Myomectomy: Surgical Techniques Anno 2018, A Systematic Review

Background: The aim of this article is to provide a practical evidence based manual of the potential surgical techniques for a myomectomy, anno 2018: minimal invasive surgery (laparoscopy versus robotic assisted laparoscopic surgery (RALS)) and laparotomy. Materials and methods: A literature review has been performed for approach, choice and correct use of instruments, procedure and closure of wound bed in the field of a myomectomy. A thorough web research showed a disappointing amount of evidence based facts regarding accurate surgical steps to take in this matter. The missing information is added as a suggestion based on the surgical technique used in a tertiary referral center in Belgium. Results: A myomectomy is a procedure performed in women with a desire to retain their uterus. The myoma is preferably vertically incised in the midline to prevent transection of the arcuate arteries of the uterus. The location of a fibroid, and not its size, is the key factor regarding impact on fertility. The main goal of the procedure is to remove the fibroid in total without opening the intra-uterine cavity. With intramyometrial injection of a vasoconstrictor blood loss during myomectomy can be significantly reduced. Uterine reconstruction is performed in multiple layers with a continuous barbed which does not require knotting. In women with child wish one can discuss leaving hyaluronic acid (Hyalobarrier) on the wound bed in order to reduce postoperative adhesions and secondary impact on fertility. Conclusion: A correct indication of surgery is primordial in advance in order to reduce complication rate and risk of conversion. At the moment minimal invasive approach (either laparoscopic or robotic) has proven to be superior over open surgery in benign gynaecological pathology. There is a significant overlap in indication with laparoscopic approach, however in this topic of minimal invasive surgery, studies lack evidence of robotic ruling over laparoscopic approach.