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How to Reduce Blood Loss During Myomectomy: Advanced Techniques in Laparoscopic Myomectomy Surgery

Author Melissa Malena covers How to Reduce Blood Loss During Myomectomy: Advanced Techniques in Laparoscopic Myomectomy Surgery
 on BackTable OBGYN

Melissa Malena • Jun 26, 2024 • 39 hits

The goal of myomectomy surgery is to safely minimize fibroid burden while sparing the patient’s uterine function and their ability to bear and birth children. Myomectomy surgery can be uniquely challenging in the case of high fibroid burden, where extended operating time can increase blood loss and heighten the risk of emergent complications.

Success in challenging myomectomy cases balances careful planning, prep, and surgical technique. Gynecologic surgeons Dr. Sarah Rassier and Dr. Mark Hoffman share advanced techniques in laparoscopic myomectomy surgery, focusing on pre-operative preparation, how to reduce blood loss, and how to counsel pregnant patients on delivery options after their myomectomy.

This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable OBGYN Brief

• Laparoscopic ultrasound can be used in myomectomy cases to assist in visualizing intramural fibroids that need to be removed.

• Fibroid-related blood loss can be minimized through anemia optimization such as iron infusions, menses suppression and Lupron utilization.

• Fibroid containment is a crucial aspect of myomectomy success, and can be accomplished through containment bags or power morcellation followed by irrigation.

• When patients with a previous myomectomy go in for delivery, multidisciplinary decision making between the myomectomy surgeon and obstetrician is required to determine the best delivery option.

How to Reduce Blood Loss During Myomectomy

Table of Contents

(1) Pre-Operative Planning for Myomectomy Surgery

(2) Minimizing Blood Loss During Myomectomy Surgery

(3) Delivery Options After Myomectomy Surgery

Pre-Operative Planning for Myomectomy Surgery

Correct port placement is a critical component of success in myomectomy surgeries. Dr. Rassier often begins with a high leftover quadrant port in cases with larger pathologies, before adjusting the position to best fit each case. Time should be spent preoperatively to carefully consider the placement of the uterine incision to best allow for fibroid removal and protections of the corneal structure.

Cell salvage machines should also be kept on standby during high fibroid burden myomectomy cases, as they can be used at a mini-laparotomy site. Dr. Rassier also implements laparoscopic ultrasound in some of her myomectomy cases, as it aids with intramural visualization and can ensure no fibroids are left behind.

[Dr. Mark Hoffman]
Interesting. Those are the ones where I have the MRI pulled up and I'm looking and I go back to the OR, and I'm going to pull it up again and turn around to the patient and go, "I think it's here." Then you dig and you're like, "Oh, thank God, there it is."

[Dr. Sarah Rassier]

[Dr. Mark Hoffman]
No, I think that's a really interesting idea to add to. Like you said, they're there, they're not necessarily small, but they're deep and they're intramural and they should come out. That's a really cool idea. Interesting.

[Dr. Mark Hoffman]
I think that when we talk about the 3D modeling and 3D sort of approach to enucleation really was what we're talking about, what instruments do you use? How do you get your fibroids out? Then talk to us about closure.

[Dr. Sarah Rassier]
For the incision planning, I actually spend quite a lot of time. Sometimes I can be sitting there for several minutes in the OR before I've even made my uterine incision, especially when they're larger or they're close to the corneal structures, just to really make sure that I feel confident that, once you make that incision, if it extends, is it going to extend into the utero-ovarian? Are you going to have enough room to get your huge fibroid out? Like you said, I don't prefer to do vertical incisions because of my suturing position, but do I need to? I spend a lot of time just planning out the incision.

Listen to the Full Podcast

Laparoscopic Myomectomy: Tips & Tricks with Dr. Sarah Cohen Rassier on the BackTable OBGYN Podcast)
Ep 41 Laparoscopic Myomectomy: Tips & Tricks with Dr. Sarah Cohen Rassier
00:00 / 01:04

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Minimizing Blood Loss During Myomectomy Surgery

Dr. Rassier combats anemia by implementing preoperative iron infusions, suppression of menses, and utilizing Lupron in severe cases. In the OR, she consistently uses a pharmacologic tourniquet of 1 gram of intravenous tranexamic acid and 600 mg of rectal misoprostol. It is critical to be efficient, as the patient will be constantly bleeding at some level for the entirety of the procedure.

When closing the layers of tissue, Dr. Rassier uses a barbed suture for all layers except the endometrium, where she implements a smooth suture to reduce intrauterine adhesions. During the fibroid removal, contained extraction is crucial, and power morcellation or a containment bag should be used to avoid spreading cells across the cavity. When implementing power morcellation, Dr. Rassier recommends stringing the fibroids in a line before enucleation. Post enucleation, aggressive irrigation of multiple liters dilutes any residual tissue or cellular spillage.

[Dr. Mark Hoffman]
One thing I forgot to ask, OR setup and those things, what are you doing to minimize blood loss? I think I actually listened to one of your talks years ago and just totally copied at least what you did then. I'm curious if I need to update my protocol. What are you doing for minimizing blood loss besides obviously surgical approach and technique and those things?

