Open Access

Temporary clipping of the uterine artery during laparoscopic myomectomy—a new technique and the results of first cases

  • Martin Voss1Email author,
  • Christhardt Koehler1,
  • Florian Elger1,
  • Susanne Kruppa1 and
  • Achim Schneider1
Gynecological SurgeryEndoscopy, Imaging, and Allied Techniques20074:280

https://doi.org/10.1007/s10397-007-0280-y

Received: 1 November 2006

Accepted: 9 February 2007

Published: 28 April 2007

Abstract

Bleeding is the most common complication in laparoscopic myomectomy. In this paper, we describe a new technique using Yasargil aneurysm clips to reduce blood loss during laparoscopic myomectomy by clipping the uterine arteries temporarily. Over a 7-month period, 13 patients with uterine fibroids larger than 5 cm underwent laparoscopic myomectomy with temporary clipping of both uterine arteries at their origin from the internal iliac artery. We assessed the clinical data of perioperative blood loss, operating time, hospital stay, complications, haemoglobin decrease and uterine artery Doppler flow prior to and after the procedure. No serious perioperative complications occurred. The mean number of removed fibroids was 7.5 (range 1–30), with an average total weight of 421 g (range 160–960 g). Mean Hb pre- vs. postoperatively was 12.5 g/cl vs. 10 g/cl. There was no significant change in the uterine artery flow prior to and after surgery. No transfusion was given to any of the patients. We conclude that temporary clipping of the uterine arteries prior to laparoscopic myomectomy is a safe procedure for controlling excessive blood loss without jeopardising the uterine blood supply.

Keywords

Laparoscopy Uterine myoma Myomectomy Blood loss Aneurysm clip Infertility Yasargil Fibroids

Introduction

Uterine leiomyoma are present in at least 25% to 35% of women over the age of 35 years [1]. Most of these women are asymptomatic, but in approximately 34% of patients, uterine fibroids are associated with a wide spectrum of disorders, such as abnormal bleeding, pelvic pain, dysmenorrhoea, dyspareunia and infertility [2].

For symptomatic women who desire to preserve fertility, myomectomy is the first choice of treatment. This can be performed by laparotomy, laparoscopy or hysteroscopy. During these procedures, bleeding is the most common complication. A recent study reported a blood loss of over 1,000 ml in 23% of patients [3]. Other studies reported blood transfusion rates between 18% and 24% [46]. The enucleation of fibroids and the reconstruction of the uterine wall may be difficult to perform while there is still bleeding. Blood transfusion or hypovolaemic shock may result. Uncontrolled bleeding sometimes renders hysterectomy inevitable [7]. Thus, the appropriate control of bleeding is a key target in myomectomy procedures.

In order to achieve better haemostasis, various approaches have been reported, such as the administration of GnRH analogues [1], embolisation [8], the administration of vasoconstrictive drugs [7], permanent bilateral uterine ligation [9] or tourniquets [10]. Whether these methods are advantageous in patients with infertility remains to be shown.

We investigate a new technique to reduce blood loss during laparoscopic myomectomy using Yasargil artery clips for the temporary and atraumatic closure of the uterine arteries.

Materials and methods

Pre- and postoperative data of women who underwent laparoscopic myomectomy at the Department of Gynaecology at Charité, Berlin University of Medicine, Germany, over a 7-month period (August 2005 to February 2006) were registered prospectively. Only patients with symptomatic uterine fibroids were included. All patients were informed preoperatively and gave written consent to this new operative method. The Charité’s institutional review board approved of the trial.

A uniform patient chart was used during this period to record data on medical history, number and size of the different myomas, operating time, pre- and postoperative Hb (haemoglobin) level, pre- and postoperative uterine artery Doppler values RI and PI (resistence and pulsatility indices) and pre- and postoperative complications. All data were collected systematically in an electronic file (Microsoft Excel).

