- Email: [email protected]
Laparoscopic adenomyomectomy and hysteroplasty: A novel method
Journal of Minimally Invasive Gynecology (2006) 13, 150 –154
Instruments and techniques
Laparoscopic adenomyomectomy and hysteroplasty: A novel method Hiroyuki Takeuchi, MD, Mari Kitade, MD, Iwaho Kikuchi, MD, Hiroto Shimanuki, MD, Jun Kumakiri, MD, Takamitsu Kitano, MD, and Katsuyuki Kinoshita, MD From the Department of Obstetrics and Gynecology, Department of Pathology, Juntendo University School of Medicine, Tokyo, Japan (all authors). KEYWORDS: Laparoscopy; Adenomyosis; Dysmenorrhea; Menorrhagia
Abstract STUDY OBJECTIVE: To evaluate a novel method of laparoscopic adenomyomectomy. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Fourteen women with adenomyosis. INTERVENTION: Laparoscopic adenomyomectomy and hysteroplasty. After local injection by diluted vasopressin solution, a transverse incision was made in the adenomyotic tissue down to the endometrium, and the adenomyotic tissue was surgically removed with a monopolar needle. The normal muscle layer on the serosal membrane side was left as an upper and lower serosal flap. The flaps were overlapped and sutured to counteract the lost muscle layer to reconstruct the uterus. MEASUREMENTS AND MAIN OUTCOME: The changes of symptoms were evaluated before and after the operation. The visual analog scale of dysmenorrhea was significantly decreased, and hypermenorrhea was improved after the surgery. Postoperative pregnancy was achieved in 2 patients, and vaginal delivery was performed in the first case. CONCLUSION: For specific cases, laparoscopic adenomyomectomy may be a suitable method to relieve symptoms with minimally invasive surgery while conserving the uteri. © 2006 AAGL. All rights reserved.
Because of changes in women’s lifestyles, such as marrying later in life and having fewer children, adenomyosis is on the rise in unmarried and nulligravid women.1 Treatment for adenomyosis to conserve fertility includes symptomatic Corresponding author: Hiroyuki Takeuchi, MD, Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Hongo, 2-1-1, Bunkyo-ku, Tokyo, 113-8421. E-mail: [email protected] Submitted October 7, 2005. Accepted for publication December 19, 2005.
1553-4650/$ -see front matter © 2006 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.12.004
treatment such as the administration of nonsteroidal antiinflammatory drugs and hormone therapy with a gonadotropin-releasing hormone (GnRH) agonist, danazol, and oral contraceptives. However, the effect of these drug treatments is temporary and shows insufficient improvement in quality of life and fertility. As for surgical treatment of adenomyosis, excision of the adenomyotic lesion by laparotomy is reported to be effective.2,3 We report on a new operative procedure and results for adenomyomectomy by minimally invasive laparoscopy.
Takeuchi et al
Laparoscopic adenomyomectomy
Material and methods Patient characteristics Fourteen women who were diagnosed with adenomyosis underwent laparoscopic adenomyomectomy at our hospital during 2003 and 2004. Each patient was sufficiently informed of all aspects of the trial before the surgery, and written consent was obtained. Additionally, this study was reported to and approved by the institutional review board. All patients underwent pelvic examination, transvaginal ultrasonography, and magnetic resonance imaging (MRI) before surgery. Preoperative diagnosis of adenomyosis was made by MRI. Patients were diagnosed as having adenomyosis in a maximal junctional zone thickness ⬍12 mm.4 The inclusion criteria of laparoscopic adenomyomectomy were symptomatic adenomyosis with the size of 30 mm or greater when taking a uterine sagittal section of a low-intensity area that is contiguous to the junctional zone on MRI. From past experience in laparoscopic myomectomy, the exclusion criteria are those with the size of 80 mm in a low-intensity area or a uterine size equivalent to about 12 weeks of pregnancy before GnRHa administration. Cases with an occurrence of adenomyosis on the posterior wall and suspected complete cul-de-sac obliteration underwent the MRI jelly method.5 The region of adenomyosis occurrence was the anterior wall for 6 cases and the posterior wall for 8 cases. Diffuse type adenomyosis, which spans the entire uterus, was excluded as unsuitable for this procedure. The median age of the subjects was 36 years of age (range, 28 to 39 years). The breakdown of past pregnancies was 1 case of spontaneous abortion, 2 cases of elective abortion, and 1 case of normal delivery. Symptoms included 14 cases of dysmenorrhea (100%), 8 cases of menorrhagia (57.1%), and 8 cases of infertility (57.1%). The breakdown of infertility cases was 5 cases of primary infertility and 3 cases of secondary infertility. The median infertility period was 47 months (range 12 to 60 months). The widest median diameter of adenomyosis measured by MRI was 47 mm (range 30 to 80 mm). Nine cases were administered the GnRH agonist (leuprolide acetate 1.88 mg: Takeda, Tokyo, Japan), and 1 case was administered oral contraceptive, totaling 10 cases with preoperative treatment.
