William W. Schuessler, MD


 	
 	Uterine myomas are the most common tumors of the female genital tract. = Hysterectomy has been a very common therapy 	in patients who have completed reproduction. In fact, uterine myomas = account for 20% of the 650,000 hysterectomies 	performed annually in the United States. Interest in uterine = preservation and organ preserving surgery through 	techniques of minimally invasive surgery has increased since the first = reports of laparoscopic myomectomy in 	1980.


 	
 	Laparoscopic myomectomy has evolved into a safe, efficient, and cost = effective approach for the treatment of 	intramural, subserosal, and pedunculated fibroids. At first the surgical approach = was limited by the technology 	available for myoma morcellation and uterine repair. Now with the availability of the = Sterner=99 Electro-mechanical 	Morcellator (Karl Storz Endoscopy - America, Inc., Culver City, CA), the Harmonic = Scalpel=99 (Ultracision, Inc., 	Smithfield, RI), and the development of instrumentation for suturing, linear = stapling, and combined bipolar coagulation 	with knife blade cutting the laparoscopic myomectomy is a procedure which = can readily become part of the armamentarium 	for all advanced laparoendoscopic surgeons.
 	
 	Pre-treatment of the uterine leiomyoma with GnRH agonist reduces the = size of the myoma, decreases the blood supply, 	and makes removal of the tissue simpler because of the decreased tissue = hardness. An 8 cm diameter myoma shrinks 	to 6 cm in diameter - a forty percent reduction in volume of the myoma. = This reduction in volume results in a 	significant decrease in blood loss and a significant reduction in time required for = removal of tissue after resection.


 	
 	This article describes a safe, effective, and efficient method for = performance of laparoscopic myomectomy, details 	the risks of laparoscopic myomectomy, and describes the methods to = prevent, recognize, and treat complications 	of this procedure.

 
 	Leiomyomas can arise from the uterus as pedunculated, subserosal, = intramural, submucosal, and intracavitary. 	These myomas derive their blood supply from a stalk containing the = plexus of arteries and veins providing the 	blood supply to the myoma. The myoma itself is derived from a single muscle = cell and will generally be homogeneous 	in its consistency unless areas of necrosis have developed from a process = of central degeneration. Laparoscopic 	treatment of pedunculated, subserosal, and intramural myomas is described in the = following sections.
 	
 	

Laparoscopic Treatment of Pedunculated = Myoma


 	
 	Pretreatment with GnRH Agonist: The pedunculated myoma provides the = laparoscopic surgeon with an opportunity 	to provide medical and surgical therapy to rid the patient of a large, = uncomfortable, unwanted mass in an outpatient 	surgical setting with a time to recovery usually not exceeding one = week.


 	
 	After physical exam has indicated the presence of the myoma, evaluation = with ultrasound allows the surgeon to 	optimally plan the surgical approach, including trocar placement based on the = position and size of the myoma. 	A color doppler flow study assists the surgeon in identifying the major venous and = arterial pathways in order 	to plan the surgical approach to minimize blood loss.
 	
 	Short term treatment with leuprolide acetate (GnRHa) has been a = successful adjunct to open surgical therapy of 	leiomyomas of the uterus.

 The reduction in the size of the = uterus was 35% by the first month and 	average reduction in the total volume was 44% after two months of treatment. In = addition, the surrounding uterus 	decreases in volume more than the leiomyomas.

 This differential = shrinkage between fibroid and uterus 	creates a cleavage plane between the uterus and myoma which can result in the = expulsion of the myoma from the 	uterine muscle, which works to the benefit of the laparoscopic and hysteroscopic = surgeon. As a result of this 	differential shrinkage, subserosal myomas with up to 25% of their volume in the myometrium will = become almost 	pedunculated with 5-10% of the myoma within the myometrium.
 	
 	For large myomas (greater than 8 cm in diameter) myoma size can be = monitored monthly by ultrasound and, if the 	myomas continue to decrease in size, the GnRH agonist can be employed = up to six months.
 	