Technique

The patient is placed lying in a 20° head-down Trendelenburg position. The procedure is started with placing a 10-mm umbilical or left subcostal laparoscopic trocar. Two 5-mm instrument trocars are placed 2 cm cranially and medially of the anterior superior iliac spine. A fourth, 12-mm, trocar is inserted 5 cm suprapubically. This trocar is also used for the morcellator during the final part of the procedure. Apart from the Yasargil clips, standard instruments were used (Fig. 1).
Fig. 1

Kelly Bipolar grasping forceps, Metzenbaum scissors (curved), Schneider lymph node grasping forceps (atraumatic), Yasargil clip, grasping forceps (atraumatic, double spoon, with multiple teeth) and tenaculum forceps (10-mm diameter). Instruments: Karl Storz, Germany

The technique of identification of the uterine vessels at their origin has been described before in the laparoscopically assisted vaginal hysterectomy (LAVH) procedure by Koehler et al. [11]. After the identification of the ureter and the external and internal iliac arteries, the upper part of the pararectal space is opened by blunt dissection. Under permanent medialisation of the ureter, we follow the internal iliac artery until its branching off into the uterine artery and the lateral umbilical ligament is visible (Fig. 2).
Fig. 2

(1) Ureter medialised with a Schneider lymph node grasping forceps to allow more vision and space to place the Yasargil clip. (2) Right uterine artery. (3) Lateral umbilical ligament. (4) Internal iliac artery

The surgeon then isolates the uterine artery over a distance of 2–3 cm from its origin, thus, achieving sufficient space for the placement of the clip.

The Yasargil clip is brought into the abdomen via the umbilical trocar (Fig. 3). The clips are fitted with a 10-cm Vicryl thread for two reasons: first, when removing the clip, pulling the thread is sufficient to let the clip slip off the artery, thus, there is no need to open the pararectal fossa again; secondly, in case of accidental loss of the tiny clip, the long thread is easily discovered in the abdomen.
Fig. 3

A Yasargil clip opened with grasping forceps (atraumatic, double spoon, with multiple teeth). Compressing the spring part will open the straight smooth blades. The Vicryl thread attached to the clip facilitates the location and removal of the clip

The clip is now placed over the uterine artery with an atraumatic, double spoon grasping forceps. Gentle lifting of the clip will show whether it is tightly closed over the whole arterial diameter (Fig. 4).
Fig. 4

(1) Right ureter medialised. (2) A Yasargil clip placed over the right uterine artery. (3) Lateral umbilical ligament. (4) Internal iliac artery

The same procedure is performed contralaterally. After the completion of myomectomy reconstruction of the uterotomy by intracorporal sutures, the fibroids are morcellated. The clips are removed using the Vicryl threads attached. It is essential to then re-check all sutures and uterotomies to safeguard appropriate haemostasis and to discover potential bleeding after the reopening of the uterine arterial circulation.

Results

Thirteen patients with large or multiple uterine fibroids were operated between August 2005 and February 2006 at the Department of Gynaecology, Charité, Berlin University of Medicine, Germany. The operative details of the patients are summarised in Table 1.
Table 1

Summary of the operative details of the patients

Operative results

Operation time (min)

273 (120–390)

Number of fibroids

7.5 (1–30)

Size of largest fibroid (mm in diameter)

67 (25–130)

Total weight of fibroids (g)

421 (150–960)

Preoperative Hb (g/cl)

12.5 (9.7–14.7)

Postoperative Hb (g/cl)

10 (6.7–11.9)

Preoperative RI/PI uterine artery Doppler

0.69/1.30

Postoperative RI/PI uterine artery Doppler

0.74/1.39

Postoperative hospital stay (days)

5,25 (3–7)

All laparoscopic myomectomies with Yasargil clips were completed successfully. The mean number of myomas removed were 7.5 (range 1–30), with a mean size of 67 mm in diameter and a total mean weight of 421 g. The mean operating time was 273 min. Given the mean preoperative Hb of 12.5 g/cl and postoperative Hb of 10 g/cl, the mean drop was 2.5 g/cl. There was no blood transfusion necessary. No intraoperative complication occurred and no case had to be converted to open surgery because of intraoperative difficulties.

The postoperative course was uneventful in all but one patient. This patient returned 15 days after the myomectomy of a single fibroid measuring 115 mm in diameter, weighing 960 g and presenting with a haematoma within the enucleation site. She was preventively treated with antibiotics and discharged 5 days later without further complaints.

