MRI serves several purposes
Fibroids can be localized and identified as pedunculated, subserosal, intramural, or submucosal via MRI. Measurements and spatial orientation of the fibroids within the uterus can be formulated using T2 weighted coronal, axial, and sagittal images.
The risk of entering the uterine cavity, as well as the risk of synechiae, may be significantly greater if leiomyomas abut and distort the cavity. Surgical strategies, such as planning the location of the hysterotomy or the inclusion of other procedures (eg, hysteroscopic resection for type 0 or type 1 submucosal fibroids), can be formulated with the information provided by MRI. In cases involving multiple fibroids or intramural fibroids, in particular, MRI serves as a surgical “treasure map” or “GPS.” Preoperative MRI is also one way to offset the lack of haptic feedback during surgery to locate the myomas for removal. As we mentioned earlier, important characteristics, such as degeneration or calcification, also can be readily observed on MRI.
Most important, MRI can distinguish adenomyosis from leiomyomas. Adenomyosis can mimic leiomyomas—both clinically and on sonographic imaging—particularly when it is focal in nature. MRI can make the distinction between these two entities so that patients can be counseled appropriately.
SURGICAL TECHNIQUES
Use a uterine manipulator
This device will facilitate the enucleation process, providing another focal point for traction and countertraction. A variety of uterine manipulators are available. We use the Advincula Arch (Cooper Surgical, Trumball, Connecticut) in conjunction with the Uterine Positioning System (Cooper Surgical). The latter attaches to the operating table and to the Advincula Arch to secure the uterus in a steady position throughout the procedure.
During enucleation, the manipulator is crucial to hold the uterus within the pelvis and the field of vision and to act as countertraction as traction is applied to the fibroid.
Individualize port placement
Rather than premeasure port placement on the abdomen, we individualize it, based on a variety of characteristics, including body habitus and uterine pathology (FIGURE 3). However, we follow some basic principles:
- We insert a Veress needle through the umbilicus to achieve pneumoperitoneum
- After insufflation, we use an upper quadrant entry (right or left, depending on which side the robot patient side cart is docked) under direct visualization using a 5-mm laparoscope and optical trocar. This entry will serve as the assistant port for surgery.
- Before placing the rest of the ports under direct visualization, relative to uterine pathology, we elevate the uterus out of the pelvis. This step ensures that enough distance is placed between the camera and the instrument arms to adequately visualize and perform the surgery.
- In patients with a uterus larger than approximately 14- to 16-weeks’ size, a supraumbilical camera port often is necessary.
- We generally employ a four-arm technique using a 12-mm Xcel trocar (Ethicon Endo-Surgery, Blue Ash, Ohio) that is 150 mm in length for the camera port, three 8-mm telerobotic trocar ports, and a 5-mm Airseal trocar (SurgiQuest, Orange, Connecticut) for the assistant port. There should be at least one hand’s breadth between the ports to minimize arm collision and maximize range of motion.
- Although the 12-mm Xcel trocar comes in a variety of lengths (75–150 mm), we strongly recommend, and exclusively use, the longest length for the camera. Once the camera is docked high on the neck of the longer trocar, more space is created between the setup joints of the robotic arms, enabling greater range of motion and fewer instrument and arm collisions.
- We generally use the following wristed robotic instruments to perform myomectomy: tenaculum, monopolar scissors, and PlasmaKinetic (PK) bipolar forceps.
Inject vasopressin into the myometrium
Vasopressin causes vasospasm and uterine muscle contraction and decreases blood loss during myomectomy. It should be diluted (20 U in 50–200 mL of normal saline), introduced with a 7-inch, 22-gauge spinal needle through the anterior abdominal wall, and injected into the myometrium and serosa overlying the fibroid (VIDEO 1 and VIDEO 2).
Perform this step with care, with aspiration prior to injection, to avoid intravascular injection. Although vasopressin is safe overall, serious complications and rare cases of life-threatening hypotension, pulmonary edema, bradycardia, and cardiac arrest have been reported after the injection of as little as 3 U into the myometrium.4–7
Relative contraindications to vasopressin, such as hypertension, should be discussed with anesthesia prior to use of the drug during surgery.
Enucleate the fibroid
Although either a vertical or a horizontal-transverse incision can be made overlying the uterus, a transverse incision allows for technical optimization of wristed movements for suturing and efficient closure. Whenever possible, therefore, we favor a transverse hysterotomy.
During enucleation, keep the use of thermal energy to a minimum. The same holds true for the uterine incision, although its length can be extended as needed.