Page 577 - Read Online

Kiss et al. Mini-invasive Surg 2021;5:55 https://dx.doi.org/10.20517/2574-1225.2021.70 Page 5 of 9

FERTILITY AND OBSTETRICAL OUTCOMES AND RECURRENCE
Robotic surgery is a suitable myomectomy approach for infertile patients. In a retrospective study, more
than half of the patients became pregnant with a 70% caesarean section rate without a report of uterine
rupture . Uterine rupture was also not reported in a comparison study, in which long-term pregnancy and
[33]
miscarriage rates did not significantly differ after robotic assisted, laparoscopic, or abdominal
[34]
myomectomy . In a study where deep intramural myomas were enucleated, the pregnancy rate reached
75% . The same pregnancy rate (70%) after robotic myomectomy was published in a Canadian cohort with
[35]
[36]
84% successful delivery or ongoing pregnancy at the time of data collection . The risk of recurrence was
167% higher in laparoscopic myomectomy than in open surgery. The authors hypothesized that it is likely
because of the extraction of small leiomyomas, which is less exhausting in manual removal than in the
laparoscopic approach. The growth of residual myoma masses then results in newly diagnosed fibroids,
[37]
which are considered recurrences . Considering the better flexibility of robotic instruments, enucleation of
small myomas should be more accessible, leading to lower recurrence. Another reason for higher recurrence
was found to be associated with the preoperative use of GnRH agonists therapy to decrease the size of
[38]
myomas .

SURGICAL TECHNIQUES
Safely extracting large and numerous myomas is often a challenge in minimal invasive surgery even for
[39]
experienced surgeons. Moawad et al. presented a reproducible technique enabling fast and safe tissue
containment and extraction. It consists of stringing numerous fibroids together with a barbed suture,
containment using a Endocatch bag, extraction through the extended umbilical incision using the Alexis
Containment and Extraction System, and finally the so-called paper roll technique for specimen extraction.
Suprapubic incision is a similar technique, which serves for initial abdomen insufflation, later assistant’s
easy access for retraction or needle entry, and finally large tissue extraction . Contained manual
[40]
morcellation is in comparison with electric power morcellation associated with shorter operation time but
[41]
similar postoperative opioid pain relief treatment and length of hospital stay . Additionally, with the
cessation of power morcellation, wound complications with the necessary mini-laparotomy for tissue
[42]
extraction has not increased .

Authors from South Korea proposed a new surgical technique called “locking suture on myoma (LSOM)”
which replaces the tenaculum forceps, thus reducing the use of one instrument and lowering the total cost
[43]
of surgery . In this technique, a locking V-Loc suture is applied on the myoma after its exposure and
traction can be easily performed by grasping the thread. Further locking sutures are applied as the dissection
advances between the myoma and myometrium. The retrieved myomas are easily collected and extracted by
grasping the threads. LSOM was also shown to be more feasible for larger, heavier, and a greater number of
myomas than using the robotic tenaculum forceps, emphasizing its use especially in single-site surgery.

A very interesting technique of submucosal FIGO 2 classified myoma without endometrial injury was
presented in a case study . The authors recommended several steps to prevent penetration of to the uterine
[44]
cavity. Proper preoperative and intraoperative imaging is crucial for planning the surgery and determining
the correct site of myometrial incision. This is followed by cold cut careful preparation of the plane between
the myoma and endometrium. Infusion of indigo carmine to dilatate the uterine cavity aids in delineating
the endometrial cavity during dissection.

Blood loss can be lowered without compromising surgical morbidity by the vascular control technique .
[45]
This method uses vascular (bulldog) clamps to temporarily occlude the uterine arteries during the
myomectomy. The maximal limit of occlusion time was set at 60 min with 5 min