Histological evaluation confirmed benign fibroids in all patients.

There were no significant changes in uterine artery Doppler RI or PI compared with preoperative values at the postoperative follow-up time of 2 to 3 days. Most of the patients were discharged 3 days after the operation.

Discussion

Yasargil aneurysm clips were introduced into neurosurgical practice more than 25 years ago. The clip is named after Michael G. Yasargil, Professor in Neurosurgery. The clips were designed to close blood vessels in difficult-to-reach intracranial locations. Made of titanium due to its better weight-to-strength ratio than its cobalt-chromium competitors, they may stay in situ without losing strength, do not corrode and show no artefacts on magnetic resonance imaging (MRI) or computed tomography (CT) scans [12].

Laparoscopic myomectomy provides an excellent alternative to abdominal myomectomy for women desiring uterine preservation and childbirth. Published reports have documented the advantages of laparoscopy over open surgery in non-blinded settings. The benefits of laparoscopic surgery include reduced hospital stay, a better cosmetic effect and decreased postoperative pain [13, 14]. However, the laparoscopic approach seems to be limited by the number and size of the fibroids [15, 16]. The major problems in laparoscopic myomectomy are operating time, bleeding control and overall blood loss.

In open myomectomy, temporary haemostatic occlusion of the uterine blood supply was first described in 1932 using metal clamps [17] following the even earlier ligation of the uterine arteries [18]. This technique of total vascular occlusion of the uterine blood supply is still recommended by some authors [19].

Various biochemical techniques of temporary haemostasis have also been described [3, 5]. Intramyometrial vasopressin has been compared with triple tourniquet and there was no reported difference [5]. It is also not approved for this indication in Germany. The preoperative administration of GnRH analogues has been shown to effectively reduce blood loss at open myomectomy [1]. However, they have been associated with symptoms of oestrogen deficiency as side effects and appear to be associated with an increase in fibroid recurrence at 6 months [1]. Newly described is the uterotonic E-prostaglandin misoprostol as a preoperative medical agent. Further studies are needed to evaluate its usefulness [20].

Incorporating the existing data, there appear to be no side-effect-free or approved agents for the preoperative treatment of uterine fibroids.

Alternatives to the surgical management of uterine fibroids are uterine artery embolisation (UAE) and MR-guided focussed ultrasound (MRgFUS) [21, 22]. Recently, UAE has been associated with a high failure and complication rate [23]. Currently, both techniques are only recommended when preservation of the uterus is not needed for future pregnancy.

For the laparoscopic approach and for women who desire to preserve fertility, we developed the technique of temporary clipping of the uterine arteries using Yasargil clips. This procedure appears to improve the control of blood loss and keeps the surgical site “blood-free.”

The mean drop in Hb was 2.5 g/cl and there was no blood transfusion required in any patient. Given the large size and average number of myomas removed, this appears to be highly satisfying. Fletcher et al. [3] report that 23% of their patients lost over 1,000 ml of blood and others report similar transfusion rates of between 18% and 24% [46]. Taylor et al. [10], using triple tourniquets at open myomectomy in a randomised controlled trial, reported a mean blood loss of 489 ml in the tourniquet group and 2,359 ml in the control group with blood transfusion rates of 0.7% and 79% respectively. The overall fall in Hb was 2.96 g/cl in the control group and 2.79 g/cl in the tourniquet group.

Our mean operating time was 273 min. This appears to be long in comparison with the published data reporting operating times in the region of 90–110 min [13, 2427]. Our technique requires an extra 10 to 20 min of operating time for the clipping procedure. However, we did not evaluate time needed for the clipping, enucleation and morcellation procedures separately. We are looking into this in a randomised controlled trial which has started in January 2007. Another explanation for the extended operating time could be the average number (7.5) and large size (67 mm/421 g) of the fibroids we removed solely laparoscopically. The larger the fibroids, then the more time consuming is the uterine wound repair and morcellation [28]. Previous reports of laparoscopic myomectomies do not include data on the total weight of fibroids.

Additionally, there appears to be a potential risk of organ damage with the opening of the pararectal fossa, although we did not observe these in this study. The learning curve might be longer for the inexperienced surgeon. However, this might be offset by the time saved due to less coagulation and suction/irrigation.

