BackTable / OBGYN / Article
Decision Points in Laparoscopic Myomectomy Surgery
Melissa Malena • Updated Jun 26, 2024 • 34 hits
Laparoscopic myomectomies require surgeons to make complex decisions regarding incision type, location and technique. The myomectomy decision making process focuses heavily on the individual patient’s history and goals while also balancing surgeon preference and comfort. Gynecologic surgeons Dr. Sara Rassier and Dr. Mark Hoffman share their tips for a successful myomectomy, focusing on the decision points that present with every myomectomy surgery. How many fibroids are too many for myomectomy? Robotic or conventional laparoscopy? Umbilicus or suprapubic incisions?
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
• Mini-laparotomy tools can be utilized to aid in tissue extraction during myomectomies with a large fibroid burden.
• Laparoscopic umbilicus incisions and mini-laparoscopic Pfannenstiel incisions are the recommended entrance techniques for laparoscopic myomectomy tissue extraction.
• Laparoscopy is the preferred myomectomy entrance technique due to its minimally invasive nature, however there is discourse over whether to utilize conventional or robotic laparoscopy.
• Umbilicus incisions should be performed superiorly to inferiorly, staying within the coronal tissue for the best healing results.
Table of Contents
(1) How Many Fibroids is Too Many for Myomectomy?
(2) Robotic vs. Conventional Laparoscopic Myomectomy
(3) Umbilicus vs Suprapubic Incisions for Myomectomy
How Many Fibroids is Too Many for Myomectomy?
For patients with over a dozen fibroids, a successful laparoscopic myomectomy of all fibroids is often not possible, as small fibroids may be left behind. Dr. Rassier recommends honest consultation with such patients on their long-term health goals to determine whether to continue with laparoscopic myomectomy or explore open procedures. In cases with a multitude of little fibroids, mini-laparotomy tools can be implemented to aid in tissue extraction. Tissue extraction can be performed through a mini-laparoscopic Pfannenstiel incision or a laparoscopic umbilicus incision. For patients with fertility goals, Dr. Rassier does not limit the number of fibroids that can be removed via laparoscopic incisions. However, for older patients with a high fibroid burden and significant associated pain, Dr. Rassier advocates for larger scale operations such as hysterectomy.
[Dr. Mark Hoffman]
I think that it just goes back to your visualization, right? Okay, if I get this one out, how am I going to get this out? All the different steps. I was lucky in residency and fellowship to get a lot of exposure to mini-lap, to doing a lot through just one little Pfannenstiel incision. I think it's like the most powerful, useful incision a gynecologist has. The benefit versus hysterectomy is the uterus moves around, you can bring the uterus up to that incision. Even for a 10-centimeter fibroid, you can move it around underneath the skin. You can get a ton done through those incisions. Is there any limit to the number of fibroids that you'll offer to remove through a midline laparotomy or through a big incision?
[Dr. Sarah Rassier]
No, I think the highest number I ever counted was 101. That was in a pretty extreme case, lots of little baby fibroids.
[Dr. Mark Hoffman]
Oh, come on. Really?
[Dr. Sarah Rassier]
Yes. I think it does come down to patient selection too. If you have a, let's say, 49-year-old, no desire for any sort of fertility preservation who just wants to have a fibroid procedure and they have innumerable fibroids, probably I'm going to counsel them towards hysterectomy. For these patients that have a really huge fibroid burden, but they want to preserve their uterus, I think that especially with fertility concerns, and that's what I would try to be as aggressive as I can.
[Dr. Mark Hoffman]
Are you just bivalving the uterus and digging them out and trying to close the whole thing? That seems to me to be a worry that I have, is if you're making 30 incisions on the uterus, I don't know that we have that data, but certainly something you worry about in their pregnancy.
[Dr. Sarah Rassier]
Exactly. I would say these are not the most common cases whatsoever. Most of my cases are under 20 fibroids by far, but I have seen the bivalve-ing technique. That's not something I use frequently. When I have that many fibroids, I'm going to want to be extra conscientious about the hysterotomy location to try to get as many as possible through each site because I do worry, how much are you creating a Swiss cheese uterus that's not going to really give you the benefits you're looking for?
