Objective: To assess the safety of laparoscopic myomectomy and consider the underlying reason for the most serious complication; that of uterine rupture.
Design: 2 case studies with review of the recent literature.
Setting: Two Australian private facilities under a single medical directorship providing comprehensive services in gynaecology, andrology and reproductive endocrinology for infertility management including in vitro fertilization (IVF). Experience with advanced laparoscopic surgery over 35 years including myomectomy over 27 years.
Patients: Two women aged 37 years and 40 years respectively, who suffered uterine rupture post laparoscopic surgery to resect adenomyosis nodules, undertaken in order to improve their prognosis for IVF. Each woman now has a healthy child but one woman suffered an explosive uterine rupture which required emergency management at several levels. Both have been advised against further pregnancies.
Intervention: Applying the same laparoscopic techniques that work so well for myomata, namely using intramural pitressin to minimise bleeding and a 2-layered suturing method to close the myometrial defect, nodules of focal adenomyosis were resected.
Main outcome measures: Haemorrhage requiring blood transfusion and uterine rupture in ensuing pregnancy.
Results: Whilst no surgical complications occurred in 1600 cases of laparoscopic myomectomy, 2 cases of excess bleeding and 2 cases of uterine rupture in the ensuing pregnancy occurred in 200 case of adenomyosis resection.
Conclusion: Advanced diagnostic tests should be applied to differentiate those cases which have underlying adenomyosis and hormonal therapy may be preferred over surgical approaches for this enigmatic condition.