 	Hemostasis: The injection of dilute vasopressin (Pitressin, = Parke-Davis, Morris Plains, NJ) (5 units in 100 ml 	of normal saline) into the stalk of a pedunculated or bed of a = subserosal myoma will further reduce the blood 	supply and therefore decrease the blood loss during the myomectomy procedure. = This solution can also be injected 	subserosally to assist with the development of the plane of dissection between the = myoma and the serosa. For 	a procedure exceeding 30 minutes of dissection, this injection may be repeated. Care must be = taken to ensure 	the vasopressin is not injected intravascularly. Notify the anesthesiologist prior to the injection of = the vasopressin 	solution to ensure proper monitoring is being conducted.
 	
 	Excision of Pedunculated Myoma Without Serosal Incision: Pedunculated = myomata and those subserosal myomas which 	have been extruded after GnRHa treatment can be excised by compressing = the bed or stalk of the myoma with a large 	grasper to allow placement of the appropriate sized linear stapler = across this vascular pedicle. The surgeon 	can then staple and cut in one step. This technique provides for excision = of the myoma and hemostatic closure 	of the serosa and underlying muscularis with one action. In a review of 40 = cases performed in this manner, estimated 	blood loss was less than 200 ml. Four patients subsequently conceived, three = of whom were delivered vaginally 	and one by cesarean section without complication. At second-look laparoscopy = performed on six patients only minimal 	adhesions had formed to the operative site.


 	
 	In each of these cases the staple line was covered with an adhesion = barrier (Intercede (TC-7), Ethicon, Inc., 	Somerville, NJ). This technique works most effectively after treatment with GnRH = agonist because the differential 	shrinkage of uterus and myoma results in a loose serosal/capsular covering of the = myoma and a softening of tissue 	which allows compression of the base to further extrude the myoma. Pretreatment also = provides for sufficient 	serosal tissue to effect closure.
 	
 	Pedunculated myomas can also be resected after endocoagulation of the = pedicle or placement of loops.

 	To utilize the loop technique, position a Roeder-Loop around the base = of the myoma. Coagulate the capsule with 	endocoagulation or electrosurgery, incise the capsule, enucleate the = myoma, provide continuous tension on the 	Roeder-Loop while dissecting the myoma, and then close the capsule with the = Roeder-Loop. In this manner the Roeder-Loop 	acts to extrude the myoma while closing the serosa = hemostatically.

 
 	
 	The Harmonic Scalpel can also be used for this procedure.

 = The ultrasonically activated LaparoSonic® 	coagulating shears (LCS=99, UltraCision, Inc., Smithfield, RI) can be = used as a cutting and coagulating device 	similar to the linear stapler leaving a hemostatic cut line with minimal tissue = damage due to thermal energy 	spread.

 Any defect left in the surface of the uterus should be closed with 4-0 = absorbable long lasting 	suture in a simple interrupted, mattress style or running technique. The use of a = Laparotie=99 (Ethicon, Inc., 	Sumerville, NJ) allows fixation of the running suture tail and segments of the running suture = to ensure a firm 	hemostatic closure technique.


 	
 	The recently introduced Endo Stitch=99 (U.S. Surgical Corporation, = Norwalk, CT) can also facilitate suturing 	of serosal defects. An innovative suturing technique was developed using this = instrument to provide closure of 	uterine defects with a continuous running locked suture.


 	
 	Using this technique, 5-10 cm uterine defects have been closed in 5-10 = minutes.

 This instrument 	is reported to shorten operative time for laparoscopic myomectomies by = approximately 40 minutes.

 	
 	
 	Removal of Myomas: The removal of a myoma can be accomplished with four = different techniques: 	

1) Extraction through a colpotomy = incision with or without morcellation.
 		
 		2) Intra-abdominal morcellation with = simultaneous extraction through an abdominal port site with a mechanical 		morcellator.
 		
 		3) Intra-abdominal morcellation with = scissors, harmonic scalpel, or knife, with extraction through port site.
 		
