uterine leiomyomata , the most common solid pelvic tumors , occur in approximately 20% of women aged 35 years or more . because of the significant operative risk associated with abdominal myomectomy
, the operation has been reserved for women who want to preserve or enhance their fertility potential . however , with the general trend towards conserving the uterus and because many women currently choose delayed childbearing , patient demand for this procedure has increased .
furthermore , with the improvement in laparoscopic techniques and their associated low morbidity , resection of myomas is now a valid alternative for women suffering from any serious symptoms related to the presence of myomas in the uterus .
the only surgical treatment available for intramural and subserous myomas in the past was laparotomy .
laparoscopic myomectomy has since been shown to be an effective means of reducing postoperative morbidity , and it expedites recuperation .
however , it quickly became apparent that the laparoscopic operation was associated with the prolonged time of anesthesia , increased blood loss , and possibly a higher risk of postoperative adhesion formation .
laparoscopic myomectomy was described 2 decades ago and has since been repeatedly shown to provide the recognized benefits of the laparoscopic approach . however , with increasing experience , it has become apparent that the technique demands a high degree of training and skill from the laparoscopic operator .
it has been suggested that at present these factors limit the application of laparoscopic myomectomy . despite significant improvements in endoscopic instrumentation , laparoscopic
myomectomy remains a technically demanding and time - consuming procedure . in the easiest cases ,
pedunculated myomas may be simply transected , and some enucleated myomas will  pop out  through an incision in the uterine wall .
the operation is time - consuming , usually because of the difficulty in morcellating and removing the myoma from the abdominal cavity through the laparoscopic trocar ports or a posterior colpotomy . the belief that the strength of the uterine scar may be compromised is based on 2 major considerations and
first , the difficulty in adequately reapproximating the incision , as with meticulous multilayer suturing , may lead to the accumulation of an intramural hematoma .
second , use of the co2 laser and electrodesiccation , which could lead to thermal injury to surrounding tissue , may result in poor vascularization and tissue necrosis . at second - look laparoscopy ,
we have observed indentations at the sites from which leiomyomas were removed that were directly proportioned to the size of the myomas removed and may therefore represent structural defects .
this is a significant potential problem when the myomectomy is performed to enhance or preserve fertility .
however , data are still limited concerning postsurgical adhesion formation and pregnancy outcome although some preliminary data are encouraging .
another concern recently raised is the possibility that , after incomplete resection of the uterine myomas , the recurrence of myomas may be higher with the laparoscopic approach .
nezhat et al developed laparoscopic - assisted myomectomy ( lam ) and reported on it in 1994 .
it has been advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery , namely , short hospital stay , lower costs , and rapid recovery . herein , the lam technique and possible associated advantages are described .
whether to proceed with lam is usually decided in the operating room after first completing the diagnostic laparoscopy and treating any associated pathology .
the criteria for lam are myomas larger than 10 to 12 cm or numerous and deep myomas requiring extensive morcellation and necessitating uterine repair with sutures .
the leiomyoma , or in patients with multiple myomas , the most prominent one , is injected at its base with 3 to 7 ml of diluted vasopressin to minimize blood loss .
an incision is made over the uterine serosa until the capsule of the leiomyoma is reached .
a corkscrew manipulator is inserted into the leiomyoma and used to elevate the uterus toward the midline suprapubic puncture . with the trocar and manipulator attached to the myoma
after incision of the fascia transversely at 4 to 5 cm , the rectus muscles are separated at the midline .
we do not routinely use preoperative gonadotrophin - releasing hormone ( gnrh ) analogues . for anemic patients , preoperative treatment with gnrh analogues may enable restoration of a normal hematocrit , decrease the size of the myomas , and reduce the need for trans - fusion .
however , the benefits of preoperative treatment with gnrh analogues for laparoscopic myomectomy have recently been challenged in a prospective randomized study .
the peritoneum is entered transversely , and the leiomyoma is located and brought to the incision using the corkscrew manipulator ; a uterine manipulator is used to raise the uterus . the corkscrew manipulator is replaced with 2 lahey tenacula . the leiomyoma is shelled sequentially and morcellated , gradually exposing new areas . after complete removal of the leiomyoma , the uterine wall defect is seen through the incision .
if uterine size allows , the uterus is brought to the skin through the minilaparotomy incision to complete the repair .
when multiple leiomyomas are found , as many as possible are removed through a single uterine incision .
when the leiomyomas are in distant locations and identification is impossible , the minilaparotomy incision is closed temporarily with 1 layer of running suture or several allis clamps
. the laparoscope is reintroduced , and the leiomyomas are identified and brought to the incision . if posterior leiomyomas are difficult to reach through a minilaparotomy incision , they are removed completely laparoscopically .
the uterus is reconstructed in layers using 4 - 0 to 2 - 0 and 0-polydioxanone suture without suturing the serosa , and the uterus is palpated to ensure that no small intramural leiomyomas are present .
the uterus is returned to the peritoneal cavity , and the fascia and skin are closed in layers .
the fascia is closed with 1 - 0 polyglactin suture , and the skin is closed in a subcuticular manner .
the pelvis is evaluated to detect and treat endometriosis and adhesions that may have been obscured previously by myomas .
laparoscopic - assisted myomectomy outcomes were compared with the results in patients who had either myomectomy by laparotomy or laparoscopic myomectomy .
