Podcast Transcript: Laparoscopic Myomectomy: Tips & Tricks

[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.

[Dr. Sarah Rassier]
I think there are some groups that are really, really great with using uterine artery clipping, like temporary clips. I find that in extreme cases, the anatomy is more challenging for that. I think it does take someone who's quite experienced with that technique. That's an option, but I really don't use it routinely.

[Dr. Mark Hoffman]
Yes. That's not something I do. We've had them in the room. I'm like, "Oh, this is one. This may be the one." Then it was totally fine. I know I could do it. I'm always curious how many people are doing it because they need to or because they can.

[Dr. Sarah Rassier]
Just routine.

[Dr. Mark Hoffman]
Yes. It's interesting. I agree. I don't feel like I've needed it.

[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.

[Dr. Mark Hoffman]
No, I definitely understand that zone where you just-- what's the term for when you're in that…

[Dr. Sarah Rassier]
You're locked in.

[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 is how to close this huge gaping hysterotomy and make sure that the myometrium really approximates well and that you're-- 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.

[Dr. Mark Hoffman]
I have the same vision in my mind. It's almost like you have to like to see a building that's fallen down and put it back together one floor at a time. It's without fail when these big ones, you start closing the inner layers, and like, "Is this the one that just never comes together? Is this the one that we, because it looks like it's not going to close." Then with each layer, it's boom. By the end, I say the same thing, "It's looking a little more uterine again." As long as you just close the dead spaces back and forth and back and forth and just put it together like a book, just closing it, you almost have to sort of visualize how it's going to go together. I'm going to have to bring this part here and this part there.

[Dr. Sarah Rassier]
Exactly.

[Dr. Mark Hoffman]
I think that is tough for trainees just to see that.

[Dr. Sarah Rassier]
There was a study I remember from a while ago that looked at the published cases of uterine rupture after a myomectomy. I remember that one of the key things that was common in all the reported cases was the few number of layers. It's just like one huge layer. I truly try to focus on a multi-layer closure. I describe it to patients as a plastic surgery reconstruction of the uterus. It really is like rebuilding the uterine wall.

[Dr. Mark Hoffman]
No, I think that's exactly right. I think getting deep enough too, I think make small skin incisions, but make the big enough uterine incision that you can get in, see deeply, if it's an open case, get your finger in there and feel how deep it is, making sure, like you said, you're not leaving any dead spaces because it may look close above and there's a big, giant hematoma forming below.

If you have to expand, extend the hysterotomy to allow yourself to get a deeper closure, I know it's heartbreaking to think about making it bigger, but if it means you get to close it better, it's something we teach for sure.

[Dr. Sarah Rassier]
I also think just, especially for people that are just starting out, it's not the absolute worst thing in the world to open or to create a small mini-lap. If you're not getting an adequate closure, it's not laparoscopic or die. It has to be what's in the patient's best interest. I think thankfully that doesn't happen often, but if you feel like the closure is just not going to be coming together, that'd be an indication for a little bigger incision to make that more optimal.

[Dr. Mark Hoffman]
Yes. Whether it's you by yourself and you have to just, no cowboys here, right? Do what's best and what's safe. You and I are in places where if I need to call someone to come take a look, whatever, we can. I do think myomectomy is that one of the cases, myomectomy is an endosurgery also, but it's one of those that it's tough to do four years of residency and come out, in my opinion, and feel confident doing and comfortable doing a laparoscopic myomectomy.

There's a lot of moving parts and a lot of technical challenges to those cases that I think it's tough to pick that up in four years. I think that's one of the big things for MIGS fellowships or whatever we're going to call it going forward is getting a lot of touches and a lot of reps on myomectomies because those are the ones that are fun, great cases, but learning can be challenging.

[Dr. Sarah Rassier]
I think sometimes even the fibroids that seem a little bit easier, the exophytic fibroids are either on a pedicle and people might mistakenly think that they're easier, but those can bleed quite a bit.

[Dr. Mark Hoffman]
They make the mistake of lopping them off at the base, right?

