{"paper_id":"cceddb4c-3bb8-4346-ab5c-88b6b6b86574","body_text":"www.ogscience.org332\nCopyright © 2021 Korean Society of Obstetrics and Gynecology \nVideo Article\nObstet Gynecol Sci 2021;64(3):332-335\nhttps://doi.org/10.5468/ogs.21025\neISSN 2287-8580\nEfficient myometrial defect closure in a layer by \nlayer fashion after robot-assisted laparoscopic \nadenomyomectomy: a novel technique\nAyah Hijazi, MD\n*\n, Youn Jee Chung, MD\n*\n, Najeeba Al Sinan, MD, Kyungmin Park, MD, Minji Ko, MD,  \nJae Yen Song, MD, Mee-Ran Kim, MD, PhD \nDepartment of Obstetrics and Gynecology, Seoul St. Mary’s Fibroid Center, College of Medicine, The Catholic University of Korea, Seoul, Korea\nObjective\nIn this video, we present our novel technique for myometrial defect closure following robot-assisted laparoscopic \nadenomyomectomy.\nMethods\nA narrated video demonstration of our technique. Our patient was a 47-year-old single woman with severe \ndysmenorrhea, who did not respond to medical therapy and wished to preserve her uterus. Surgery was performed \nafter thorough counseling and obtaining informed consent from the patient (Institutional Review Board number: \nKC17OESI0238; approval date: March 19, 2018). After removal of the adenomyotic tissue during surgical intervention, \nthe myometrial defect was closed in three steps. First, the defect between the anterior and posterior innermost \nmyometrial layers was closed using a 2-0 Stratafix suture, CT-1 (circle taper) needle (Ethicon, Somerville, NJ, USA). \nNext, the two sides were approximated using a 2-0 PDS\n®\n (polydioxanone) Suture (Ethicon, Somerville, NJ, USA) and \nV-34 (TAPERCUT\n®\n) surgical needle (Ethicon, Somerville, NJ, USA). Finally, the serosa was sutured in a baseball fashion \nusing a 2-0 PDS suture, slim half-circle [SH] needle (Ethicon, Somerville, NJ, USA). \nResults\nThe patient had no postoperative complications, and her pain was greatly improved. The CA125 level decreased from \n434 U/mL to 45.99 U/mL, and the transvaginal ultrasound showed a reduction in posterior myometrial thickness from \n5.61 cm to 2.69 cm.\nConclusion\nThis technique maintained the integrity of the endometrial cavity, posterior myometrial thickness, and uterine layer \nalignment. We believe that it is a feasible technique and may be a solution for adenomyosis in patients seeking for \nfertility preservation.\nKeywords: Adenomyosis; Myometrium; Surgical procedures, Robotic\nReceived: 2021.01.10.   Revised: 2021.02.23.   Accepted: 2021.03.11.\nCorresponding author: Mee-Ran Kim, MD, PhD\nDepartment of Obstetrics and Gynecology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-\ndaero, Seocho-gu, Seoul 06591, Korea\nE-mail: mrkim@catholic.ac.kr\nhttps://orcid.org/0000-0003-4492-0768\n*These authors contributed equally to this work.\nMee-Ran Kim has been an Editorial Board of Obstetrics & Gynecology Science; however, she was not involved in the peer reviewer selection, evaluation, or decision process of this \narticle. Otherwise, no other potential conflicts of interest relevant to this article was reported. \nArticles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/\nlicenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.\n\n\nwww.ogscience.org 333\nAyah Hijazi, et al. Myometrial closure after adenomyomectomy\nAdenomyosis, affecting about 20% of reproductive aged \nwomen, is characterized by the presence of endometrial \nglands within the myometrium, which gets frequently sur -\nrounded by hyperplastic and hypertrophic smooth muscle \n[1]. Adenomyosis mostly involves heavy menstrual bleeding, \nfollowed by dysmenorrhea. Less common presentations in -\nclude dyspareunia and chronic pelvic pain [2]. In recent years, \nwomen are more likely to postpone pregnancy towards the \nend of their reproductive lives; thus, adenomyosis may in -\ncreasingly become a factor causing infertility, and its diagno-\nsis is an important part of the infertility workup [3]. \nAs more patients are requesting us for fertility preserving \nmanagement for adenomyosis, we have opted for methods \nthat not only would preserve the uterus but also allow a safe \npregnancy. Surgery for adenomyosis had started with the \nlaparotomic approach, followed by less invasive laparoscopy, \nwhich was hampered by the loss of tactile sensation, and \npoorer operative access [4]. Robotic surgery, on the other \nhand, still allows a minimally invasive procedure, while hav -\ning the benefit of open surgery with the EndoWrist technol -\nogy [5].