the myoma weight was significantly greater in the lam group than in the patients undergoing laparoscopic myomectomy .
it was found that lam could safely replace myomectomy by laparotomy , because patient selection criteria were comparable , and the myoma weights of these 2 groups were similar .
in contrast , blood loss among the patients undergoing laparoscopic myomectomy was significantly lower and may be attributed to the smaller myomas removed .
although subserosal myomas less than 5 cm can be managed easily laparoscopically , larger and intramural lesions require prolonged morcellation and laparoscopic suturing of the uterine defect .
some surgeons have suggested that the size of the myoma to be removed laparoscopically should be limited to 10 cm or even 6 to 7 cm .
consequently , it has also been suggested that no more than 4 myomas , 3 cm or more in size , should be attempted to be removed laparoscopically .
lam , with conventional morcellation and suturing through the minilaparotomy incisions , allows fast removal of multiple and large myomas and reduces the duration of the operation and the need for extensive laparoscopic experience .
similar mean operating times for laparoscopic myomectomy and lam techniques were observed despite larger myomas and their intramural positions , adjunctive laparoscopic procedures , and the smaller incisions in the lam groups .
hospitalization was significantly longer for the patients who underwent myomectomy by laparotomy when compared with that for the groups having lam or laparoscopic myomectomy . currently , the hospitalization time is similar for patients undergoing lam and patients having laparoscopic myomectomy . for both procedures , day surgery is used , and the patient is usually discharged on the first postoperative day .
the postoperative recovery time is comparable for patients undergoing lam versus laparoscopic myomectomy , despite the differences in the size of the different incisions .
the use of lam offers several obvious and potential long and short - term benefits ( table 1 ) .
the major advantages of lam are ease of repair of the uterus and rapid morcellation of the fibroids .
in addition , lam allows more meticulous suturing of the uterus , thus maintaining better uterine wall integrity .
the most feared postoperative complication , uterine rupture during pregnancy , has been reported to date in 5 cases after laparoscopic myomectomy . because the number of procedures performed over the last few years remains unknown , it is difficult to determine whether these 5 cases represent an incidence higher or lower than expected after any myomectomy .
uterine rupture after myomectomy is rare , but has been reported to account for approximately 2% of all pregnancy - related uterine ruptures .
all large series reported to date did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy .
however , it must be remembered that inadequate approximation of the uterine wall and poor healing may predispose patients to uterine rupture .
second - look laparoscopies performed on postmyomectomy patients with pedunculated and superficial subserosal myomas show complete uterine healing .
in contrast , intramural and deep subserosal myomas are associated with evidence of granulation tissue and indentation of the uterus proportional to the size of the leiomyoma removed , unless sutures are used to approximate the edges .
the use of sutures is associated with a higher rate of adhesions . in a recent study of second - look after laparoscopic myomectomy
the factors that influenced the occurrence of an adhesion on the myomectomy site were posterior location of the myoma and the existence of sutures .
meticulous suturing techniques facilitated by lam may therefore reduce the rate of postoperative adhesions . in patients with intramural fibroids and significant uterine wall defects ,
currently , the meticulous suturing made possible during laparotomy is very challenging to perform at laparoscopy .
lam therefore may provide a safer approach allowing more complete multilayer correction of the postmyomectomy uterine defects . a similar approach , combined
laparoscopic and vaginal myomectomy , has also been suggested for treating extensive and deeply infiltrating fundal and posterior wall leiomyomata .
the posterior colpotomy permits delivery of the myomas and allows uterine reconstruction by conventional suturing performed transvaginally .
a long - established dogma dictates that , if the endometrial cavity is entered or a submucous or large intrauterine myoma is removed during abdominal myomectomy , the patient should undergo cesarean delivery for subsequent pregnancies .
currently , women with large intramural fibroids , who wish to have children , should be strongly cautioned regarding the relative paucity of data regarding the precise risk during pregnancy after laparoscopic myomectomy .
lam , in carefully selected cases , is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy .
lam may also be a more appropriate approach for women who desire a future pregnancy because uterine healing and adhesion formation remain a significant concern .
in such women , lam may offer better management , because it allows careful suturing of the uterine defect in layers and avoids excessive electrocoagulation . by decreasing the technical demands , and thereby the operative time , lam may be more widely offered to patients .
thus , providing them with the well - recognized advantages of minimal access surgery , including a shorter hospital stay , and better patient convenience and recovery .
 laparoscopic myomectomy has recently gained wide acceptance . however , this procedure remains technically highly demanding and concerns have been raised regarding the prolonged time of anesthesia , increased blood loss , and possibly a higher risk of postoperative adhesion formation . 
 laparoscopic - assisted myomectomy ( lam ) is advocated as a technique that may lessen these concerns regarding laparoscopic myomectomy while retaining the benefits of laparoscopic surgery , namely , short hospital stay , lower costs , and rapid recovery . by decreasing the technical demands , and thereby the operative time , lam may be more widely offered to patients.in carefully selected cases , lam is a safe and efficient alternative to both laparoscopic myomectomy and myomectomy by laparotomy . 
 these cases include patients with numerous large or deep intramural myomas . 
 lam allows easier repair of the uterus and rapid morcellation of the myomas . in women who desire a future pregnancy , 
 lam may be a better approach because it allows meticulous suturing of the uterine defect in layers and thereby eliminates excessive electrocoagulation . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION