One of the most perplexing findings when evaluating women with a variety of pelvic complaints is the presence of uterine myomas, frequently called fibroids. These benign tumors of the reproductive tract are so common that in population studies they can be detected by ultrasound in 40–60% of women by age 35 and 70–80% by age 50, with a higher prevalence among those of African ancestry [4]. The clinician is then faced with the task of linking the findings with the symptoms, rather than simply treating something which could otherwise be coined an unrelated bystander, given the high prevalence in women. Uterine myomas can cause pelvic pressure, urinary frequency, constipation, and abnormal uterine bleeding. In specific circumstances, depending on location and size, they can be linked with reduced fertility in couples trying to conceive. Surgical management of uterine myoma, the focus of this segment, represents only one of many options for women who are symptomatic. Figure 10.1 demonstrates location of myoma and their potential for abnormal uterine bleeding or pressure-related symptoms.

The original uterus-sparing surgical concept is actually a group of procedures collectively called myomectomy , whereby the myoma is enucleated and the muscular defect reconstructed with suture in a layered fashion. This repair is critical to the integrity and contractile function of this smooth muscle during pregnancy. The open approach was first reported by Atlee in 1845 [5] and is considered the gold standard for women wishing to conceive.

The most appropriate myomectomy approach and technique depends upon a number of factors including the patient’s desire for future fertility as well as the size, number, location, and relationship of the deepest aspect of the myoma(s) to the uterine serosa. An abdominal approach [open, laparoscopic (LM) or robotic-assisted laparoscopic myomectomy (RALM)] is most appropriate for transmural lesions , when the myoma extends from a submucosal location to the serosa.

The principle potential advantages of LM and RALM , compared to the open approach, include reduced morbidity, shorter hospitalization, improved cosmesis, and faster return to normal activity (Table 1) [6]. Notwithstanding these benefits, an open approach remains a commonplace procedure due to the complexity of the laparoscopic approach, primarily due to the skillset needed to identify the myoma(s) of interest with less tactile feedback and to place multiple sutures laparoscopically, which are often in deep and difficult-to-access spaces.

The da Vinci robotic surgical system was designed to overcome these dynamic surgical obstacles. The first case series of RALM was reported by Advincula more than a decade ago [7]. Although the average procedural time was 230 min, the perioperative outcomes were promising. As a result, the robotic platform seemed to represent an enabling device for an otherwise complex procedure. Early adopters believed that the instrument articulation, which allowed the surgeon to enucleate anatomically challenging myomas and effectively reconstruct large surgical defects, may be the defining feature of the device when it comes to myomectomy. Evidence-based guidelines for surgical candidacy of either LM or RALM have yet to be defined. Experts typically refer to 15 cm as a relative maximum size limit for an isolated myoma when considering a laparoscopic or robotic-assisted approach, but location, number of myomas, and volume of disease represent equally critical variables when considering this approach.

With clear benefits of a minimally invasive approach to myomectomy, both LM and RALM, specific questions remain as to which represents the ideal approach for the individual patient. The leiomyoma recurrence rates and likelihood of severe complications appear to be similar in women undergoing myomectomy by either approach [8], but it would appear that when performed by a skilled operator, RALM may allow for a minimally invasive completion of more complex cases. The data currently available on fertility outcomes indicate that the two approaches are also similar, with about 50–60% conception rates in the follow-up period with resulting pregnancy outcomes, as well comparable risk of spontaneous abortion, preterm delivery, and uterine rupture [9].

Gargiulo and colleagues evaluated the perioperative outcomes of similar groups of women undergoing either LM or RALM, both by high-volume surgeons who had a preference for surgical approach. Both the laparoscopic and robotic surgeons had reached the perceived learning curves for the respective technique. In this observational study, the authors documented similar findings in each group with two exceptions: a longer operating time (absolute difference of 77 min) and a higher estimated blood loss (absolute difference 24 mL) for the robotic group. A major confounder was the introduction of barbed suture, only utilized by the laparoscopic group. This suture type allowed for faster uterine reconstruction with the potential for decreased blood loss because of its ability to close the defects more efficiently and by creating an internal tourniquet within the myometrium [9]. Barakat and colleagues evaluated the outcome of 575 women undergoing myomectomy performed at a single institution, comparing all three approaches [10]. The majority of cases (68.3%) were performed by laparotomy with the remaining evenly distributed between LM and RALM. Consistent with other study findings, patients undergoing the open approach experienced a shorter procedure compared to LM (absolute difference 29 min), whereas those undergoing RALM experienced the longest operating time (absolute difference of 55 min vs. 26 min for open and LM, respectively). Patients who underwent open myomectomy had more blood loss compared to both LM or RALM, as well as a longer hospital stay. Mean myoma size and weight of those in the RALM were closer to that of those undergoing open myomectomy, suggesting an increased capacity to address larger myomas. Reproductive outcomes were not assessed in this retrospective trial. The authors concluded that RALM may allow surgeons to perform more difficult cases laparoscopically and prevent conversion to laparotomy.

One critical surgical tenet for performing RALM is that the surgeon utilizes the same technique(s) described for the abdominal counterpart. Surgical planning with appropriate imaging and knowledge of where the myomas sit within the uterus allows for better efficiency in the operating room. Specifically, this allows the surgeon to decide which myomas to address and in what particular order, allowing for streamlined removal and repair. Maintaining proper surgical planes between the myoma itself and overlying myometrium will minimize bleeding and subsequent hematoma formation which impedes muscular repair. Gentle tissue handling and appropriate use of electrosurgery will further aid in tissue repair and minimize adhesion formation.

Robotic instruments commonly used are monopolar Metzenbaum scissors or hook, using a low voltage setting, a Maryland dissector that can aid in enucleation of the myoma from its bed, and a single tooth tenaculum or claw grasper that can be used to place traction on the myoma. Many surgeons typically use a dilute form of vasopressin (example: 20 units vasopressin diluted in 50 mL normal saline) to minimize bleeding as the overlying serosa and myometrium are incised. Bleeding during this portion is expected since these muscular tissues have abundant blood supply, and so a combination of vasoactive agents and electrosurgery will help to keep the surgical field clear. An incision is created to allow for adequate exposure, but smaller serosal injuries will minimize subsequent adhesion formation.

Enuclation is the process by which the myoma is removed from its bed. Typically, there is a relatively avascular cleavage plane between the myoma surface and myometrium. Excessive bleeding during this portion of the procedure may indicate dissection within an incorrect plane. Once removed, the defect must be repaired in layers with absorbable suture of the surgeon’s choosing. The advent of barbed suture resulted in a similar phenomenon as did the robotic platform, allowing for a more efficient and hemostatic myometrial reconstruction and enabling surgeons not as skilled in laparoscopic suturing to offer this procedure.

Upon completion of the myomectomy, the myomas must be extracted from the peritoneal cavity. With the current and limited use of mechanical morcellators , many surgeons are removing uterine myomas with a scalpel and some form of a containment system. Adhesion prevention with use of a barrier remains a separate discussion, but it is the opinion of this author that surgical technique and use of a minimally invasive approach are key to reducing this potentially morbid phenomenon.