''

A 10mm trocar, which will be necessary for the morcellator, is placed on the left side from now in order to accelerate and facilitate the introduction of the suture. The closure of the large hysterotomy is performed in two layers in order to have no dead spaces and hematomas, which could entail a fistula and a weakness point with a great risk for uterine rupture during pregnancy. The deeper layer suture is performed with separate 2/0 monofilament stitches using an extracorporeal knotting technique. The superficial layer is closed by means of a continuous V-Loc™ 3/0 barbed suture. The superficial hysterotomies are closed using a single layer suture of monofilament 2/0. After closure of all hysterotomies, some other subserous myomas are removed with no need for suture.

7. Removal of clips and morcellation of myomas 18'49''

Before proceeding to the myomas’ morcellation, clips are removed by gentle traction using a flat fenestrated grasper. It is very important to remove the clips before starting morcellation because if there is secondary bleeding, there is still time to see it. Electrical morcellation of the myomas is performed at the end of the procedure using a non-disposable Storz™ device.