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As you do resections, and take a myoma that is about 70% intracavitary and 30% intramural – a classic submucous myoma – as you distend the cavity and begin the resection, what happens? Well, the uterus knows how to do one thing – it knows how to contract; it is a smooth muscle. As you put that pressure head inside, the uterus will come down on the myoma. What it does is that it will squeeze this myoma out towards you. Often times as you are doing these cases, you are getting there and at this point you are flush with the cavity. That is where I take it down to; at that point, you are safe. I don’t go digging around in the intramural portion; I don’t think that is optimal. But then you stop, take out the chips, let the uterus contract some more and put the instrument back in. Often times what you are going to find is that there is still myoma sitting there. It allows us to get at the intramural portion. At the point where that stops happening, I call it a day. I think whatever little portions of myoma are left, what I have found in following these patients over a lot of years is that it infarcts; it is not going to become clinically relevant. But what we do is get out a lot more of the fibroid than what we think we would first be able to get out when we look in.
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There are now devices where we are able to coagulate fibroids and these are very useful. You still have to have a fragment so you can send it off for pathology, because we have seen leiomyosarcomas. You have to have continuous flow. I&O’s should be checked every 10 to 15 minutes. This is the one thing I care that my nurses do; I don’t need them to put together my instruments, put the tips on or plug anything in, but I need them to follow the I&O’s. This is the one thing that is somewhat difficult to do while we are doing the surgery. When I get in, I am looking at the entire cavity and trying to figure out if this is more than fifty percent intramural, in which case I may want to change how I am going to approach this fibroid. I need to see where it is sitting – is it sitting up by the ostia, an area that may be somewhat dangerous? I will use a cutting current, pure-cut current of 110; with the loop, it ought to cut through like butter. If it is not doing it, it may be a more calcified fibroid and you may need to go up. Just like a LEEP procedure, you want to put it on just before you contact it.
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The hardest cases are the ones that are near the ostia. A patient who has been put on a GnRH analog may have a thinned out uterine wall and it is relatively easy to get out and perforate into that area and get into trouble. Those arising from the fundus can be difficult; if you get a myoma that is coming from a fundus, it is very hard to make this motion that we like to make of bringing the instrument back towards us . If you are pulling that loop back towards yourself, it is almost impossible to perforate the uterus and cause a problem. But the ones in the fundus, you can’t do that well. In those kinds of cases, you have to use a back and forth and across type of motion. If you think that in those cases you need to drop a laparoscope in, then you drop a laparoscope in. If it is going to keep you safe and keep you from having a problem, use the laparoscope. Another problem is the sin of the stalk, where you are looking at a fibroid and there is a nice little stalk that is sitting up there, you’re thinking about it and the O.R. is urging you on to just cut it. But now what’s the problem? What is your ground? You just lost your ground. So now you have the slippery thing sitting there, floating around in the cavity and you can’t anchor it . If you are using unipolar cautery, your ground is sitting out here and you have no way to ground it and you are going to have trouble getting it out. I have heard of cases up to 6 to 8 cm of people transecting these stalks and then not knowing what to do. If you leave it in there, hoping it will slough out, you have a problem. Your stalk is your saving grace; it ought to be the last thing to go.