Review Article

Hemostatic Techniques for Myomectomy: An Evidence-Based

Approach
Lisa Caronia Hickman, MD*, Alexander Kotlyar, MD, Shirley Shue, BS, and
Tommaso Falcone, MD
From the Department of Obstetrics and Gynecology (Drs. Hickman, Kotlyar, and Falcone), Cleveland Clinic Foundation, Cleveland, Ohio, and Case
Western Reserve University School of Medicine (Ms. Shue), Cleveland, Ohio.

ABSTRACT Uterine leiomyomas are the most common benign gynecologic tumor. They are also a significant cause of morbidity, neces-
sitating treatments ranging from hormonal suppression to surgical intervention. Myomectomy, the removal of these highly
vascular tumors, offers significant quality of life and fertility-sparing benefit for patients affected by uterine leiomyomas
but with a risk of substantial intraoperative blood loss. This risk of hemorrhage leads not only an increased transfusion
rate but also he need for hysterectomy and other potential operative complications. Numerous medical and surgical techniques
have been developed to minimize potentially significant blood loss during abdominal, laparoscopic, and robotic-assisted myo-
mectomies. Combined with judicious preoperative assessment, these techniques substantially enhance patient safety during a
myomectomy and outcomes during recovery. Journal of Minimally Invasive Gynecology (2016) -, -–- Ó 2016 AAGL.
All rights reserved.
Keywords: Hemostasis; Leiomyoma; Myomectomy

Uterine leiomyomas are benign monoclonal neoplasms of
unclear etiology that arise from myometrial smooth muscle
cells. Leiomyomas are the most common benign gyneco-
logic tumor, with an estimated incidence of 70% to 80% in
women by age 50 years [1]. Risk factors for leiomyomas
include increasing age, family history, and African
American race. The clinical impact of leiomyomas can be
variable. Most women with leiomyomas are asymptomatic;
however, abnormal uterine bleeding, pelvic pain or pressure,
and infertility are all possible manifestations of these tu-
mors. The number, location, size, and behavior of the my-
omas (degeneration, prolapse) all have a significant impact
on the associated clinical manifestations. The diagnostic
modalities used for leiomyomas include physical examina-
tion findings (enlarged bulky, irregularly contoured uterine
shape), transvaginal ultrasound, saline-infusion sonogram,
hysteroscopy, and magnetic resonance imaging.
There are no financial disclosures or conflicts of interest to report.
Corresponding author: Lisa Caronia Hickman, MD, Cleveland Clinic Foun-
dation, 9500 Euclid Avenue A81, Cleveland, OH 44195.
E-mail: hickmal@ccf.org
Submitted December 25, 2015. Accepted for publication January 28, 2016.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Ó 2016 AAGL. All rights reserved.
http://dx.doi.org/10.1016/j.jmig.2016.01.026
For some leiomyomas observation may be appropriate,
especially in perimenopausal women, because decreasing
estrogen levels may lead to myoma involution and improve-
ment of clinical symptoms. Medical management may be an
appropriate option for certain patients, especially those who
are poor surgical candidates and use anti-inflammatory
drugs, tranexamic acid, and hormonal therapies to reduce
symptomatology. Radiologic interventional procedures,
such as uterine artery embolization, can also be used in
well-selected patients. When the decision is made to proceed
with surgical management, one must consider the location,
size, and number of myomas and the desire for future child-
bearing, because this will likely affect the surgical approach
and technique (open, hysteroscopic, vaginal, or minimally
invasive techniques) [2]. Patients must also be adequately
counseled on the risks and benefits of surgical intervention,
especially related to the risk of intraoperative hemorrhage.
Blood loss during a myomectomy can vary from approxi-
mately 100 mL in a conventional laparoscopic case to twice
that in an abdominal case, as demonstrated by Barakat et al
[2]. Further, a retrospective study comparing surgical out-
comes by route of myomectomy found that 6.5% of patients
undergoing an abdominal approach and 1.1% of patients
undergoing a minimally invasive approach (laparoscopic
2 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016

