How to facilitate suturing in laparoscopic myomectomy,

Laparoscopic myomectomy is the best treatment option for symptomatic women with uterine fibroids who wish to maintain their fertility. Afterwards the step of laparoscopic suturing comes with a big challenge to the surgeon, hence we will demonstrate the main tips and tricks to facilitate it The surgical technique starts with infiltrating the myometrium surrounding the fibroid with a dilute solution of vasopressin (20 units in 100 mL of saline) to decrease bleeding. An incision on the serosa and myometrium is then performed using a unipolar ‘spoon’, needle electrode or other energy sources. Once the cleavage plane is reached, the fibroid will protrude out, and complete enucleation can be achieved. Suturing is performed using polydioxanone suture material or polyglycan 910. The myometrium is repaired in single or multiple layers accordingly. The use of electromechanical morcellator is highly controversial and if used it must be in a bag, or better cold morcellation or colpotomy. At the completion of the procedure, irrigation and meticulous haemostasis are performed. Despite being increasingly regarded as an alternative to open myomectomy, laparoscopic myomectomy should still be considered a complex procedure requiring specific operative skills and advanced surgical instrumentation. Therefore, many efforts were made to facilitate the different steps of laparoscopic myomectomy. Many methods are recommended to facilitate suturing in laparoscopic myomectomy including: alternative positioning of the trocars, direction of the uterine incision, use of endoscopic loops under progressive tension, modification of the classic technique of suturing, use of barbed sutures, laparoscopic assisted vaginal myomectomy.