[Dr. Sarah Rassier]
It probably is not much different than what I would've said years ago. I try to be conscious about anemia optimization ahead of time. I really love using iron infusions. You just get so much of a quicker bounce back on your blood count. I love that along with suppression of menses or Lupron if it's really severe. Then in the OR, I pretty much universally use what I call a pharmacologic tourniquet. I use intravenous tranexamic acid, rectal misoprostol.

[Dr. Mark Hoffman]
One gram IV of TXA?

[Dr. Sarah Rassier]
Yes, exactly.

[Dr. Mark Hoffman]
Then I think 800 micrograms or 1,000 micrograms of meso per rectum?

[Dr. Sarah Rassier]
Yes, I usually use 600, but I think there's some variation of what's been reported for miso, and it's tolerated quite well per rectum. One thing our anesthesia team often asks us is in ortho, they usually repeat the TXA. I usually just give it once at the beginning. Then I'll use a dilute vasopressin during the case too.

[Dr. Mark Hoffman]
That's exactly what I do because I probably copied a few exactly from your talk. It works great, honestly. The number of times I've had to transfuse, unless someone is severely anemic and some of these myomectomies, you're cutting muscle bleeds, but I think it dramatically reduces little stuff that can build up over a long case.

[Dr. Sarah Rassier]
Yes. I'm thoughtful about whether I want to do any structural hemostasis, like vascular clips of the uterine arteries or tourniquets, but I find that I don't need it too much. I'm sort of one of these, if it's not broken, don't fix it. Sometimes for these extreme cases, this is another one of these "thinking outside the box" things. If I have a suprapubic mini-lap for these huge cases, I might put a tourniquet in through my open incision, just like you would for an open hysterectomy. Make a hole in the broad and put a Penrose strain or something similar as a tourniquet. I don't do that often at all. I'd say that's more for these extreme cases, and same thing with clipping the arteries.

[Dr. Mark Hoffman]
I've obviously gotten to the uterines laparoscopically and visualized them if I had to get them, but the number of times I need to do that for a hysterectomy, one hand. On a myomectomy, I've never felt like that was necessary. I feel like you said, if you do these things and you're thoughtful in your approach and you're relatively efficient in your nucleation and your closure because I think, in residency, we did so many myomectomies that were open, but the tenet was speed.

Be efficient. This thing is going to bleed until we're done. Go, go, go. Just be efficient with your steps. Don't rush, but every second counts. Once you get those layers closed and you've got a hemostasis, mechanically that's going to be the biggest way that you can create hemostasis. I think that other stuff buys you some time, no, that's exactly what I do as well.

[Dr. Sarah Rassier]
Your comment about efficiency, that's my number one thing I'm always talking about is from the moment you make your hysterotomy incision until it's closed, it's going to continuously ooze. You want it to ooze because if the myometrium is ablated, it's not going to heal well. Sometimes you can't tell because you're in your little zone and you don't really see, there's actually a pool of blood accumulating by the liver. I think, just consciously looking at the time, making sure you're making forward progress, especially if you have trainees involved, being thoughtful about how that is progressing with the efficiency of the case is really important.

[Dr. Mark Hoffman]
Time is, yes, meaningless. You're just working and you go, go, go. Yes, it's been oozing down there that whole time. Okay. Closure and layers, right? Is it always going to be a barbed suture for you?

[Dr. Sarah Rassier]
For me, I'm pretty much always a barbed suture. If I know that I've gone through the endometrium, I'll usually do a smooth suture for endometrial, over-sewing over the endometrial cavity. I don't know if there's any data. It's just more so that's how I would do it open. I'm trying to replicate it laparoscopically.

[Dr. Mark Hoffman]
I do the exact same thing. I just feel better knowing that whatever's inside is smooth and maybe would reduce the risk of there being intrauterine adhesions.

[Dr. Sarah Rassier]
Yes. I have some colleagues that use barbed, so I'm sure it's fine, but that's just how I do it. I try to think about obliterating the dead space. There's not really a pocket for hematomas to form as much. This is the part that I think is the hardest for people to grasp when they're learning how to close this huge gaping hysterotomy and make sure that the myometrium really approximates well. I equate it to closing a book or closing a clamshell, just getting it to rebuild itself. I do multiple layers with the barbed suture and then a separate cirrhosal closure.

[Dr. Mark Hoffman]
Tissue extraction, I know we've talked about this endlessly in the last 12 years of our careers, but tell us a little bit about how you get fibroids out.

[Dr. Sarah Rassier]
I'm a huge proponent of contained extraction. I think, in my opinion, everything should be done within a containment bag when feasible. It can be power morcellation if you have it or you want to do that and the patient's amenable to it. I usually do manual extraction with a scalpel, but I have heard a lot of people say, "Well, the cat's already out of the bag. If you're doing a myomectomy, the fibroid has been dissected out. You could be spreading cells through the cavity."