and robot-assisted) will require a blood transfusion [2].
Approximately 2% of patients will require conversion to a
hysterectomy [2,3].
A variety of preoperative medical and intraoperative med-
ical and surgical techniques are available to aid with hemo-
stasis during myomectomy (Tables 1 and 2). The purpose of
this review is to provide an evidence-based approach to
myomectomy by comparing the medical and surgical inter-
ventions available for reducing blood loss.
Methods
We searched for published articles in Ovid-Medline, the
Cochrane Library, and PubMed. The search syntax was
tailored individually for each database but included the
following main medical subject headings and text words:
‘‘myomectomy AND hemostasis,’’ ‘‘myomectomy AND
GnRH,’’ ‘‘myomectomy AND prostaglandins,’’ ‘‘myomec-
tomy AND hemostatic agents,’’ ‘‘myomectomy AND uter-
ine artery occlusion,’’ AND ‘‘myomectomy AND barbed
suture.’’ Our search was limited to studies from 1946 to
2016, with the last search performed in January 2016. We
limited our selection to peer-reviewed articles including
systematic reviews, meta-analyses, and prospective trials,
preferably randomized controlled trials (RCTs). When
none of these types of studies could be found to address a
topic, retrospective studies were also included. Articles
that were not published in English were used only if an En-
glish translation was available.
Search Results
The electronic and manual searches identified 1652
articles. Of these, 1608 were excluded based on lack of rele-
vance for this review. In total, 45 articles were included for
review in this article (Fig. 1).
Results and Discussion
Medical Interventions to Decrease Blood Loss
Gonadotropin-Releasing Hormone Agonists
Given the well-understood impact of estrogen on leio-
myoma growth and maintenance, the utility of
gonadotropin-releasing hormone agonist (GnRHa) treat-
ment before myomectomy has been extensively studied.
A Cochrane review examined the impact of GnRHa treat-
ment before myomectomy and analyzed the outcomes of
14 RCTs of GnRHa versus no pretreatment and 6 trials eval-
uating GnRHa versus placebo [4]. All studies included
reproductive-aged women undergoing either hysterectomy
or myomectomy (open, laparoscopic, or hysteroscopic)
who received 3 to 4 months of pretreatment with GnRHa
or placebo before surgical intervention. The study revealed
pretreatment with GnRHa had a small but significant posi-
tive impact on preoperative hemoglobin and hematocrit
levels, likely secondary to an improvement in menorrhagia
and therefore anemia. A reduction in intraoperative
estimated blood loss (EBL) was also demonstrated in
those receiving GnRHa before myomectomy (mean differ-
ence, 267.46 mL; 95% confidence interval [CI], 290.55
to 244.37). Only 1 trial demonstrated a significantly higher
postoperative hemoglobin concentration in women treated
with GnRHa versus no pretreatment (mean difference,
.8 g/dL; 95% CI, .2–1.4). Other notable findings in the
GnRHa group included a reduction in uterine volume and
size, myoma volume, and duration of postoperative hospital-
ization. This analysis did not demonstrate a translation of
decreased EBL to decreased transfusion requirement in the
treatment versus control groups. Thus, the true clinical appli-
cability of these data is not entirely clear. Given the rela-
tively small number of laparoscopic myomectomies (LMs)
included in this analysis, there was little evidence to support
an added benefit of GnRHa on reducing blood loss in

Table 1
Impact of medical interventions on hemostasis during myomectomy

Estimated Length of
intraoperative Postoperative Transfusion Operating postoperative
Intervention [reference] blood loss [Hb] rate time hospitalization
GnRHa [4,5] Y [ No change No change Y
Intravaginal prostaglandin [6–8] Y [/No change Y/No change Y/No change No change
Vasopressin*[9,10] Y [ Y N/A Y
Bupivacaine 1 epinephrine [11] Y N/A N/A Y N/A
Oxytocin infusiony [12] Y N/A Y N/A N/A
Gelatin thrombin matrix [13] Y [ Y N/A Y
Fibrin sealant–coated suture [14] Y [ N/A Y N/A
Intravenous tranexamic acid [15] No change N/A No change No change N/A

