25

Myomectomy and Adhesion Formation

Susie Lau and Togas Tulandi

CONTENTS
Incidence of Postmyomectomy Adhesions ......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Factors Involved in Postmyomectomy Adhesion Formation .................................. 289
Mechanism of Adhesion Formation Mter Myomectomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290
Technique to Prevent Adhesion Formation ............................................... 291
Agents Used to Prevent Postmyomectomy Adhesion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
Pharmacologic Adjuvants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291
PeritonealInstillates ............................................................... 291
Adhesion Barriers ................................................................. 292
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Leiomyoma is the most common benign tumor occur-
ring in the uterus and female pelvis. It is estimated that
25% of women over the age of 35 years have leio-
myoma. 1 Symptomatic leiomyoma embellishes the spec-
trum of pelvic pain, pressure, and bleeding, as well as
unexplained infertility or recurrent pregnancy losses. As
women continue to delay their childbearing until the
third and fourth decades oflife, symptomatic leiomyoma
will be encountered more frequently. Myomectomy is ad-
vocated for the treatment of symptomatic leiomyoma in
women wishing to preserve their reproductive potential.
Incidence of
Postmyomectomy Adhesions
Myomectomy can be accomplished via laparoscopy or
laparotomy or via a combination of the two techniques
known as laparoscopically assisted myomectomy.2.3 U n-
fortunately, all these techniques cause adhesion forma-
tion. The best method to evaluate adhesion formation
and reformation is by a second-look laparoscopy. It is in-
appropriate and biased to evaluate adhesion formation
during a cesarian section. It is obvious that those who
did conceive and subsequently required a cesarian sec-
tion have a lesser degree of adnexal adhesions than
those who did not.
Using a second-look laparoscopy as a tool, Tulandi et
al. 4 found adnexal adhesions in 93.7% of women after
an abdominal myomectomy with a posterior uterine inci-
sion and in 55.5% of women after myomectomy with an-
terior or fundal uterine incisions (Fig. 25.1). Ugur et aU
found that, following an abdominal myomectomy, 83.3%
of patients had adhesions between the uterus and omen-
tum or intestines. In their study, adnexal adhesions
occurred with a frequency of 64.6% after myomectomy.
Adhesion formation after laparoscopic myomectomy ap-
pears to be less than after myomectomy by laparot-
omy.7,11-16 The incidence of adhesions is approximately
48% after laparoscopic myomectomy (Table 25.1) and
70% after myomectomy by laparotomy (Table 25.2). Ad-
hesion after laparotomy is often found between the in-
testines and the site of previous abdominal incision (Fig.
25.2).
Factors Involved in
Postmyomectomy Adhesion
Formation
Nothing replaces good surgical technique. However, be-
sides operative technique, other factors influence the oc-
currence of adhesion after myomectomy. Suturing of the

G. S. diZerega et al. (eds.), Peritoneal Surgery 289

© Springer Science+Business Media New York 2000
290 Susie Lau and Togas Tulandi

FIG. 25.1. Adhesions from the anterior uterine wall 1 year after FIG. 25.2. Intestinal adhesions to the previous abdominal inci-
a laparoscopic myomectomy (filmy adhesions, small arrow; sion after myomectomy by laparotomy. Pl£ase see insert for color
dense adhesions, large arrow). Please see insert for color reproduc- reproduction of this figure.
tion of this figure.

uterine inclSlon produces good approximation of the Mechanism of Adhesion

uterine defect and promotes better healing, but the pres-
ence of suture material may produce more adhesion for-
mation. 6 It seems that the presence of adhesions at the
initial myomectomy is correlated with an increased adhe-
sion formation at second-look laparoscopy.7 Posterior
uterine incision is also associated with more and a higher
degree of adnexal adhesions than that with fundal or an-
terior uterine incisions. 4 In addition, a transverse uterine
incision and treatment with LHRH-a (luteinizing hor-
mone releasing hormone agonist) may promote more ad-
hesions.l 2
Formation Mter Myomectomy
Perhaps no other gynecologic surgery causes more adhe-
sion formation than a myomectomy. This occurs for sev-
eral reasons: the uterine defect is relatively large and the
incision could be multiple, and hemostasis at the my-
omectomy incision is rarely absolute and this predis-
poses to adhesion formation. Blood itself does not cause
adhesion, but a combination between blood and raw
peritoneal surfaces predisposes adhesion formation. Be-

TABLE 25.1. Adhesion formation following laparoscopic myomectomy.

Total number Incidence of adhesions at
Reference of patients Myoma size (em) second-look laparoscopy
Nezhat et aI. (1991)6 154 3-15 30/56 sites (54%)
Hasson et al. (1992) 7 56 3-16 16/24 patients (67%)
Dubuisson et aI. (1991)8 43 1-11 1/6 patients (17%)
Daniell and Gurley (1991)9 17 3-7 1/1 patient (100%)
Dubuisson et al. (1994) 10 102 NA 2/17 patients (11.8%)
Bulletti et al. (1996) 11 16 4.2-10.9 4/14 patient. (29%)
Stringer et al. (1997) 12 50 4-11 7/12 patients (58%)

TABLE 25.2. Adhesion formation following abdominal myomectomy.

Total number
Reference
Berkeley et al. (1983) 13
Starks (1988) 14
Fayez and Dempsey (1993)15
Gehlbach et al. (1993) 16
Tulandi et aI. (1993) 4
Bulletti et aI. (1996) 11
Incidence of adhesions at a second-look
of patients Myoma or uterine size procedure or at subsequent operation
50 283 g (average) 4/4 patients at laparoscopy (100%)
32 4-18 em 10/10 patients at cesarean and 10/10 patients
at laparoscopy (100%)
148 10-16 weeks or more sized uterus 3/32 patients at laparoscopy (9%)
37 8.2 :!: 0.9 em (pregnant) and 13/19 patients at laparoscopy (68%)
7.8 :!: 0.6 em (nonpregnant)
25 18.2 :!: 0.6 weeks sized uterus 20/25 patients at laparoscopy (80%)
388.1 :!: 71.1 g, myoma weight
16 5.1-10.6 em 9/14 patients atiaparoscopy (64%)