Intraoperative Strategies to Minimize Blood Loss During Myomectomy

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Myomectomy is a common procedure performed by gynecologists for the conservative management of leiomyomas (fibroids). The surgical removal of fibroids can be associated with significant intraoperative blood loss and subsequent blood transfusion, which is an important morbidity associated with this elective procedure in reproductive-aged women.

This video demonstrates various evidence-based strategies aimed at minimizing surgical bleeding during myomectomy. Techniques covered in this presentation include:

(1) Preoperative use of medications such as vaginal/rectal misoprostal and intravenous tranexamic acid.

(2) Intramyometrial injection of dilute vasopressin.

(3) Temporary uterine artery occlusion with pericervical tourniquet.

We demonstrate how these techniques can be used to minimize blood loss during abdominal, laparoscopic and robotic myomectomy.

Presented By

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Dr. Deborah Robertson
 

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University of Toronto

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What is Intraoperative Strategies to Minimize Blood Loss During Myomectomy?

Intraoperative strategies to minimize blood loss during myomectomy, a surgical procedure to remove fibroids from the uterus, are crucial for enhancing patient safety, reducing the need for blood transfusions, and facilitating quicker recovery. These strategies are designed to manage and reduce bleeding effectively during the surgery. Key approaches include:

  • Preoperative Planning: Careful assessment of the fibroids’ size, location, and number through imaging studies helps in planning the surgical approach and anticipating potential blood loss.
  • Use of Vasopressin: Injection of vasopressin, a synthetic hormone, into the myometrium around the fibroid to constrict blood vessels and reduce blood supply to the area, thereby minimizing bleeding.
  • Tourniquets or Mechanical Devices: Application of tourniquets or other mechanical devices to temporarily restrict blood flow to the uterus during the procedure.
  • Electrocautery and Ultrasonic Scalpels: These tools are used for cutting and coagulating tissue simultaneously, reducing blood loss by sealing blood vessels as the fibroid is removed.
  • Uterine Artery Embolization (UAE) before Surgery: This procedure involves blocking the blood supply to the fibroids, reducing their size and blood loss during the subsequent myomectomy.
  • Bipolar Coagulation: Utilization of bipolar energy for coagulating blood vessels around the fibroids, offering precise control over bleeding.
  • Suturing Techniques: Advanced suturing techniques, including the stepwise devascularization of the uterus and selective arterial ligation, help control bleeding from larger vessels.
  • Hemostatic Agents: Application of agents such as fibrin sealants, gelatin sponges, or oxidized regenerated cellulose to the surgical site to promote clotting and reduce bleeding.

These intraoperative strategies are selected based on individual patient factors, including the extent of fibroid involvement, patient health status, and specific surgical approach (e.g., laparoscopic, hysteroscopic, or open myomectomy). The goal is to ensure the surgery is as safe and effective as possible, with minimal complications.

What are the Risks of Intraoperative Strategies to Minimize Blood Loss During Myomectomy?

The intraoperative strategies to minimize blood loss during myomectomy, while crucial for reducing the risks associated with surgery, carry their own set of potential risks and complications. Here are some of the risks associated with these strategies:

  • Allergic Reactions: Use of synthetic hormones like vasopressin can cause allergic reactions in some patients, ranging from mild to severe.
  • Tissue Damage: Techniques that involve thermal energy, such as electrocautery and ultrasonic scalpels, can lead to thermal injury to the surrounding uterine tissue or adjacent organs if not carefully applied.
  • Vascular Complications: Tourniquets or mechanical devices used to restrict blood flow might inadvertently damage blood vessels, leading to vascular complications.
  • Fluid Overload or Electrolyte Imbalance: Excessive use of vasopressin or incorrect administration can lead to water intoxication or electrolyte imbalance, potentially causing serious health issues.
  • Incomplete Hemostasis: While hemostatic agents and suturing techniques aim to control bleeding, there’s a risk of incomplete hemostasis, which could lead to postoperative bleeding and the need for further intervention.
  • Infection: Any surgical intervention increases the risk of infection, including the use of devices or agents introduced into the uterine cavity during myomectomy.
  • Adhesions: Surgical interventions, especially those involving incisions on the uterus, can lead to the development of scar tissue (adhesions), which might cause pain, fertility issues, or complications in future pregnancies.
  • Impact on Fertility: Although these strategies aim to preserve fertility, any surgical procedure on the uterus carries a risk of affecting future fertility due to potential changes in uterine anatomy or function.

