Suprapubic laparoscopic-assisted myomectomy

Uterine myomas are the most prevalent benign gynecological neoplasms in women of reproductive age, affecting approximately 70% to 80% of the population. Clinical manifestations vary widely, ranging from abnormal uterine bleeding and symptomatic anemia to pelvic pain and pressure-induced symptoms such as urinary frequency and constipation. Myomas are significantly associated with infertility and adverse obstetric outcomes, including malpresentation and placental complications. Approximately 25% of patients experience symptoms that are severe enough to require surgical intervention. 1 For women desiring fertility or uterine preservation, myomectomy remains the gold standard. 2 , 3 Current clinical guidelines, including a recent Cochrane review, advocate minimally invasive myomectomy because of its association with reduced postoperative pain, shorter hospital stays, and faster recovery than open laparotomy. 4 However, conventional laparoscopic myomectomy (LM) presents technical challenges. First, robust multi-layer closure of the myometrium, which is critical for preventing uterine rupture in subsequent pregnancies, requires advanced intracorporeal suturing skills that entail a steep learning curve. Second, the use of power morcellation for specimen retrieval has received increasing attention because of the risk of disseminating occult malignancies. 5 To address these challenges, various “hybrid” techniques have been explored to bridge the gap between pure laparoscopy and mini-laparotomy. In this study, we introduced a modified minimally invasive approach, termed suprapubic laparoscopic-assisted myomectomy (SLAM). This technique uses a 2 to 3 cm transverse suprapubic incision to facilitate manual extracorporeal suturing and direct specimen extraction, thereby providing tactile feedback and ensuring surgical safety without the need for power morcellation. Despite the emergence of several hybrid methods, a clear clinical consensus regarding the most effective approach remains elusive. This retrospective cohort study aimed to evaluate the clinical significance and surgical outcomes of SLAM by comparing it with conventional LM. We sought to determine whether SLAM is a safe, feasible, and sustainable alternative for managing symptomatic uterine myomas.

This retrospective cohort study was conducted at Cathay General Hospital, Taipei, Taiwan, and was approved by the Institutional Review Board (IRB No. CGH-P113010). We identified 36 patients who underwent myomectomies for symptomatic myomas between October 2019 and June 2020. Patients were allocated into two groups according to patient preference following shared decision-making (SDM): Group SLAM (n = 16) underwent SLAM, and group LM (n = 20) received conventional LM. The surgical indications included symptomatic myomas associated with pelvic pain, bulk symptoms (mass effects), abnormal uterine bleeding, and infertility in patients who desired uterine preservation. Baseline preoperative data, including age, body mass index (BMI), and myoma characteristics (size, number, and type), were recorded. To ensure surgical safety during the introductory phase of this novel technique, patients with BMI >30 kg/m 2 or a dominant uterine mass >10 cm were excluded from this pilot cohort. To ensure technical consistency, all procedures were performed under general anesthesia by a single senior surgeon with more than 20 years of experience in advanced gynecological laparoscopy. The patients were placed in the dorsal lithotomy position with a Foley catheter and a routine uterine manipulator. After establishing pneumoperitoneum, diluted vasopressin (20 units in 100 mL of normal saline) was routinely injected into the myometrium to minimize intraoperative blood loss. Enucleation was performed using monopolar scissors, and bipolar forceps were used for hemostasis. In both groups, uterine defects were closed using absorbable self-retaining barbed sutures (V-Loc; Covidien Medtronic, Minneapolis, MN). A 2 to 3 cm transverse suprapubic incision was made to accommodate a laparoscopic access system (LAGIS LAGIPORT ® Single Port Solution) (Fig. 1 ). The surgeon stood on the left side of the patient during the laparoscopic and repair phases. The myomas were manually extracted through a suprapubic incision. Large specimens were debulked through the incision site under direct visualization (manual cold cutting). Suturing was performed through a suprapubic incision under direct visualization, providing tactile feedback similar to that in a traditional laparotomy (Fig. 2 ). The final wound is shown in Fig. 3 . A 1.1 cm umbilical incision was made for the laparoscope (10 mm). A transverse 2-3 cm suprapubic incision was made for a laparoscope cap system (LAGIS LAGIPORT ® Single Port Solution, TRL0210R), which allowed the insertion of laparoscopic instruments. The excised myomas were extracted through the suprapubic incision with or without manual morcellation. The skin incisions at the end of the surgery. The suprapubic wound was about 3 cm. An ipsilateral four-port configuration was used. Uterine defects were closed using intracorporeal sutures. Specimen retrieval was performed using power morcellation (WOLF) through an ipsilateral trocar site. Continuous variables were analyzed using Student’s t test and are presented as mean ± SD along with 95% CI. Categorical variables were evaluated using the chi-square test or Fisher’s exact test (for cells with expected counts <5) and reported as percentages (counts). Statistical significance was set at p < 0.05. All analyses were performed using IBM SPSS Statistics for Windows (version 27.0; IBM Corp., Armonk, NY).

