A Technique for Vascular Control During Robotic-assisted Laparoscopic Myomectomy

Study objective: To show and describe a unique method for improved vascular control when performing a robotic myomectomy.

Design: A video showing skeletonization of the uterine vessels and uterine artery occlusion to maximize vascular control and minimize blood loss during robotic-assisted myomectomy (Canadian Task Force classification III).

Setting: Myomectomy is a procedure often reserved for the treatment of symptomatic leiomyomas in women who desire fertility preservation. Although traditionally performed via laparotomy, laparoscopic and robotic-assisted approaches are increasing in popularity. One of the limitations of myomectomy is the potential for increased blood loss and surgical morbidity. Although studies suggest a decrease in blood loss with a robotic approach, the risk of requiring a blood transfusion remains.

Interventions: In this video, we show a technique for maximizing vascular control during myomectomy in a Jehovah's Witness. In addition to subserosal injection with a dilute solution of vasopressin, we used vascular clips and bulldog clamps to temporarily occlude the uterine arteries. The uterine vessels were skeletonized at the level of the cervix to provide access for placing the vascular clips. Additionally, a peritoneal window was created in the mesosalpinx, and bulldog clamps were available to transiently occlude the utero-ovarian vessels in case of increased blood loss.

Conclusion: Temporary occlusion of the uterine vessels can be used during robotic-assisted myomectomy to provide improved vascular control. We were able to use this technique during robotic-assisted myomectomy in a Jehovah's Witness patient. This approach can be considered for selected patients by experienced laparoscopic surgeons to lower blood loss and potentially decrease the need for transfusion.