Technique THE LAAM® TECHNIQUE
The LAAM-BUAO® (or LAAM-BUAL) technique is a hybrid that takes the best elements of both laparoscopic and open approaches for myomectomy. The LAAM® fertility-sparing technique uses just two small incisions, one 5 mm incision at the belly button and one 3 cm (1.5 in) incision at the bikini line. The LAAM technique is one of the least invasive and most thorough surgeries for removing fibroids for fertility.
LAAM is only performed on patients who are able to retain fertility, and is performed at the discretion of the CIGC specialist.*
The LAAM technique can accommodate fibroids large and small. The CIGC specialists determine if a patient is a candidate for this surgery based on a review of imaging tests. The CIGC specialist will indicate to the patient in advance of the consultation which imaging tests will be required (ultrasound or MRI). For many patients, if the uterus is damaged or fertility is extremely low, LAAM is not recommended.
Most procedures using the LAAM technique are done in an outpatient setting. The LAAM technique is safer than other fibroid removal procedures, because it controls for blood loss and ensures the surgeon can see the entire pelvic cavity. Patients who are starting fertility treatments usually start feeling well enough to start exploring their options sooner than patients who have open or robotic procedures.
*A WOMAN’S AGE IS THE SINGLE MOST IMPORTANT FACTOR AFFECTING HER FERTILITY.
Rates of fertility decrease as a woman reaches her mid-30s, and women who conceive later are at a greater risk of pregnancy complications. Women in their late 30s are approximately 40 percent less fertile than women in their early 20s. However, once a woman is in her 40s, rates of fertility decrease exponentially. Ovarian reserve is diminished, and the lower quality of the eggs affects the quality of the potential embryo, leading to high rates of complications, including miscarriage.
At age 40, fertility has fallen by half. (At age 30, the chance of conceiving each month is about 20%; at age 40 the chance of conceiving is about 5%.)
At age 43-44, women have a 1% chance of getting pregnant with IVF. The integrity of the eggs, and the embryos that form are 80% likely to have chromosomal abnormalities.
Without IVF, women aged 43-44 have less than 1% chance of getting pregnant.
WHY THIS MATTERS FOR FIBROID REMOVAL
When fertility is no longer a viable option (1% or less), and fibroids are controlling your life, a myomectomy is not recommended.
Performing fibroid removal alone (a myomectomy), versus removing the uterus (hysterectomy), when fertility is no longer possible increases the risks to the patient. Women 45 or over, unless they have arranged to have a donor egg prior to having fibroid removal, should consider the benefits of a hysterectomy to ensure fibroids do not grow back.
A DualPortGYN hysterectomy at CIGC has a faster recovery than all other hysterectomy procedures, as well as any myomectomy procedure, and the recovery is less painful. Leaving the ovaries intact if they are healthy, a hysterectomy does not have to mean early menopause. The hormones that make estrogen are not affected by the removal of the uterus.
The hormone therapy implications for treating symptoms of menopause are significant for women who retain their uterus. Estrogen-only therapy is the safer approach to manage symptoms of menopause, but can only be used on women who have had a hysterectomy. Women who retain their uterus and who require hormone therapy for menopause must take combination therapy to minimize risks of uterine cancer. However, this therapy increases risks for breast and colorectal cancers.
THE LAAM-BUAO or LAAM-BUAL TECHNIQUE | UTERINE-SPARING FIBROID REMOVAL
Fibroid removal from the uterus, with preservation of the uterus for fertility, is known as myomectomy. Myomectomy from the latin: myoma = fibroid, ectomy = remove. Myomectomy is one of the most difficult procedures to complete successfully in benign gynecology. Fibroids can be located throughout the uterus, including the serosa (outside), intramural (within the muscle), near the cavity or in the cavity (submucosal or intracavitary), or on stalks (pedunculated). The LAAM technique is one of the safest minimally invasive fibroid surgeries available. The LAAM BUAO or LAAM BUAL technique are differentiated by the technique to control blood loss during the procedure. Bilateral Uterine Artery Occlusion (BUAO) is a technique performed on women who both desire and are able to maintain fertility. Bilateral Uterine Artery Ligation is a technique performed on women who do not wish to maintain fertility after a myomectomy, but who wish to retain their uterus.
THE CENTER FOR INNOVATIVE GYN CARE AND LAAM
The CIGC practice approach to myomectomy is unique, and has been very successful for the removal of fibroids of all sizes and number in thousands of patients. This approach is abbreviated as LAAM-BUAO or LAAM-BUAL. LAAM stands for Laparoscopic Assisted Abdominal Myomectomy. BUAO refers to Bilateral Uterine Artery Occlusion, which is the temporary blockage of the uterine artery during the procedure to control bleeding. BUAL refers to Bilateral Uterine Artery Ligation, which is the permanent blockage of the artery during a GYN procedure to control bleeding.
NOTE: CIGC NEVER uses electronic morcellation techniques with any of its procedures, including the DualPortGYN technique for hysterectomies as well as for removal of fibroids during myomectomies.
THE LAAM-BUAO/LAAM-BUAL TECHNIQUE DIFFERENCE | THE SAFER FIBROID REMOVAL SURGERY
- The sense of touch is a very important part of our daily lives. Success in some surgical procedures requires the ability to feel in order to create the best possible result. A successful myomectomy requires the surgeon to remove fibroids often deep in the muscle of the uterus that cannot be easily seen. It also requires the surgeon to remove all of the fibroids, including smaller ones, which can only be located by feeling them. The LAAM technique approach to myomectomy allows the surgeon to feel all of the fibroids at any location in or around the uterus, and allows for their safe and effective removal no matter the size.