 		4) Mini-laparotomy incision with = extraction and morcellation.


 	A technique which combines the advantages of mini-laparotomy with = laparoscopy uses the Maher abdominal elevator 	to facilitate quick enucleation and morcellation of myomas and suturing = of the myoma cavity.

 This 	technique utilizes gasless laparoscopy with an abdominal wall elevator. = This technique also allows rapid enucleation 	of a myoma by finger dissection as well as myoma reduction with the use = of scalpel and scissors inserted into 	the abdomen through the same incision. A laparoscope is used to guide the = closure of the myoma cavity with long-handled 	needle holders used normally at laparotomy. Combined use of = mini-laparotomy and laparoscopy is a singular benefit 	of the gasless laparoscopy approach and results in a significant = reduction of the time required for this form 	of surgery.
 	
 	The introduction of the Steiner=99 Electro-mechanical Morcellator (Karl = Storz Endoscopy-America, Inc., Culver 	City, CA) reduces time required for morcellation and extraction of myomas = through the operative port site by 	an average of 53 minutes on myomas whose average weight is 160 gms with a range of = 20 gms to 475 gms.

 	Fourteen myomas were extracted using the 15 mm manual morcellator compared to = 

 similar myomas extracted 	using the Steiner=99 Electro-mechanical Morcellator in this study. Myoma = weight in the manual morcellator group 	ranged from 30-410 gms with an average weight of 152 gms. In the manual = morcellation group, the average time 	required for morcellation was 79 minutes with a range from 20-240 minutes. In = the Steiner=99 Electro-mechanical 	Morcellator group, the average weight was 160 gms, with a range of 20-470 gms. The = average time required for 	morcellation and extraction was 26 minutes with a range of 30-90 minutes, with 90 = minutes being required for 	a 475g fibroid. On average, 53 minutes was saved using the Steiner=99 Electro-mechanical = Morcellator and, at 	an average operating room cost of $10.00/minute, the use of this device results in a $530.00 = operating room savings 	and an additional $150.00 anesthesia savings for a total savings per case of $680.00.
 	
 	During this comparative series there were no complications with the use = of the Steiner=99 Electro-mechanical 	Morcellator. With the use of the 15 mm manual morcellator, one surgeon developed = epicondylitis, renamed "manual 	morcellator elbow" as a result of the repetitive motion required for the use = of the manual morcellator.
 	
 	A simple technique for maximizing the effectiveness of the Steiner=99 = Electro-mechanical Morcellator is to fix 	the myoma into firm grasping instruments so that the myoma can be passed = into the Morcellator without causing 	rotation of the myoma and without endangering adjacent structures.
 	
 	Subserosal Myomas: Subserosal myomas which are too deeply embedded to = be treated with the compression technique 	described previously can be extracted safely using the following nine = steps:

1) Injection of dilute = vasopressin.
 		
 		2) Positioning of Roeder loop around = the base of the myoma.
 		
 		3) Coagulation of the capsule.
 		
 		4) Incision of the capsule.
 		
 		5) Myoma enucleation.
 		
 		6) Tension on the Roeder loop.
 		
 		7) Dissection of myoma.
 		
 		8) Closure of the capsule with Roeder = loop or linear stapler.
 		
 		9) Myoma extraction with morcellator.

The Roeder loop assists in maintaining hemostatic control of the = pedicle to the myoma. Linear staplers may 	in fact allow for a more secure hemostatic linear staple line for larger = subserosal myomas. For this purpose 	the U.S. Surgical linear stapler is designed with a flexible opening which allows = grasping of tissues thicker 	than can be finally stapled. These tissues are compressed to a size which can then be = stapled. The Ethicon produced 	stapler does not allow flexibility in the jaw and, therefore, a second compressing = grasper must be used if the 	Ethicon system is applied.
 	
