The evolution of myomectomy: from laparotomy to minimally invasive surgery

Abstract

In approximately 400 years BC, Hippocrates described a woman afflicted with ‘labour-like pains’ who would pass ‘rough uterine stones’ from her vagina, while mediaeval texts made reference to women who, during parturition, would expel ‘birds eggs’ from their vaginas. In the early 1800s, Drs Rokitansky and Virchow identified these ‘stones’ and ‘eggs’ pathologically as leiomyomas. It was not until 1845 that the first successful fertility-sparing treatment, abdominal myomectomy, was described by Dr Atlee in the USA. However, myomectomy, intended as a heroic fertility-sparing procedure in the pre-antibiotic, pre-transfusion era of surgery, fell out of favour due to unacceptably high mortality. In fact, five of the first 14 cases treated by Dr Atlee, died during or shortly after the procedure. In 1904, Professor John W. Taylor, then president of the British Gynaecological Society, wrote about the many surgical options for symptomatic fibroids. He advocated supravaginal (i.e. supracervical) hysterectomy as the most useful for large fibroids, followed by, albeit inferior in his eyes, abdominal pan-hysterectomy. Myomectomy, he believed, would leave the uterus, ‘more or less permanently damaged’, and he questioned whether ‘its [uterus] retention is of any sufficient value to warrant the increased danger’ (Taylor. J Obstet Gynaecol Br Emp 1904;6:125–31). As a result, myomectomy was viewed as an inferior treatment option until 1922, when English surgeon, Mr Victor Bonney, developed a uterine artery clamp that allowed for a substantially less morbid procedure (Figure 1). Bonney went on to perform over 700 myomectomies with only eight reported deaths. He later described the challenge of fibroid surgery as ‘… so variable and the methods of surgical treatment so many and so diverse, that wise and successful practice by no means follows unalterable lines, but is to a large extent eclectic and often rightly subservient to the bent or genius of the operator’. It has taken, however, almost a century to debunk the original stigma of myomectomy as the heroic alternative to the default hysterectomy. The development of minimally invasive surgery would shift this paradigm dramatically. In 1980, German surgeons Drs Semm and Mettler first described laparoscopic myomectomy for subserosal fibroids with intracorporeal morcellation for extraction. By 1991, Dr Nezhat in the USA was treating all sub-types of fibroids laparoscopically. As further refinements were made, laparoscopic myomectomy was shown to have clear clinical benefits over open surgery; including decreased postoperative pain and shorter hospital stay, as well as comparable pregnancy and myoma recurrence rates (Bhave Chittawar et al. Cochrane Database Syst Rev 2014;10). Still, laparoscopic myomectomy remains under-utilised due to its objective technical difficulty. In 2004, the robotic assisted laparoscopic myomectomy was introduced and allowed surgeons easily to overcome the technical difficulty of laparoscopic suturing and dissection. Recent case–control studies from the USA have demonstrated that both laparoscopic and robotic myomectomy are safe in patients with large and numerous fibroids (Gargiulo et al. Obstet Gynecol 2012;120:284–91; Vargas et al. J Minim Invasive Gynecol 2017;24:315–22). In the 21st century, minimally invasive myomectomy is the gold standard in fertility-sparing surgery, and robotic assistance holds the promise to facilitate wider adoption of this technique by the next generation. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.