Advanced Fibroid Removal with the LAAM Myomectomy
The Laparoscopically Assisted Abdominal Myomectomy (LAAM®) technique was developed by The Center for Innovative GYN Care® (CIGC®) surgical specialists in 2005 and it is a uniquely powerful procedure that can remove uterine fibroids of almost any size, at all locations in the uterus. Thousands of patients from all over the US and the world have opted for this fertility-sparing fibroid removal procedure. CIGC specialists have used the LAAM technique to remove fibroids greater than 20 cm as well as up to 160 fibroids in one patient. The procedure is minimally invasive, allowing patients to leave the surgical facility the same day of the operation, and provides for a recovery time of two weeks on average. When considerations are made for the number, size, and location of fibroids, LAAM has no equal when compared to standard laparoscopic or robotic procedures. LAAM has been proven to be as thorough in its ability to remove fibroids and provide the strongest muscle closure as compared to open surgery, but allows for a much faster recovery, less pain, and fewer complications. LAAM procedures have been published in peer-reviewed journals in large retrospective reviews and provide a superior minimally invasive surgical option for uterine-sparing fibroid removal surgery.
Despite its benefits as a minimally invasive option, the LAAM technique is not for all patients. Myomectomy procedures are limited to those patients who desire fertility, and for those patients that can realistically become pregnant. The following is a series of questions and answers regarding LAAM that will assist patients in understanding the procedure, its application, and outcomes.
What Is LAAM and Why Was It Developed?
LAAM is a hybrid procedure, meaning it is a combination of laparoscopy and a mini laparotomy, or small incision, for the removal of fibroids. Only two incisions are used. The mini incision is typically only 1.5 to 2 inches (3 – 4 cm) in size and is placed at the bikini line. The second incision is ½ inch in size, about 7 mm, and is placed at the belly button.
CIGC surgeons clearly understood the problems associated with minimally invasive fibroid surgery as performed by robotic and standard laparoscopy. They also understood that open surgery certainly can remove any size and number of fibroids at any location in the uterus, but at the cost of significant pain and an eight-week recovery time for the patient. LAAM was developed as a more reasonable option to open surgery, providing the same result with regards to the removal of fibroids, but with a much smaller incision and a recovery time of only two weeks. Robotic surgery is just not effective in the removal of deeper fibroids, larger fibroids, and greater numbers of fibroids, and requires more incisions throughout the abdominal wall, with a combined length much greater than LAAM. Robotic myomectomy often requires three to four times the operative time, and has a higher conversion rate to open procedures.
LAAM bridges laparoscopic and robotic procedures as a hybrid, and uses the best of both to obtain superior results and faster recovery times.
How Is LAAM Performed?
Laparoscopy allows a magnified view of the pelvis, and can identify and remove endometriosis that otherwise would not have been seen with open surgery. The belly button incision allows the CIGC surgeon to view the entire pelvis, and identify other potential problems that can lead to fertility. For example, CIGC studies on patients undergoing LAAM procedures are now showing that many patients with fibroids also have endometriosis found at the time of fibroid removal.
LAAM uses various techniques for blood loss control. Blood loss is the major factor that creates problems with myomectomy procedures for OBGYNs. By controlling blood loss, the procedure becomes safer, more effective, and decreases the time and complication rates of the procedure.
LAAM procedures start with the ½ inch (7 mm) incision at the belly button, to evaluate the fibroids and their location and to assess the pelvis. The next step in the procedure is the use of a second incision in the bikini line for placement of a laparoscopic tourniquet to control blood supply. Once the tourniquet is in position, the bikini line incision is extended to 1.5 inches and the fibroids are removed directly through the incision. After each fibroid is removed, the incision into the uterus to remove the fibroid is now closed through the mini incision with standard suturing techniques. These standard techniques have been used for decades in open myomectomy, and allow for a very strong closure to the uterine muscle. This closure is stronger and more secure than robotic or standard laparoscopic closure, and helps to prevent rupture of the uterus during pregnancy.
As fibroids are continually removed, the uterus decreases in size and additional fibroids are moved toward the incision for removal. With excellent blood loss control, the procedure is performed much faster than any other type of myomectomy surgery, including open, with the ability to remove all fibroids especially those in or near the uterine cavity. Removal of these fibroids can cause more symptoms, such as bleeding, and also have a greater negative impact on fertility.
Are Power Morcellators Used During LAAM Procedures?
