Laparoscopic myomectomy technique - Use of colpotomy and the harmonic scalpel

OBJECTIVE: To describe the use of colpotomy and the harmonic scalpel in laparoscopic myomectomy and to compare estimated blood loss when using unipolar cautery versus the harmonic scalpel and surgical time for colpotomy versus morcellation. STUDY DESIGN: A retrospective, cohort study was performed on 168 patients who were diagnosed with and treated for uterine leiomyomata between January 1992 and January 2000. Patients presented with infertility, menometrorrhagia, dysmenorrhea, masses on ultrasound or a combination of these symptoms. Two patients required hysterectomy, and I required conversion to laparotomy due to bleeding, leaving 165 patients who underwent laparoscopic myomectomy, 143(87%) by colpotomy and 22 (13%) by morcellation. Unipolar cautery was used for uterine incision in 112 of the 165 myomectomies (68%) and the harmonic scalpel in 53 (32%). Surgery was performed at one of two community hospitals in the Seattle area or a general hospital in Taiwan. RESULTS: Mean estimated blood loss using the harmonic scalpel (243 mL, range 150-350) was significantly less (P < .01) than that using unipolar cautery (378 mL, range 203-800)for uterine incision. Mean surgical time for colpotomy (144 minutes, range 110-260) was less (P < .05) than that for morcellation (168 minutes, range 140-244) despite having removed a larger median number of myomata per patient of comparable or larger size (seven by colpotomy versus four by morcellation). CONCLUSION: These data suggest that the harmonic scalpel is effective for uterine incision during myomectomy and may result in less bleeding than unipolar cautery while offering some advantages in safety. Multiple leiomyomata can generally be extracted more quickly via posterior colpotomy than by morcellation. This difference is smaller and therefore less important in patients with only a few small to medium-sized (< 10 cm)fibroids. For these patients, the minimal invasiveness of morcellation may offer a more significant benefit.