 	Intramural and Deep Subserosal Myomas: The excision of myomas up to a = size of 500-700 gms is possible. Such myomas 	may interfere with embryo growth and pregnancy, produce massive uterine = bleeding, and produce pressure symptoms 	on the urinary bladder or rectum. In these circumstances excision of = the myoma is advisable.

 Complications 	can be avoided by following the Eight-Step approach as outlined = here:

1) Injection with dilute solution of = vasopressin.
 		
 		2) Regulation of entry point for = incision.
 		
 		3) Incision of uterus and capsule.
 		
 		4) Enucleation of myoma.
 		
 		5) Dislocation of myoma from = uterus.
 		
 		6) Coagulation of uterine bed.
 		
 		7) Closure of wound with deep muscular = and superficial serosal closure.
 		
 		8) Morcellation and extraction of = myoma.

The use of endocoagulation, electrocautery, contact-tip Nd:YAG laser, = and harmonic scalpel have all been used 	for the process of enucleation. The most difficult part of this procedure = is the control of the bleeding that 	will occur from the final vascular pedicle which provides the myoma with its = source of nutrients. The control 	of this vascular pedicle by using bipolar coagulation, linear staplers, or = LaparoSonic Coagulating Shears (LCS=99, 	Ultracision, Inc., Smithfield, RI) allows the surgeon to remove the myoma = hemostatically from the base. If the 	vascular pedicle is not controlled prior to the final enucleation of the myoma from its = base, there is a significant 	risk of extensive blood loss from this site. Control of bleeding from the retracted = vessels at the base of the 	myoma is very difficult laparoscopically. Deep sutures into the base of the myoma bed will = ligate these vessels 	hemostatically but are difficult to place if the bed is highly vascular and bleeding. To avoid = this situation, 	obtain control of the vascular pedicle prior to final excision of the myoma. Superficial bleeding from = the bed 	can be readily controlled with the use of argon beam electrocoagulation, spray coagulation and the use = of Endotherm 	and unipolar or bipolar coagulation. However, vessels which have retracted deep in the myometrium will not = be 	affected with these techniques. Two or three layer closure should be performed depending on the depth into the 	= myometrium and whether the endometrial cavity has been entered during the process of removal of the myoma. = 	
 	
 	Laparoscopic Versus Abdominal Myomectomy: As outlined above, the = resection of myomas from the uterus can be performed 	laparoscopically. The question then is, should they be performed? In a = comparative review of 20 cases performed 	laparoscopically with 20 performed abdominally, where the average = weight of myoma was 160 gms in the laparoscopic 	and 170 gms in the abdominal group, with a range of 20-475 gms in the = laparoscopic and 35-450 gms in the abdominal 	group, the results in 

 were obtained.
 	
 	Laparoscopic myomectomy resulted in less blood loss, fewer = complications, shorter hospital stay, a faster return 	to work, and fewer transfusions than abdominal hysterectomy. If the = laparoscopic myomectomy can be performed, 	it should be performed because of the benefits resulting to the = patient.
 	
 	Myoma Reduction by Electrosurgery: Myoma reduction by the procedure of = myolysis was first performed using Nd:YAG 	Laser techniques.

 However, the technique of laser = coagulation for myolysis is expensive and lasers 	are not always available at every hospital. In addition, second-look = laparoscopy revealed significant adhesion 	formation associated with this procedure.

 A 1.5 cm = length bipolar needle was developed to perform 	electrosurgical myolysis. This needle was not appropriate to treat = symptomatic large leiomyomas.

 	A 5 cm laparoscopic bipolar coagulation needle was then developed, and = its use in 150 patients with symptomatic 	myomas no larger than 10 cm has been evaluated.

 Patients = underwent pelvic examination and endovaginal 	ultrasound to determine myoma size and location. Those with symptomatic subserosal = and intramural myomas who 	were experiencing pain, pressure, and abnormal uterine bleeding, and whose myomas were 10 = cm or less were candidates 	for laparoscopic coagulation.
 	
