4. Discussion
bleeding, myomas, intraoperative bleeding, blood loss, uterine fibroids, blood transfusions, allergic reactions, embolic agents, fibroid, hemoglobin loss, ischemia, hemorrhage, postoperative blood transfusions, intraoperative blood loss, myoma, infection, fibroids, uterine artery occlusion, tissue damage, scar ectopic pregnancy
BLEEDING, RECURRENCE, MYOMAS, BLOOD LOSS, UTERINE FIBROIDS, ADVERSE EFFECTS, VAGINA, INTRAOPERATIVE BLEEDING, UTERUS, FIBROID, ALLERGIC REACTION, ISCHEMIA, HEMORRHAGE, INTRAOPERATIVE BLOOD LOSS, HEMODYNAMIC INSTABILITY, MYOMA, INFECTION, FIBROIDS, CAVITY, COMPLICATIONS
Throughout the past few decades, there have been significant changes in the treatment of fibroids. A laparoscopic myomectomy, a surgical procedure used to remove uterine fibroids through small incisions, was first reported in 1979 [However, there are some limitations associated with a laparoscopic myomectomy, such as operative blood loss, difficulty in suturing, and locating small myomas through the laparoscope. To address the issue of blood loss during the procedure, various methods have been employed, such as uterotonics, vasopressin, antifibrinolytic drugs, a peri-cervical mechanical tourniquet, laser dissection, temporary cutting of the uterine arteries, misoprostol through the vagina, or the intravenous injection of tranexamic acid or ascorbic acid. Despite these methods, they may have limitations and adverse effects [The article describes a novel technique for a laparoscopic myomectomy (LM) combined with the placement of a tourniquet in the lower segment of the uterus. This innovative approach aims to block blood flow in the ascending branch of the uterine artery, leading to a reduction in intraoperative bleeding during the procedure. The authors emphasize that this technique has the potential to make LM safer and less complicated for patients. The authors underline the lack of studies in the literature on this specific approach of tourniquet.This study aims to investigate the effectiveness of using the tourniquet in reducing blood loss associated with the surgery. The first outcome measured in our study was operative blood loss as measured by the change in hemoglobin. We found that the surgical use of a tourniquet at the time of an LM compared with an SLM resulted in a statistically significant reduction in the estimated blood loss, expressed as the mean differences in the Hb measured shortly before and on first day after the surgery. The mean differences in Hb (Delta Hb) were statistically significant (1.38(1.20–1.57) vs. 2.32(1.99–2.67), Akbaba et al. found that the use of a temporary tourniquet has shown to be statistically effective in reducing hemoglobin loss in patients with multiple large-sized myomas [In a prospective observational study, the application of the tourniquet was found to significantly diminish blood loss, simplifying the myoma resection process. Notably, 83.3% of patients experienced blood loss below 200 mL, and the rest experienced blood loss between 200 and 400 mL. The use of a tourniquet proves to be a cost-effective, safe, and easily accessible solution, effectively minimizing blood loss during a myomectomy without introducing additional complications to the procedure [The effectiveness of using a tourniquet during surgery in reducing blood loss can be evaluated through various parameters, such as the postoperative drop in hemoglobin, intraoperative blood loss, and the postoperative rate of transfusions. Measuring the difference between preoperative and postoperative hemoglobin levels can provide valuable insight into the amount of blood loss experienced during surgery. While measuring intraoperative blood loss is challenging due to factors like variability in the irrigation fluid, a postoperative Hb drop is a more reliable indicator of the use of a tourniquet in reducing blood loss during the surgery.A high rate of postoperative blood transfusions can be indicative of significant blood loss during the surgery. The use of a tourniquet that effectively reduces blood loss should be associated with a lower need for transfusions, as the patient’s own blood is better conserved. In our study, the rate of required iron perfusion was 17 (28.33%) in all patients, and the rate of blood transfusions was 4 (6.66%) in all patients. The rate of postoperative iron perfusion in the TLM group was significantly lower compared to the SLM group (4 vs. 13 patients). All four patients that required a blood transfusion were from the SLM group. Other studies also reported a higher incidence of blood transfusions in a standard laparoscopic myomectomy compared to a laparoscopic myomectomy with the use of tourniquet [Uncontrolled bleeding can lead to significant blood loss, potentially resulting in hemodynamic instability and, in severe cases, even a life-threatening hemorrhage. To avoid these complications, sometimes a conversion to laparotomy is needed to ensure proper hemostasis. No patients in the tourniquet group required a conversion to laparotomy, and only two patients in the non-tourniquet group required a conversion to laparotomy.Regarding the duration of the operation, there was no significant difference between the two groups in our experience: 98.50 (95.89–101.10) min in the TLM group vs. 92.50 (90.11–94.89) min in the SLM group (On the other hand, in the laparoscopic myomectomy group, more time is spent trying to maintain the hemostasis of the sutured wounds of the uterine cavity. Other studies also reported that fastening a tourniquet during a myomectomy is an additional procedure that does not prolong the duration of the surgery [The embolization of the uterine artery (UAE), temporary uterine artery clipping, and tourniquet placement are three different techniques used in the context of myomectomy for the treatment of uterine fibroids. Each method has its own advantages and disadvantages, and the choice between them depends on various factors, including the patient’s condition, the size and location of the fibroids, and the surgeon’s expertise. A uterine artery embolization does not involve a major surgery, which means shorter hospital stays and faster recovery times compared to a traditional myomectomy. Since it is a non-surgical approach, blood loss during the procedure is minimal. However, a UAE may not be as effective for large fibroids or those located deep within the uterine wall. While a UAE is generally safe, there are risks of infection, allergic reactions to the embolic agents, and potential damage to nearby organs. The fibroid recurrence rate after the embolization was 17.2% [Artery uterine clipping allows for the surgeon to control the blood flow to the fibroids, reducing bleeding during the myomectomy. Dubuisson et al. conducted a literature review to define the role of preventive uterine artery occlusion during a laparoscopic myomectomy. They reported that six of eight comparative studies showed a substantial decrease in operative blood loss in patients who underwent preventive a uterine artery occlusion during surgery. Temporary clipping has a lower risk of ischemia, minimizing the risk of tissue damage. However, these vascular clamping techniques with vascular clips require the surgeon to undergo a learning curve for operative skills, such as opening the retroperitoneum and identifying the pelvic vasculature [This article describes an efficient method to minimize blood loss during a conservative uterine surgery. Other types of surgical uterine-sparing procedures such as caesarean scar ectopic pregnancy [Overall, these findings suggest that the use of a tourniquet during a laparoscopic myomectomy could be a viable option for improving patient outcomes and reducing complications related to blood loss during the procedure. Applying a tourniquet is a straightforward technique that does not require advanced surgical skills or specialized equipment. By minimizing bleeding, the surgeon can have a clearer view of the surgical site. It is important to consider these aspects when interpreting the results of the studies and to be cautious about drawing strong conclusions based on incomplete or potentially biased data.Our investigation has some limitations, including the facts that it used a single-center design and all procedures were performed by a single team. Additionally, the hospital’s protocol limited the blood loss estimation to measuring differences in the hemoglobin levels. However, our study’s strengths lie in its prospective design. Notably, we maintained consistency in the surgical approach, except for the tourniquet technique, which we introduced to limit blood loss. This novel technique holds great promise and offers numerous potential applications for uterine-sparing procedures, making it a key strength of our study.