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Robotic vs. Conventional Laparoscopic Myomectomy
Unlike hysterectomy which features two major blood supplies, in myomectomy the vasculature can vary in size and location. When developing a myomectomy management decision tree, providers must consider conventional laparoscopy versus robotic laparoscopy. Although robotic laparoscopy offers ergonomic benefits to the surgeon, Dr. Rassier primarily implements conventional laparoscopy due to its physical flexibility. Laparoscopy is the preferred myomectomy technique as it is minimally invasive, however it limits visualization which poses a challenge in cases featuring many small fibroids. Before deciding to abandon a traditional laparoscopic approach, Dr. Rassier administers Lupron pre-operatively in complex cases to shrink the existing fibroids.
[Dr. Mark Hoffman]
Myomectomy can be a little trickier because, unlike a hysterectomy, the two major blood supplies or four, depending on who you're asking, the fibers can be anywhere, right? They can be any size, they can be any number. How do you counsel patients on your approach? If we're talking about abdominal, large incision, mini-lap, are you doing any robotics or are you doing only traditional or conventional laparoscopy?
[Dr. Sarah Rassier]
I've started to think that I may need to get a little more into the robotics realm, especially as I'm valuing the ergonomic benefits of not bending over and leaning over long laparoscopic cases, but I definitely trained very straight six-heavy. It's like, if you're a hammer, everything's a nail. I feel very comfortable with just the flexibility that conventional laparoscopy affords me. I really like that.
I think sometimes for the bigger fibroid cases, it's nice to be able to be flexible when you need to start up very high, super umbilically, but then also work down low later. I really don't use robotics hardly at all at the moment, but it's something I keep in mind.
…
[Dr. Mark Hoffman]
I actually just got back on the robot after seven years, primarily in one aspect to get my residents some more training because they wanted to do more and more of it. A lot of them are doing it when they come out. Myomectomy, I was like, "That's the reason why I got to get back on the robot." Doing all these hysterectomies, all these closures, straight stick. It's cool that I can do it, but my shoulder disagrees at the end of the day.
To be able to do my myomectomies robotically now in fellowship, I did almost all robotics. I had to make that transition on my own because we didn't have a robot where I was operating for most of the first 10 years of my practice, but I've just gotten back on within the last year, and a little bit of a frustrating curve when you first get back on.
[Dr. Sarah Rassier]
Yes, I know. There is some humility required to switch platforms when you're so good at one option because you're going to inevitably go back a little bit, be a little slower, a little less efficient. Not that we can't do the same steps, but I think that's a hard hurdle to make yourself be slower.
…
[Dr. Mark Hoffman]
The biggest reason for me with robotics was that the hysterotomy, I might need to make a vertical hysterotomy or at an angle that is not super easy from the direction that I'm working. That's part of the reason why I made the switch. I'm glad I did, but also, like you said, it's nice to be able to offer those through a different approach. Just doing conventional laparoscopy for your MIS cases, but what's your decision tree when it comes to offering a laparoscopic approach versus a mini-lap versus an open case?
[Dr. Sarah Rassier]
I have really transitioned to more hybrid options lately, which I just equate to thinking outside the box. I feel like I really try to push minimally invasive whenever possible, but sometimes if you have super numerous fibroids, lots of little teeny tiny pebbles in the uterus, or just the size where you just don't have enough room to get your visualization and manipulation, sometimes you have to think, "Okay, is this better that it's done open?"
I think one thing I do is I use a lot of Lupron in my practice. Even if it seems like when you first see the patient, you're like, "Ooh, this is not going to be feasible laparoscopically," I'll still give it a try, trying to shrink it a little bit with Lupron and see if we can get some benefit.
[Dr. Mark Hoffman]
You're doing that for pre-op prep for myomectomies?
[Dr. Sarah Rassier]
Yes, not for everybody, but just for the extreme cases.
Umbilicus vs Suprapubic Incisions for Myomectomy
When deciding between umbilicus versus suprapubic laparoscopic incisions, Dr. Rassier emphasizes the importance of patient-centered decision-making. In patients at risk for hernias, umbilicus incisions should be avoided. While classical myomectomy training focuses around suprapubic incisions, Dr. Rassier only does mini-laps at the umbilicus, utilizing suprapubic incisions for cases with large pathologies. For the best healing results, keep umbilicus incisions within the corona and if expansion of the incision is necessary, expand vertically. When making the incision, cut vertically superiorly to inferiorly. Post myomectomy, after closing the fascial incision, grab a piece of fascia at the subdermal umbilical fascia with a U-stitch to create the desired reconstructed belly button.