- The LAAM technique is more advanced than standard or robotic laparoscopic procedures. Standard and robotic laparoscopic approaches to myomectomy do not allow the surgeon to feel fibroids in the uterus, and they can often miss those deep in the muscle which can cause problems with infertility and cause persistent bleeding. In addition, if smaller fibroids are missed with these approaches, that can allow continued fibroid growth and increase the need for additional surgery.
- The LAAM technique uses only two small incisions cosmetically placed with an overall length smaller than either standard laparoscopic and robotic approaches. The recovery with the LAAM technique is similar if not better than standard laparoscopy, with far fewer complications or need for blood transfusion. There is no overnight hospital stay.
Using the sense of touch, the LAAM technique has revolutionized the laparoscopic approach to myomectomy. It is one of the safest fibroid removal surgeries available, affording patients a far more effective outcome, with a faster recovery.
A Note About Occlusion Versus Ligation
For many patients, bilateral uterine artery occlusion (BUAO) is the right technique for fibroid removal if the patient both desires and is able to maintain fertility. For others, bilateral uterine artery ligation (BUAL) may be appropriate. Both of these techniques help to control blood loss during the LAAM procedure and each technique is discussed with the patient prior to the surgery based on individual expectations.
Occlusion is temporary. A tourniquet is placed at the neck of the uterine artery, and is released after the fibroids have been removed and the uterus repaired.
Ligation is permanent. Once the artery is dissected from the uterus, sutures are used to seal off the flow of blood.
The Preferred Choice
THE LAAM TECHNIQUE IS THE PROCEDURE OF CHOICE FOR PATIENTS WITH MODERATE TO LARGE FIBROIDS
THE LAAM TECHNIQUE IS THE CHOICE FOR PATIENTS WITH NUMEROUS FIBROIDS
Only two incisions are used, with overall incision size being less than with the robotic approach, and about the same size as the standard laparoscopic approach. The difference between these types of procedures is vast, however. Where robotic and standard approaches are very limited in the size and number of fibroids they can remove, the LAAM technique can remove any size or number of fibroids within the uterus. A LAAM myomectomy can remove fibroids deep in the muscle and in the cavity of the uterus that may be impossible with standard or robotic laparoscopic approaches.
WHY DON’T ALL SURGEONS PERFORM THE LAAM-BUAO/LAAM-BUAL TECHNIQUE?
Special training and skill is required to master this procedure, especially in cases of very large fibroids. Ability to identify important anatomy structures, and avoid excessive blood loss with advanced occlusion or ligation techniques play a major role in successfully completing the surgery. The LAAM technique in the hands of inexperienced surgeon can lead to major complications.
THE LAAM-BUAO/LAAM-BUAL TECHNIQUE USES ADDITIONAL SPECIAL TECHNIQUES TO AVOID EXCESSIVE BLEEDING AND POTENTIAL HYSTERECTOMY.
The permanent or temporary blockage of the uterine artery before removal of the fibroids allows for excellent control of bleeding. In many cases, there is almost no blood loss while the blockage is in place, allowing for the controlled removal of fibroids and closure of the muscle safely and effectively.
A hysterectomy has never been required at the time of surgery for any patient undergoing a myomectomy using the LAAM technique. (Determination of whether a patient is a candidate for a LAAM myomectomy versus DualPortGYN hysterectomy is made during the patient consultation.) For fertility patients, the lining of the uterine cavity can be preserved and reconstructed to prevent adhesions from forming within the cavity because the patient is not at risk of blood loss.
Standard closure techniques are used. These techniques have been used for years with open surgery procedures, and they allow for the strongest closure possible, which is essential for women who wish to get pregnant.
UNLIKE STANDARD OR ROBOTIC PROCEDURES, THE LAAM/BUAO TECHNIQUE CAN REMOVE ALL TYPES OF FIBROIDS
THE LAAM/BUAO TECHNIQUE ELIMINATES LIMITATIONS OF LAPAROSCOPIC AND ROBOTIC PROCEDURES WHILE MAINTAINING EXCELLENT RECOVERY
Why Choose LAAM Over Other Procedures
THE DISADVANTAGES OF TRADITIONAL OPEN MYOMECTOMIES or STANDARD OR ROBOTIC LAPAROSCOPIC PROCEDURES
Open procedures are still the most commonly performed, since with this approach all fibroids can be removed in all locations. The major disadvantage with the open approach is of course a much larger incision, resulting in more pain and longer recovery times of 6 to 8 weeks. There is a much higher rate of complications as well.
Open surgical myomectomy procedures increases the need for longer hospitalization. There is more pain and extended recovery times.
STANDARD AND ROBOTIC LAPAROSCOPIC APPROACHES
Laparoscopic approaches have been tried for myomectomy with different levels of success. Most laparoscopic approaches can remove fibroids on stalks, or from the outside without too much difficulty through a well-trained laparoscopic surgeon. However, large numbers of fibroids, fibroids within the muscle, or larger fibroids involving the cavity are much more difficult to remove. Standard or robotic approaches for removal of very large fibroids or large numbers of fibroids in the uterus are not very successful. The procedural time is far too long, increasing the risks to the patient. The bleeding too heavy, and not all fibroids can be removed.
The most difficult problem associated with myomectomy is heavy bleeding. The uterus has an excellent blood supply. Myomectomy requires removal of the fibroids from the muscle, then closure of the defect using sutures. Extensive bleeding can occur with the removal of many fibroids, or larger fibroids deep in the uterine muscle. In some cases, hysterectomy is required due to uncontrollable bleeding.
Additional problems with any standard or robotic laparoscopic approach to myomectomy includes poor closure of the uterine muscle, and the potential for increased risk of uterine rupture during pregnancy.
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.
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