Tamer A. Seckin, MD

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 I am Victor Gomel. I am a  Professor at the University of British Columbia in Vancouver, Canada,  and my guest today is Dr. Tamer Seckin, who is a well-known gynecologic  surgeon in New York, New York. Dr. Seckin, I understand you get a lot of  patients referred to you for myomectomy. What are the indications for  which they are referred to you?

  Well, first of all, thank you, Victor,  for the introduction. I also thank OBGYN.net for this opportunity. I  mainly get three groups of patients: mainly patients who are referred  for fertility reasons, patients who are symptomatic with fibroids, that  is the second group, and maybe the third group, I must say, patients who  are asymptomatic but incidentally diagnosed with fibroids on routine  exam but they are looking for answers, if possible, maybe prophylactic  myomectomy surgery.

  The first group were patients who wanted to become pregnant. What are the characteristics of these patients?

  These patients are typically looking  for getting pregnant or have failed extensive and expensive course of  IVF treatments. They are referred by infertilitists to me for surgical  eradication of their fibroids. These fibroids are uniquely intrauterine  or outside the uterine cavity, obstructing the tubes.

  So you have then patients who have either failed IVF, as you say.

  Or patients who wish to become pregnant, have no other parameters of infertility but have fibroids.

 Yes, this group of people is essentially  thought to have lyomyomas causing their infertility. They are referred  without any treatment to me prior to the trial of IVF.

  So I will return to this group of  patients. What about the other group of patients who are those in whom  fertility is not a problem? What are their characteristics?

   These are patients later in their  reproductive years, close to menopause, who have typically  fibroid-related issues with their uteruses. Their characteristics are  rather larger fibroids or they are bleeding symptomatically and with  pain or pressure symptoms. These patients are usually advised to have  hysterectomy or told they are candidates for hysterectomy and they are  coming to me as a hysterectomy alternative: myomectomy, solitary or  multiple myomectomy, or they are basically coming for hysteroscopy,  prevention of fibroids, a simple first episode that we treat if they do  not want to have laparoscopy if the fibroids are in the uterine cavity.  That is the second group of patients.

   Is your approach to these two groups of patients different?

   Mainly, my approach is not different. I  use the minimally invasive technique of laparoscopic myomectomy, which  is well-known to perform on these cases through small scars and they are  usually sent home the same day. My approach is essentially the same.  However, in the infertility group, extensive effort is made to eradicate  and remove the intrauterine cavity and clean the uterine cavity with a  hysteroscope. Not even leave anything bulging from above. Additional  laparoscopic approach is also taken on this group.

   I will come to the technique, but if  you have in the group of patients who come to you for symptoms, they may  have intramural fibroids and also submucous fibroids. What do you treat  first? Do you treat the submucous and see what would happen, maybe you  do not need to treat the others? How do you handle that?

   Well, this is a very tough group of  patients, but essentially submucosal resection is the first step in  their treatment. I personally prefer looking to our past experience,  prefer everything in one surgical episode after the removal of the  hysteroscopic fibroids, submucosals, I go above and take the intramurals  that are impinging on the cavity. Usually after myomectomy, there is a  tendency for the intramural fibroids to impinge more on the cavity. They  will come back as a cavitary fibroid in two months or so. I have seen  these patients.

   Your technique for dealing with the  intramural and subserous fibroids is the same irrespective of the  indication for which you are doing it?

   Would you please describe your technique? This is your abdominal approach we are talking about.

   Yes. The challenging cases are  obviously with the number and the size, it gets into a tougher surgery,  but I have found over the years that if we solve the bleeding issue  during myomectomy, the size and the number does not become an obstacle  to my surgical procedure.

   Intraoperatively, I do one thing that  is very special to these patients. I put a tourniquet, apply the  tourniquet and cut the total uterine arteries’ blood supply and this  allows me to have a total bloodless myomectomy and number-wise, nothing  becomes a challenge because there is no bleeding. We can put as many and  as tight suturing as we want at our total control.

   It is very unique. I apply the  tourniquet to a very tiny, half centimeter, 3 ml to 4 ml incision on the  culdotomy, through a culdotomy I performed through the laparoscopy to  the back of the uterine meninplative. I put the tourniquet abdominally  through one of the trocars and I grabbed the tourniquet at one end from  the vagina that is stable and the free end I pass through the broad  ligaments like a ring around the neck of the uterus and I have two hands  in the vagina and I tighten it down to the uterine manipulator. That  basically cuts total uterine arterial pulsatile blood supply. You may  have some small venous bleeding, but that is not going to be any  obstacle in your way during surgery.

   And you do the whole procedure laparoscopically?

   I do the whole process  laparoscopically. This also enables me to remove larger fibroids without  any bleeding, so I have time and control of the case.

   What do you use to suture the site from which you remove the…?

   The uterine defect is typically closed  one or two layers according to the thickness of the uterus muscle  layer, but I use all Vicryl on a CT1 needle and I use interrupted, very  snug and frequent suturing.

   Can you tell me how many patients you have operated on in each group?

   I do have around fifty patients for  infertility purposes on whom I have operated and close to 500 for  hysterectomy alternatives in the last 15 years.

   Outcomes are pretty satisfactory. In  the myomectomy group, we do have 10% of the patients who got pregnant  without any IVF in the interim period of six months of resting period,  accidental pregnancies are there, and the IVF group, half of those  patients have got pregnant and I have only one patient with a morbid  outcome during their c-section and the follow-up c-section but most of  these patients are delivered by c-section without any incident. Of the  myomectomy group, only 10% to 15% have come back for hysterectomy  requests and these were patients, incidentally, who had adenomyosis and  other complicated pelvic pathology that made their cases difficult with  pain or some other issues.

   In the overall group that I have,  because typically I deliver these masses through culdotomy, in the  myomectomy group, I have one infection and one urethral obstruction  which was relieved by removal of the culdotomy stitches on the corner,  an overzealous bite on the corners which was due to the surgical  technique. But these happened in the beginning of my career in the first  six years. Absolutely the most important thing is, I think, is  hemostasis under laparoscopic control after the tourniquet release, the  bipolar forceps is used to clean the edges of small oozings and also  meticulous approximation of the tissues equally on each side of the  defect. I think these are  basic, simple surgical principles that apply  to the uterus also.

   Thank you very much, Dr. Seckin, for this opportunity.

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From the 35th Annual Meeting - Las Vegas, Nevada- November 2006

Myomectomy, Fibroids and Fertility

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Myomectomy, Fibroids and Fertility Video

Tamer A. Seckin, MD
872 Fifth Avenue
New York, NY 10021-4953
USA
Phone: 212.988.1444
Fax: 212.988.1755
Email: tamer@deep.net 


Accreditation Council for Gynecologic Endoscopy, Inc.

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35th Annual Clinical Meeting of Advancing Minimally Invasive Gynecology Worldwide (AAGL)Las Vegas, NV - November 2006

Author | Tamer A. Seckin, MD

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