[Hb] 5 hemoglobin concentration; GnRHa 5 gonadotropin-releasing hormone agonist; N/A 5 not applicable.
* Combination of vasopressin 1 pedicle ligation or vasopressin 1 rectal misoprostol showed more efficacious results.
y
Only 1-time oxytocin infusion of 15 IU given at initiation of surgery demonstrated these results.
Hickman et al. Hemostatic Techniques for Myomectomy 3

Table 2
Impact of surgical interventions on hemostasis during myomectomy

Estimated Length of
intraoperative Postoperative Operating postoperative
Intervention [reference] blood loss [Hb] Transfusions time hospitalization
Laparoscopic myomectomy*[16,17] Y N/A N/A [ Y
Laparoscopic-assisted myomectomy*[18,19] Y N/A N/A Y Y
Robot-assisted laparoscopic No consensus N/A N/A No consensus No consensus
myomectomyy[20–22]
Uterine artery occlusion [23,24] Y N/A Y [ N/A
Vascular clips [25,26] Y [ No change [ No change
Pericervical tourniquet [27] Y N/A Y No change N/A
Monopolar vs bipolar cautery [28] No change N/A N/A N/A N/A
Harmonic scalpel [29] Y N/A N/A Y Y
Barbed suture [30,31] Y [ N/A Y N/A
Loop ligation of myoma pediclez [32] Y N/A Y N/A Y

[Hb] 5 hemoglobin concentration; N/A 5 not applicable.

* As compared with abdominal myomectomy.
y
As compared with laparoscopic and abdominal myomectomy.
z
Data shown for when loop ligation is combined with vasopressin.

minimally invasive surgery as compared with its significant
effect on open myomectomies [4].
In an effort to further elucidate the impact of GnRHa
treatment before LM, 3 RCTs with this aim were evaluated
in a meta-analysis [5]. A cohort of 85 of 168 women received
pretreatment with GnRHa therapy before surgery, and the
remaining patients were given placebo. In this analysis pre-
treatment with a GnRHa resulted in a significant decrease in
intraoperative EBL (mean difference, 60 mL; 95% CI,
39–82), thereby demonstrating an additive effect of GnRHa
with laparoscopic surgery on intraoperative hemostasis.
Fig. 1
Study selection strategy.
Accordingly, postoperative hemoglobin concentrations
were higher in the GnRHa group (mean difference,
1.15 g/dL; 95% CI, .46–1.83). No differences in transfusion
requirements, surgical complications, or conversions to
laparotomies were appreciated between the treatment
groups. GnRHa treatment did not reduce operative time,
perhaps because of a degenerative impact on the myoma
capsule and size, leading to increased surgical difficulty [5].
Taken together, there appears to be a clear benefit of
pretreatment with GnRHa before hysterectomy and open
myomectomy; however, the magnitude of its effect on hemo-
stasis in minimally invasive surgery is still not entirely as
clear, given the modest yet statistically significant impact
on postoperative hemoglobin levels. Further, the added
benefit on hemostasis must be weighed against the GnRHa
impact on operative time and technical challenge of the
myomectomy. Other considerations before GnRHa treat-
ment include cost and counseling on common side effects,
such as vasomotor symptoms, vaginal dryness, and
bone loss.

