Cold Scissors and Small Myotomy: A Laparoscopic Intracapsular Myomectomy Method for Women in Reproductive Age

Uterine myomas, or fibroids, are the most common benign tumors affecting 20%–40% of women of reproductive age and up to 75% of all premenopausal women.[ 1 ] Despite various conservative treatments, such as uterine artery embolization and suppressive medication, myomectomy remains the gold standard surgical procedure for managing fibroids.[ 2 ] In recent years, the endoscopic approach has increasingly prevailed over laparotomy overall in gynecological surgery.[ 3 4 5 6 ] Myomectomy constitutes a surgical intervention essential for maintaining the functional integrity of the uterus in females presenting with symptomatic fibroids or as a conventional fertility-preserving procedure to be conducted in select women desiring conception in the presence of fibroids.[ 7 8 ] A relatively new laparoscopic technique, known as laparoscopic intracapsular myomectomy (LIM), has further refined the procedure by focusing on sparing the myoma’s pseudocapsule.[ 9 ] The fibroid pseudocapsule, an anatomical neuro-fibrovascular structure surrounding the leiomyoma, maintains continuity with the myometrium and separates it from the myoma. This structure, which expresses various neurotransmitters and neuropeptides, positively influences myometrial healing and exhibits angiogenic activity. Preserving the pseudocapsule during fibroid removal is crucial for promoting faster and more effective uterine healing. The LIM procedure is hypothesized to reduce blood loss, postsurgical adhesions, wound healing time, and the risk of uterine rupture in subsequent pregnancies.[ 9 ] Current research highlights that the length and depth of the surgical incision, along with thermal damage from bipolar coagulation, contribute to tissue hypoxia, ischemia, adhesion formation, and imperfect healing.[ 10 11 ] The “cold scissors” technique in hysteroscopic intracapsular myomectomy has demonstrated that minimizing incision length and thermal damage while preserving the myometrium’s anatomical and physiological integrity can lead to reduced surgical trauma, fewer intrauterine adhesions, and improved healing.[ 12 ] This study introduces a novel approach by applying the “cold scissors” technique, previously successful in hysteroscopic procedures, to laparoscopic surgery. Unlike other laparoscopic myomectomy techniques that may involve more extensive incisions and thermal damage, this method focuses on preserving the pseudocapsule while minimizing myometrial trauma. By reducing incision size and thermal exposure, this study aims to demonstrate improved myometrial healing, fewer adhesions, and lower risks of complications such as uterine rupture in subsequent pregnancies. This approach addresses an important gap in the current literature and has the potential to enhance clinical outcomes and patient care in LIM.

Out of 139 initially eligible women, 112 underwent surgery. Each patient had an average of 2.7 fibroids, with a mean diameter of 7.3 cm. The mean initial uterine incision was 3.6 ± 0.4 cm, reducing to 2.5 ± 0.3 cm ( P < 0.001). Operative time averaged 65 ± 23.4 min, with blood loss at 115 ± 35.6 mL and a Hb drop of 1.2 ± 0.7 g/dL. There were no urologic, intestinal, or vascular injuries, nor postoperative anemia, ileus, or fever. Bowel peristalsis occurred within 6.1 ± 1.8 h, and hospitalization lasted 7.2 ± 2.6 h. Full recovery was achieved in 1.8 ± 0.2 days, and myometrial healing was observed within 30-50 days. Reproductive outcomes included 45 pregnancies, with five miscarriages; 24 cesarean sections and 16 vaginal births were reported, with no uterine ruptures or intraoperative adhesions noted. Detailed epidemiological characteristics are outlined in Table 1 . The surgical outcomes demonstrated significant improvements. The mean initial uterine incision size was 3.6 ± 0.6 cm, and this was reduced to 2.5 ± 0.4 cm by the procedure’s conclusion, suggesting the myometrium’s contractile ability to minimize incision size postenucleation. The average operative time was 65 ± 23.4 min, and blood loss during surgery was 115 ± 22.3 mL, indicating controlled hemostasis throughout the procedure. Importantly, there were no reported cases of postoperative anemia, ileus, or fever, highlighting the procedure’s safety. The mean hospital stay was 7.2 ± 2.6 h, with full recovery within 1.8 ± 0.2 days, and complete myometrial healing observed within 30–50 days, as confirmed by postoperative follow-up. Concerning reproductive outcomes, 45 spontaneous pregnancies occurred between 4- and 38-month postsurgery. Out of these, five resulted in miscarriage, and among the successful deliveries, 24 were by cesarean section and 16 via vaginal birth. No cases of uterine rupture were documented, nor were any intraoperative adhesions observed during subsequent cesarean deliveries, emphasizing the technique’s contribution to excellent reproductive outcomes. Concerning the primary and secondary outcomes, these are presented in Table 2 . Epidemiological characteristics of the operated patients SD: Standard deviation Primary and secondary surgical outcomes of the operated patients SD: Standard deviation, Hb: Hemoglobin