Surgical techniques All procedures were performed with the patients under general anesthesia by endotracheal intubation in the lithotomy position. The patients were placed in lithotomy, and the Uterine Manipulator (Ethicon, Tokyo, Japan) was replaced into the uterine cavity for mobilization
151 of the uterus. The laparoscopic procedures were performed by the closed method. After the pneumoperitoneum was established, a 10-mm scope was inserted periumbilically. Three additional puncture sites were made: two 5-mm sites 2 cm above the anterior superior iliac supine; and a 12-mm site 3 cm above the umbilicus on the left anterior axial line—an ideal laparoscopic position providing a large operative field. The operator stood on the patient’s left side, controlling the 12-mm trocar with his right hand, and manipulating the left lower 5-mm trocar with his left hand. The right lower 5-mm trocar was controlled by the assistant’s right hand. After observing the abdominal cavity, cystectomy was performed on the cases of adenomyosis complicated with endometrioma and lysis of adhesions, and the removal of deep endometriotic lesions around Douglas’ pouch were performed for the complete cul-de-sac obliteration cases. Vasopressin 20 IU in 1 mL diluted 100 times with saline solution was infused into the adenomyotic tissue (Figure 1A). A transverse incision was made in the adenomyotic region with a monopolar needle down to the endometrium or penetrating into the interior of the cavity. Because of sufficient incision depth, the adenomyotic tissue splits and opens into 2 parts, an upper part and a lower part. The adenomyotic tissue on both sides of the incision line was carved away by the monopolar needle and then removed (Figure 1B and C). While identifying the adenomyotic tissue by visual inspection and probing with an aspirator tube, adenomyotic tissue was excised as near as possible to the serosal membrane and the endometrium. After excision of the adenomyotic tissue, any perforations to the endometrium were sewn up with 2/0 Polysorb (Tyco Healthcare, Tokyo, Japan). Since the region where adenomyotic tissue was excised lost much of the normal muscle layer, the upper and lower serosal flaps were used to counteract the loss of myometrium. First, the inner side of the lower serosal flap was sutured with 1/0 Polysorb, and the upper fringe of the serosal flap was sutured to the muscle layer continuously (Figure 1D). Likewise, the inner side of the upper serosal flap was sutured to the muscle layer, while overlapping with the lower serosal flap and the bottom fringe of the serosal flap, and lower serosal flap surface was continuously sutured to close the muscle layer incision (Figure 1E). A fibrin sheet (Tacho Comb; ZLB Behring, Tokyo, Japan) was placed to prevent bleeding from the uterine muscle layer incision. If the excised adenomyotic tissue was large, an electric morcellator (Karl Storz, Germany) was used to fragment the tissue and extract it from the abdominal cavity. The pelvic region was irrigated thoroughly with physiological saline solution, and a closed-end drain (SB bag; Sumitomo Bakelite, Tokyo, Japan) was placed in Douglas’ pouch. Dysmenorrhea was measured by VAS (visual analog scale),6 and the changes in symptoms before and after laparoscopy were compared. VASs before and after surgery were compared by use of the Wilcoxon test, and p ⬍ .05 was considered significant.
152
Journal of Minimally Invasive Gynecology, Vol 13, No 2, March/April 2006
Figure 1 Procedures of laparoscopic myomectomy. Diluted vasopressin is locally injected into adenomyotic tissue (A). Extraction of adenomyotic tissue at lower part of incision by monopolar cautery after transverse incision (B). Extraction of adenomyotic tissue at upper part of incision (C). Suturing lower serosal flap to muscle layer (D). After completion of suturing of upper serosal flap (E).
