Laparoscopic myomectomy for symptomatic uterine myomas Bradley S. Hurst, M.D., Michelle L. Matthews, M.D., Paul B. Marshburn, M.D.  Fertility and Sterility  Volume 83, Issue 1, Pages 1-23 (January 2005) DOI: 10.1016/j.fertnstert.2004.09.011 Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 1 Placement of trocars for laparoscopic myomectomy. The laparoscope is placed through an umbilical incision (D), although the left upper quadrant may be used as an alternate site (95, 96 Golan 2003; Jansen 2004). Two 5-mm trocars are placed on the primary surgeon's side of the table: a suprapubic trocar (B) lateral to the insertion of the round ligament and the other trocar (C) placed lateral to the umbilical trocar, parallel to the suprapubic trocar and lateral to the inferior epigastric vessels. A 10- to 11-mm trocar (A) is placed on the assistant's side midway between the pubic symphysis and the umbilicus and lateral to the inferior epigastric vessels (Inf. epigastric a., v.). These trocar sites (A, B, C, D) are used in subsequent figures. Artwork by Nancy Marshburn. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 2 Myoma enucleation. A transverse elliptical incision exposes the myoma after injection with vasopressin. The Harmonic Scalpel is placed through port “B.” An aspirator/irrigator placed through the ipsilateral port “C” for countertraction against the myometrium, to identify tissue planes, and rinse the surgical site. The assistant places a tenaculum or a myoma screw through the 10- to 11-mm port “A” to provide tension on the myoma (M). Gentle pressure is placed on the edge of the Harmonic Scalpel blade to facilitate cutting and coagulation along the pseudocapsule. If needed, the Harmonic Scalpel is inserted through ports “A” or “C” to facilitate dissection. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 3 Uterine defect after myoma enucleation. The combination of vasopressin and the Harmonic Scalpel provides good hemostasis. The myoma “M” has been placed in the anterior cul de sac. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 4 Technique of laparoscopic suturing. The deep myometrial layer is closed with a continuous running suture. A Lapra-Ty clip has been placed at the beginning of the suture line. A self-righting needle driver is placed through port B and held in a right-handed surgeon's right hand. A second needle driver is inserted through port C and held in the left hand. The assistant uses a third-needle driver inserted through port A to provide traction on the suture. Sutures are placed anterior to posterior, from the distal end of the incision to the proximal end. The needle is placed into the superior margin, then is pulled out by needle driver C and immediately reloaded into driver A. Artwork by Nancy Marshburn. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 5 Uterus after three-layer closure. The serosa is closed with a continuous running layer. If possible, the Lapra-ty clips are buried under the serosal layer. A Lapra-ty clip (arrow) has been placed at the terminal end of the running suture. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions

FIGURE 6 Placement of Interceed (arrow) over the ectomy incision to reduce adhesions. Fertility and Sterility 2005 83, 1-23DOI: (10.1016/j.fertnstert.2004.09.011) Copyright © 2005 American Society for Reproductive Medicine Terms and Conditions