No, there is never a need for power morcellators during LAAM procedures, since the fibroids are segmented through the lower incision and fibroid removal from the uterus is not directly exposed to the abdominal cavity. This approach is faster and safer than standard laparoscopic or robotic approaches, and avoids the need for power morcellation of potentially cancerous fibroids.
What Is the Incidence of Cancerous Fibroids?
Leiomyosarcoma of the uterus, the most common malignant fibroid, is very rare, with rates as low as 1:1500 in the literature. Almost all patients with uterine fibroids do not have sarcoma. For those patients in which a sarcoma is suspected, MRI may be helpful in the diagnosis.
How Is LAAM Different from Standard Laparoscopic or Robotic Myomectomy?
Both standard and robotic procedures use laparoscopic surgical techniques to remove the fibroid from the uterine muscle, and to close the defect. The main disadvantage of pure laparoscopic approaches to myomectomy is the lack of tactile sense. Tactile sense refers to the ability to actually feel the fibroids in the uterus. Robotic or standard laparoscopic surgery do not allow the surgeon to feel the uterus or the fibroids. With LAAM, the surgeon can actually identify and feel the fibroids through the 1.5 inch incision, which assists in the removal of very large fibroids and can help with identification and removal of much smaller fibroids that can grow with time. The ability to feel fibroids is extremely effective for removal of deeper fibroids near or in the uterine cavity that can cause very heavy bleeding and lead to infertility. In addition to the ability to feel the fibroids to help with removal, in LAAM the uterine muscle is closed directly through the 1.5 inch incision using standard suturing techniques allowing for a very strong and effective closure. This is especially important for patients desiring fertility. Robotic and standard laparoscopy require the closure to be performed using laparoscopic techniques. These techniques require increased time, and often do not provide the same strength of closure.
LAAM Compared to Other Myomectomy Techniques
1 Paul MacKoul, MD, FACOG, Rupen Baxi, MD, FACOG, Natalya Danilyants, MD, FACOG, Louise Q. van der Does, PhD, Leah R. Haworth, BSN, RN, Nilofar Kazi, BS. Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation. JMIG. 2019.
2 Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. AJOG, 2009;201:566.e1-5.
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4 Barakat et al. Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy: A Comparison of Surgical Outcomes. 2011; 117(2): 256-266.
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6 Seinera et al. Laparoscopic myomectomy: indications, surgical technique and complications. Human Reproduction vol.12 no.9 pp.1927–1930, 1997.
7 Alessandri, Franco et al. Randomized study of laparoscopic versus minilaparotomic myomectomy for uterine myomas. JMIG. 2006; 13(2):92-97.
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9 Sangha R, Eisenstein D, George A, Munkarah A,Wegienka G. Comparison of surgical outcomes for robotic assisted laparoscopic myomectomy compared to abdominal myomectomy. JMIG. 2010;17(Suppl):S108.
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12 Mayo Clinic
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14 Jones, H. W., III, & Rock, J. A. (2015). Te Linde’s operative gynecology (Eleventh edition). Philadelphia: Wolters Kluwer.
Can LAAM Procedures Remove All the Fibroids in the Uterus and at Any Location?
Yes. OBGYNs often tell patients that their uterine fibroids are too large or in a bad location for removal, or there are too many fibroids and open surgery is required. First, realize that that an OBGYN is not a surgical specialist but more of an obstetrician since they are concentrating mostly on the management and delivery of babies 60 – 70 percent of the time in their practices. As a result, the OBGYN often does not understand what LAAM procedures are and what the procedure can do. A common problem for the OBGYN is the posterior — or back of the uterus — fibroid that can be difficult to remove through laparoscopic or robotic techniques. LAAM allows the CIGC surgeon to identify the fibroid, move the fibroid toward the incision, and remove it easily and safely. The same is also true for very large fibroids at any location.
Through the ability to remove the fibroids through the mini incision, to feel the fibroids and locate deeper fibroids in the muscle, and the ability to actually move the uterus as needed to access fibroids throughout the uterus, LAAM becomes a far more effective and safer option than laparoscopic or robotic approaches. These advantages are inherent to the LAAM approach, which is a much more common-sense approach to myomectomy, providing better surgical outcomes for patients.
What Is the Recovery Time for the LAAM Procedure?
Recovery depends on the number and size of fibroids removed.