A total of 36 patients were enrolled in the study. Sixteen patients underwent SLAM, and 20 underwent LM between October 2019 and June 2020. There were no significant differences between the two groups in baseline characteristics, including age, BMI, number of myomas, preoperative hemoglobin levels, and size or type of the dominant mass (Table 1 ). Baseline characteristics between patients who received SLAM or LM BMI = body mass index; LM = conventional laparoscopic myomectomy; SLAM = suprapubic laparoscopic-assisted myomectomy. A comparison of the surgical outcomes revealed no significant differences between the two groups. The average hospitalization duration was 4.19 ± 0.40 days for SLAM and 4.15 ± 0.49 days for LM ( p = 0.807). Operative time was slightly shorter in the SLAM group (186 ± 59.3 minutes) compared with the LM group (213.8 ± 48.8 minutes), though the difference was not statistically significant ( p = 0.133). Although blood loss was lower in the SLAM group (140.6 ± 148.3 mL vs 197.5 ± 223.1 mL; p = 0.387), the difference did not reach statistical significance. Hemoglobin decrease was also comparable (1.14 ± 1.63 mg/dL vs 1.06 ± 1.87 mg/dL; p = 0.897). The blood transfusion rates were 18.8% (3/16) for the SLAM group and 15.0% (3/20) for the LM group ( p = 1.000). None of the patients required a conversion to an alternative surgical approach. The use of a powered morcellator was 0% (0/16) and 100% (20/20) in the SLAM and LM groups, respectively (Table 2 ). Surgical outcomes between patients who received SLAM or LM Data are presented as mean ± SD or number (%). p values are calculated using independent t test or *Fisher’s exact test. Hb = hemoglobin; LM = conventional laparoscopic myomectomy; SLAM = suprapubic laparoscopic-assisted myomectomy.

