Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

This procedure was developed to protect patient fertility by preventing the possibility of uterine rupture in post-myomectomy pregnancies induced by large, barely closed, residual cavities and pulling healed myometrium. The key advantage of this procedure is that it minimizes the surgical injury to the myometrium on the outside of pseudo-capsular, and the vascular tissue inside of the pseudo-capsule. This intracapsular rotary-cut procedure requires patients and care for needs, especially of the beginning of the procedure and during the application of the electrical monopolar knife.

Before beginning the procedure, use standard techniques to establish a 10 millimeter umbilical port and two five millimeter ports, and one 10 millimeter ancillary port in the lower and middle abdomen in the anesthetized patient. When all of the ports have been placed, carefully inspect the pelvis to confirm the size, number and location of the fibroids and use a 10 millimeter syringe to inject an ischemic solution into the myometrium around the fibroids. Determine the incision position on the most protruding side of the fibroid and use a monopolar hook electrode at 30 watts to make a longitudinal incision, taking care the length is no longer than half of the fibroid diameter.

After exposing the fibroid surface, use laparoscopic forceps to pull the fibroid outward to expose the boundary between the fibroid and pseudo-capsule. Use a monopolar electrical knife to make the first cut on the exposed part of the fibroid, then hold the edge of the first cut with the forceps to pull the fibroid outward. Next, make multiple long rotary cuts on all sides of the fibroid that have been isolated from the capsule, at different levels of the fibroid, partially overlapping with the prior cuts to shirt the diameter of the tumor.

While the cuts are being made, switch the forceps from the previous cut to the next cut, to keep pulling the tissue outward to facilitate further exposure of the gap between the fibroid and pseudo-capsule. Use vacuum drainage to remove the smoke to maintain a clear viewing field as necessary. When more than half of the fibroid is outside of the incision, the pseudo-capsule in the myometrium will contract, squeezing the fibroid out of the cavity.

The pseudo-capsule should slip to the base of the fibroid. Continue making the incisions until the base of the fibroid is exposed and can be isolated from its pseudo-capsule. Then use electrocautery forceps to coagulate and cut off the blood vessels, to completely remove the fibroid, leaving only a shallow residual cavity.

Starting at five millimeters outside of the incisal edge, close the empty fibroid cavity in a single layer with a running 30 centimeter 1-O polyglyconate, unidirectional barbed suture, in one centimeter increments, taking care that the stitching passes through the bottom of the residual cavity. Then enlarge the 10 millimeter port to 15 to 20 millimeters, and morcellate the fibroid with a reusable morcellator. There is only a little bleeding in the whole procedure.

In this clinical study, after excluding the nine laparoscopic myomectomy cases that were converted to laparotomy, the average age of patients in the two groups was statistically similar, as were the mean diameters of the fibroids. However, the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were all significantly lower in the intracapsular rotary-cut procedure group than in the laparoscopic myomectomy group. The intracapsular rotary-cut procedure significantly minimizes the damage to the uterus, protects the myofibers of pseudo-capsule, and leaves a shallower residual cavity for easier stitching and healing of the myometrium.

Our outreach have to preserve to preserve patient fertility.