 	Procedures were performed only if patients had no further interest in = preserving fertility. Depo Leuprolide Acetate, 	3.75 mg (TAP Pharmaceuticals, Deerfield, IL), was administered by = injection at the onset of menses and thereafter 	every 28 days for a minimum of three cycles. A volume reduction of = 40-50% resulted from this treatment.
 	
 	At surgery the bipolar needle was placed through a 5 mm suprapubic = cannula. The myoma was pierced repeatedly 	every 3-5 mm with the needle in a contiguous fashion to obtain numerous cores = of coagulation. Coagulation current 	for the bipolar was set at 70 watts, although powers of 100 watts as well = as 120 watts

 have been 	described. In 150 cases reported with this technique

 no patient = required hysterectomy or repeat 	procedure because of myoma regrowth. One patient developed a pelvic abscess and = subsequently underwent hysterectomy, 	and a second patient developed bacteremia which responded to intensive antibiotic = therapy. On average, a 10 cm 	myoma which was reduced to 5.9 cm diameter after Leuprolide treatment was further = reduced to 3.7 cm diameter 	after myolysis procedure. With three years follow up, no regrowth of these myomas has been = reported.


 	
 	The performance of laparoscopic leiomyoma coagulation (myolysis) can be = combined easily with hysteroscopic resection 	of submucosal fibroid myomas as well as hysteroscopic endometrial = ablation or resection procedure to treat menorrhagia.

 	In 87 patients the mean operating time was 28.7 minutes, with a mean = blood loss of 28 mL.

 Total 	uterine volume, which was measured at 598 cm3 on average prior to Leuprolide = treatment, was 279 cm3 after Leuprolide 	treatment and 7-12 months postoperatively was 110 cm3. No patient undergoing = bipolar coagulation for myolysis 	experienced a recurrence of symptoms.


 	
 	Myolysis with or without endomyometrial resection and resection of = submucous myomas is an alternative to hysterectomy 	and to myomectomy for perimenopausal women with symptomatic leiomyomas = who do not wish to become pregnant. Further 	evaluation is required to determine if the procedure is appropriate for = women who desire future childbearing.
 	
 	Arterial Embolization for Treatment of Uterine Myomata: The goal of = minimally invasive surgery is to provide 	treatment of the affected portion of an organ while preserving the organ itself = through incisions and ports as 	small as possible while maintaining a safe environment for the patient. The procedure of = arterial embolization 	for the treatment of uterine myomata is perhaps the least invasive of all methods = available for treatment of 	this benign condition.


 	
 	Unilateral femoral artery catheterization was performed and the pelvic = arteries mapped to identify uterine arteries 	and visualize tumor hypervascularization. The right and left uterine = arteries were then catheterized and inert 	particles of Ivalon were introduced in free-flow, gradually increasing = the size of the particles until tumor 	blood flow was eliminated. After completion of embolization, a fragment of = Spongel was left in the trunk of the 	uterine artery to ensure stability of the devascularization.

 = Menorrhagia was controlled, menstrual 	cycles returned to normal, and anemia resolved in 9 of 14 patients. = Menorrhagia decreased considerably in three 	patients as anemia resolved, but remained bothersome and required curettage in = two cases wherein simple hyperplasia 	was discovered.

 Two failures occurred: one with a pedunculated = submucosal myoma in the process of 	being expelled through the cervix and a second with multiple interstitial and = submucosal myomata who required 	myomectomy after six months because of persistent uterine bleeding. Embolization = of myoma did cause pelvic pain 	which was sometimes intense. It is probably of the ischemic origin and starts at = the time of embolization and 	usually lasts 6-12 hours.

 This pain requires analgesia, including = intravenous anti-inflammatory 	drugs and patient-controlled intravenous injection of narcotic analgesics.


 	
 	The use of preoperative Lupron depot (3.75 mg IM) (TAP Pharmaceutical, = Deerfield, IL) for one to three months 	reduces the caliber of uterine arteries by up to 50%. In an early series this = has resulted in a 50% reduction 	in the quantity of Ivalon particles used and a reduction in pain such that only mild = oral analgesics are required.


