How to Reduce Blood Loss During Myomectomy: Advanced Techniques in Laparoscopic Myomectomy Surgery

[Dr. Mark Hoffman]
One thing I forgot to ask, OR setup and those things, what are you doing to minimize blood loss? I think I actually listened to one of your talks years ago and just totally copied at least what you did then. I'm curious if I need to update my protocol. What are you doing for minimizing blood loss besides obviously surgical approach and technique and those things?

[Dr. Sarah Rassier]
It probably is not much different than what I would've said years ago. I try to be conscious about anemia optimization ahead of time. I really love using iron infusions. You just get so much of a quicker bounce back on your blood count. I love that along with suppression of menses or Lupron if it's really severe. Then in the OR, I pretty much universally use what I call a pharmacologic tourniquet. I use intravenous tranexamic acid, rectal misoprostol.

[Dr. Mark Hoffman]
One gram IV of TXA?

[Dr. Sarah Rassier]
Yes, exactly.

[Dr. Mark Hoffman]
Then I think 800 micrograms or 1,000 micrograms of meso per rectum?

[Dr. Sarah Rassier]
Yes, I usually use 600, but I think there's some variation of what's been reported for miso, and it's tolerated quite well per rectum. One thing our anesthesia team often asks us is in ortho, they usually repeat the TXA. I usually just give it once at the beginning. Then I'll use a dilute vasopressin during the case too.

[Dr. Mark Hoffman]
That's exactly what I do because I probably copied a few exactly from your talk. It works great, honestly. The number of times I've had to transfuse, unless someone is severely anemic and some of these myomectomies, you're cutting muscle bleeds, but I think it dramatically reduces little stuff that can build up over a long case.

[Dr. Sarah Rassier]
Yes. I'm thoughtful about whether I want to do any structural hemostasis, like vascular clips of the uterine arteries or tourniquets, but I find that I don't need it too much. I'm sort of one of these, if it's not broken, don't fix it. Sometimes for these extreme cases, this is another one of these "thinking outside the box" things. If I have a suprapubic mini-lap for these huge cases, I might put a tourniquet in through my open incision, just like you would for an open hysterectomy. Make a hole in the broad and put a Penrose strain or something similar as a tourniquet. I don't do that often at all. I'd say that's more for these extreme cases, and same thing with clipping the arteries.

[Dr. Mark Hoffman]
I've obviously gotten to the uterines laparoscopically and visualized them if I had to get them, but the number of times I need to do that for a hysterectomy, one hand. On a myomectomy, I've never felt like that was necessary. I feel like you said, if you do these things and you're thoughtful in your approach and you're relatively efficient in your nucleation and your closure because I think, in residency, we did so many myomectomies that were open, but the tenet was speed.

Be efficient. This thing is going to bleed until we're done. Go, go, go. Just be efficient with your steps. Don't rush, but every second counts. Once you get those layers closed and you've got a hemostasis, mechanically that's going to be the biggest way that you can create hemostasis. I think that other stuff buys you some time, no, that's exactly what I do as well.
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[Dr. Sarah Rassier]
Your comment about efficiency, that's my number one thing I'm always talking about is from the moment you make your hysterotomy incision until it's closed, it's going to continuously ooze. You want it to ooze because if the myometrium is ablated, it's not going to heal well. Sometimes you can't tell because you're in your little zone and you don't really see, there's actually a pool of blood accumulating by the liver. I think, just consciously looking at the time, making sure you're making forward progress, especially if you have trainees involved, being thoughtful about how that is progressing with the efficiency of the case is really important.

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[Dr. Mark Hoffman]
Time is, yes, meaningless. You're just working and you go, go, go. Yes, it's been oozing down there that whole time. Okay. Closure and layers, right? Is it always going to be a barbed suture for you?

[Dr. Sarah Rassier]
For me, I'm pretty much always a barbed suture. If I know that I've gone through the endometrium, I'll usually do a smooth suture for endometrial, over-sewing over the endometrial cavity. I don't know if there's any data. It's just more so that's how I would do it open. I'm trying to replicate it laparoscopically.

[Dr. Mark Hoffman]
I do the exact same thing. I just feel better knowing that whatever's inside is smooth and maybe would reduce the risk of there being intrauterine adhesions.

[Dr. Sarah Rassier]
Yes. I have some colleagues that use barbed, so I'm sure it's fine, but that's just how I do it. I try to think about obliterating the dead space. There's not really a pocket for hematomas to form as much. This is the part that I think is the hardest for people to grasp when they're learning how to close this huge gaping hysterotomy and make sure that the myometrium really approximates well. I equate it to closing a book or closing a clamshell, just getting it to rebuild itself. I do multiple layers with the barbed suture and then a separate cirrhosal closure.

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[Dr. Mark Hoffman]
Tissue extraction, I know we've talked about this endlessly in the last 12 years of our careers, but tell us a little bit about how you get fibroids out.

[Dr. Sarah Rassier]
I'm a huge proponent of contained extraction. I think, in my opinion, everything should be done within a containment bag when feasible. It can be power morcellation if you have it or you want to do that and the patient's amenable to it. I usually do manual extraction with a scalpel, but I have heard a lot of people say, "Well, the cat's already out of the bag. If you're doing a myomectomy, the fibroid has been dissected out. You could be spreading cells through the cavity."

That's definitely true. I explain that to patients that this is not an oncologically sterile procedure. This is going to potentially disseminate some cells from just enucleating the fibroid. I think that the potential for leaving little tissue pieces or leaving little fibroid chunks in there as you're morcellating is really significant. We're seeing more and more cases of these peritoneal fibroids after prior myomectomy or prior hysterectomy. Those are pretty morbid in terms of if you have to go in there and reoperate on them in some cases.

[Dr. Mark Hoffman]
Interesting.

[Dr. Sarah Rassier]
I like the containment bag. I think it doesn't eliminate the risk, but it might minimize the chance of leaving a little fibroid piece behind.

[Dr. Mark Hoffman]
No question with the mechanical morcellator, we were shooting little pieces of fibroid bits everywhere. I think that we're morcellating by hand as well now. It's the little bits and it just keeps it together. There's a lot of fibroids, putting them in a bag, it's a smart way to do it. Are you using a fishing line at all to keep them?

[Dr. Sarah Rassier]
If I have a lot of tiny fibroids, I'll do that. Create a string of pearls where I have a suture that's in there. Then as I'm collecting them, I'll just string them up. Or if you already had a mini-lap for the case, let's just say you made your suprapubic mini-lap at the beginning, I'll just take out the smaller fibroids as I go just to avoid losing track of them. That's the worst. You don't want to lose track of it and then spend forever searching for small fibroids.

[Dr. Mark Hoffman]
30, 45 minutes looking for that one. Make sure you count as you go because otherwise, is there another fibroid? You don't want to find that MRI in six months and realize that you left it there for sure.

[Dr. Sarah Rassier]
I also like to do what I call excessive irrigation. I sort of say I'm in recovery for being an over-irrigator because, at the end of the case, there had been fibroids potentially sitting in the pelvis the whole time. I just try to do several liters of irrigation to ideally try to dilute if there's any residual tissue spill or cellular spillage that's in there.