“Massive or Very Large Fibroids.” Overall uterine size — with fibroids — greater than 20cm
Patients with larger fibroids and greater numbers of fibroids may require two to three weeks of recovery time. LAAM procedures can be performed on patients with massive or very large fibroids and a greater number of fibroids — if they did not have a LAAM approach to surgery, they would absolutely require an open surgical procedure with a recovery time of eight weeks or more. In these larger open procedures, usually performed by an OBGYN, hospitalization of at least three days or more is required, and patients often need blood transfusions during and after these open surgeries. LAAM easily converts open surgery to minimally invasive in this group of patients, and they leave the facility the same day and are back to work during a two to three-week time frame. The recovery is a functional one, meaning patients are performing normal activities within two to three days. There are some patients within this group of “massive or very large fibroids” undergoing LAAM procedures that may require hospitalization for blood transfusion after the procedure, but this is unusual.
Large/Moderate Fibroids. Overall uterine size — with fibroids — less than 20 cm
Recovery time is typically from 10 to 14 days with this group of patients. As with any LAAM procedure, the recovery is far more functional than typical open or robotic approaches to surgery. After the first day, patients are generally mobile, are using mostly Motrin for pain relief, and feeling much better by the third and fourth day.
Small/Moderate Fibroids. Overall uterine size — with fibroids — less than 10 cm
Recovery time in this group of patients can be as fast as seven days. Depending on the location and number of fibroids removed, these patients will generally have smaller incisions and less blood loss during surgery.
Why Should I Choose the LAAM Procedure over Other Types of Myomectomy Procedures?
There are several reasons to choose the LAAM procedure over other types of myomectomy procedures to remove uterine fibroids, as follows.
1. CIGC surgeons are laparoscopic specialists, not OBGYNs.
This is a critical point, since the OBGYN is focusing mainly on obstetrics, as opposed to gynecologic surgery. True laparoscopic surgeons do NOT do obstetrics, but focus entirely on surgery. They are usually fellowship-trained and have dedicated their careers toward minimally invasive GYN surgery. Many OBGYNs describe themselves as laparoscopic specialists. The best way to determine this is to look at their website and see if they are also performing obstetrics. If they are, their focus is not entirely on surgery. Patients need to be aware of what their OBGYN or specialist skill set actually is regarding minimally invasive surgery. The OBGYN specialty is unlike any other specialty when it comes to surgery. OBGYNs are NOT dedicated surgeons performing surgery full time but, in reality are mostly obstetricians performing surgery part time. Think of a general surgeon, or orthopedic surgeon, or any other surgical specialty. These specialties are dedicated to surgery 100 percent of the time. An OBGYN is not.
CIGC surgeons are dedicated to surgery 100 percent of the time, are fellowship-trained either in Minimally Invasive Surgery or both Minimally Invasive Surgery and Gynecologic Oncology, and have higher volumes and numbers of procedures performed to allowing for the development of superior techniques resulting in better outcomes. The OBGYN does not have the training, the expertise, or the volume of surgery to become an expert at minimally invasive surgical procedures. CIGC continually refines and publishes data on its procedures. All patients should understand what the capability and experience of their surgeon is to ensure a safe and effective procedure, and to avoid conversion to open surgery even though the procedure was scheduled as laparoscopic.
2. LAAM procedures are inherently a superior approach to myomectomy than either robotic, laparoscopic, or open surgery.
LAAM is a hybrid procedure combining the best of open surgery with laparoscopy using only two incisions and providing for a very safe, fast, and effective result.
Tactile Sense or “Feel”
Laparoscopic and robotic approaches to myomectomy cannot feel the fibroids in the uterus. These procedures have to rely on visualization of the fibroids, which often misses deeper fibroids in the uterine muscle that cannot be seen. Deeper uterine fibroids lead to persistent and heavier bleeding, and can severely compromise fertility.
Strength of Closure
Laparoscopic and robotic approaches cannot provide the same strength of closure to the uterine muscle as can LAAM procedures since the closure is performed through the laparoscope. LAAM actually closes the uterine muscle incision through the mini incision, which is a faster and stronger closure.
