Reducing Blood Loss and Need for Blood Transfusion During Laparoscopic Myomectomy

INTRODUCTION: Myomectomy is one of the most common gynecologic surgical procedures performed in the United States. Myomectomy has high rates of intraoperative bleeding compared to hysterectomy, often due to anatomic distortion or tumor-related vascularization. The rate of blood transfusion following myomectomy is 10%, and women who require blood transfusions following myomectomy are independently at increased risk for experiencing a major postoperative complication. As such, it is essential to both optimize preoperative hemoglobin levels and minimize intraoperative blood loss for the safety of patients. OBJECTIVE: To review the pre- and intraoperative management strategies for decreasing blood loss during laparoscopic myomectomy. METHODS: We describe the preoperative interventions to improve anemia prior to surgery and the associated average increase in hemoglobin levels, including oral and IV iron, gonadotropin hormone-releasing analogues like leuprolide, and ulipristal acetate. The efficacy of perioperative interventions like the use of vaginal misoprostol and intramyometrial vasopressin are also reviewed. Two patients with abnormal uterine bleeding in the setting of fibroids are presented, detailing the injection of vasopressin, minimal incision technique, and efficient myometrial closure. RESULTS: IV iron results in rapid increase in hemoglobin level compared to oral iron and should be reserved for patients who do not respond to oral iron, those with severe anemia, or those in which a rapid rise in hemoglobin level is required. Gonadotropin hormone-releasing analogues and ulipristal acetate are also effective means of improving preoperative anemia but take 2–4 months for full effect. The two perioperative interventions that are routinely recommended and used in our practice are vaginal misoprostol and intramyometrial vasopressin, both of which significantly improve intraoperative blood loss, reduce the need for blood transfusions, and have moderate-quality evidence to substantiate their use. We demonstrate the preparation and injection of vasopressin in our surgical video, showing hydrodissection between the fibroid and the myometrium, blanching, and avoidance of major vessels. Incisions are made in the horizontal in order to incise as many fibroids as efficiently as possible. Myometrial layers are closed with 2-0 barbed suture with synching between throws, which provides efficient closure that minimizes intraoperative bleeding. CONCLUSIONS: We discuss the key pre- and intraoperative techniques to limit blood loss during laparoscopic myomectomy, including improving anemia prior to surgery, injection of vasopressin, careful incisions along the myometrium, and closure with barbed suture.