Hum. Reprod. Advance Access originally published online on July 31, 2006
Human Reproduction 2006 21(12):3278-3281; doi:10.1093/humrep/del296
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Pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure
Center for Advanced Endoscopy and Infertility Treatment, Paul’s Hospital, Cochin, Kerala, India
1 To whom correspondence should be addressed at: Center for Advanced Endoscopy and Infertility Treatment, Paul’s Hospital, Vattekkattu Road, Kaloor, Cochin 682017, Kerala, India. E-mail: abykkoshy{at}rediffmail.com
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Abstract |
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BACKGROUND: To evaluate pregnancy outcomes following laparoscopic myomectomy and single-layer myometrial closure. METHODS: This study conducted at a private advanced endoscopy and assisted reproductive technology centre retrospectively evaluated outcomes of 115 women who had pregnancies subsequent to laparoscopic myomectomy. RESULTS: Of the 217 women followed up, 115 had pregnancies subsequent to a laparoscopic myomectomy. Of 141 pregnancies, there were 87 Caesarean sections, 19 vaginal deliveries, 29 abortions and 6 ectopic pregnancies. There were no incidents of uterine scar rupture in any of these pregnancies. CONCLUSIONS: Uterine rupture during pregnancies following laparoscopic myomectomy is rare following single-layer myometrial closure.
Key words: laparoscopic myomectomy/pregnancy/single-layer closure/uterine rupture
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Introduction |
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It is found that there is an increasing concern over the incidence of uterine rupture in pregnant women with a history of an earlier laparoscopic myomectomy. The fact that uterine rupture has been reported remote from term (Grande et al., 2005
) and following myomectomies performed for subserous (Pelosi and Pelosi, 1997) and even pedunculated myomas (Lieng et al., 2004) are especially worrying. Uterine rupture has also been reported to have occurred without signs of fetal distress (Banas et al., 2005).
Most cases of uterine rupture have been described as isolated case reports, and several case series have had no or very low rates of this complication. (Dubuisson et al., 2000a,b; Seinera et al., 2000) Laparoscopic surgeons are trying to reduce this complication by changing over from single-layer to multi-layer suturing techniques (Stringer et al., 2001). The underlying principle is that good approximation without haematoma formation is important in the healing of myomectomy wounds (Dubuisson et al., 2000b). This study was performed to look for any increased incidence of scar rupture in patients who have become pregnant after laparoscopic myomectomy, where single-layer closure of the myometrium was done.
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Materials and methods |
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We retrospectively analysed data of women who underwent laparoscopic myomectomy for uterine leiomyomas from June 1993 to August 2003. Those patients who had myomectomies for myomas <3 cm were excluded. Data were collected on demographic characteristics; the chief indication for the intervention; number, size and location of fibroids; surgical technique; concomitant pelvic pathologies; intraoperative and post-operative morbidity. Postal questionnaires enquiring the occurrence of pregnancies, their outcome and the time duration between the surgical procedure and the time of conception were sent to these women. The questionnaires were followed up with telephonic enquiries with the patient and her obstetrician if required.
Pre-operative evaluation was similar to that before any other major procedure. All cases had pre-operative transvaginal and trans-abdominal sonography. GnRH agonists were not used before surgery because we found that degeneration of the myoma made the surgical dissection more difficult in those cases who had received such treatment elsewhere.
