{"id":320,"date":"2020-08-13T17:55:06","date_gmt":"2020-08-13T17:55:06","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=320"},"modified":"2020-08-13T17:55:06","modified_gmt":"2020-08-13T17:55:06","slug":"myomectomy","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/surgery-2\/myomectomy\/","title":{"rendered":"Myomectomy"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/KZFu_gPiUm8\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>Duration: 8:26<\/p>\n<input type='hidden' bg_collapse_expand='69e9c8eeb3a1c3075698742' value='69e9c8eeb3a1c3075698742'><input type='hidden' id='bg-show-more-text-69e9c8eeb3a1c3075698742' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9c8eeb3a1c3075698742' value='Hide Transcript'><button id='bg-showmore-action-69e9c8eeb3a1c3075698742' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9c8eeb3a1c3075698742' ><\/p>\n<p>00:00<br \/>\nthis video is an example of a simple<br \/>\n00:02<br \/>\nbasic robotic-assisted laparoscopic<br \/>\n00:04<br \/>\nmyomectomy of a single uterine fibroid<br \/>\n00:07<br \/>\nthe patient is a 36 year old white<br \/>\n00:10<br \/>\nfemale grabbed at a 3 para 0 with<br \/>\n00:12<br \/>\nrecurrent pregnancy loss in a two-year<br \/>\n00:14<br \/>\nhistory of worsening dyspareunia in mini<br \/>\n00:16<br \/>\nraja ultrasound showed a single<br \/>\n00:19<br \/>\nintramural fibroid 2.5 centimeters in<br \/>\n00:21<br \/>\ndiameter the patient desired to have a<br \/>\n00:23<br \/>\nlaparoscopic myomectomy at laparoscopy<br \/>\n00:27<br \/>\nthe location of the fibroid is quite<br \/>\n00:29<br \/>\nobvious the procedure is began by using<br \/>\n00:32<br \/>\na mono polar scissor with a pure cutting<br \/>\n00:34<br \/>\ncurrent of approximately 50 watts to<br \/>\n00:35<br \/>\nincise the serosa the cutting current is<br \/>\n00:42<br \/>\ncontinued with minimal coagulation until<br \/>\n00:44<br \/>\na uterine fibroid is reached<br \/>\n00:45<br \/>\nthe incision is continued into the body<br \/>\n00:48<br \/>\nof the fibroid and then the fibroid is<br \/>\n00:50<br \/>\ngrasped with a single tooth tenaculum<br \/>\n00:56<br \/>\nplacing the fibroid on traction helps to<br \/>\n00:59<br \/>\nstop venous bleeding as well as aid in<br \/>\n01:01<br \/>\nthe enucleate of the myoma the<br \/>\n01:07<br \/>\nfenestrated bipolar forcep and the mono<br \/>\n01:09<br \/>\npolar scissors are used to provide<br \/>\n01:10<br \/>\nmostly blunt dissection along the border<br \/>\n01:12<br \/>\nof the fibroid<br \/>\n01:19<br \/>\nwhen bleeding is encountered it is<br \/>\n01:21<br \/>\nusually due to the dissection plane<br \/>\n01:23<br \/>\ndrifting away from the body of the fire<br \/>\n01:25<br \/>\nboy<br \/>\n01:28<br \/>\nwhen this occurs electric cautery is<br \/>\n01:30<br \/>\nused to cut back into the body of the<br \/>\n01:32<br \/>\nfibroid to reach the correct dissection<br \/>\n01:34<br \/>\nplay<br \/>\n01:35<br \/>\nparticular care must be taken on the<br \/>\n01:37<br \/>\nposterior aspect of the fibroid where<br \/>\n01:39<br \/>\nthe blunt dissection plane will often<br \/>\n01:41<br \/>\ntear into the surrounding vascular<br \/>\n01:43<br \/>\nnetwork if this occurs a minimal amount<br \/>\n01:51<br \/>\nof electric cautery can be used to<br \/>\n01:53<br \/>\nobtain hemostasis shown here with the<br \/>\n01:55<br \/>\nbipolar forceps on a setting of 20 watts<br \/>\n02:08<br \/>\nthe dissection then continues stay near<br \/>\n02:11<br \/>\nto the body of the fibroid<br \/>\n02:30<br \/>\nany large bleeders are coagulated with<br \/>\n02:33<br \/>\nas