Decision Points in Laparoscopic Myomectomy Surgery

[Dr. Mark Hoffman]
I think that it just goes back to your visualization, right? Okay, if I get this one out, how am I going to get this out? All the different steps. I was lucky in residency and fellowship to get a lot of exposure to mini-lap, to doing a lot through just one little Pfannenstiel incision. I think it's like the most powerful, useful incision a gynecologist has. The benefit versus hysterectomy is the uterus moves around, you can bring the uterus up to that incision. Even for a 10-centimeter fibroid, you can move it around underneath the skin. You can get a ton done through those incisions. Is there any limit to the number of fibroids that you'll offer to remove through a midline laparotomy or through a big incision?

[Dr. Sarah Rassier]
No, I think the highest number I ever counted was 101. That was in a pretty extreme case, lots of little baby fibroids.

[Dr. Mark Hoffman]
Oh, come on. Really?

[Dr. Sarah Rassier]
Yes. I think it does come down to patient selection too. If you have a, let's say, 49-year-old, no desire for any sort of fertility preservation who just wants to have a fibroid procedure and they have innumerable fibroids, probably I'm going to counsel them towards hysterectomy. For these patients that have a really huge fibroid burden, but they want to preserve their uterus, I think that especially with fertility concerns, and that's what I would try to be as aggressive as I can.

[Dr. Mark Hoffman]
Are you just bivalving the uterus and digging them out and trying to close the whole thing? That seems to me to be a worry that I have, is if you're making 30 incisions on the uterus, I don't know that we have that data, but certainly something you worry about in their pregnancy.

[Dr. Sarah Rassier]
Exactly. I would say these are not the most common cases whatsoever. Most of my cases are under 20 fibroids by far, but I have seen the bivalve-ing technique. That's not something I use frequently. When I have that many fibroids, I'm going to want to be extra conscientious about the hysterotomy location to try to get as many as possible through each site because I do worry, how much are you creating a Swiss cheese uterus that's not going to really give you the benefits you're looking for?

[Dr. Mark Hoffman]
Talk to me about why you choose belly button or umbilicus versus suprapubic because I personally have gone almost exclusively to suprapubic because I think in terms of cosmetic, I think in terms of healing, I always felt like the hernia rate or at least what I've read is the hernia rates appear to be lower through a Pfannenstiel, mini-lap Pfannenstiel than through a larger umbilical incision. What can you tell us about that?

[Dr. Sarah Rassier]
Yes. I feel like it really is patient-dependent. If someone is obese, has a prior hernia repair, or it seems like they're more prone to hernia, then I definitely want to avoid the umbilicus or sometimes people have sort of like subtle subclinical hernias that you notice on exam now that you're a belly button expert. I definitely avoid it in those cases, but I have some patients that they really would like for cosmesis to avoid any other bigger incisions elsewhere.

I also don't operate using a suprapubic port. It's an additional incision that I wouldn't already be using for my surgery, whereas the umbilicus, I'm just expanding a preexisting incision. I feel like I've to some extent become a belly button plastic surgeon over my career. I really spend a lot of time thinking about how to reconstruct it. You can get a sense of, "Okay, this is going to look really good," or, "This is actually not the best umbilicus for a big incision. That's not going to go well together."

[Dr. Mark Hoffman]
I definitely feel like I got really good at my suprapubics and my belly button plastic surgery skills maybe are not up to the Sarah Rassier level of expertise. I definitely feel like that's an area for professional and surgical development on my end because I do feel like it's one of those things that, we have large patients where we are. I know a lot of people have big patients, but I just feel like there's a lot of complaints about the belly button. People are very picky about their belly buttons. We'll definitely add belly button expert to your list of credentials in post to make sure we have that in there as well. I'm assuming that means you're an ipsilateral sower, ipsilateral ports operator.

I was trained that way too, but for my myomectomies, I was using a suprapubic, I was using that Pfannenstiel port. I would just do an ipsilateral, or the diamond rather, not ipsilateral, but the diamond port configuration for myomectomies specifically. I think, yes, it makes sense if you're going to use that umbilical port anyway to do it that way.

[Dr. Sarah Rassier]
Yes. I've been trying to challenge myself to really only do small mini-laps at the umbilicus. If you have a huge pathology where you're like, "Okay, this needs more than a three-centimeter of any lap to be efficient," then I'll go suprapubic for sure. I'd say I'm probably 70/30 on my distribution, so I try to keep it like three, three and a half centimeters at the umbilicus.

You probably do all the same stuff. My tips are that the corona or the ring of the belly button tissue, if you can keep your incision within that to the most degree, it's like an invisible incision at the end. I usually do a vertical incision through the base of the umbilicus, and if I have to go beyond that coronal ring of tissue, I just try to go vertically either superiorly or inferiorly a little bit, and that usually heals pretty nicely.

[Dr. Mark Hoffman]
Are you going directly through the belly button, like you cut it in half, or do you go around the base?

[Dr. Sarah Rassier]
Just vertically, just straight through. Yes, superiorly to inferiorly, just straight through the base. A tip that one of my old colleagues at Brigham taught me was how to tag the fascia to the subdermal umbilical base. Basically, after you closed your fascial incision, you grab a little bite of fascia and then you do a little U-stitch on the base, the absolute densest tissue at the base of the umbilicus, in that little subdermal tissue, and then just mirror it on the other side. Fascia, skin, skin, fascia, and it really brings it down and recreates a nice innie. That's something that I think helps a little bit to hide the incision.

[Dr. Mark Hoffman]
That's a video that needs to be made, I think, for one of these meetings, so you can show me exactly because it is like 3D reconstruction in that area. I think some people go around the belly button and I've seen other surgeons will do a big crescent or around it. It doesn't look great cosmetically. The ones that go sort of straight through seem to heal and look the best because it mimics one of the natural creases and folds in the belly button. Maybe I'll just have to get more used to that.

[Dr. Sarah Rassier]
Yes. I think I'm the opposite of you in terms of my suprapubics. I feel like I get more complaints about cosmesis in terms of that. I think it's just whatever you get really fast that gets better.