Laparoscopic Adenomyomectomy Under Transient Occlusion of Uterine Arteries with an Endoscopic Vascular Clip

Introduction

Adenomyosis is a benign gynecological condition characterized by ectopic endometrial gland invasion of the myometrium associated with hyperplasia of the adjacent smooth muscle. ¹ The disease is usually divided into diffuse and localized adenomyosis, according to lesion extent. The localized type is called adenomyoma, and the clinical manifestations include dysmenorrhea, chronic pelvic pain, and menorrhagia. ² Reflecting social and cultural changes, many women with symptomatic uterine adenomyoma wish to preserve their uterus for fertility reasons and other factors.^3,4

Few reports support laparoscopic adenomyomectomy with a safe and effective outcome for women with a strong desire to preserve their fertility.^5,6 Additionally, unlike laparoscopic myomectomy, there are several limitations to laparoscopic adenomyomectomy, including bleeding, obscure tumor boundaries, and difficult uteroplasty. Excellent surgical technique and a clean and stable operative field are required to overcome these limitations.

We introduce a safe and effective laparoscopic surgical technique, laparoscopic adenomyomectomy under transient occlusion of uterine arteries (TOUA), for women with uterine adenomyoma who have a strong desire to preserve their uterus and fertility.

Subjects and Methods

From May 2011 to September 2012, 34 patients undergoing laparoscopic adenomyomectomy with TOUA were enrolled in this study. The patients were selected consecutively. Inclusion criteria were the presence of a symptomatic adenomyoma diagnosed by ultrasonographic examination that was refractory to conservative medical treatment and the patient's strong desire to preserve her uterus. The diffuse adenomyosis type was excluded. Postoperatively negative pathological findings of adenomyoma were also excluded. Laparoscopic adenomyomectomy with TOUA was preoperatively suggested to all the patients who fulfilled the inclusion criteria and was performed with consent of the patients. The operating time was defined as the period from skin incision to closure. The size of the adenomyoma was the maximum diameter of the adenomyoma on ultrasonography. Operative blood loss was estimated by subtracting the rinse volume from the blood volume that was collected in the suction apparatus. This study was approved by the Ulsan University Hospital Institutional Review Board, Ulsan, Korea.

Surgical technique

The patient was placed in a dorsal lithotomy position under general anesthesia with endotracheal intubation. A uterine manipulator (Hangzhou Shikonghou Medical Equipment Co. Ltd., Shanghai, China) was placed in the uterine cavity to allow movement of the uterus. This manipulator facilitates moving the uterus into the optimal position during excision and suturing. Intraabdominal pressure was maintained at 13 mm Hg with carbon dioxide gas. Once the pneumoperitoneum was achieved, videolaparoscopy (laparoscopic camera; Karl Storz GmbH & Co. KG, Tuttlingen, Germany) was performed using a 10-mm trocar that was introduced through the umbilicus. Furthermore, three trocars were needed for the operation: a 12-mm trocar for the endoscopic vascular clip was placed on the left side, a 5-mm trocar was placed on the right side of the lower abdomen, and another 5-mm trocar was placed on the median line just above the pubic hairline. These ports were inserted for introducing surgical instruments. The peritoneum was incised using a monopolar electrode through the triangular area (round ligament, ovarian ligament, and infundibulopelvic ligament, and psoas muscle), along the nfundibulopelvic ligament. Using blunt-tip suction, the umbilical artery was first isolated, and the assistant moved the umbilical artery upward and in a lateral direction. Second, it was possible to isolate the branching uterine artery along the umbilical artery using blunt-tip suction. The isolated uterine artery was occluded with an endoscopic vascular clip (temporary atraumatic endo-vessel-clips; B. Braun Korea Co., Ltd., Seoul, Korea). The uterine artery on the other side was occluded by using the same method with an endoscopic vascular clip (Fig. 1).

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FIG. 1.

Transient occlusion of uterine arteries with endoscopic vascular clips. (A and B) Transient occlusion of uterine arteries with an endoscopic vascular clip on the right and left side, respectively.

About 3 minutes was spent evacuating out uterine blood after completing both transient uterine artery occlusions. The uterine serosa covering the adenomyoma was deeply incised with a monopolar cutting electrode until the underlying endometrium was visually exposed. The adenomyoma was completely excised using endoscopic scissors. The operator should distinguish the adenomyoma from normal myometrium using tactile and visual sensations for a complete cytoreductive excision. The serosa covering the adenomyoma should remain at a 5 mm depth to help with easy suturing of excisional defects. The involved endometrium was spared as much as possible to preserve fertility.