It’s important for patients to discuss these risks thoroughly with their healthcare provider before undergoing a myomectomy. The decision to use specific intraoperative strategies will be based on a comprehensive evaluation of the patient’s health, the characteristics of the fibroids, and the surgical approach being considered. The goal is always to balance the benefits of minimizing blood loss with the potential risks of the strategies employed.

Video Transcript: Intraoperative Strategies to Minimize Blood Loss During Myomectomy

The objective of this video is to demonstrate various evidence-based strategies aimed at minimising surgical bleeding during open, robotic and laparoscopic myomectomy. Fibroids are common benign masses which can result in significant morbidity for affected women due to heavy menstrual bleeding and anaemia, bulk symptoms and infertility. In women who are premenopausal or wishing to retain future fertility, the surgical management of symptomatic fibroids is by way of myomectomy.

Myomectomy can result in a significant degree of blood loss and intraoperative transfusion rates can be as high as 20%. Major surgical bleeding and intraoperative transfusion are correlated with increased short-term morbidity and mortality, as well as other long-term complications such as transmission of infection and alloimmune sensitisation. Gynaecological surgeons have utilised a number of interventions in an attempt to reduce rates of surgical bleeding during myomectomy.

A recent Cochrane review groups these interventions into four main categories. Temporary or permanent occlusion of uterine arteries, uterotonic medications, myoma dissection techniques and chemical manipulation of the coagulation cascade. While a number of interventions are discussed and reviewed in the literature, clinical practice varies considerably between surgeons. A recent Delphi study presented by Bao et al in 2018 presents a standardized approach to decreasing blood loss during myomectomy.

This clinical practice bundle is an expert consensus designed by a multidisciplinary team and takes into account evidence and guidelines from multiple specialties. This video will highlight the various elements of this clinical bundle which can be used to minimize intraoperative blood loss during abdominal laparoscopic or robotic myomectomy. Tranexamic acid is an antifibrinolytic agent which can be administered at a dose of one gram intravenously prior to the start of the case.

While the data supporting the use of tranexamic acid during myomectomy is still limited, its low cost, wide availability, favourable side effect profile and strong evidence for effectiveness in orthopaedic surgery, cardiac surgery and postpartum haemorrhage, support its use during myomectomy. Misoprostal is a uterotonic agent which has also been shown to reduce blood loss and transfusion rates during myomectomy. It can be administered vaginally or rectally at a dose of 600 micrograms prior to the start of the case.

Intramyometrial vasopressin has been shown to reduce blood loss and transfusion rates during myomectomy when compared to placebo. The maximum safe dose of vasopressin has not been established, but the literature describes diluting 20 to 40 international units in 100 to 200 millilitres of normal saline. Anaesthesia should be informed prior to injection of vasopressin and care should be taken to avoid intravascular injection as there have been rare cases reported of bradycardia and cardiovascular collapse.

Blanching of the myometrium and fibroid capsule can be seen after injection. In the case of robotic or laparoscopic myomectomy, a spinal needle can be passed directly through the anterior abdominal wall, as demonstrated here, and vasopressin can be injected directly into the fibroid. With the assistance of the laparoscopic or robotic instruments, vasopressin is injected in various spots along the proposed incision route. Once again, blanching of the myometrium is seen with injection of vasopressin.

And due to this intervention, bleeding is minimal once the uterine incision is made. For large intramural fibroids, a paracervical tourniquet can be used to temporarily occlude the uterine blood supply. The broad ligament is palpated at the level of the internal cervical os, and a clear space is identified, free of vessels or the ureter. A one-centimetre incision is made, and the tourniquet is passed through the incision. In this example, a red rubber catheter is used as a tourniquet.

Depending on the resources available, various other items can be used, including a Foley catheter or a flexible Penrose drain. After repeating the appropriate landmarking, an identical incision is made in the broad ligament on the contralateral side and the tourniquet is passed through the hole with the assistance of a curved clamp. The tourniquet can be secured on the anterior or posterior surface of the uterus. In this example, it will be secured on the posterior side, and so the tourniquet is placed just above the level of the internal cervical os anteriorly.

 Posteriorly, the ends of the tourniquet are tied together. Care should be taken to avoid enlarging the broad ligament incisions or injuring surrounding structures. Clamps are used in a hand-over-hand technique to sequentially tighten the tourniquet. A similar technique can be used during laparoscopic or robotic myomectomy using an O-suture as the tourniquet. Intraoperative blood loss is a significant surgical risk during laparoscopic, robotic and abdominal myomectomy, and perioperative transfusion rates are high.

There are significant short-term and long-term risks associated with blood transfusions, and gynaecologic surgeons must employ evidence-based interventions in order to minimize blood loss and decrease the need for blood transfusions.