The LIM using cold scissors and a small myotomy is a promising minimally invasive technique that significantly reduces surgical impact on the uterine muscle. Our study highlights that this approach not only can reduce blood loss and myometrial damages but can also prevent intrauterine adhesions, enhancing myometrial healing and postoperative recovery. The favorable outcomes observed suggested that LIM by cold scissors and a small myotomy can be a safe and feasible option for women of reproductive age to submit to myomectomy. However, to confirm these findings and refine the technique, larger sample sizes and extended follow-up periods are necessary. Conceptualization, E.M-C.P. and Y.P.; Software, E.M.-C.P.; Validation, A.T.; Formal analysis, G.P. and A.M.; Investigation, P.X. and N.P.; Resources, A.M.; Data curation, P.X. and A.M.; Writing – original draft, E.M.-C.P.; Writing – review and editing, A.T.; Visualization, G.P.; Supervision, N.P.; Project administration, Y.P. All authors have read and agreed to the published version of the manuscript. The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request. There are no conflicts of interest.

This prospective cohort study, with follow-up of up to 5 years, demonstrates that the “cold scissors” LIM was a safe and feasible surgical approach. It leads to rapid postsurgical recovery and effective myometrial healing, with favorable intraoperative and postoperative outcomes. The technique’s smaller myotomy, which preserves the pseudocapsule, results in reduced blood loss and minimizes dead space, eliminating the need for double-layer suturing. This contrasts with other laparoscopic myomectomy variations that may involve full-thickness removal of the myometrial wall, including the serous layer and pseudocapsule, using power instruments or techniques that extend the surgical wound to match the fibroid’s diameter.[ 20 ] One-layer sutures following myomectomy are not presented as “new discoveries” in this publication; rather, they are a well-established and reliable technique for myomas up to 14 cm in diameter.[ 21 ] Hence, due to the reasons mentioned, the “cold scissors” LIM may reduce the risk of hematoma formation and potential uterine rupture in subsequent pregnancies.[ 22 ] Contrast-enhanced MRI has demonstrated that while myometrium sutured in double layers after myomectomy exhibits improved vascularization at 6 months compared to 3 months, large avascular areas suggestive of fibrosing tissue are still present. These areas may contribute to a decline in the contractile function and tensile strength of the myometrial muscles.[ 10 ] During a cold scissors LIM, with limited and selective coagulation of the arteries on the myoma surface, the surgeon carefully enucleates the fibroids while preserving the pseudocapsule. This technique aims to leave a surgical bed with normal, healthy uterine tissue covered by the preserved pseudocapsule, resulting in minimal damage to the surrounding myometrium and reduced bleeding. Although the procedure may dislocate the myometrium, this displacement is not detrimental, as the integrity and contractility of the uterine structure are preserved.[ 23 ] Consequently, the risk of hematoma is minimized, as the myometrium is preserved and gradually returns to its original length without leaving any dead space, as in hysteroscopic intracapsular myomectomy.[ 17 ] Moreover, the cold scissors technique facilitates the progressive movement of the fibroid during surgery, from the inner myometrium to the surface area. This is achieved through the blunt dissection of the fibroconnective bridges that anchor the myoma to the pseudocapsule. This process explains how an intramural fibroid (FIGO classification types 4 or 5) can ultimately be reclassified to FIGO types 6 or 7 fibroids. Additionally, a specific variant of the fibro neurovascular bundle [ Figure 3 ] plays a crucial role in preserving the integrity of the uterine cavity during LIM and significantly reduces the risk of intraoperative complications. In intramural myomectomies, double-layer suturing has traditionally been justified by the increased risk of intramyometrial hematoma formation, which could have adverse effects in subsequent pregnancies. However, based on transvaginal ultrasound evaluations conducted at the end of the surgeries, the authors reported that the pseudocapsule, identifiable on ultrasound as hyperechoic tissue, filled the presumed dead space created by the intracapsular myomectomy.[ 21 ] Moreover, it has been demonstrated that the pseudocapsule exhibits increased expression of endoglin, which is associated with heightened angiogenic activity.