Intravaginal Prostaglandins
Prostaglandins are commonly used in obstetrics for their
ability to stimulate uterine contraction, thereby mitigating
postpartum hemorrhage. More than 20 years ago an observa-
tional study investigated the use of sulprostone, a prosta-
glandin E2 analog, and demonstrated its ability to reduce
blood loss during open myomectomies [33]. Since then,
multiple studies have examined the role of prostaglandins
on hemostasis during myomectomies. To evaluate its effi-
cacy, a randomized, double-blind, placebo-controlled study
of a single preoperative dose of dinoprostone, a vaginal
prostaglandin E2 suppository, 1 hour before abdominal
4 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
myomectomy was performed. This study revealed a signifi-
cant reduction in EBL and transfusion rates as well as higher
postoperative hemoglobin in the treatment group [6]. Simi-
larly, 2 randomized placebo-controlled trials examined the
impact of a single 400-mg dose of intravaginal misoprostol
(prostaglandin E1 analog) 1 hour before abdominal and
LM. Both studies demonstrated a significant reduction in
EBL and need for postoperative blood transfusion in the
treatment group, as compared with placebo [7,8].
Vasopressin
Vasopressin, known for its role in regulating homeostasis
and thereby peripheral vascular resistance, has also been
investigated for its role in controlling blood loss during myo-
mectomy. A prospective study of nearly 300 women under-
going LM were randomized to either leiomyoma pedicle
ligation, low-dose vasopressin injection (12 IU) in the area
surrounding the myoma, higher dose vasopressin injection
(20 IU) plus pedicle ligation, or oxytocin injection plus
pedicle ligation [9]. The study demonstrated that vasopressin
injection significantly reduced EBL and postoperative
hemoglobin change as compared with pedicle ligation; how-
ever, vasopressin injection and pedicle ligation together
were more efficacious than either treatment alone. Addition-
ally, length of hospital stay was significantly decreased in the
vasopressin plus pedicle ligation group. Oxytocin injection,
in contrast, had no significant effect on hemostatic measures
[9]. Another study investigated the use of 20 units of perivas-
cular vasopressin versus rectal misoprostol 400 mg plus 20
units of perivascular vasopressin in 50 women undergoing
abdominal myomectomy [10]. This study found that the
combination of perivascular vasopressin plus rectal miso-
prostol had a significant impact on EBL (mean, 334 mL vs
623 mL; p , .03), change in postoperative hemoglobin
levels (mean change of 1.6 g/dL vs 3.0 g/dL; p , .02), and
transfusion requirements (0 vs 5 transfusions; p , .02).
It is important to note, however, that vasopressin use is
not without consequence. Although uncommon, several
studies have reported severe cardiopulmonary complications
in healthy individuals, including hypotension, bradycardia,
cardiac arrest, and pulmonary edema at doses ranging
from .2 to .6 units/mL [34–38]. Given the potential serious
side effects, vasopressin should be diluted to a
concentration of .05 to .3 units/mL [36]. Open communica-
tion with anesthesia staff should also be a priority, so that
vasopressin side effects may be rapidly identified and treated
if they occur.
Bupivacaine Plus Epinephrine
The impact of bupivacaine plus epinephrine versus placebo
was evaluated in a double-blind, randomized, placebo-
controlled trial of women undergoing LM [11]. Bupivacaine
plus epinephrine or saline was injected into the serosa
and/or myometrium overlying the myoma before dissection.
Intraoperative treatment with bupivacaine plus epinephrine
resulted in significantly decreased EBL, operative time,
surgical difficulty, and postoperative pain. Further, there
was no impact on blood pressure or heart rate in the 2 groups.
This study provides support for the efficacy of bupivacaine
plus epinephrine on hemostasis during LM [11].
Oxytocin Infusion
The role of oxytocin on hemostasis can be best appreciated
with its commonplace obstetric use in achieving hemostasis
after delivery and preventing postpartum hemorrhage.