Theoretically, there is a risk of uterine artery thrombosis due to the temporary stasis of blood flow. There are no data available on uterine artery flow pattern changes in laparoscopic myomectomy using uterine depletion techniques. In open myomectomy, Taylor et al. [10] showed no increase in the RIs of uterine artery flow with postoperative follow-up of up to 6 months. In accordance with their data, our pre- and postoperative uterine artery Doppler flow measures were unaltered and we have not encountered any thromboembolic complications so far.

Earlier studies suggest that laparoscopic myomectomy should be reserved for patients with less than four myomas and a maximum diameter of 7 cm [29] to avoid complications and the need to convert to laparotomy [30]. In our study, the largest fibroid was 13 cm in diameter, with no need for conversion to laparotomy. With the use of Yasargil clips, blood loss control appears to be improved and larger myomas can be treated by minimally invasive surgery.

In summary, our results demonstrate the potential effectiveness and convenience of Yasargil clipping of the uterine arteries at laparoscopic myomectomy to control intraoperative blood loss. In a two-armed, single-blinded randomised controlled trial that commenced in January 2007, we are evaluating this new technique versus conventional laparoscopic myomectomy. This will include additional information regarding detailed operating times and the use of newly developed clip application forceps.

Authors’ Affiliations

(1)
Department of Gynaecology, Charité—Universitätsmedizin Berlin

References

  1. Lethaby A, Vollenhoven B (2005) Fibroids (uterine myomatosis, leiomyomas). Clin Evid 14:2264–2282PubMedGoogle Scholar
  2. Buttram VC Jr, Reiter RC (1981) Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 36(4):433–445PubMedGoogle Scholar
  3. Fletcher H, Frederick J, Hardie M, Simeon D (1996) A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy. Obstet Gynecol 87(6):1014–1018PubMedView ArticleGoogle Scholar
  4. Berkeley AS, DeCherney AH, Polan ML (1983) Abdominal myomectomy and subsequent fertility. Surg Gynecol Obstet 156(3):319–322PubMedGoogle Scholar
  5. Ginsburg ES, Benson CB, Garfield JM, Gleason RE, Friedman AJ (1993) The effect of operative technique and uterine size on blood loss during myomectomy: a prospective randomized study. Fertil Steril 60(6):956–962PubMedGoogle Scholar
  6. Gehlbach DL, Sousa RC, Carpenter SE, Rock JA (1993) Abdominal myomectomy in the treatment of infertility. Int J Gynaecol Obstet 40(1):45–50PubMedView ArticleGoogle Scholar
  7. Frederick J, Hardie M, Reid M, Fletcher H, Wynter S, Frederick C (2002) Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study. Hum Reprod 17(11):2967–2971PubMedView ArticleGoogle Scholar
  8. Volkers NA, Hehenkamp WJ, Birnie E, de Vries C, Holt C, Ankum WM, Reekers JA (2006) Uterine artery embolization in the treatment of symptomatic uterine fibroid tumors (EMMY trial): periprocedural results and complications. J Vasc Interv Radiol 17(3):471–480PubMedView ArticleGoogle Scholar
  9. Bradley EA, Reidy JF, Forman RG, Jarosz J, Braude PR (1998) Transcatheter uterine artery embolisation to treat large uterine fibroids. Br J Obstet Gynaecol 105(2):235–240PubMedGoogle Scholar
  10. Taylor A, Sharma M, Tsirkas P, Di Spiezio Sardo A, Setchell M, Magos A (2005) Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG 112(3):340–345PubMedView ArticleGoogle Scholar
  11. Koehler C, Hasenbein K, Klemm P, Tozzi R, Schneider A (2003) Laparoscopic-assisted vaginal hysterectomy with lateral transsection of the uterine vessels. Surg Endoscopy 17(3):485–490View ArticleGoogle Scholar
  12. Wichmann W, Von Ammon K, Fink U, Weik T, Yasargil GM (1997) Aneurysm clips made of titanium: magnetic characteristics and artifacts in MR. AJNR Am J Neuroradiol 18(5):939–944PubMedGoogle Scholar