 	
 	The treatment of benign leiomyomata of the uterus by arterial = embolization techniques is a promising and exciting 	approach to reducing the invasiveness required for treatment of = symptomatic disease and reducing the risks associated 	with many surgical procedures.


 	
 	In reviewing over 750 laparoscopic myomectomies

performed by skilled laparoscopists, 	complications were minimal. None of the patients required laparotomy or = blood transfusions for bleeding. While 	operative time was generally longer than would be required for an open = procedure, patient recovery was much quicker. 	For those less experienced in laparoscopic procedures, performing = laparoscopic myomectomies with a colleague 	who has experience with these procedures is essential to reduce the risks = of complication. Skill in suturing 	should be obtained prior to, not during, the performance of this procedure. = The addition of hysteroscopic resection 	and ablation procedures will improve the patient satisfaction with the = results. The future of image-guided intervention 	such as embolization holds great promise for reducing even further the = need for invasive surgical procedures 	for treatment of this benign disease.

Intraoperative Situations During = Laparoscopic Myomectomy


 	
 	Certain intraoperative situations confront the laparoscopic surgeon in = the process of performing a laparoscopic 	myomectomy. Frequently, the way the surgeon initiates the procedure = determines the outcome both in success and 	in time required for the surgery. This section describes several of = these situations with recommendations on 	ways to avoid complications by thinking through the operation prior to = performing it.
 	
     

 Surgeon encounters a large myoma which fills the pelvis making surgery through standard lower 	pelvic trocar = sites (along Pfannenstiel line) very difficult.
 	
     

 When operating on = moderate to large size myomas, the ancillary trocars should be placed very 	nearly in the same plane as the umbilical = trocar. At times, it is appropriate to place the laparoscope in the 	left upper quadrant (Palmer's Point) so = that a true panoramic view of the operative field can be obtained. If 	the laparoscope is placed in Palmer's Point, = the umbilical site can be used for instrumentation. Placement of 	three additional trocars (two for grasping, dissecting and = cutting instruments and one for a myoma screw) facilitates 	the operation.
 	
     

 The surgeon examines the uterus and notes that, by external exam of the shape and consistency, 	the position = of the myomas cannot be determined.
 	
     

 This frequently = occurs with intramural myomas. Have available in the OR ultrasound capability 	to locate the position and safest route to = the myomas.
 	
     

 Significant bleeding = occurs with the first incision of the serosa overlying the myoma.
 	
     

 Re-evaluate the = effect of the Pitressin injection. If sufficient Pitressin has not been administered, 	carefully re-administer the = Pitressin. If the bleeding is simply from a dilated venous channel, use electrocoagulation 	to control it.
 	
     

 The dissection of the myoma from the serosa is very difficult and no planes appear to develop.
 	
     

 Re-evaluate the depth = of the incision. When the plane of dissection is not clear the incision 	is frequently too deep and has entered the = myoma itself. This is true especially for large subserosal myomas 	where serosa is very thin, only millimeters = thick. This can also happen if the myoma is surrounded by a pseudo-capsule 	of reactive tissue which must be opened = in order to enter the proper space. In other words, the incision is either 	too deep or not deep enough or the mass = is an adenomyoma. Aquadissection may help in this case.
 	
     

 The myomas are = intraligamentous and portions appear through the posterior surface and the anterior 	surface. The surgeon attempts an = anterior opening and finds the dissection very difficult.
 	
     

 Approach = intraligamentous myomas from the posterior aspect of the uterus. The limited angle 	available to instruments through trocars, = together with the limited space between the anterior aspect of the 	myoma and the abdominal wall, make dissection = from the anterior aspect very difficult. With a posterior approach 	the uterus can be ante-flexed and the myoma can be = approached along a nearly straight line from the periumbilical 	lateral trocar sites. This allows the surgeon to = open under the myoma and begin the dissection with traction 	appropriately placed to assist with dissection of the = myoma from the space.
 	