All procedures were performed using a similar technique under general anaesthesia. The operative procedure is described. Hysteroscopy was performed to evaluate the uterine cavity. This was especially useful in patients with large multiple myomas where submucous myomas could have been easily missed on ultrasound examination. Hysteroscopy was also useful in cases where the myomas were distorting the endometrium. Normal saline was used as the distension media for diagnostic hysteroscopy. For submucous myomas, a 4 mm, 30° hysteroscope with a 26 F resectoscope was used. Glycine was used as the distension media. A pneumoperitoneum at a pressure of 12 mm of Hg was established using a Veress needle and a carbon dioxide insufflator. For occasional cases, a 15 mm pressure was required. Entry into the abdominal cavity through an umbilical incision or a higher one in the case of larger uteri was accomplished using a 10 mm trocar. In patients with a previous history of an open surgery or in cases where intra-abdominal adhesions were suspected, entry under direct vision using a Ternamian Endotip (Karl Storz, Tuttlingen, Germany) was performed. Two ancillary 5-mm trocars lateral to the right and left epigastric vessels and a median supra-pubic trocar were inserted. A Spackman cannula was used for uterine manipulation. Vasopressin was not used, as it was not available in our country until 2003. For subserous peduncualted myomas, the pedicle was coagulated using a bipolar forceps and cut using a hook electrode. For intramural myomas, an incision was made on the most prominent part of the myoma through the uterine wall and the pseudocapsule. The incision was usually vertical in the case of midline myomas and transverse in lateral ones. The myoma was enucleated by a combination of traction using a 5-mm myoma screw and dissection using a grasping forceps and suction-irrigation cannula. The myoma screw is successively moved over the enucleated part so that traction can be applied in a direction perpendicular to the surface of the myoma. Any bleeding vessels on the pseudocapsule are coagulated before further dissecting the myoma, the use of bipolar forceps being kept to a minimum. Intrauterine instillation of methylene blue was used to confirm location of the endometrial cavity in cases of deep intramural myomas. The incision is closed using interrupted absorbable sutures by intracorporeal suturing (Figure 1). The sutures used were either 1-0 polyglycolic acid with 40 mm, half circle, taper cut needle (Dexon II, Tyco Healthcare, Norwalk, CT) or polyglactin 910 with 36 mm, half circle reverse cutting needle (Vicryl, Ethicon, India). We suture the myometrium in one layer using curved needles, which enable deep bites on the myometrium to be taken. They are seromuscular, evenly spaced, around a centimetre apart, and the edges of the uterine wound are always everted. If the endometrial cavity is entered, the endometrium is closed in a separate layer (Figure 2). The fibroids are removed with an electro-mechanical morcellator. At the end of the procedure, the peritoneal cavity was washed with saline solution. No additional adhesion prevention measures were used. A silicone drain was applied through one of the lateral ports and kept for 12 h for drainage of blood and irrigation fluid.
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Blood loss and drop in haemoglobin concentration was estimated and recorded.
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Results |
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Data were collected on laparoscopic myomectomies performed from June 1993 to August 2003. Of the 506 questionnaires sent, we received 217 replies. Of them 115 women had conceived. Retrospective analysis of patient charts gave the following information.
The median age of patients at the time of surgery was 30 years (range 19–43). The chief indication for surgery was infertility (74 patients, 64.3%). The remaining indications were menstrual symptoms (14), pain (10), pressure related (10) and others (7).
One hundred and fifteen patients had laparoscopic myomectomies. Two patients had hysteroscopic resection for submucous myomas in addition to laparoscopic myomectomy. The median number of myomas removed per patient was 1 (range 1–5). The median diameter of the largest myoma enucleated was 5 cm (range 3–16 cm) (Figure 3). Most myomas removed were intramural (151, 84.8%). Twenty-one subserous, four intra-ligamentous and two submucous myomas were also removed. Twenty-nine patients had additional surgery mostly for endometriosis (17 cases). In nine cases, the endometrial cavity was opened. The median duration of surgery was 112 min, the median blood loss was 157 ml and the mean drop in haemoglobin concentration was 1.75 g.
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One hundred and fifteen women had a total of 141 pregnancies. Eight (6.9%) women conceived after infertility treatment, although none required assisted reproduction techniques (ART). Eighteen women had two pregnancies, and four had three. One hundred and six of the 141 pregnancies went on to result in live births. All women received obstetric care at hospitals different from ours. There were no cases of uterine rupture. Eighty-two percent of them had Caesarean sections. The most common reason cited was the presence of a uterine scar. Although four women had emergency Caesarean sections for fetal distress, none of them had evidence suggesting scar dehiscence or rupture (Table I). The mean interval between the surgical procedure and conception was 8.9 ± 9.4 months (range 1–60 months, Figure 4). The average gestational age in those who had live births was 38.2 ± 1.1 weeks.