Results Ovarian endometrioma coexisted in 5 cases, and complete cul-de-sac obliteration was detected in 6 cases, all with posterior wall occurrence. Endometriosis complicated with adenomyosis was detected in 9 cases (64.3%), and the median revised American Society for Reproductive Medicine (rASRM)7 was 11 (range 0-128). The median operative time was 101.5 minutes (range 70-200), estimated blood loss was 225 mL (range 10-530), and weight of the excision specimen was 24 g (range 7-75). There were no cases of serious complications during the operation. The standard hospital stay after
laparoscopy is 3 days, and all patients were discharged on the third day after surgery, with no abnormalities detected during the postoperative course. Figure 2 shows the MRI before and after operation of the largest adenomyosis case (excision weight 75 g). The 7 cm of adenomyotic tissue on the anterior wall had almost disappeared by 4 months after operation. Investigation by MRI of 10 cases 3 to 6 months after operation confirmed that none of the cases had hematoma or thinning in the muscle layer of the incision. Furthermore, among the 7 patients who underwent a secondlook laparoscopy8 4 to 8 months after operation, none of the 5 cases where the surgery wound could be confirmed had thin-
Takeuchi et al
Laparoscopic adenomyomectomy
153
Figure 2 Preoperative and postoperative MRI observations (above, T2 sagittal; below, T2 axial). Adenomyotic tissue of about 7 cm on anterior uterine wall has almost disappeared after operation.
ning or loss in the wound area. No abnormalities in the surgery wound were detected by dye tests with an 8F Foley catheter inserted into the uterus. Median VAS during menstruation significantly decreased (p ⬍ .01) from 10 (range 9 –10) before operation to 2.5 (range 1– 6) after operation. All 8 cases of polyhypermenorrhea improved after operation. Two patients conceived, and the patient with the 4-cm excision gave birth vaginally to a 2856 g girl at 38 weeks. The other patient is still currently pregnant.
Discussion Adenomyosis is a disorder often affecting woman in their late reproductive years who have already finished child-bearing. Therefore hysterectomy has been a common surgical treatment.1 However, because of the recent trend of marrying later in life and having fewer children, the incidence of adenomyosis in unmarried and nulligravid women is increasing, and there is a higher demand for adenomyomectomy to conserve fertility and the uterus. Uterine myoma is a condition where miotic tissue enlarges and presses on the normal muscle layer. The boundary between the normal muscle layer and myoma is clear, allowing facile enucleation of the myoma, and it is fairly easy to suture and reconstruct the remaining muscle layer. In contrast, adenomyosis is a condition where the endometrial tissue has penetrated the uterine muscle layer and the boundary between the lesion and normal muscle layer is unclear. Therefore adenomyomectomy requires techniques
for excising the adenomyotic tissue and reconstructing the remaining muscle layer after removing adenomyoma. We performed adenomyomectomy by making a transverse incision through the adenomyotic tissue down to the endometrium and tried to conserve as much of the normal muscle layer and as near the serosal membrane as possible. Adenomyotic tissue and the normal muscle layer were distinguished according to the color and hardness of the incision surface. The adenomyotic tissue was excised by slicing in layers with a monopolar needle on 70W incision mode. We counteracted the substantial loss in the muscle layer after adenomyomectomy by overlapping the normal muscle layer on the serosal membrane side above and below the incision line as serosal flaps. According to MRI, the normal muscle layer only exists between the serosal membrane and adenomyotic tissue in adenomyosis growing continuously from the junctional zone.4 Effective uterine reconstruction after adenomyomectomy has become possible by use of this marginal amount of normal muscle layer. Suturing was performed with 2 to 3 layers from the proximal side of the serosal flap so that there would be no dead space. Adenomyomectomy is an operative procedure that requires time for the excision of adenomyotic tissue with unclear boundaries and the suturing process. Therefore controlling bleeding is an important factor. Preoperative administration of GnRH agonists to decrease uterine blood flow and vasopressin administration during the surgery is effective to control bleeding. As with laparoscopic myomectomy, the injection of vasopressin diluted 100-fold by physiological saline solution into adenomyotic tissue suppresses bleeding from the incision for around 30 minutes.9 The
154
Journal of Minimally Invasive Gynecology, Vol 13, No 2, March/April 2006