Blood Loss Control
LAAM procedures use a laparoscopic tourniquet to control blood supply, which provides a continuous and safe method of controlling bleeding during the LAAM procedure. Laparoscopic and robotic approaches require the use of Pitressin, which is an injection that wears off during the procedure, with repeat injections every 30 minutes. This is a tedious and difficult method to control blood supply, and can often lead to frequent bleeding after myomectomy when the Pitressin wears off. Decreasing bleeding is one of the most challenging issues facing any surgeon performing a myomectomy. The laparoscopic tourniquet is a temporary occlusion of the blood supply to uterus used during the procedure. First, the tourniquet is placed and the fibroids are removed, providing excellent blood loss control. After the uterus is repaired, the tourniquet is removed, restoring blood supply to the uterus. The use of a tourniquet during LAAM procedures is highly effective, and dramatically decreases blood loss during LAAM procedures, thereby increasing the safety and effectiveness of the operation.
There are many factors influencing recovery from the LAAM procedure, including the size, number, and location of fibroids removed. LAAM in general provides very consistent recovery times, as noted above, for patients with even the largest fibroid uteri. Complications after these procedures are rare, the most significant being the need for blood transfusion after removal of massive or very large fibroids in very few patients. The inherent common-sense approach to fibroid removal with LAAM over laparoscopic and robotic procedures results in a safer, highly effective surgical procedure with very high patient satisfaction.
LAAM has the ability to remove fibroids of any size and location from almost any uterus. Very large numbers of fibroids can be removed quickly and safely with procedures that control blood loss, such as a tourniquet or in some cases the use of uterine artery ligation, or permanent occlusion of the uterine artery blood supply to the uterus. Blood loss control procedures along with tactile sense and the use of a mini incision allows LAAM to be accessible to almost all patients with fibroids.
3. LAAM procedures rarely, if ever, result in conversion to open myomectomy.
LAAM procedures use a mini incision, or “minilap,” to access and remove fibroids with a result and recovery time that is superior to robotic, standard laparoscopic, or open surgery. With the ability of LAAM to control bleeding and access fibroids throughout the uterus, conversion to open surgery is a very rare event. Robotic and standard laparoscopic myomectomy have a conversion rate to open as high as 30 percent or more due to an inability to control bleeding or access all the fibroids. Often, robotic or standard laparoscopic myomectomy are limited to the fibroids that are clearly visible to the uterus, and do not remove deeper fibroids. In many cases, the OBGYN will not convert to an open procedure but will simply remove only those fibroids that are accessible, leaving the deeper fibroids to continue to grow and worsen symptoms such bleeding and infertility. In that situation, a second procedure is often required to remove these deeper fibroids. Conversion to open myomectomy is common with standard laparoscopic or robotic procedures, and is a failure for the patient, who has entered the surgery expecting a minimally invasive approach.
LAAM is the Fibroid Removal Procedure of Choice for
All Fibroid Types
Moderate to Large Fibroids
What Is Uterine Artery Occlusion Vs Ligation?
In general, most patients undergoing LAAM procedures require only the temporary placement of a laparoscopic tourniquet to control blood supply. This is considered a temporary occlusion of the blood supply, with the tourniquet being used throughout the procedure to remove fibroids and then removed after the defects in the uterine muscle are closed. A tourniquet is the use of a surgical rubber band around the neck of the uterus, which controls a significant percentage of blood supply to the uterus. In certain cases of massive or very large fibroids, permanent uterine artery ligation may be necessary to control bleeding during the procedure, either to avoid hysterectomy or prevent bleeding after the surgery. If used, ligation is often only required for one uterine artery associated with removal of a fibroid to the lateral, or side of the uterus, where the artery is present. There are four main blood supplies to each side of the uterus — the uterine artery, the cervical and vaginal branches, and the ovarian blood supply. Ligation, or permanent occlusion, of one of the uterine arteries may have a minimal effect on fertility. A recent research article revealed that ligation of both arteries at the time of myomectomy versus not ligating the arteries showed no difference in fertility. Unfortunately, for those patients with massive or very large fibroids, there has often been a delay in care, to the extent that the growth of the fibroids has severely damaged the uterus, and in many cases patients with these types of situations may have a uterus that is nonfunctional after fibroid removal, regardless of the technique used to remove the fibroids.
What Patients Are Candidates for LAAM Procedures?
In general, patients requiring fertility will need to have a myomectomy — actual removal of the fibroids — to ensure their best chance at fertility. Almost all patients with fibroids are candidates for the LAAM procedure, however there are some patients that either are not interested in fertility, or are at a specific age that severely limits their options for pregnancy.
