Laparoscopic-assisted myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series

Abstract

Background: Non-hysteroscopic myomectomy is infrequently performed in a freestanding ambulatory setting, in part due to risks of intraoperative hemorrhage. There are also concerns about increased surgical risks for morbidly obese patients in this setting. The purpose of this study is to report the surgical outcomes of a series of laparoscopic-assisted myomectomy (LAM) cases at a freestanding ambulatory surgery center (ASC), including a comparative analysis of outcomes in morbidly obese patients (BMI > 40 kg/m 2). Methods: A retrospective comparative analysis was performed of 969 women, age 18 years or older, non-pregnant, who underwent LAM by one of two high volume, laparoscopic gynecologic surgical specialists at a freestanding ambulatory surgery center serving the Washington, DC area, between October 2013 and February 2019. Reversible occlusion was performed laparoscopically by placing a latex-based rubber catheter as a tourniquet around the isthmus of the uterus, causing a temporary occlusion of the bilateral uterine arteries. Permanent occlusion was performed laparoscopically via retroperitoneal dissection and uterine artery ligation at the origin of the anterior branch of the internal iliac artery. Minilaparotomy was performed for specimen removal in all cases. No power morcellation was used. Postoperative complications were graded using the Clavien-Dindo Classification system. Outcomes were compared across BMI categories using Pearson Chi-Square. Results: Average myoma weight and size were 422.7 g and 8.3 cm, respectively. Average estimated blood loss (EBL) was 192.1 mL; intraoperative and grade 3 postoperative complication rates were 1.4% and 1.6%, respectively. While EBL was significantly higher in obese and morbidly obese patients, this difference was not clinically meaningful, with no significant difference in blood transfusion rates. There were no statistically significant intraoperative or postoperative complication rates across BMI categories. There was a low rate of hospital transfers (0.7%) for all patients. Conclusion: Laparoscopic-assisted myomectomy can be performed safely in a freestanding ambulatory surgery setting, including morbidly obese patients. This is especially important in the age of COVID-19, as elective surgeries have been postponed due to the 2020 pandemic, which may lead to a dramatic and permanent shift of outpatient surgery from the hospital to the ASC setting.

Laparoscopic myomectomy – The importance of surgical techniques

“…Before dissection, there are some techniques that can be used to help reduce blood loss. Placing a tourniquet at the base of the leiomyoma can significantly reduce the blood supply with the most effect on smaller fibroids ( 30 ). In case of a larger or more vascular nodule, the intermittent uterine artery clamping can be realized through laparoscopy ( 31 ).…”

How to minimize bleeding in laparoscopic myomectomy

“…A recent retrospective study [22] was conducted with 969 consecutive patients who underwent laparoscopic myomectomy with UAO at an ambulatory surgery center with same-day discharge. The use of UAO as a transient or permanent blood loss control method was determined based on the patient's desire for fertility, uterine size, number of myomas, and complexity of the case.…”