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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.
Table of ContentsIntroduction Surgical Anatomy = and Technique
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 1980.1
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.2
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.12-14
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.15 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.16 Fourteen myomas were extracted using the 15 mm manual morcellator compared to = 14 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:13
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.17 Complications can be avoided by following the Eight-Step approach as outlined = here:13
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 Table 1 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.19,20 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.19,21 A 1.5 cm = length bipolar needle was developed to perform electrosurgical myolysis. This needle was not appropriate to treat = symptomatic large leiomyomas.22 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.23 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 watts24 have been described. In 150 cases reported with this technique23 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.23
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.23,25 In 87 patients the mean operating time was 28.7 minutes, with a mean = blood loss of 28 mL.26 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.26
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.27
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.28 = 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.28 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.28 This pain requires analgesia, including = intravenous anti-inflammatory drugs and patient-controlled intravenous injection of narcotic analgesics.28
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.29
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.27-29RESULTS
In reviewing over 750 laparoscopic myomectomies5,7,8,11-13,15,18 = 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
|Laparoscopic Myomectomy||Abdominal Myomectomy||Sig.|
|Number of cases||20||20|
|Average weight (grams)||160||170 NS|
|Avg. length of stay (days)||1.2||3.1||< .05|
|Range - Length of stay||0 - 3 days||2.2 - 5 days|
|% Outpatient surgery||40%||0%||< .005|
|Blood transfusion||0%||10%||< .01|
|Return to work||1 week||6 weeks||< .005|
|Total avg. surgery time (minutes)||125||90||< .01|
|Complications to patient||0||4|
return to text
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Â©Society of Laparoendoscopic Surgeons, 1999
Reprinted with permission from the Society of Laparoendoscopic = Surgeons.
Carter JE, Schuessler WW. Laparoscopic urinary bladder surgery. In = Kavic MS, Levinson CJ, Wetter PA, eds. Prevention and Management of Laparoendoscopic Surgical Complications. Miami: = Society of Laparoendoscopic Surgeons; 1999:207-219.
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