Efficient myometrial defect closure in a layer by layer fashion after robot-assisted laparoscopic adenomyomectomy: a novel technique

Article information

Obstet Gynecol Sci. 2021;64(3):332-335

Publication date (electronic) : 2021 March 19

doi : https://doi.org/10.5468/ogs.21025

Ayah Hijazi, MD^*, Youn Jee Chung, MD^*, Najeeba Al Sinan, MD, Kyungmin Park, MD, Minji Ko, MD, Jae Yen Song, MD, Mee-Ran Kim, MD, PhD

Department of Obstetrics and Gynecology, Seoul St. Mary’s Fibroid Center, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding author: Mee-Ran Kim, MD, PhD, Department of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea, E-mail: mrkim@catholic.ac.kr

*These authors contributed equally to this work.Mee-Ran Kim has been an Editorial Board of Obstetrics & Gynecology Science; however, she was not involved in the peer reviewer selection, evaluation, or decision process of this article. Otherwise, no other potential conflicts of interest relevant to this article was reported.

Received 2021 January 10; Revised 2021 February 23; Accepted 2021 March 11.

Adenomyosis, affecting about 20% of reproductive aged women, is characterized by the presence of endometrial glands within the myometrium, which gets frequently surrounded by hyperplastic and hypertrophic smooth muscle [1]. Adenomyosis mostly involves heavy menstrual bleeding, followed by dysmenorrhea. Less common presentations include dyspareunia and chronic pelvic pain [2]. In recent years, women are more likely to postpone pregnancy towards the end of their reproductive lives; thus, adenomyosis may increasingly become a factor causing infertility, and its diagnosis is an important part of the infertility workup [3].

As more patients are requesting us for fertility preserving management for adenomyosis, we have opted for methods that not only would preserve the uterus but also allow a safe pregnancy. Surgery for adenomyosis had started with the laparotomic approach, followed by less invasive laparoscopy, which was hampered by the loss of tactile sensation, and poorer operative access [4]. Robotic surgery, on the other hand, still allows a minimally invasive procedure, while having the benefit of open surgery with the EndoWrist technology [5].

The defect created in the myometrium following adenomyomectomy can be quite large (Video 1), and maintaining the uterine wall thickness can be a challenge. In our technique, we aimed to maintain normal uterine muscle fiber alignment. This was done by enforcing each layer separately (Fig. 1); we also aimed to keep the endometrium intact, as we believe that its injury might have an effect on future fertility.

Fig. 1

Surgical procedure. The adenomyotic tissue was grasped using a tenaculum forceps, while dissection was continued using a monopolar curved scissors or a monopolar spatula (A). The defect between the anterior and posterior innermost myometrial layers was closed using a 2-0 stratafix suture, CT-1 needle (B). After the anteroposterior planes were sutured on either side of the incision, the two sides were approximated using a 2-0 PDS suture, V-34 needle (C). Both sides of the serosa were brought together using a 2-0 PDS suture, slim half needle in a baseball fashion (D).

Our patient was a 47-year-old woman who was referred to our clinic with severe dysmenorrhea. She had tried medical therapy before with not much improvement. After thorough counseling, we decided to perform robot-assisted laparoscopic adenomyomectomy. In this video, we detail our technique for closure of the myometrial defect using the layer-by-layer technique. Maintaining endometrial integrity could be achieved by careful preoperative planning with the aid of pelvic MRI (Fig. 2) and the assistance of intraoperative ultrasound.

Fig. 2

Pelvic magnetic resonance imaging (MRI). (A) Sagittal and (B) axial pelvic MRI showed adenomyosis involving the posterior uterine wall.

The duration of the surgery was approximately 5 hours and 30 minutes, and the estimated blood loss was 500 milliliters. She was discharged on the 3rd postoperative day for social reasons. On follow-up, we found that our patient had minimal dysmenorrhea and was very satisfied. Further, an ultrasound scan, repeated post-surgery, showed a great reduction in the posterior myometrial wall thickness (Fig. 3).

Fig. 3

Transvaginal ultrasound. Follow up transvaginal ultrasound (B) done 2 months postoperatively showed a posterior myometrial thickness of 2.69 cm compared to the previous measurement of 5.61 cm in the preoperative ultrasound (A).