Myomectomy

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this video is an example of a simple
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basic robotic-assisted laparoscopic
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myomectomy of a single uterine fibroid
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the patient is a 36 year old white
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female grabbed at a 3 para 0 with
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recurrent pregnancy loss in a two-year
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history of worsening dyspareunia in mini
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raja ultrasound showed a single
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intramural fibroid 2.5 centimeters in
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diameter the patient desired to have a
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laparoscopic myomectomy at laparoscopy
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the location of the fibroid is quite
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obvious the procedure is began by using
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a mono polar scissor with a pure cutting
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current of approximately 50 watts to
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incise the serosa the cutting current is
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continued with minimal coagulation until
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a uterine fibroid is reached
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the incision is continued into the body
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of the fibroid and then the fibroid is
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grasped with a single tooth tenaculum
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placing the fibroid on traction helps to
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stop venous bleeding as well as aid in
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the enucleate of the myoma the
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fenestrated bipolar forcep and the mono
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polar scissors are used to provide
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mostly blunt dissection along the border
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of the fibroid
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when bleeding is encountered it is
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usually due to the dissection plane
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drifting away from the body of the fire
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boy
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when this occurs electric cautery is
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used to cut back into the body of the
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fibroid to reach the correct dissection
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play
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particular care must be taken on the
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posterior aspect of the fibroid where
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the blunt dissection plane will often
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tear into the surrounding vascular
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network if this occurs a minimal amount
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of electric cautery can be used to
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obtain hemostasis shown here with the
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bipolar forceps on a setting of 20 watts
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the dissection then continues stay near
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to the body of the fibroid
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any large bleeders are coagulated with
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as little electric cautery as possible
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it is not necessary to obtain full
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complete hemostasis as this will be
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achieved with the suture closure I
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routinely used the V lock in a
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directional barbed suture for myomectomy
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closures this suture speeds the closure
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of the incision thereby reducing blood
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loss and the barbed design helps to
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maintain tension on the myometrium edges
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thereby limiting any dead space I use
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the same suture for multiple running
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layers a place as many layers as needed
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to adequately close the dead space
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Andreea proximate the native myometrium
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tissue in a simple closure such as this
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I will place three layers the first or
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running suture to approximate the deep
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edges of the myometrium defect
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you
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the second suture is a horizontal
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mattress suture through the body of the
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myometrium this provides most of the
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strength of the closure Aria proximate
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s’ this Rosso edges
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the final layer is a horizontal mattress
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sub cirrhosis suture
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this type of closure has many advantages
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over the so called baseball stitch
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serosal closure by not puncturing the
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serosa this closure is very hemostatic
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and by leaving no exposed suture
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adhesion formation is theoretically
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reduced
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at the end of the closure the suture
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simply cut off flesh with a serosa
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after irrigation the incision can be
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seen to be fully human static I then
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place a piece of intercede anti adhesion
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material over the incision I only use
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intercede in cases with complete ela
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stasis as it is known to promote
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fibrosis of blood in cases with multiple
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incisions I use adapt 4% i Codex trans
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solution for adhesion prevention total
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real time from uterine incision to
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completion of closure was 16 minutes the
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patient also had several areas of pelvic
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endometriosis which was excised as well
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total surgical time skin to skin was 35
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minutes ultrasound over uterus three
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months postoperatively barely shows any
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evidence of the location of her previous
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fibroid so this was a very simple
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myomectomy the same principles apply to
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more advanced cases my experience in the
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past 12 months with robotic-assisted
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laparoscopic myomectomy includes
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performing approximately 62 myomectomy
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x’ now averaging approximately seven to
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eight per month removing a total of 292
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fibroid the number of fibroids removed
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have ranged from 1 to 22 with more than
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25 percent of cases having more than 10
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fibroids removed of all unselected cases
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presenting to our practice I have been
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able to complete more than 96% of them
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laparoscopically no laparoscopic case
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has been converted to an open case and
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only 3 open myomectomy x’ have been
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performed removing 33 35 and in a case
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of diffused Myo Myo mitosis 145 fibroids
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the average estimated blood loss is 112
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CCS
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ranging from less than 10 cc’s to 500
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CCS 65% of all cases have less than 100
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CC’s blood loss
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100% of all cases began in the mornings
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are discharged on the same day the
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recovery period is excellent with
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patients only using narcotics for an
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average of 1.5 days and return to work
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in an average of 7 days
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in my opinion there are a few surgical
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limitations to a robotic-assisted
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laparoscopic myomectomy fibroids size is
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not a limitation as I have frequently
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removed fibroids larger than 15
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centimeters and operated on uteri larger
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than 20 weeks gestational sized fibroid
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location is also not a problem as a
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robotic approach is ideal for patients
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with a posterior fibroid or some mucosal
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fibroid prior surgeries such as
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myomectomy x’ or other pelvic procedures
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should not deter a surgeon from
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approaching in laparoscopically fibroid
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number is the only situation in which I
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have some concern as to whether or not a
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patient may be a candidate for a
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laparoscopic myomectomy I routinely
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complete laparoscopic cases with up to
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15 fibroids however patients with more
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than this run the risk of not having
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every single fibroid removed
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typically any fibroid larger than 1
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centimeter can be found and removed
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laparoscopically I have found that most
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patients with very large numbers of
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fibroids would rather complete their
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surgery laparoscopically and run the
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risk of leaving one or two small
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fibroids behind rather than having an
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open procedure