[ 23 ] Thus, for the healing process to proceed swiftly and with minimal fibrosis, it is crucial that the pseudocapsule’ fibro neurovascular network surrounding the fibroids remains intact. A significant advantage of our approach is the use of a one-layer suture following myoma enucleation, which can measure up to 10 cm. Despite potential concerns about this suture length, the minimally invasive nature of the suturing procedure is facilitated by the small longitudinal incisions described in the manuscript and the preservation of the pseudocapsule. The pseudocapsule helps fill the empty space and compress any residual bleeding arteries. By reducing the extent of suturing, the risk of complications – such as suture rejection reactions and elevated rates of necrosis in myometrial tissues – can be minimized, as highlighted in the literature.[ 24 25 ] Using the irrigation cannula or Manhès clamps to apply pressure and observe the tissue’s response was the sole method for intraoperatively identifying the hyperechogenic material seen sonographically during the intraoperative scan. The hyperechogenic tissue would contract under pressure and expand again when pressure was released, indicating it was the pseudocapsule rather than residual hematomas, which typically present with fibrin streaks and a hypoechogenic appearance. This tissue would heal 45 days after surgery, restoring the myometrial wall to its original state and removing any fibrotic alterations [ Figure 4 ]. The length of the incision in myomectomies has long been regarded as a risk factor for the formation of fibrous tissue and adhesions, which can, in turn, pose potential risks for complications in future pregnancies.[ 26 ] In the current investigation, the contractility, extensibility, and flexibility of the muscle were leveraged to minimize the initial incision during intracapsular myomectomy, to less than half of the myoma’s diameter. In addition, the authors observed that by the end of the procedure, the incision length was gradually reduced by 28%–29% compared to its original size, owing to the myometrium’s natural contractility,[ 21 ] also observed by us in the present study. Thus, employing cold scissors for LIM may reduce the likelihood of the aforementioned side effects. Traditional myomectomy has been linked with postoperative development of intrauterine adhesions due to the opening of the uterine cavity and the laparotomy approach.[ 27 28 ] Although laparoscopic myomectomy is considered a minimally invasive surgery, it is not adhesion free.[ 29 ] Indeed, the underlying mechanisms of adhesion formation are still largely unknown, with implicated multiple risk factors.[ 30 ] All cases underwent a second-look diagnostic hysteroscopy in an office setting 3 months postoperatively, with no intrauterine adhesions detected. Preoperative drugs were not used, as they could impact both the fibroid and the myometrium, including the pseudocapsule, and thereby increasing the difficulty of dissecting the myoma from the surrounding myometrium.[ 31 ] The innovative aspect of the proposed surgical technique pertains to the specific type of suture employed, which is markedly less complex and more minimally invasive. Historical literature has extensively discussed the practice of suturing the myometrium in multiple layers, primarily due to concerns regarding the stabilization of the muscular tissue during the labor process, as well as to mitigate the risk of hematomas within the muscular fovea of the myoma. Our study aligns with existing literature by confirming that preserving the pseudocapsule leads to favorable outcomes, as the reduction of postoperative adhesions and promoting a better myometrial healing.[ 32 ] However, our study diverges by demonstrating that a single-layer suture, even for fibroids up to 10 cm, is effective and safe – contrasting with traditional practices that typically use double-layer suturing to prevent hematoma and enhance healing. This prospective observational study suggests that our approach can be safe and effective for patients seeking to become pregnant, yielding favorable reproductive outcomes. Strengths of the study refer to the discrete number of patients, with the same characteristics and all operated with the same technique. Furthermore, the applied method was tested for the first time by the authors, one of whom has already scientifically standardized intracapsular myomectomy in literature. However, the study has notable limitations. It lacks a control group, as the technique was developed based on a series of patients treated by expert surgeons with over 20 years of experience in laparoscopic myomectomy. In addition, there may be selection bias, as the study excluded women with fibroids larger than 10 cm and/or more than five fibroids. To address these limitations, the authors plan to conduct further surgical trials. These will compare outcomes between the traditional technique with a wider incision and our minimal incision approach. In addition, the trials will assess tissue damage and healing delays between the use of power instruments and cold scissors through ultrasound examinations at days 0, 30, 45, and 60. Laparoscopic image of a fibroid undergoing enucleation from the uterus: The final cut of the “neurovascular bundle” by cold scissor technique during intracapsular myomectomy Transvaginal ultrasound examination of the uterus at after 50 days from myomectomy. The pseudocapsule is completely reabsorbed in the myometrium, without evidence of fibrous tissue or hematoma at the site of incision and removal of the fibroid