administration of GnRH agonists decreases the size of adenomyotic tissue and further facilitates the surgical procedures. However, the boundary between adenomyotic tissue and the normal muscle layer becomes even more unclear, and this increases the risk of incomplete removal. In contrast, in posterior wall cases with complete cul-de-sac obliteration, the preoperative administration of GnRH agonists is recommended for safer separation procedures of the rectum and posterior uterine wall. The MRI gel method is very useful for preoperative diagnosis of complete cul-de-sac obliteration. Further studies on GnRH agonist usage for adenomyomectomy are expected. An adenomyomectomy method to treat adenomyosis involving the excision of the adenomyotic region in strips has been reported.2 Wedge-shaped excisions would increase the risk of incomplete removal of adenomyotic tissue and complicate uterine reconstruction due to the large loss in the muscle layer since adenomyosis grows continuously from the endometrium and the normal muscle layer remains on the serosal membrane side. Therefore incising the adenomyotic tissue in half and excising it from the bottom while conserving the serosal membrane for use in uterine reconstruction after adenomyomectomy was reported by Hyams3 and Osada.9 These methods were performed by laparotomy and reports on laparoscopic adenomyomectomy are rare; the wedge-shaped excision methods reported by Wood10 and Morita11 are the only reports using laparoscopy. Laparoscopic adenomyomectomy requires time for adenomyoma removal and uterine reconstruction and is significantly more difficult to perform compared with laparoscopic myomectomy of similar size. However, it is considered that with proficiency in the operative procedures, it is possible to operate on adenomyosis with a maximum size of 7 to 8 cm and uterine size equivalent to about 12 weeks of pregnancy. It is necessary to ensure that there is sufficient uterine wall strength to withstand pregnancy and labor when treating adenomyosis and benign tumors of the uterus by conservative surgery. Conditions for performing enucleation of adenomyosis where boundaries are unclear because lesions occur in continuity with the junctional zone between the endometrium and muscle layer are stricter than those for laparoscopic myomectomy. This procedure should be attempted by surgeons with sufficient experience in laparoscopic myomectomy cases12,13 and suturing intracorporeally. We believe that this method of conserving as much normal muscle layer on the serosal membrane side as possible is superior to wedge resection in strengthening the muscle layer. Postoperative observations of the wound area by MRI and second-look laparoscopy have indicated that sufficient wound healing is possible even if the muscle layer
is overlaid on the normal serosal membrane. One of the 2 cases of subsequent pregnancy succeeded in natural delivery after vaginal birth after laparoscopic myomectomy14 performed at our hospital. Unlike laparoscopic myomectomy, there are few cases of conservative laparoscopic adenomyomectomy and little data on indication and surgical performance. An extended excision to prevent reoccurrence leads to difficulty in uterine reconstruction and may lead to uterine rupture during pregnancy or labor. Further investigation on operative procedures and postoperative management of laparoscopic adenomyomectomy is necessary. Laparoscopic myomectomy to treat myomas is now widespread, and techniques for enucleation and suturing under laparoscopy are developing rapidly.13 By applying laparoscopic myomectomy techniques, we believe we have established a safer and more effective technique for laparoscopic adenomyomectomy.
References 1. Reber R. Adenomyosis. J Reprod Med. 1994;39:841– 853. 2. Van Praagh I. Conservative surgical treatment for adenomyosis uteri in young women: local excision and metroplasty. Can Med Assoc J. 1965;93:1174 –1175. 3. Hyams LL. Adenomyosis: Its conservative surgical treatment (hysteroplasty) in young women. NY J Med. 1952;52:2778 –2783. 4. Renhold C, Tafazoli F, Wang L. Imaging features of adenomyosis. Human Reprod Update. 1998;4:337–349. 5. Takeuchi H, Kuwatsuru R, Kitade M, et al. A novel technique using magnetic resonance imaging jelly for evaluation of rectovaginal endometriosis. Fertil Steril. 2005;83:442– 447. 6. Huskisson EC. Measurements of pain. Lancet. 1974;2:1127–1131. 7. The American Society for Reproductive Medicine. Revised American Society for Reproductive Medicine Classification of Endometriosis: 1996. Fertil Steril. 1997;67:817– 821. 8. Takeuchi H, Kinoshita K. Evaluation of adhesion formation after laparoscopic myomectomy by systematic second-look laparoscopy. Am Assoc Gynecol Laparosc. 2002;9:137–143. 9. Osada H, Seiji A, Taketani T, Yamamoto M. Surgical treatment for adenomyosis. Gynecol Obstet Surg. 2003;14:101–107. 10. Wood C. Surgical and medical treatment of adenomyosis. Hum Reprod Update. 1998;4:323–336. 11. Morita M, Asakawa Y, Nakakuma M, et al. Laparoscopic excision of myometrial adenomyomas in patients with adenomyosis uteri and main symptoms of severe dysmenorrhea and hypermenorrhea. A J Assoc Gynecol Laparosc. 2004;11:86 – 89. 12. Takeuchi H, Kuwatsuru R. The indications, surgical techniques, and limitations of laparoscopic myomectomy. JSLS. 2003;7:89 –95. 13. Takeuchi H, Kitade M, Kikuchi I, et al. Effect of vasopressin on blood flow and RI of the uterine during laparoscopic myomectomy. J Minim Invasive Gynecol. 2005;12:10 –11. 14. Kumakiri J, Takeuchi H, Kitade M, et al. Pregnancy and delivery after laparoscopic myomectomy. J Minim Invasive Gynecol. 2005;12:241– 246.
