Laparoscopic Myomectomy for a Plethora of Submucous Myomas.

STUDY OBJECTIVE: To demonstrate a laparoscopic myomectomy technique for the removal of multiple submucous myomas. DESIGN: A step-by-step demonstration of the surgical procedure (Canadian Task Force classification III-C). SETTING: In cases of multiple submucous myomas, hysteroscopic resection of myomas might not be a viable option, especially in cases requiring fertility preservation. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae [1]. The procedure is technically challenging and requires prolonged operating time owing to impaired visibility and the need for repeated specimen removal. This can lead to complications, such as fluid overload and, rarely, air embolism [2]. Thus, laparoscopic myomectomy may be a better option in such cases [1]. INTERVENTIONS: A 30-year-old nulligravida presented with a 3-year history of heavy menstrual bleeding and dysmenorrhea. She had received no symptom relief with hormonal medications and magnetic resonance-guided focused ultrasound. On examination, she was anemic, and her uterus was enlarged to 16-weeks gravid size. Ultrasonography revealed an intramural fundal myoma of 6 × 4.2 cm and numerous submucous myomas of 1 to 3.2 cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from type 0 to type 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20 U in 200 mL dilution), and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of the submucous myomas. Most of the myomas were removed with mechanical force, along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes, and estimated blood loss was 850 mL. The patient did not require blood transfusion, but was advised to take hematinics. At a 6-month follow-up, the patient reported significant improvement in her symptoms. A repeat hysteroscopy revealed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. The patient was advised to attempt conception after 2 months. CONCLUSION: Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful for identifying any residual myomas and synechiae.

Laparoscopic Tubal Reanastomosis Using Barbed Sutures.

STUDY OBJECTIVE: To show a new technique of laparoscopic tubal reanastomosis using barbed sutures. DESIGN: Step-by-step explanation of the technique using videos. SETTING: Laparoscopic tubal reanastomosis is an effective procedure with a high success rate for reversal of tubal sterilization. Conventionally, 4 equidistant interrupted sutures are placed under a magnified view for laparoscopic tubal reanastomosis. This step demands high precision and requires a lot of skill and experience. We have tried to simplify this suturing technique by using barbed sutures because they do not require knotting. Two separate 5-0 Quill barbed sutures (Angiotech Puerto Rico Inc, Aguadilla, Puerto Rico) are used in this technique. The first suture is used for taking 6 and 3 o' clock stitches. The second suture is used for taking 9 and 12 o' clock stitches. With this technique, the purse-string effect on the tubal lumen is reduced. INTERVENTIONS: Laparoscopic tubal reanastomosis using 5-0 Quill barbed sutures (equivalent to United States Pharmacopeia suture size 6-0). CONCLUSION: This technique of laparoscopic tubal reanastomosis using barbed sutures is a feasible and simpler alternative to conventional suturing.