Age, Fertility, and LAAM
Fertility dramatically decreases with advancing age. For example, at the age of 25 – 30, patients have a 60 percent chance of becoming pregnant. At age 40 – 42, that chance becomes less than five percent. At 42 – 43, pregnancy rates are so low, even with IVF (< one percent), that often a donor egg is required (the use of a younger egg from an egg donor) to allow for pregnancy. An example of this is Janet Jackson, who used a donor egg to become pregnant at the age of 50. Understanding this, LAAM procedures or any myomectomy procedure should only be chosen for fertility purposes. This is important to understand since even though the LAAM procedure provides better results compared to other approaches, it is still a myomectomy — removal of fibroids from the uterine muscle — and is a more involved surgery than any form of hysterectomy. The point is, myomectomy is a more invasive surgical procedure as compared to hysterectomy with a longer recovery, more pain, and a higher risk of bleeding.
Hysterectomy, as performed by CIGC with the DualPortGYN® approach, allows for a faster recovery with less pain and better short- and long-term benefits as compared to LAAM. Further, hysterectomy is performed faster, decreases costs, and prevents uterine fibroid regrowth over time. Patients in their 40s considering surgical treatment of fibroids need to strongly consider a partial hysterectomy as their best option. This procedure uses smaller incisions than LAAM, a recovery of seven days back to work with less pain and fewer complications, and prevents recurrence of fibroids. The ovaries are ALWAYS left in these patients, so MENOPAUSE DOES NOT OCCUR until later. As a result, with hysterectomy there is no bleeding, no pain, and an increase in energy and overall wellbeing. At menopause, patients who have had a hysterectomy can use estrogen safely per the Women’s Health Initiative study, thereby extending the benefits of menopausal estrogen therapy for 10 or more years. That same patient who opted for a myomectomy in her early 40s cannot use estrogen safely at menopause with her uterus still in place since there is an increased risk of breast cancer. Menopausal symptoms include hot flashes, night sweats, mood swings, anxiety, depression, vaginal dryness and pain with intercourse, osteoporosis, and many others.
LAAM and Patients NOT Desiring Fertility
For those patients in which hysterectomy, despite its many benefits, is not an option, a LAAM procedure can be performed with necessary safety precautions considered. The first is the use of uterine artery ligation to better control bleeding during and after the procedure, especially in those patients with massive or very large fibroids. The physicians at CIGC are sympathetic to the needs of patients but also MUST CONSIDER THEIR SAFETY FIRST, as well as the short- and long-term effects of the surgical procedure. Patients need to be honest in their motivations regarding myomectomy, and if they desire the uterus be retained but actually do NOT want fertility, they should express this during their consultation. CIGC surgeons can accommodate to make the procedure safe and effective. After extensive counseling regarding the risks and benefits of hysterectomy versus myomectomy have been discussed, including the potential for fibroid recurrence, a LAAM procedure can be scheduled at the patient’s request. The CIGC surgeon will clearly indicate to the patient that if at the time of the LAAM procedure there is a significant risk of bleeding during or after the procedure, or if the uterus appears to be completely replaced by fibroids or would be nonfunctional after fibroid removal, a supracervical hysterectomy may be performed at the time of the procedure. This operation uses the same incisions, but removes the top of the uterus only, leaving the cervix and the ovaries thereby maintaining hormone production and vaginal integrity. The result of this procedure is no bleeding, no pain, no fibroid recurrence, continued hormone production, increased energy levels, and the better long-term option of using estrogen therapy after menopause to prevent hot flashes, night sweats, mood swings, osteoporosis, vaginal dryness and pain with intercourse, skin health, and other menopause symptoms.
Uterine Fibroid Embolization versus LAAM Procedures
Patients should not consider uterine artery embolization (UFE) as their primary route for fibroid treatment if they desire fertility. Studies have shown that uterine artery embolization can increase the risk of miscarriages in patients trying to become pregnant after this procedure. Further, UAE does not remove fibroids at all, but relies on stopping the blood supply to the fibroids to control bleeding and eventually to decrease the size of the fibroids. For most patients desiring fertility, the concept of waiting for the type of procedure to decrease the size of the fibroids is flawed. Fibroids present deep in the uterus and near the uterine cavity can still cause problems with fertility after UAE, simply because the embryo may implant near the fibroid resulting in miscarriage. Removal of the fibroids prevents this from happening. Further, LAAM procedures not only remove all the fibroids, the recovery is actually shorter than most UAE recovery times. There is overall less pain and the symptoms of distension, bloating, pelvic pressure, and frequency of urination — all symptoms due to fibroid bulk — are completely resolved after LAAM, but many require months to resolve after UAE.
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