Instruments and techniques
Laparoscopic adenomyomectomy and hysteroplasty: A novel method Hiroyuki Takeuchi, MD, Mari Kitade, MD, Iwaho Kikuchi, MD, Hiroto Shimanuki, MD, Jun Kumakiri, MD, Takamitsu Kitano, MD, and Katsuyuki Kinoshita, MD From the Department of Obstetrics and Gynecology, Department of Pathology, Juntendo University School of Medicine, Tokyo, Japan (all authors). KEYWORDS: Laparoscopy; Adenomyosis; Dysmenorrhea; Menorrhagia
Abstract STUDY OBJECTIVE: To evaluate a novel method of laparoscopic adenomyomectomy. DESIGN: Prospective study (Canadian Task Force classification II-3). SETTING: University-affiliated hospital. PATIENTS: Fourteen women with adenomyosis. INTERVENTION: Laparoscopic adenomyomectomy and hysteroplasty. After local injection by diluted vasopressin solution, a transverse incision was made in the adenomyotic tissue down to the endometrium, and the adenomyotic tissue was surgically removed with a monopolar needle. The normal muscle layer on the serosal membrane side was left as an upper and lower serosal flap. The flaps were overlapped and sutured to counteract the lost muscle layer to reconstruct the uterus. MEASUREMENTS AND MAIN OUTCOME: The changes of symptoms were evaluated before and after the operation. The visual analog scale of dysmenorrhea was significantly decreased, and hypermenorrhea was improved after the surgery. Postoperative pregnancy was achieved in 2 patients, and vaginal delivery was performed in the first case. CONCLUSION: For specific cases, laparoscopic adenomyomectomy may be a suitable method to relieve symptoms with minimally invasive surgery while conserving the uteri. © 2006 AAGL. All rights reserved.
Because of changes in women’s lifestyles, such as marrying later in life and having fewer children, adenomyosis is on the rise in unmarried and nulligravid women.1 Treatment for adenomyosis to conserve fertility includes symptomatic Corresponding author: Hiroyuki Takeuchi, MD, Department of Obstetrics and Gynecology, Juntendo University School of Medicine, Hongo, 2-1-1, Bunkyo-ku, Tokyo, 113-8421. E-mail: [email protected] Submitted October 7, 2005. Accepted for publication December 19, 2005.
1553-4650/$ -see front matter © 2006 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.12.004
treatment such as the administration of nonsteroidal antiinflammatory drugs and hormone therapy with a gonadotropin-releasing hormone (GnRH) agonist, danazol, and oral contraceptives. However, the effect of these drug treatments is temporary and shows insufficient improvement in quality of life and fertility. As for surgical treatment of adenomyosis, excision of the adenomyotic lesion by laparotomy is reported to be effective.2,3 We report on a new operative procedure and results for adenomyomectomy by minimally invasive laparoscopy.
