Three-dimensional imaging reconstruction and laparoscopic robotic surgery: a winning combination for a complex case of multiple myomectomy

Objective: To demonstrate the intraoperative use of three-dimensional (3D) imaging reconstruction for a complex case of multiple myomectomy assigned to robot-assisted laparoscopic surgery. Design: Stepwise demonstration of the technique with narrated video footage. Setting: University tertiary care hospital. Patient(s): A 36-year-old nulliparous infertile woman with multiple uterine myomas (>20) presented with menorrhagia and pelvic discomfort for many months. Because of the huge number of fibroids present, the patient was considered eligible for laparoscopic robotic-assisted myomectomy. Intervention(s): A robotic-assisted laparoscopic myomectomy was performed with the use of intraoperative 3D imaging reconstruction. After opening the retroperitoneum through the adnexal triangle and identifying the ureters, to reduce intraoperative bleeding, bulldog clamps were used to temporarily reduce uterine vascularization. A multiple myomectomy was then performed with the use of tenaculum and Maryland bipolar forceps. During the intervention, the surgeon used the 3D uterine reconstruction to adapt its surgical strategy. Multilayer running closure was achieved using a bidirectional barbed suture ensuring introflexion of the serosa. Patients' consent was obtained for publication of the case; institutional review board approval was not required for this case report as per our institution's policy. Main outcome measure(s): Description of a robotic-assisted myomectomy with the intraoperative use of 3D imaging reconstruction. Result(s): The total operative time was 105 minutes. A total of 21 fibroids were removed with 150 mL of intraoperative blood loss. The patient was discharged the day after. Conclusion(s): The application of 3D imaging technology could overcome one of the limitations of robot-assisted minimally invasive surgery, the lack of haptic feedback, enabling the surgeon to rapidly locate myomas and guide the intraoperative plan to optimize the results. Additional studies evaluating the clinical impact of this technique and its improvement are required.