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Discussion |
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Pregnancies following any surgical procedure involving the uterus have an increased risk of rupture or dehiscence during pregnancy and labour. Such risks in relation to Caesarean sections have been well quantified (Phelan et al., 1987
; Nielsen et al., 1989; Farmer et al., 1991; Flamm et al., 1994). This has helped in improved management of post-Caesarean pregnancies before and during labour. The same cannot be applied in cases of women with a previous history of myomectomy, whether open or laparoscopic, because of the absence of good quality studies. Most cases of uterine rupture reported are case reports without data on the total number of pregnancies. Several reports of uterine rupture following open myomectomy have been published (Golan et al., 1990; Ozeren et al., 1997). The retrospective study by Roopnarinesingh et al. (1985) reported the incidence of uterine rupture following open myomectomy to be as high as 5.3%.
Dubuisson et al. (2000b) study of 100 patients following laparoscopic myomectomy had three cases of uterine rupture, though only one involving the myomectomy scar. Two other large studies involving 57 and 65 pregnancies reported no cases of uterine rupture (Seinera et al., 2000; Landi et al., 2003). Hurst et al. (2005) reviewed 21 different studies involving a total of 626 patients who had pregnancies following laparoscopic myomectomy. There was only one reported case of uterine rupture. All these studies underline the fact that uterine rupture following laparoscopic myomectomy is infrequent.
Even though there were no cases of uterine rupture in our study, the fact is that we have not been able to follow up all the patients operated and that the obstetric outcomes were at centres different from ours. This should be kept in mind while evaluating the results. Our and most studies have reported an increased incidence of Caesarean section (Hurst et al., 2005). This is not unexpected in the presence of a scarred uterus. In addition, most patients have a history of infertility and are in the older age groups. This though does not make myomectomy a mandatory indication for elective Caesarean sections, high vaginal delivery rates have been achieved in studies by Dubuisson et al. (2000b) and Kumakiri et al. (2005). Recommendations for a waiting period before attempting pregnancy to ensure adequate wound healing though recommended have been questioned (Landi et al., 2003) and are not backed by good evidence. In fact, the majority of our patients conceived in the first year after surgery (82.6%) and a significant number in the first six months (55.6%). The frequencies of early pregnancy losses and preterm deliveries in our series were within normal limits, though that for ectopic pregnancies was higher (4.3%). This is consistent with the higher incidence of ectopic pregnancies in patients with infertility. (Pisarska and Carson, 1999).
The absence of any case of uterine rupture in our series may be due to the importance we give to the judicious use of electrosurgery for achieving haemostasis and correct reapproximation of the uterine edges after myomectomy. Both thermal damage and haematoma formation have been blamed as causes for sub-optimal healing and rupture during a future pregnancy. (Dubuisson et al., 2000b; Landi et al., 2003) Thermal damage has been especially blamed in cases where subserous myomas were removed (Nkemayim et al., 2000). Correct reapproximation is not dependent on the number of layers of sutures but on the technique of full thickness, evenly spaced suture placement, thus avoiding haematoma formation. Overaggressive control of bleeders using electrosurgical techniques should be avoided. Increasing the numbers or layers of sutures without adhering to the above principles may in fact compromise healing by causing tissue ischaemia.
In conclusion, uterine rupture following laparoscopic myomectomy is rare following single-layer myometrial closure. This data though reassuring are not conclusive, and there is a need for a randomized study to compare single-layer and multi-layer suturing techniques. Obstetricians dealing with antenatal patients with a history of a previous myomectomy should be aware of possible complications and should consider management of such patients as in cases of post-Caesarean pregnancies.
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Submitted on April 1, 2006; resubmitted on June 8, 2006; accepted on June 28, 2006.
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