[Dr. Sarah Rassier]
Exactly.

[Dr. Mark Hoffman]
I'm like, "No, no." You have to make a little turtleneck around it, so you have some cirrhosis because otherwise, it'll retract and you'll just have a big ulcer that you'll never stop the bleeding. Yes, those are easy if you do them right. If you do them wrong, boy, well, those are the ones that bleed the worst sometimes.

[Dr. Sarah Rassier]
Exactly.

[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.

I think another option is the posterior cul-de-sac is another opportunity for removal that I don't use that often, but there may be some patients whose umbilical or suprapubic is not going to be either a good option or necessary. Potentially, you can take some fibroids out through a posterior colpotomy and the vagina accommodates stretching a little bit nicer too. You can potentially slate that way.

[Dr. Mark Hoffman]
When I was retraining on the robot, that was funny because the guy was like, "Have you done this before?" I had to watch a surgeon,- he was a really nice guy. He was a good surgeon, and got to watch a guy operating, and he took four or five or six fibers out through a posterior colpotomy, and it looked super smooth the way he did it. I guess I get a little nervous about, number one, any type of vaginal incision, dehiscence, or infection. Also, again, if they're going to get a C-section, this is a patient who we already know they're going to get a C-section. I don't know. I see the value in all of it. I think it's another good option for V-notes, for example. Are you doing V-notes at all?

[Dr. Sarah Rassier]
We're talking about it. I haven't done any cases, but I think it's interesting for select people, not for every case for sure.

[Dr. Mark Hoffman]
My partners have done a few. We've done the training and stuff, but that was one of those, I felt like if you could learn that doing the posterior colpotomy for tissue extraction would be very similar and a similar approach that would allow you to get comfortable doing that as well.

[Dr. Sarah Rassier]
I think it's important to talk to the patients too because especially if some of these fibroid patients are young, reproductive age, sexually active, they might not want a vaginal incision that's going to potentially have a little longer pelvic rest, or God forbid, some sort of dyspareunia happens from it. I don't think issues with it are common, but it is important I think to chat with the patient ahead of time and see what their preference would be.

[Dr. Mark Hoffman]
That's great. I think we've gone over a lot. I think your process is-- you've seen as many of these as anybody. I think your insight is invaluable. Again, the reason why we do this show, if you and I were in Nashville in a few weeks talking about this, I would be talking to you about this because I'm genuinely curious about what you're doing and the fact that we get to do this and now have a few other people listen to it afterwards that I think is awesome. Tell me about what the future for myomectomy looks like in your mind.

[Dr. Sarah Rassier]
I think, like we were talking about, putting ourselves out of business, doing some more preventative work. What is it about any environmental lifestyle risk factors that we could modify? There's some work on vitamin D deficiency. Are there any other substances or supplements people could be taking to decrease their risk of fibroid formation? What can we do to identify them before they're a problem, either using new medications like the GnRH analogues or some of these radiofrequency procedures, something that we can do to stop them before they get to be as big of a problem? I think that would be really, really interesting.

[Dr. Mark Hoffman]
When I tell people, med students who are picking their profession or their specialty, I'm like, "Imagine whatever that procedure you love to do. Imagine we come up with a pill that makes that procedure obsolete. Would you still like that specialty? If you're curious about the medicine, if you're curious about treating fibroids, being a gynecologic surgeon is fantastic. If you just like myomectomies, think about what 30 years from now looks like because your career will be, a big chunk of that will be long after that stuff can be developed."

I think there's a lot to be said for trying to minimize the number of myomectomies we do. I think these technologies we talked about earlier on this evening are going to be things that hopefully prevent the number of myomectomies, at least certainly the big ones down the road. I am excited about that for sure.

[Dr. Sarah Rassier]
I think there's a lot of work to be done with just advocacy and patient education, especially in groups like Black women who tend to get fibroids earlier or have more aggressive disease, and just empowering people to really find these things before they become the 15-centimeter that requires a huge surgery.