Takeuchi et al
Laparoscopic adenomyomectomy
Material and methods Patient characteristics Fourteen women who were diagnosed with adenomyosis underwent laparoscopic adenomyomectomy at our hospital during 2003 and 2004. Each patient was sufficiently informed of all aspects of the trial before the surgery, and written consent was obtained. Additionally, this study was reported to and approved by the institutional review board. All patients underwent pelvic examination, transvaginal ultrasonography, and magnetic resonance imaging (MRI) before surgery. Preoperative diagnosis of adenomyosis was made by MRI. Patients were diagnosed as having adenomyosis in a maximal junctional zone thickness ⬍12 mm.4 The inclusion criteria of laparoscopic adenomyomectomy were symptomatic adenomyosis with the size of 30 mm or greater when taking a uterine sagittal section of a low-intensity area that is contiguous to the junctional zone on MRI. From past experience in laparoscopic myomectomy, the exclusion criteria are those with the size of 80 mm in a low-intensity area or a uterine size equivalent to about 12 weeks of pregnancy before GnRHa administration. Cases with an occurrence of adenomyosis on the posterior wall and suspected complete cul-de-sac obliteration underwent the MRI jelly method.5 The region of adenomyosis occurrence was the anterior wall for 6 cases and the posterior wall for 8 cases. Diffuse type adenomyosis, which spans the entire uterus, was excluded as unsuitable for this procedure. The median age of the subjects was 36 years of age (range, 28 to 39 years). The breakdown of past pregnancies was 1 case of spontaneous abortion, 2 cases of elective abortion, and 1 case of normal delivery. Symptoms included 14 cases of dysmenorrhea (100%), 8 cases of menorrhagia (57.1%), and 8 cases of infertility (57.1%). The breakdown of infertility cases was 5 cases of primary infertility and 3 cases of secondary infertility. The median infertility period was 47 months (range 12 to 60 months). The widest median diameter of adenomyosis measured by MRI was 47 mm (range 30 to 80 mm). Nine cases were administered the GnRH agonist (leuprolide acetate 1.88 mg: Takeda, Tokyo, Japan), and 1 case was administered oral contraceptive, totaling 10 cases with preoperative treatment.
Surgical techniques All procedures were performed with the patients under general anesthesia by endotracheal intubation in the lithotomy position. The patients were placed in lithotomy, and the Uterine Manipulator (Ethicon, Tokyo, Japan) was replaced into the uterine cavity for mobilization
151 of the uterus. The laparoscopic procedures were performed by the closed method. After the pneumoperitoneum was established, a 10-mm scope was inserted periumbilically. Three additional puncture sites were made: two 5-mm sites 2 cm above the anterior superior iliac supine; and a 12-mm site 3 cm above the umbilicus on the left anterior axial line—an ideal laparoscopic position providing a large operative field. The operator stood on the patient’s left side, controlling the 12-mm trocar with his right hand, and manipulating the left lower 5-mm trocar with his left hand. The right lower 5-mm trocar was controlled by the assistant’s right hand. After observing the abdominal cavity, cystectomy was performed on the cases of adenomyosis complicated with endometrioma and lysis of adhesions, and the removal of deep endometriotic lesions around Douglas’ pouch were performed for the complete cul-de-sac obliteration cases. Vasopressin 20 IU in 1 mL diluted 100 times with saline solution was infused into the adenomyotic tissue (Figure 1A). A transverse incision was made in the adenomyotic region with a monopolar needle down to the endometrium or penetrating into the interior of the cavity. Because of sufficient incision depth, the adenomyotic tissue splits and opens into 2 parts, an upper part and a lower part. The adenomyotic tissue on both sides of the incision line was carved away by the monopolar needle and then removed (Figure 1B and C). While identifying the adenomyotic tissue by visual inspection and probing with an aspirator tube, adenomyotic tissue was excised as near as possible to the serosal membrane and the endometrium. After excision of the adenomyotic tissue, any perforations to the endometrium were sewn up with 2/0 Polysorb (Tyco Healthcare, Tokyo, Japan). Since the region where adenomyotic tissue was excised lost much of the normal muscle layer, the upper and lower serosal flaps were used to counteract the loss of myometrium. First, the inner side of the lower serosal flap was sutured with 1/0 Polysorb, and the upper fringe of the serosal flap was sutured to the muscle layer continuously (Figure 1D). Likewise, the inner side of the upper serosal flap was sutured to the muscle layer, while overlapping with the lower serosal flap and the bottom fringe of the serosal flap, and lower serosal flap surface was continuously sutured to close the muscle layer incision (Figure 1E). A fibrin sheet (Tacho Comb; ZLB Behring, Tokyo, Japan) was placed to prevent bleeding from the uterine muscle layer incision. If the excised adenomyotic tissue was large, an electric morcellator (Karl Storz, Germany) was used to fragment the tissue and extract it from the abdominal cavity. The pelvic region was irrigated thoroughly with physiological saline solution, and a closed-end drain (SB bag; Sumitomo Bakelite, Tokyo, Japan) was placed in Douglas’ pouch. Dysmenorrhea was measured by VAS (visual analog scale),6 and the changes in symptoms before and after laparoscopy were compared. VASs before and after surgery were compared by use of the Wilcoxon test, and p ⬍ .05 was considered significant.