little electric cautery as possible<br \/>\n02:41<br \/>\nit is not necessary to obtain full<br \/>\n02:44<br \/>\ncomplete hemostasis as this will be<br \/>\n02:45<br \/>\nachieved with the suture closure I<br \/>\n02:49<br \/>\nroutinely used the V lock in a<br \/>\n02:51<br \/>\ndirectional barbed suture for myomectomy<br \/>\n02:53<br \/>\nclosures this suture speeds the closure<br \/>\n02:57<br \/>\nof the incision thereby reducing blood<br \/>\n02:58<br \/>\nloss and the barbed design helps to<br \/>\n03:00<br \/>\nmaintain tension on the myometrium edges<br \/>\n03:02<br \/>\nthereby limiting any dead space I use<br \/>\n03:06<br \/>\nthe same suture for multiple running<br \/>\n03:08<br \/>\nlayers a place as many layers as needed<br \/>\n03:11<br \/>\nto adequately close the dead space<br \/>\n03:12<br \/>\nAndreea proximate the native myometrium<br \/>\n03:14<br \/>\ntissue in a simple closure such as this<br \/>\n03:18<br \/>\nI will place three layers the first or<br \/>\n03:20<br \/>\nrunning suture to approximate the deep<br \/>\n03:22<br \/>\nedges of the myometrium defect<br \/>\n03:29<br \/>\nyou<br \/>\n03:45<br \/>\nthe second suture is a horizontal<br \/>\n03:48<br \/>\nmattress suture through the body of the<br \/>\n03:49<br \/>\nmyometrium this provides most of the<br \/>\n03:52<br \/>\nstrength of the closure Aria proximate<br \/>\n03:54<br \/>\ns&#8217; this Rosso edges<br \/>\n04:20<br \/>\nthe final layer is a horizontal mattress<br \/>\n04:22<br \/>\nsub cirrhosis suture<br \/>\n04:29<br \/>\nthis type of closure has many advantages<br \/>\n04:31<br \/>\nover the so called baseball stitch<br \/>\n04:33<br \/>\nserosal closure by not puncturing the<br \/>\n04:36<br \/>\nserosa this closure is very hemostatic<br \/>\n04:38<br \/>\nand by leaving no exposed suture<br \/>\n04:41<br \/>\nadhesion formation is theoretically<br \/>\n04:43<br \/>\nreduced<br \/>\n05:12<br \/>\nat the end of the closure the suture<br \/>\n05:14<br \/>\nsimply cut off flesh with a serosa<br \/>\n05:19<br \/>\nafter irrigation the incision can be<br \/>\n05:22<br \/>\nseen to be fully human static I then<br \/>\n05:25<br \/>\nplace a piece of intercede anti adhesion<br \/>\n05:27<br \/>\nmaterial over the incision I only use<br \/>\n05:30<br \/>\nintercede in cases with complete ela<br \/>\n05:32<br \/>\nstasis as it is known to promote<br \/>\n05:34<br \/>\nfibrosis of blood in cases with multiple<br \/>\n05:38<br \/>\nincisions I use adapt 4% i Codex trans<br \/>\n05:41<br \/>\nsolution for adhesion prevention total<br \/>\n05:46<br \/>\nreal time from uterine incision to<br \/>\n05:48<br \/>\ncompletion of closure was 16 minutes the<br \/>\n05:50<br \/>\npatient also had several areas of pelvic<br \/>\n05:52<br \/>\nendometriosis which was excised as well<br \/>\n05:54<br \/>\ntotal surgical time skin to skin was 35<br \/>\n05:57<br \/>\nminutes ultrasound over uterus three<br \/>\n06:00<br \/>\nmonths postoperatively barely shows any<br \/>\n06:02<br \/>\nevidence of the location of her previous<br \/>\n06:03<br \/>\nfibroid so this was a very simple<br \/>\n06:07<br \/>\nmyomectomy the same principles apply to<br \/>\n06:09<br \/>\nmore advanced cases my experience in the<br \/>\n06:12<br \/>\npast 12 months with robotic-assisted<br \/>\n06:13<br \/>\nlaparoscopic myomectomy includes<br \/>\n06:15<br \/>\nperforming approximately 62 myomectomy<br \/>\n06:17<br \/>\nx&#8217; now averaging approximately seven to<br \/>\n06:19<br \/>\neight per month removing a total of 292<br \/>\n06:22<br \/>\nfibroid the number of fibroids removed<br \/>\n06:24<br \/>\nhave ranged from 1 to 22 with more than<br \/>\n06:27<br \/>\n25 percent of cases having more than 10<br \/>\n06:29<br \/>\nfibroids removed of all unselected cases<br \/>\n06:32<br \/>\npresenting to our practice I have been<br \/>\n06:34<br \/>\nable to complete more than 96% of them<br \/>\n06:35<br \/>\nlaparoscopically no laparoscopic case<br \/>\n06:38<br \/>\nhas been converted to an open case and<br \/>\n06:40<br \/>\nonly 3 open myomectomy x&#8217; have been<br \/>\n06:42<br \/>\nperformed removing 33 35 and in a case<br \/>\n06:46<br \/>\nof diffused Myo Myo mitosis 145 fibroids<br \/>\n06:49<br \/>\nthe average estimated blood loss is 112<br \/>\n06:52<br \/>\nCCS<br \/>\n06:53<br \/>\nranging from less than 10 cc&#8217;s to 500<br \/>\n06:56<br \/>\nCCS 65% of all cases have less than 100<br \/>\n06:59<br \/>\nCC&#8217;s blood loss<br \/>\n07:00<br \/>\n100% of all cases began in the mornings<br \/>\n07:03<br \/>\nare discharged on the same day the<br \/>\n07:05<br \/>\nrecovery period is excellent with<br \/>\n07:07<br \/>\npatients only using narcotics for an<br \/>\n07:08<br \/>\naverage of 1.5 days and return to work<br \/>\n07:11<br \/>\nin an average of 7 days<br \/>\n07:13<br \/>\nin my opinion there are a few surgical<br \/>\n07:17<br \/>\nlimitations to a robotic-assisted<br \/>\n07:18<br \/>\nlaparoscopic myomectomy fibroids size is<br \/>\n07:21<br \/>\nnot a limitation as I have frequently<br \/>\n07:23<br \/>\nremoved fibroids larger than 15<br \/>\n07:25<br \/>\ncentimeters and operated on uteri larger<br \/>\n07:27<br \/>\nthan 20 weeks gestational sized fibroid<br \/>\n07:30<br \/>\nlocation is also not a problem as a<br \/>\n07:32<br \/>\nrobotic approach is ideal for patients<br \/>\n07:34<br \/>\nwith a posterior fibroid or some mucosal<br \/>\n07:37<br \/>\nfibroid prior surgeries such as<br \/>\n07:39<br \/>\nmyomectomy x&#8217; or other pelvic procedures<br \/>\n07:41<br \/>\nshould not deter a surgeon from<br \/>\n07:42<br \/>\napproaching in laparoscopically fibroid<br \/>\n07:45<br \/>\nnumber is the only situation in which I<br \/>\n07:47<br \/>\nhave some concern as to whether or not a<br \/>\n07:48<br \/>\npatient may be a candidate for a<br \/>\n07:50<br \/>\nlaparoscopic myomectomy I routinely<br \/>\n07:52<br \/>\ncomplete laparoscopic cases with up to<br \/>\n07:54<br \/>\n15 fibroids however patients with more<br \/>\n07:57<br \/>\nthan this run the risk of not having<br \/>\n07:59<br \/>\nevery single fibroid removed<br \/>\n08:01<br \/>\ntypically any fibroid larger than 1<br \/>\n08:03<br \/>\ncentimeter can be found and removed<br \/>\n08:05<br \/>\nlaparoscopically I have found that most<br \/>\n08:08<br \/>\npatients with very large numbers of<br \/>\n08:09<br \/>\nfibroids would rather complete their<br \/>\n08:11<br \/>\nsurgery laparoscopically and run the<br \/>\n08:13<br \/>\nrisk of leaving one or two small<br \/>\n08:15<br \/>\nfibroids behind rather than having an<br \/>\n08:17<br \/>\nopen procedure<\/p>\n<p><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Duration: 8:26<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":784,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-320","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/320","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=320"}],"version-history":[{"count":0,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/320\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/784"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=320"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}