\nThe defect created in the myometrium following adeno -\nmyomectomy can be quite large (Video 1), and maintaining \nthe uterine wall thickness can be a challenge. In our tech -\nnique, we aimed to maintain normal uterine muscle fiber \nalignment. This was done by enforcing each layer separately \n(Fig. 1); we also aimed to keep the endometrium intact, as \nwe believe that its injury might have an effect on future fer\n-\ntility.\nOur patient was a 47-year-old woman who was referred to \nour clinic with severe dysmenorrhea. She had tried medical \ntherapy before with not much improvement. After thorough \ncounseling, we decided to perform robot-assisted laparo\n-\nscopic adenomyomectomy. In this video, we detail our tech -\nnique for closure of the myometrial defect using the layer-\nby-layer technique. Maintaining endometrial integrity could \nFig. 1. Surgical procedure. The adenomyotic tissue was grasped using a tenaculum forceps, while dissection was continued using a mono-\npolar curved scissors or a monopolar spatula (A). The defect between the anterior and posterior innermost myometrial layers was closed \nusing a 2-0 stratafix suture, CT-1 needle (B). After the anteroposterior planes were sutured on either side of the incision, the two sides \nwere approximated using a 2-0 PDS suture, V-34 needle (C). Both sides of the serosa were brought together using a 2-0 PDS suture, slim \nhalf needle in a baseball fashion (D).\nA\nC\nB\nD\n\nwww.ogscience.org334\nVol. 64, No. 3, 2021\nbe achieved by careful preoperative planning with the aid of \npelvic MRI (Fig. 2) and the assistance of intraoperative ultra -\nsound. \nThe duration of the surgery was approximately 5 hours and \n30 minutes, and the estimated blood loss was 500 milliliters. \nShe was discharged on the 3rd postoperative day for social \nreasons. On follow-up, we found that our patient had mini\n-\nmal dysmenorrhea and was very satisfied. Further, an ultra -\nsound scan, repeated post-surgery, showed a great reduction \nin the posterior myometrial wall thickness (Fig. 3).\nAcknowledgments\nThis video has not been published elsewhere, it is not ac -\ncepted for publication and is not under review for possible \npublication at any other journal. We presented our video as \nan oral session in the 48th AAGL Global Congress on MIGS \non November 12, 2019.\nConflict of interest\nNo potential conflict of interest relevant to this article was \nreported.\nEthical approval\nThis study does not require approval of the Institutional \nReview Board because no patient data is contained in this \narticle. The study was performed in accordance with the \nFig. 3. Transvaginal ultrasound. Follow up transvaginal ultrasound (B) done 2 months postoperatively showed a posterior myometrial \nthickness of 2.69 cm compared to the previous measurement of 5.61 cm in the preoperative ultrasound (A).\nA B\nFig. 2. Pelvic magnetic resonance imaging (MRI). (A) Sagittal and (B) axial pelvic MRI showed adenomyosis involving the posterior uterine \nwall.\nBA\n\nwww.ogscience.org 335\nAyah Hijazi, et al. Myometrial closure after adenomyomectomy\nprinciples of the Declaration of Helsinki.\nPatient consent\nWritten informed consent was obtained from the patient for \npublication of this case report and any accompanying images.\nFunding information\nThis research was supported by Basic Science Research \nProgram through the National Research Foundation of Ko\n-\nrea (NRF) funded by the Ministry of Education (2017R1D -\n1A1B03028045, 2020R1F1A1063199).\nVideo clip\nVideo can be found with this article online at https://doi.\norg/10.5468/ogs.21025.\nReferences\n  1. Donnez J, Donnez O, Dolmans MM. Introduction: uter -\nine adenomyosis, another enigmatic disease of our time. \nFertil Steril 2018;109:369-70.\n  2. Struble J, Reid S, Bedaiwy MA. Adenomyosis: a clinical \nreview of a challenging gynecologic condition. J Minim \nInvasive Gynecol 2016;23:164-85.\n  3. Leyendecker G, Kunz G, Kissler S, Wildt L. Adenomyosis \nand reproduction. Best Pract Res Clin Obstet Gynaecol \n2006;20:523-46.\n  4. Thain S, Tan HH. Approaches to adenomyomectomy. \nGynecol Minim Invasive Ther 2015;4:49-54.\n  5. Sinha R, Sanjay M, Rupa B, Kumari S. Robotic surgery in \ngynecology. J Minim Access Surg 2015;11:50-9.","source_license":"CC0","license_restricted":false}