152
Journal of Minimally Invasive Gynecology, Vol 13, No 2, March/April 2006
Figure 1 Procedures of laparoscopic myomectomy. Diluted vasopressin is locally injected into adenomyotic tissue (A). Extraction of adenomyotic tissue at lower part of incision by monopolar cautery after transverse incision (B). Extraction of adenomyotic tissue at upper part of incision (C). Suturing lower serosal flap to muscle layer (D). After completion of suturing of upper serosal flap (E).
Results Ovarian endometrioma coexisted in 5 cases, and complete cul-de-sac obliteration was detected in 6 cases, all with posterior wall occurrence. Endometriosis complicated with adenomyosis was detected in 9 cases (64.3%), and the median revised American Society for Reproductive Medicine (rASRM)7 was 11 (range 0-128). The median operative time was 101.5 minutes (range 70-200), estimated blood loss was 225 mL (range 10-530), and weight of the excision specimen was 24 g (range 7-75). There were no cases of serious complications during the operation. The standard hospital stay after
laparoscopy is 3 days, and all patients were discharged on the third day after surgery, with no abnormalities detected during the postoperative course. Figure 2 shows the MRI before and after operation of the largest adenomyosis case (excision weight 75 g). The 7 cm of adenomyotic tissue on the anterior wall had almost disappeared by 4 months after operation. Investigation by MRI of 10 cases 3 to 6 months after operation confirmed that none of the cases had hematoma or thinning in the muscle layer of the incision. Furthermore, among the 7 patients who underwent a secondlook laparoscopy8 4 to 8 months after operation, none of the 5 cases where the surgery wound could be confirmed had thin-
Takeuchi et al
Laparoscopic adenomyomectomy
153
Figure 2 Preoperative and postoperative MRI observations (above, T2 sagittal; below, T2 axial). Adenomyotic tissue of about 7 cm on anterior uterine wall has almost disappeared after operation.
ning or loss in the wound area. No abnormalities in the surgery wound were detected by dye tests with an 8F Foley catheter inserted into the uterus. Median VAS during menstruation significantly decreased (p ⬍ .01) from 10 (range 9 –10) before operation to 2.5 (range 1– 6) after operation. All 8 cases of polyhypermenorrhea improved after operation. Two patients conceived, and the patient with the 4-cm excision gave birth vaginally to a 2856 g girl at 38 weeks. The other patient is still currently pregnant.
