Surgical technique: minimal skin incision abdominal myomectomy

All patients were operated on in the lithotomy position under general endotracheal anesthesia, and a Foley catheter was placed inside the bladder. Epidural anesthesia was also added. A skin incision less than approximately 5 cm in length was made longitudinally (4.3 ± 0.7 cm, 3–5.5 cm, n = 76), and the adipose tissue and abdominal fascia were cut using a monopolar electric scalpel (Fig. 1a). After the rectus abdominis muscle was spread, the peritoneal membrane was opened with a scalpel and surgical scissors. In this procedure, the abdominal fascia and peritoneal membrane were cut longitudinally at a length of approximately 6 cm. A Small or Medium Alexis® Wound Protector/Retractor (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA) was placed inside the wound to provide a wide operative view, making the uterus visible (Fig. 1b). Vasopressin solution was injected into the surrounding tissue to decrease bleeding after the locations of the leiomyomas were detected. The surface of the uterine trunk was cut with a monopolar electric scalpel, and a part of the leiomyoma was grasped with a sharp clamp. While pulling the leiomyoma through the wound in an upward direction, a surgeon cut part of it to remove it from the wound and then grasped a different location (Fig. 1c). By repeating these procedures, even leiomyomas that were larger than the wound could be removed (Fig. 1d). The uterine wound was sutured with layered sutures (Fig. 1e), and then the peritoneum, fascia, and skin were sutured (Fig. 1f).

Surgical procedures of minimal skin incision abdominal myomectomy. This patient was a 36-year-old woman with two uterine leiomyomas. The larger leiomyoma was 10 cm in diameter on admission, and it decreased to 8 cm in diameter after two doses of gonadotropin-releasing hormone analogue. The patient had a history of gravida 2 para 1. The operation time was 75 minutes, and the patient’s blood loss was 28 ml. The incision site was 3.5 cm. We extracted two leiomyomas from the site. The total weight of the leiomyoma was 234 g. a The size of the skin incision. b The appearance of the wound with the Small Alexis® Wound Protector/Retractor. c The leiomyoma was grasped with sharp clamps and pulled through the wound after some cuts were made and the diameter of leiomyoma was reduced. d The appearance of the resected leiomyomas. e The uterine wound was sutured with layered sutures. f The appearance of the sutured skin wound