     

 During dissection of an intraligamentous myoma the surgeon encounters severe bleeding and has 	difficulty = recognizing the source.
 	
     

 Intraligamentous = myomas rest next to the uterine artery and frequently their blood supply 	is intimately associated with this vessel. If the = myoma is large and multiobulated, the process of extracting 	the myomas by twisting and pulling (which is the standard = practice for enucleation) may result in avulsion of 	this vessel. When this occurs, the surgeon can place an = atraumatic grasper in the space between the myoma and 	the uterus and clamp against the uterus. With suction placed = near the tip of the grasper, the vessel will become 	evident and can be further occluded. Once the vessel has = been occluded, it can be coagulated by bipolar or clipped 	with a clip applier. Recognize that once the vessel has been = occluded it is possible to avulse it further down 	in its course during the remainder of the dissection.
 	
     

 During dissection of = an intramural myoma the surgeon encounters the endometrium and recognizes 	that the uterine cavity has been = entered.
 	
     

 Staining the endometrial cavity with methylene blue assists in recognizing entry. If the patient 	desires = continued fertility, it is appropriate to make a small mini-lap incision after the myoma has been dissected 	free of = the uterus in order to effect a standard multi-layered closure of the uterus. If fertility is not desired 	then a standard = laparoscopic closure can be effected.
 	
     

 In dissecting an = intramural myoma, the surgeon recognizes that the myoma extends very close 	to and perhaps into the cornual region. = Further dissection may affect tubal patency.
 	
     

 Prior to initiating a = myomectomy on a patient who desires fertility, perform a hysterosalpingogram 	to determine tubal patency. Determine by = ultrasound the position of the myoma in relationship to the cornua. 	Prior to initiating surgery, perform a = tubal dye study to stain the tubal structures and determine their patency. 	Place methylene blue in the endometrium so = that the endometrium can be recognized easily if it is entered.
 	
     

 The surgeon initiates = laparoscopic enucleation of a cervical myoma and encounters severe bleeding.
 	
     

 In the case of severe = bleeding encountered while operating in the lower uterine segment where 	laparoscopic vision may be compromised by = blood, the possibility of damage to adjacent organs such as the ureter 	increases. With severe bleeding in the lower = uterine segment, open surgery (laparotomy) may be the surgeon's 	best choice.

Table 1.18 = Comparison of Laparoscopic and Abdominal Myomectomy

1. Carter JE, Bailey TS. Procedure for laparoscopic resection of = uterine fibroid previously treated by GnRH agonist. Presented at Third World Congress on Endometriosis, 1992; Brussels, = Belgium; N1-3.

2. Semm K, Mettler L. Technical progress in pelvic surgery via = operative laparoscopy. Am J Obstet Gynecol. 1980;138:121125.

3. Coddington CC, Brzyski R, Hansen KA, Corley DR, McIntyre-Seltman K, = Jones HW. Short term treatment with leuprolide acetate as a successful adjunct to surgical therapy of leiomyomas of = the uterus. Surg Gynecol Obstet. 1992;175:5763.

4. Schlauff WD, Zerhouni EA, Hugh JA. A placebo controlled trial of a = depo-gonadotrophin releasing hormone analogue (leuprolide) in the treatment of uterine leiomyomata. Obstet Gynecol. = 1989;74:856-862.

5. Carter JE, Bailey TS, Baginski LJ. Laparoscopic myomectomy. ISGE = Annual Meeting. March 1998, Sun City, South Africa.

Articles

Uterine myomas are the most common tumors of the female genital tract. = Hysterectomy has been a very common therapy in patients who have completed reproduction. In fact, uterine myomas = account for 20% of the 650,000 hysterectomies performed annually in the United States. Interest in uterine = preservation and organ preserving surgery through techniques of minimally invasive surgery has increased since the first = reports of laparoscopic myomectomy in 1980.

William W. Schuessler, MD

Articles

Prevention and Management of Laparoendoscopic Surgical Complications Laparoscopic Myomectomy