This prospective observational cohort study was approved by the Institutional Review Board of YAKENTRO Medical Center in Greece (approval code: 58/2017, approved on 10/1/2017), in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975. Patients with uterine fibroids who were referred to the center for LIM between May 2017 and June 2022 were eligible to participate. They were informed about the study protocol and the potential need for conversion to abdominal myomectomy if necessary.[ 13 ] Written informed consent was obtained from each patient before participation. The including criteria are: age (18–45 years), intramural fibroids classified as FIGO types 4–6, measuring between 4 and 10 cm in diameter. None of these patients had received preoperative treatment with gonadotropin-releasing hormone (GnRH) analogs or other medications. Patients were excluded if they had pedunculated myomas, more than five fibroids, or any uncertain pathology of the genital tract, such as adenomyosis, adenomyoma, adnexal masses, or endometrial hyperplasia. In addition, any patient who declined to sign the informed consent was excluded. Preoperative assessments included transvaginal ultrasound and pelvic magnetic resonance imaging (MRI) to map the fibroids (number, diameter, and location). LDH isoenzymes and CA125 levels were measured to exclude the possibility of leiomyosarcoma. All surgical procedures were conducted between days 7 and 17 of the menstrual cycle by the same team of physicians (Y. P., P. X., E. M.-C. P.), with Y. P. as the primary operator to minimize potential intervention bias. No preoperative treatment with GnRH analogs or other drugs was administered. At the end of each procedure, the surgeons counted the resected fibroids and compared this number to the preoperative ultrasound [ Figure 1 ] and MRI findings. The morcellation technique was employed in accordance with the guidelines provided by the European Society of Gynecological Endoscopy.[ 14 ] All women received multimodal perioperative analgesia, which included both local and systemic pharmaceutical agents in addition to the standard anesthesia protocol.[ 15 ] Laparoscopic access was achieved using a 10-mm port through the umbilicus or, in cases of bulky fundal fibroids, a higher insertion point. In addition, two lateral 5-mm ports and one 10-mm port were placed in the suprapubic area, adjusted based on the height of the uterine fundus. None of the conventional hemostatic strategies (vasopressin, aqua dissection, etc.,) were employed, as the innovative nature of our methodology has underscored the complete ineffectiveness of all traditionally utilized hemostatic interventions during myomectomy procedures. The approach was predicated on an understanding of uterine biology and on the adherence to biological constructs, such as the pseudocapsule of the myoma, which serves as an anatomical entity integral to uterine vascularization. After visualizing the entire peritoneal cavity, the fibroids were identified. A bipolar diathermic coagulation was used to unveil the fibroids’ surface through a 1–2 cm transverse or oblique incision in the overlying myometrium, creating a window [ Figure 2 ] to access and open the pseudocapsule and reach the clear surface of the myoma. The authors do not claim that a myomectomy can be performed on a 10 cm fibroid through a 1–2 cm incision. This incision is specifically used to create the myometrial window and achieve the necessary depth for intracapsular myomectomy. While a larger incision might facilitate fibroid enucleation, it would contradict the technique’s core principle of minimizing tissue trauma. The incision was expanded only minimally, leveraging the myometrium’s inherent elasticity. Effective hemostasis was crucial for reaching the required depth during intracapsular myomectomy. Focal diathermic coagulation was the preferred method at the surgical center for preventing significant hemorrhage.[ 15 16 ] A strong grasper was inserted through the myometrial window, to provide steady traction on the fibroid, while the pseudocapsule was gradually opened and dissected using cold scissors, cutting and pushing down on the myoma’s surface. Targeted hemostasis, if required, was selectively achieved using a low-energy bipolar clamp, set to no more than 35 watts. Manhès or Collins forceps, along with cold scissors, were employed to create the intracapsular cleavage plane between the myoma and the pseudocapsule through traction and counter-traction. The myometrial incision was gradually extended with cold scissors as needed, depending on the diameter of the myoma. Subsequently, less than half of the fibroid would be freed from its pseudocapsule, following the principles outlined in hysteroscopic intracapsular myomectomy.