Discussion Adenomyosis is a disorder often affecting woman in their late reproductive years who have already finished child-bearing. Therefore hysterectomy has been a common surgical treatment.1 However, because of the recent trend of marrying later in life and having fewer children, the incidence of adenomyosis in unmarried and nulligravid women is increasing, and there is a higher demand for adenomyomectomy to conserve fertility and the uterus. Uterine myoma is a condition where miotic tissue enlarges and presses on the normal muscle layer. The boundary between the normal muscle layer and myoma is clear, allowing facile enucleation of the myoma, and it is fairly easy to suture and reconstruct the remaining muscle layer. In contrast, adenomyosis is a condition where the endometrial tissue has penetrated the uterine muscle layer and the boundary between the lesion and normal muscle layer is unclear. Therefore adenomyomectomy requires techniques
for excising the adenomyotic tissue and reconstructing the remaining muscle layer after removing adenomyoma. We performed adenomyomectomy by making a transverse incision through the adenomyotic tissue down to the endometrium and tried to conserve as much of the normal muscle layer and as near the serosal membrane as possible. Adenomyotic tissue and the normal muscle layer were distinguished according to the color and hardness of the incision surface. The adenomyotic tissue was excised by slicing in layers with a monopolar needle on 70W incision mode. We counteracted the substantial loss in the muscle layer after adenomyomectomy by overlapping the normal muscle layer on the serosal membrane side above and below the incision line as serosal flaps. According to MRI, the normal muscle layer only exists between the serosal membrane and adenomyotic tissue in adenomyosis growing continuously from the junctional zone.4 Effective uterine reconstruction after adenomyomectomy has become possible by use of this marginal amount of normal muscle layer. Suturing was performed with 2 to 3 layers from the proximal side of the serosal flap so that there would be no dead space. Adenomyomectomy is an operative procedure that requires time for the excision of adenomyotic tissue with unclear boundaries and the suturing process. Therefore controlling bleeding is an important factor. Preoperative administration of GnRH agonists to decrease uterine blood flow and vasopressin administration during the surgery is effective to control bleeding. As with laparoscopic myomectomy, the injection of vasopressin diluted 100-fold by physiological saline solution into adenomyotic tissue suppresses bleeding from the incision for around 30 minutes.9 The
154
Journal of Minimally Invasive Gynecology, Vol 13, No 2, March/April 2006
administration of GnRH agonists decreases the size of adenomyotic tissue and further facilitates the surgical procedures. However, the boundary between adenomyotic tissue and the normal muscle layer becomes even more unclear, and this increases the risk of incomplete removal. In contrast, in posterior wall cases with complete cul-de-sac obliteration, the preoperative administration of GnRH agonists is recommended for safer separation procedures of the rectum and posterior uterine wall. The MRI gel method is very useful for preoperative diagnosis of complete cul-de-sac obliteration. Further studies on GnRH agonist usage for adenomyomectomy are expected. An adenomyomectomy method to treat adenomyosis involving the excision of the adenomyotic region in strips has been reported.2 Wedge-shaped excisions would increase the risk of incomplete removal of adenomyotic tissue and complicate uterine reconstruction due to the large loss in the muscle layer since adenomyosis grows continuously from the endometrium and the normal muscle layer remains on the serosal membrane side. Therefore incising the adenomyotic tissue in half and excising it from the bottom while conserving the serosal membrane for use in uterine reconstruction after adenomyomectomy was reported by Hyams3 and Osada.9 These methods were performed by laparotomy and reports on laparoscopic adenomyomectomy are rare; the wedge-shaped excision methods reported by Wood10 and Morita11 are the only reports using laparoscopy. Laparoscopic adenomyomectomy requires time for adenomyoma removal and uterine reconstruction and is significantly more difficult to perform compared with laparoscopic myomectomy of similar size. However, it is considered that with proficiency in the operative procedures, it is possible to operate on adenomyosis with a maximum size of 7 to 8 cm and uterine size equivalent to about 12 weeks of pregnancy. It is necessary to ensure that there is sufficient uterine wall strength to withstand pregnancy and labor when treating adenomyosis and benign tumors of the uterus by conservative surgery. Conditions for performing enucleation of adenomyosis where boundaries are unclear because lesions occur in continuity with the junctional zone between the endometrium and muscle layer are stricter than those for laparoscopic myomectomy. This procedure should be attempted by surgeons with sufficient experience in laparoscopic myomectomy cases12,13 and suturing intracorporeally. We believe that this method of conserving as much normal muscle layer on the serosal membrane side as possible is superior to wedge resection in strengthening the muscle layer. Postoperative observations of the wound area by MRI and second-look laparoscopy have indicated that sufficient wound healing is possible even if the muscle layer
is overlaid on the normal serosal membrane. One of the 2 cases of subsequent pregnancy succeeded in natural delivery after vaginal birth after laparoscopic myomectomy14 performed at our hospital. Unlike laparoscopic myomectomy, there are few cases of conservative laparoscopic adenomyomectomy and little data on indication and surgical performance. An extended excision to prevent reoccurrence leads to difficulty in uterine reconstruction and may lead to uterine rupture during pregnancy or labor. Further investigation on operative procedures and postoperative management of laparoscopic adenomyomectomy is necessary. Laparoscopic myomectomy to treat myomas is now widespread, and techniques for enucleation and suturing under laparoscopy are developing rapidly.13 By applying laparoscopic myomectomy techniques, we believe we have established a safer and more effective technique for laparoscopic adenomyomectomy.
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