That's definitely true. I explain that to patients that this is not an oncologically sterile procedure. This is going to potentially disseminate some cells from just enucleating the fibroid. I think that the potential for leaving little tissue pieces or leaving little fibroid chunks in there as you're morcellating is really significant. We're seeing more and more cases of these peritoneal fibroids after prior myomectomy or prior hysterectomy. Those are pretty morbid in terms of if you have to go in there and reoperate on them in some cases.

[Dr. Mark Hoffman]

[Dr. Sarah Rassier]
I like the containment bag. I think it doesn't eliminate the risk, but it might minimize the chance of leaving a little fibroid piece behind.

[Dr. Mark Hoffman]
No question with the mechanical morcellator, we were shooting little pieces of fibroid bits everywhere. I think that we're morcellating by hand as well now. It's the little bits and it just keeps it together. There's a lot of fibroids, putting them in a bag, it's a smart way to do it. Are you using a fishing line at all to keep them?

[Dr. Sarah Rassier]
If I have a lot of tiny fibroids, I'll do that. Create a string of pearls where I have a suture that's in there. Then as I'm collecting them, I'll just string them up. Or if you already had a mini-lap for the case, let's just say you made your suprapubic mini-lap at the beginning, I'll just take out the smaller fibroids as I go just to avoid losing track of them. That's the worst. You don't want to lose track of it and then spend forever searching for small fibroids.

[Dr. Mark Hoffman]
30, 45 minutes looking for that one. Make sure you count as you go because otherwise, is there another fibroid? You don't want to find that MRI in six months and realize that you left it there for sure.

[Dr. Sarah Rassier]
I also like to do what I call excessive irrigation. I sort of say I'm in recovery for being an over-irrigator because, at the end of the case, there had been fibroids potentially sitting in the pelvis the whole time. I just try to do several liters of irrigation to ideally try to dilute if there's any residual tissue spill or cellular spillage that's in there.

Delivery Options After Myomectomy Surgery

For patients with a history of myomectomy, decisions between vaginal and C-section deliveries should be made through multidisciplinary discussion with all care teams treating the patient. Dr. Rassier does not subscribe to the previously held belief that if the uterine cavity has been previously breached a C-section is necessary. However, she recommends that patients who had a significant amount of myometrium removed during a previous myomectomy be counseled toward C-section. For cases where previous myomectomies focused more on exophytic fibroids and the myometrium remained in good shape, vaginal deliveries can be a valid option along with C-sections.

[Dr. Mark Hoffman]
Interesting. I will say for myomectomies though, if they're getting a C-section, I think I have to talk to Tatney about this too, if they're getting a C-section, then they're going to get a Pfannenstiel anyway. Even if it's cosmetically similar, rather if it's cosmetically not as preferable for our patients, they're going to get a bigger one through there anyway. If we're doing it, then that's what I usually counsel to my patients. If they're patients who are trying to get pregnant, then that may be an option. Are you recommending all patients who get a myomectomy undergo C-section for delivery?

[Dr. Sarah Rassier]
Yes. I feel like that's a tricky one that I usually try to weasel out of because I'm luckily not doing any obstetrics.

[Dr. Mark Hoffman]
Ask your obstetrician.

[Dr. Sarah Rassier]
Yes. I do basically tell them that I don't really believe in the whole “if the cavity is breached or not.” Basically, if you have an extensive myomectomy involving significant myometrium, I think you should probably get a C-section or at least be counseled about that. If people have more exophytic fibroids where we're really hardly touching the myometrium and it's just more cirrhosal work, then I'll really encourage them to discuss that with their OB. Maybe that could be something that would be a trial of labor. I think I usually just give them the op notes and say, "Make sure to show your pictures to your OB and explain what happened."

[Dr. Mark Hoffman]
I knew you were smart. Yes. Unless it's pedunculated, we're digging in there and tearing this thing apart to get it out. I don't mean that literally, but these big internals. If they're large enough to require a myomectomy, for the most part, we're making pretty big incisions or if they're small fibroids, there's usually a bunch of them. Forget if it's in the cavity or not. If I'm making 80% cut deep into the uterine wall, whether the last little bit of endometrium was compromised or not is not why they're having a uterine tear in my mind. I also like to sleep at night. Call me crazy.

[Dr. Sarah Rassier]
Exactly. I don't know where that urban legend about if the cavity is breached or versus not breached came from, but I really don't think that there's much data to support that.

Podcast Contributors

Dr. Sarah Cohen Rassier discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Sarah Cohen Rassier

Dr. Sarah Cohen Rassier is a minimally invasive gynecologic surgeon at Mayo Clinic in Rochester, Minnesota.

Dr. Amy Park discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Amy Park

Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.

Dr. Mark Hoffman discusses Laparoscopic Myomectomy: Tips & Tricks on the BackTable 41 Podcast

Dr. Mark Hoffman

Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.

Cite This Podcast

BackTable, LLC (Producer). (2023, December 21). Ep. 41 – Laparoscopic Myomectomy: Tips & Tricks [Audio podcast]. Retrieved from

Disclaimer: The Materials available on are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.



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