Laparoscopic myomectomy, Result of baseball suture

Uterine fibroids, myomas, or leiomyomata are smoothmuscle cell tumours and are the most common benigngynaecologic tumour in women of reproductive age.They are often found as part of the investigation of aninfertile couple. They are rarely found before menarcheand usually regress after menopause. They arehormonally responsive, and estrogens appear to promotetheir growth. Local estrogen concentrations have beenshown to be higher in myomas than in the surroundingmyometrium, possibly because of a higher concentrationof aromatase. Hormonal responsiveness appears to begreater in submucosal than subserosal myomas.The prevalence of fibroids in the infertile population ofwomen is controversial. According to Donnez,approximately 5-10% of women presenting withinfertility are found to have one or multiple fibroids.However, when all other causes of infertility areexcluded, fibroids are found in only 1-2% of theremaining women. There have been no appropriatelydesigned studies to demonstrate a direct causalrelationship between the presence of fibroids andinfertility. Six systematic reviews or meta-analysespublished between 2001 and 2010 assessed whetherfibroids have an impact on fertility. On the whole, itappears that women with fibroids have decreased fertility.The impact of fibroid number and size on fertility has notbeen clearly elucidated. Reproductive success does seemto be related to fibroid location.Subserosal fibroids do not appear to have an impact onfertility; all systematic reviews and meta-analyses agreedon this point. Submucosal fibroids have been shownuniformly to have a negative impact on rates ofimplantation, clinical pregnancy, miscarriage, and livebirth/ ongoing pregnancy, The greatest debate remains onthe impact and treatment of intramural fibroids.Ultrasound has been shown to be an adequate, rapid, safe,and cost-effective means of evaluating the size, number,and location of fibroids. Ultrasound may, however, besuboptimal for multiple fibroids, because of acousticshadowing, and for the proper evaluation of endometrialimpingement. Interobserver variation has also been foundto be greater with this technique than with MRI MRI hasbeen well studied in the evaluation of fibroid uteruses,especially for fibroid mapping and submucosalpenetration. It was shown to be the most reliable methodof evaluation when compared with vaginal ultrasound,hysterosonography, and hysteroscopy, with 100%sensitivity and 91% specificity (gold standard waspathological examination). The main drawbacks of MRIevaluation are lack of accessibility and high cost.Submucosal fibroids are managed hysteroscopically. Thefibroid size should be <5 cm, although larger fibroidshave been managed hysteroscopically, but repeatprocedures are often necessary (III-B). The first lessonphysicians must learn is that if the patient isasymptomatic, no treatment is necessary. The presence ofan abdominal mass is not an indication for hysterectomyor myomectomy unless it is of significant concern to thepatient. There is no universally accepted criteriaregarding number and size of myoma to be removedlaparoscopically but as our techniques, especiallysuturing techniques and instruments for laparoscopyadvance, our ability to do more complicated cases oflaparoscopic myomectomy increase as well, Beforelaparoscopic myomectomy uterine mapping ismandatory, because the surgeon does not have sense ofpalpation during procedure, in order to have successfullaparoscopic myomectomy the surgeon should answer thefollowing questions before surgery,How many myomas are there Where are the exact location of myomas How is the distance of myoma from cavity Is uterine cavity distorted Are we able to perform operation Laparoscopic myomectomy is a challenging procedureand the most challenging part of this procedure issuturing. The goal of suturing is to restore myometrialintegrity, prevent hematoma formation, prevention ofdefect & dehesence in myometrium and adhesionprevention . If any one of these goals are not met duringprocedure the future pregnancy would be in danger. Skillof surgeon is the most important factor for successfuloperation. In video clip base ball myometrial closure willbe demonstrated, followed by cesarian section.