The defect area after excision of the adenomyoma was sutured with three layers, including a wide, deep, single interrupted suture, a continuously nonlocking running suture, and a continuously interlocking suture (Fig. 2). The first assistant held the stitch to maintain suture tension throughout the repair process. Finally, both endoscopic vascular clips were removed safely, and the excised tumor was removed using an electrical morcellater (Gynecare; Ethicon, Inc., Somerville, NJ). A drainage tube was inserted through the suprapubic incision.

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FIG. 2.

Three-layer suturing method of laparoscopic adenomyomectomy: (A) a 5.0-×6.0-cm adenomyoma on the posterior body of the uterus; (B) the first layer, including a wide, deep, single interrupted suture; (C) the second layer, including a continuously nonlocking running suture; and (D) the third layer, including a continuously interlocking suture.

At the 6-month follow-up, we assessed the improvement in symptoms, including dysmenorrhea and menorrhagia, using questionnaires, and we performed ultrasonography to monitor patients for recurrence. The questionnaire with a focus on specific pelvic symptoms included items to evaluate the presence and severity of dysmenorrhea and menorrhagia. The questionnaire was completed by the simple, clinical interview. An 11-point numerical rating scale was used to evaluate the intensity of pain during menstruation (from 0=no pain to 10=excruciating pain). ⁷ The Mansfield–Voda–Jorgensen menstrual bleeding scale was used to evaluate menorrhagia; this is a subjective Likert-type scale from 1 (spotting) to 6 (very heavy bleeding or gushing). ⁸ Complete remission of dysmenorrhea was defined as 0 on the numerical rating scale, and complete remission of menorrhagia was defined as 2–3 on the Mansfield–Voda–Jorgensen scale at 6 months after the laparoscopic adenomyomectomy with TOUA. Partial remission was defined as >50% improvement in symptoms at 6 months after the laparoscopic adenomyomectomy with TOUA. Transvaginal sonography was performed by the same physician, who was not involved in this study and was blinded to preoperative ultrasonographic findings before and after surgery. Criteria for adenomyosis are the presence of a myometrial cyst, distorted and heterogeneous myometrial echotexture, poorly defined focus of abnormal myometrial echotexture, and a globular and/or asymmetric uterus. ⁹ The maximum diameter of the adenomyotic lesion was used for analysis. The criteria for recurrence were increasing size of residual lesions or development of new lesions as detected by ultrasonography during the follow-up period.

Statistical Package for Social Science software (SPSS, Inc., Chicago, IL, USA) was used for the statistical analysis. Data are expressed as mean±standard deviation (SD) values or absolute number (%). A value of P<.05 was considered significant.

Results

From May 2011 to September 2012, 34 patients with symptomatic uterine adenomyoma who were refractory to medical treatment and who had a strong desire to preserve their uterus were enrolled. All patients underwent a laparoscopic adenomyomectomy by a single surgeon (Y.-S.K.). Their mean age was 43.79 years (range, 34–53 years; SD, 4.94). The major site of adenomyoma was the posterior uterine body (38.2%), and the most common symptom associated with uterine adenomyoma was dysmenorrhea (Table 1).

The mean diameter of the adenomyomas was 5.29 cm (range, 2.5–9.5 cm; SD, 1.82). The mean total surgical time was 84.09 minutes (range, 50–240 minutes; SD, 31.48). Mean estimated blood loss was 148.18 mL (range, 20–500 mL; SD, 93.99) and no injury to the uterine arteries or pelvic nerves occurred. The mean TOUA time was 7.33 minutes (range, 5–25 minutes; SD, 4.12). Mean hospital stay was 3.82 days (range, 2–6 days; SD, 1.24) (Table 2). No cases of conversion to a laparotomy or major complications requiring reoperation or readministration occurred during the mean follow-up period of 8.9 months (range, 7–14 months).

At the 6-month follow-up, the main symptoms including dysmenorrhea and menorrhagia improved (complete remission of dysmenorrhea and menorrhagia occurred in 72.2% and 87.5% of patients, respectively). Five of the 34 patients revealed remnant adenomyomic lesions or recurrent lesions >1.0 cm in maximum diameter on ultrasonography (Table 3).