Conventional LM remains technically demanding, particularly for high-quality myometrial repair and the safe extraction of large specimens. Various techniques, including in-bag power morcellation and vaginal extraction, have been developed to address these challenges. Although mini-laparotomic myomectomy allows efficient uterine closure, it is often associated with increased blood loss and longer recovery than pure laparoscopy. 5 – 7 Although minimally invasive, vaginal extraction is frequently limited by parity, pelvic anatomy, and tissue elasticity. 8 The SLAM technique presented in this study serves as a “hybrid” approach that bridges the gap between conventional LM and mini-laparotomy. SLAM offers a panoramic laparoscopic view for precise lesion identification while using a small 2 to 3 cm transverse suprapubic incision for specimen retrieval and manual suturing. The laparoscopic component ensures safe adhesiolysis and optimal visualization in patients with complex surgical histories or endometriosis. 5 , 6 The principal advantage of SLAM lies in its ergonomic facilitation of uterine repair. Unlike conventional or single-port LM that require advanced intracorporeal suturing skills and specialized instrumentation, SLAM allows manual suturing under direct visualization. This not only facilitates a robust, multi-layer closure, essential for future pregnancy safety, but also significantly reduces the learning curve for surgeons familiar with traditional Pfannenstiel incisions. However, the successful implementation of the SLAM technique requires the synergy of two distinct skill sets: refined dissection capabilities and visual field management acquired in LM, alongside the fundamental principles of hemostasis and uterine reconstruction established in open myomectomy. Therefore, both surgical approaches are highly recommended by practitioners who adopt this technique. Furthermore, as shown in Table 3 , SLAM provides tactile feedback comparable to that of open surgery, enabling the detection of deep-seated or submucosal myomas that may be missed using laparoscopic instruments alone. 9 , 10 Comparison of minimally invasive myomectomy techniques LM = conventional laparoscopic myomectomy; SLAM = suprapubic laparoscopic-assisted myomectomy. Regarding the concerns raised about operative time (186.0 ± 59.3 minutes in SLAM vs 213.8 ± 48.8 minutes in LM), these figures reflect “skin-to-skin” time, which includes meticulous manual specimen extraction and multi-layer suturing. Although these times were relatively long, they represent a conservative and safety-first approach during the initial implementation phase of the novel technique. Our raw data showed that in later SLAM cases, the operative time dropped to approximately 80 to 110 minutes, suggesting a favorable learning curve. The hospitalization duration (4.19 ± 0.40 days) was comparable between groups ( p = 0.807). Although this is longer than that in some outpatient-focused centers, it reflects the standardized postoperative observation protocols and health insurance-driven recovery practices at our institution. One of the most significant advantages of SLAM is its elimination of power morcellation. By extracting specimens through a suprapubic incision via manual “cold-cutting” under direct vision, the risk of tissue dissemination is minimized owing to the presence of few visible fragments. While a single port with an additional trocar is a known alternative, SLAM’s specific use of a suprapubic site offers a more ergonomic perspective for manual work, and uses a cosmetically favorable site that is already familiar to gynecologists. Table 3 summarizes the advantages and limitations of currently available minimally invasive myomectomy techniques. 1 , 5 , 6 , 9 Fundamentally, the surgical philosophy of our proposed SLAM shares strong procedural concepts with classic laparoscopic-assisted myomectomy (LAM), particularly when using a hybrid approach that bridges laparoscopic visualization with the security of manual uterine repair. However, to precisely delineate the technical evolution and clinical value of SLAM amid recent advancements in port-reduction surgery, a comprehensive review of the contemporary literature is essential. Therefore, we established a systematic matrix (Table 4 ) to compare the technical nuances and inherent limitations between our technique and other representative myomectomy strategies published in recent years. 11 – 14 Methodological evolution of laparoscopic-assisted myomectomy: comparing SLAM with standard and modified LAM LAM = laparoscopic-assisted myomectomy; LETS-M = laparoendoscopic two-site myomectomy; SLAM = suprapubic laparoscopic-assisted myomectomy. In our cohort, five successful post-SLAM pregnancies have been recorded to date, suggesting that the integrity of uterine repair is sufficient for future reproductive function. However, owing to the small sample size and the retrospective nature of this pilot study, these findings should be considered preliminary. Large-scale prospective randomized controlled trials are necessary to confirm long-term obstetric outcomes, cost-effectiveness, and definitive learning curves associated with the SLAM technique. Our study had certain limitations. First, the small sample size (n = 36) limited the statistical power to detect subtle differences; thus, our findings should be viewed as a preliminary feasibility assessment rather than a definitive claim of superiority. Second, the exclusion of patients with BMI >30 kg/m 2 or myomas >10 cm was a deliberate safety measure during the pilot phase. While this limits generalizability to morbidly obese patients or those with massive uteri, it ensures a controlled environment for evaluating the baseline safety of SLAM. Finally, the retrospective nature of the study and the single-operator design may have introduced selection bias, although it ensured technical consistency across all procedures. In conclusion, SLAM is a safe and feasible alternative to conventional LM and offers effective myometrial closure and specimen retrieval. SLAM represents a promising hybrid approach that combines the advantages of laparoscopy with those of mini-laparotomy. Simple repositioning of the incision facilitates synergy between laparoscopic visualization and safety of manual interventions.

We thank Dr. New Geok Huey for her help with sample collection and data management. We are also grateful to Dr. Po-Kai Yang for assistance with the statistical analysis in our study.