[Dr. Mark Hoffman]
Talk to me about why you choose belly button or umbilicus versus suprapubic because I personally have gone almost exclusively to suprapubic because I think in terms of cosmetic, I think in terms of healing, I always felt like the hernia rate or at least what I've read is the hernia rates appear to be lower through a Pfannenstiel, mini-lap Pfannenstiel than through a larger umbilical incision. What can you tell us about that?
[Dr. Sarah Rassier]
Yes. I feel like it really is patient-dependent. If someone is obese, has a prior hernia repair, or it seems like they're more prone to hernia, then I definitely want to avoid the umbilicus or sometimes people have sort of like subtle subclinical hernias that you notice on exam now that you're a belly button expert. I definitely avoid it in those cases, but I have some patients that they really would like for cosmesis to avoid any other bigger incisions elsewhere.
I also don't operate using a suprapubic port. It's an additional incision that I wouldn't already be using for my surgery, whereas the umbilicus, I'm just expanding a preexisting incision. I feel like I've to some extent become a belly button plastic surgeon over my career. I really spend a lot of time thinking about how to reconstruct it. You can get a sense of, "Okay, this is going to look really good," or, "This is actually not the best umbilicus for a big incision. That's not going to go well together."
[Dr. Mark Hoffman]
I definitely feel like I got really good at my suprapubics and my belly button plastic surgery skills maybe are not up to the Sarah Rassier level of expertise. I definitely feel like that's an area for professional and surgical development on my end because I do feel like it's one of those things that, we have large patients where we are. I know a lot of people have big patients, but I just feel like there's a lot of complaints about the belly button. People are very picky about their belly buttons. We'll definitely add belly button expert to your list of credentials in post to make sure we have that in there as well. I'm assuming that means you're an ipsilateral sower, ipsilateral ports operator.
I was trained that way too, but for my myomectomies, I was using a suprapubic, I was using that Pfannenstiel port. I would just do an ipsilateral, or the diamond rather, not ipsilateral, but the diamond port configuration for myomectomies specifically. I think, yes, it makes sense if you're going to use that umbilical port anyway to do it that way.
[Dr. Sarah Rassier]
Yes. I've been trying to challenge myself to really only do small mini-laps at the umbilicus. If you have a huge pathology where you're like, "Okay, this needs more than a three-centimeter of any lap to be efficient," then I'll go suprapubic for sure. I'd say I'm probably 70/30 on my distribution, so I try to keep it like three, three and a half centimeters at the umbilicus.
You probably do all the same stuff. My tips are that the corona or the ring of the belly button tissue, if you can keep your incision within that to the most degree, it's like an invisible incision at the end. I usually do a vertical incision through the base of the umbilicus, and if I have to go beyond that coronal ring of tissue, I just try to go vertically either superiorly or inferiorly a little bit, and that usually heals pretty nicely.
[Dr. Mark Hoffman]
Are you going directly through the belly button, like you cut it in half, or do you go around the base?
[Dr. Sarah Rassier]
Just vertically, just straight through. Yes, superiorly to inferiorly, just straight through the base. A tip that one of my old colleagues at Brigham taught me was how to tag the fascia to the subdermal umbilical base. Basically, after you closed your fascial incision, you grab a little bite of fascia and then you do a little U-stitch on the base, the absolute densest tissue at the base of the umbilicus, in that little subdermal tissue, and then just mirror it on the other side. Fascia, skin, skin, fascia, and it really brings it down and recreates a nice innie. That's something that I think helps a little bit to hide the incision.
[Dr. Mark Hoffman]
That's a video that needs to be made, I think, for one of these meetings, so you can show me exactly because it is like 3D reconstruction in that area. I think some people go around the belly button and I've seen other surgeons will do a big crescent or around it. It doesn't look great cosmetically. The ones that go sort of straight through seem to heal and look the best because it mimics one of the natural creases and folds in the belly button. Maybe I'll just have to get more used to that.
[Dr. Sarah Rassier]
Yes. I think I'm the opposite of you in terms of my suprapubics. I feel like I get more complaints about cosmesis in terms of that. I think it's just whatever you get really fast that gets better.
Podcast Contributors
Dr. Sarah Cohen Rassier
Dr. Sarah Cohen Rassier is a minimally invasive gynecologic surgeon at Mayo Clinic in Rochester, Minnesota.
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
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 https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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.