Discussion

The therapeutic goals of women with symptomatic uterine adenomyoma refractory to medical treatment include relief from adenomyoma-related symptoms and preservation of fertility. Most women with symptomatic uterine adenomyoma have completed childbearing, but there has been an increasing trend for women with benign uterine tumors to strongly desire to preserve their uterus.^10–12 These trends are weighted toward relief of symptoms rather than preservation of fertility in the treatment strategy for women with symptomatic uterine adenomyoma.

The most important surgical option for symptomatic uterine adenomyoma is surgical excision of the adenomyoma with preservation of the uterus. However, there are several limitations to surgical excision in women with diffuse uterine adenomyosis. These limitations include heavy intraoperative bleeding and long-term sequelae such as reduced uterine capacity. Few reports have introduced surgical excision of diffuse uterine adenomyosis to avoid complications,^13,14 and surgical excision in women with diffuse uterine adenomyosis has been achieved via laparotomy, not laparoscopy.

Unlike diffuse uterine adenomyosis, localized adenomyosis, called adenomyoma, can be more feasibly repaired or excised than the diffuse type. According to the extent and location of the lesion, the proper approach could be either a laparotomy or laparoscopy by an expert surgeon.

Focal adenomyoma can be excised laparoscopically, and there are several reports on excising focal adenomyomas via laparoscopy.^15–19 Enucleating the lesion is similar to myomectomy but is more difficult because of unclear boundaries with adjacent normal tissue. Thus, visual and tactile sensations of the operator are very important to completely and safely excise the lesion. Intraoperative bleeding can frequently disturb visual and tactile sensations and cause intraoperative transfusion or an incomplete excision. The operative time is usually longer for a laparoscopic adenomyomectomy than for a laparoscopic myomectomy, and operative time is strongly associated with intraoperative bleeding. Efforts to reduce intraoperative bleeding have been introduced by Morita et al., ¹⁵ who used vasopressin, and Osada et al., ¹⁴ who used a supracervical tourniquet via laparotomy. Stable and limited bleeding is very important to complete a laparoscopic adenomyomectomy operation safely and easily.

In the present study, mean TOUA time (both uterine arteries) was 7.33 minutes, which was considered reasonable, and mean estimated blood loss was 148.18 mL, which was less than that in other reports: 745±56 mL in Nishida et al. ¹³ and 372±314 mL in Osada et al. ¹⁴ Because of differences in patients with uterine adenomyoma or adenomyosis, this comparison might not be accurate. A safe operative condition for TOUA can be achieved with less bleeding and a clean operative field regardless of time, which is very important for both a novice and an expert surgeon. In a previous report,^5,20 a laparoscopic adenomyomectomy was described as more difficult than a myomectomy because of increased bleeding, the obscure boundary unlike the myoma-pseudocapsule, and suture techniques.

Another important factor is the suture technique to minimize dead spaces on myometrial defects after excising the adenomyomic lesions via laparoscopy. In the present study, the defect area was sutured in three layers after excision of the adenomyoma, which included a widely deep single interrupted suture (Fig. 2B), a continuously nonlocking running suture (Fig. 2C), and a continuously interlocking suture (Fig. 2D). The first assistant held the stitch to maintain suture tension throughout the repair process. This suture method shortens the operative time and obliterates dead space when suturing the myometrial defect. To approximate the edges of the outer myometrial serosa and maintain suture tension, a minimum depth of 5 mm in the remaining outer myometrial serosa is required during complete excision of the adenomyoma.

The response rate in the present study was 100% for dysmenorrhea and menorrhagia after laparoscopic adenomyomectomy with TOUA. A partial response to both symptoms was not refractory to pain killers or nonsteroidal anti-inflammatory drugs, which were tolerable to the women.

There were a few limitations in this study. First, the sample size was small. Second, the follow-up period was short, and we could not obtain the pregnancy outcomes of the treated patients who wanted to have a baby. However, this prospective study is the first report on laparoscopic adenomyomectomy by controlling both uterine arteries.

In conclusion, to perform a laparoscopic adenomyomectomy safely, less bleeding can be achieved by TOUA, which may be an important additional technique during a difficult laparoscopic adenomyomectomy. Laparoscopic adenomyomectomy with TOUA could be a surgical option in women with symptomatic uterine adenomyoma who want to preserve their uterus.