[ 17 ] The remaining fibroid was then removed through straightforward traction and dissection, ensuring that the pseudocapsule remained intact and minimizing myometrial trauma and blood loss. Myometrial suturing was performed using a single layer of continuous sutures (Vicryl 1-0, Ethicon ® ). Barbed sutures were intentionally avoided to prevent introducing confounding factors, and traditional sutures were used instead.[ 18 ] Since the pseudocapsule was left in place, the resulting dead space was minimal, eliminating the need for a second layer of sutures. Fibroids were extracted using an electrosurgical morcellator through the suprapubic 10 mm port. All morcellations were performed within an endobag to prevent the peritoneal spread of potential malignant cells. No drain was placed in the abdominal cavity to avoid additional postoperative disturbance. To ensure complete hemostasis and rule out hematoma formation, the trocars were left in situ for an additional 15 min following the procedure. Intraoperatively, the length of the longest sutured wound on the uterine surface was measured using a laparoscopic ruler, graded in centimeters. A vaginal ultrasound was performed before leaving the operating room to check for any possible hematoma, and the Foley catheter was removed. Postoperative care included evaluating hemoglobin (Hb) levels with a blood sample taken 6 h postoperatively. Antithrombotic therapy with enoxaparin in prophylactic doses was standardly initiated 12 h postoperatively to reduce the risk of postoperative thromboembolic events.[ 19 ] All patients were ambulated 6 h after surgery, once they had urinated and bowel peristalsis had resumed. Postoperatively, patients were monitored every 30 days for 3 months via ultrasound, to assess myometrial healing. A diagnostic office hysteroscopy was performed 3 months postsurgery to check for intrauterine adhesions. Patients were advised to avoid pregnancy for at least 3 months following the operation. Primary surgical outcomes were defined as the uterine incision size (initial, final, and percentage difference) and the time required for postoperative healing. Completed healing was defined as the time until the uterine incision showed no significant abnormalities on follow-up, with the pseudocapsule reabsorbed and the myometrial wall appearing normal. The mean value of 45 days was derived from monthly follow-up assessments, capturing the average healing time across all patients. Secondary outcomes included operative time, intraoperative injuries (urologic, intestinal, and vascular), blood loss, pain scores at 2 h and 6 h postoperatively, postoperative time to bowel peristalsis (monitored through 6-h postsurgery auscultation and daily while hospitalized), fever, ileus, length of hospitalization, time to full recuperative activity, and readmission for surgery within 30 days. In addition, obstetrical outcomes of pregnancies occurring during the follow-up period were included in the analysis. Fibroid ultrasonography before the operation; the white arrows indicate the pseudocapsule (evident in white outside the fibroid) and the white line indicates the diameter of the fibroid The initial incision, or “myometrial window,” for fibroid enucleation during laparoscopic myomectomy involves the following steps: After incising the uterine serosa, the surgeon advances through the myometrium until reaching the surface of the fibroid. This is achieved by incising the pseudocapsule using cold-blade scissors. This approach allows direct access to the fibroid, which is then hooked and removed intact within the pseudocapsule using the intracapsular technique Descriptive statistics were used to summarize both primary and secondary outcomes of the LIMs’ procedure. Continuous variables, including initial and final uterine incision sizes, operative time, estimated blood loss, and healing time, were reported as means with standard deviations. Categorical outcomes were expressed as frequencies and percentages. A paired t -test was conducted to compare the initial uterine incision size (3.6 ± 0.4 cm) with the final incision size (2.5 ± 0.3 cm). This analysis revealed a statistically significant reduction in incision size ( P < 0.001), indicating effective myometrial contraction and healing. The mean operative time was 65 ± 23.4 min, with an estimated blood loss of 115 ± 35.6 mL. Hb levels decreased by 1.2 ± 0.7 g/dL postoperatively, which was also analyzed using paired t -tests, showing no significant correlation with increased blood loss ( P = 0.32). Time to bowel peristalsis averaged 6.1 ± 1.8 h, and the mean length of hospitalization was 7.2 ± 2.6 h. Time to full recuperative activity was 1.8 ± 0.2 days. Postoperative complications, including anemia, ileus, and fever, were absent in the cohort. Reproductive outcomes were assessed with chi-square tests. Out of 45 pregnancies occurring between 4- and 38-month postsurgery, there were five miscarriages, and 24 deliveries were via cesarean section while 16 were vaginal births. No cases of uterine rupture or intraoperative adhesions were reported.