  13. Holzer A, Jirecek ST, Illievich UM, Huber J, Wenzl RJ (2006) Laparoscopic versus open myomectomy: a double-blind study to evaluate postoperative pain. Anesth Analg 102(5):1480–1484PubMedView ArticleGoogle Scholar
  14. Mais V, Ajossa S, Guerriero S, Mascia M, Solla E, Melis GB (1996) Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. Am J Obstet Gynecol 174(2):654–658PubMedView ArticleGoogle Scholar
  15. Ribeiro SC, Reich H, Rosenberg J, Guglielminetti E, Vidali A (1999) Laparoscopic myomectomy and pregnancy outcome in infertile patients. Fertil Steril 71(3):571–574PubMedView ArticleGoogle Scholar
  16. Marret H, Chevillot M, Giraudeau B; Study Group of the French Society of Gynaecology and Obstetrics (Ouest Division) (2004) A retrospective multicentre study comparing myomectomy by laparoscopy and laparotomy in current surgical practice. What are the best patient selection criteria? Eur J Obstet Gynecol Reprod Biol 117(1):82–86PubMedView ArticleGoogle Scholar
  17. Bonney V (1931) The technique and results of myomectomy. Lancet 220:171–177View ArticleGoogle Scholar
  18. Lock FR (1969) Multiple myomectomy. Am J Obstet Gynecol 104(5):642–650PubMedGoogle Scholar
  19. Thompson JD, Rock JA (1997) Leiomyomata uteri and myomectomy. In: Thompson JD, Rock JA (eds) Te Linde’s operative gynaecology. Lippincott-Raven, Philadelphia, Pennsylvania, pp 731–770Google Scholar
  20. Celik H, Sapmaz E (2003) Use of a single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy. Fertil Steril 79(5):1207–1210PubMedView ArticleGoogle Scholar
  21. Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, Merland JJ (1995) Arterial embolisation to treat uterine myomata. Lancet 346(8976):671–672PubMedView ArticleGoogle Scholar
  22. Stewart EA, Rabinovici J, Tempany CM, Inbar Y, Regan L, Gastout B, Hesley G, Kim HS, Hengst S, Gedroye WM (2006) Clinical outcomes of focused ultrasound surgery for the treatment of uterine fibroids. Fertil Steril 85(1):22–29PubMedView ArticleGoogle Scholar
  23. The Royal College of Obstetricians and Gynaecologists (2001) Clinical recommendations on the use of fibroid embolisation in the management of uterine fibroids. Report of a joint working party. RCOG Press, LondonGoogle Scholar
  24. Zullo F, Palomba S, Corea D, Pellicano M, Russo T, Falbo A, Barletta E, Saraco P, Doldo P, Zupi E (2004) Bupivacaine plus epinephrine for laparoscopic myomectomy: a randomized placebo-controlled trial. Obstet Gynecol 104(2):243–249PubMedGoogle Scholar
  25. Fanfani F, Fagotti A, Bifulco G, Ercoli A, Malzoni M, Scambia G (2005) A prospective study of laparoscopy versus minilaparotomy in the treatment of uterine myomas. J Minim Invasive Gynecol 12(6):470–474PubMedView ArticleGoogle Scholar
  26. Landi S, Zaccoletti R, Ferrari L, Minelli L (2001) Laparoscopic myomectomy: technique, complications, and ultrasound scan evaluations. J Am Assoc Gynecol Laparosc 8(2):231–240PubMedView ArticleGoogle Scholar
  27. Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, Flamigni C (2000) Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy. Hum Reprod 15(12):2663–2668PubMedView ArticleGoogle Scholar
  28. Olive DL, Lindheim SR, Pritts EA (2006) Conservative surgical management of uterine myomas. Obstet Gynecol Clin North Am 33(1):115–124PubMedView ArticleGoogle Scholar
  29. Darai E, Deval B, Darles C,Benifla JL,Guglielmina JN,Madelenat P (1996) Myomectomy: laparoscopy or laparotomy (in French). Contracept Fertil Sex 24(10):751–756PubMedGoogle Scholar
  30. Dubuisson JB, Chapron C, Chavet X, Gregorakis SS (1996) Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results. Hum Reprod 11(3):518–522PubMedGoogle Scholar

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