Capitalizing on its known physiologic role of stimulating uter-
ine contraction via its action on smooth muscle cells, oxyto-
cin’s utility in attenuating blood loss during myomectomies
has been evaluated in multiple research studies. In a random-
ized, double-blind, placebo-controlled study of nearly 100
women undergoing either open or vaginal myomectomy, the
role of intraoperative oxytocin infusion versus placebo was
evaluated for its impact on EBL and blood transfusion require-
ments [39]. In this study treatment with oxytocin had no
impact on outcome measures as compared with the placebo
group. In contrast, a prospective study evaluated the effect of
oxytocin infusion on EBL and transfusion requirements dur-
ing laparoscopic-assisted vaginal myomectomy [12]. The
authors found blood loss and transfusion rates were signifi-
cantly higher in the untreated group (485.7 6 321.6 mL vs
364.1 6 173.2 mL [p , .05] and 26.7% vs 6.1% [p , .05],
respectively). A similar study by the same group evaluated
the impact of oxytocin infusion on women undergoing LM
[40]. Again, the authors identified a significant impact on
EBL, with a mean decrease of 176 mL (p , .05) in the
oxytocin-treated group. The discordance of these findings as
compared with the study by Agostini et al [39] may be attrib-
uted to the oxytocin dosing differences between the studies
(a 1-time 15-IU infusion vs a continuous infusion at a rate of
40 mU/min), the timing of treatment administration (at the
initiation of surgery vs the initiation of anesthesia), and the
surgical approach (open/vaginal vs laparoscopic).
Hemostatic Agents
The utility of hemostatic agents to reduce blood loss in
myomectomy has also been the subject of investigation.
The efficacy of gelatin-thrombin matrix (FloSeal; Baxter
Healthcare Corp., Fremont, CA) versus placebo was evalu-
ated in a prospective randomized cohort of 50 women [13].
In this study the average EBL was significantly decreased
in the treatment group (mean 80 6 25.5 mL vs
625 6 120.5 mL; p 5 .01), as was the need for intraoperative
blood transfusion (0 vs 20%; p , .001). Postoperative blood
loss, as assessed by surgical drain output 48 hours after
surgery, was 10 times less (25 6 5 mL vs 250 6 75 mL;
p 5 .001) and postoperative hemoglobin was significantly
higher (.5 6 .2 vs 2.8 6 .9, p 5 .005) in the treatment versus
control groups. Length of hospitalization was also signifi-
cantly reduced in the treatment group. Although the cohort
size was relatively small, FloSeal’s significant impact on
hemostasis suggests that it may be an effective tool; however,
further investigation is required.
Hickman et al. Hemostatic Techniques for Myomectomy
Similarly, the use of a novel fibrin sealant–coated
(Tisseel; Baxter Healthcare Corp., Deerfield, IL) suture dur-
ing LM was examined in a case-control study composed of
30 women [14]. This study, despite a relatively small patient
population (15 in each group), demonstrated a significantly
reduced mean time to achieve hemostasis, operative time,
EBL, and postoperative hemoglobin change in the treatment
group.
Intravenous Injection of Tranexamic Acid
Tranexamic acid has been used in a variety of specialties
for its antifibrinolytic properties and has been used orally
with good effect in patients with heavy uterine bleeding
[15]. An RCT investigated the efficacy of intravenous tra-
nexamic acid during abdominal myomectomy. In this study
patients were given a 10-mg/kg bolus of vasopressin
(100 mg/mL) over a 10-minute period in the 15 minutes
before surgery, followed by a continuous infusion of
1 mg/kg/hr in 1 L of saline for a total of 10 hours. This dosing
regimen was chosen given its use in other subspecialties. The
study was unable to demonstrate any significant impact on
blood loss, duration of surgery, or need for blood transfusion
[41]. Given the positive impact of tranexamic acid on hemo-
stasis in other specialties, perhaps modifications to the intra-
venous tranexamic acid dosing and administration regimens
may translate to a positive impact on hemostasis during
myomectomy.
Surgical Methods to Decrease Blood Loss during the
Minimally Invasive Myomectomy
Laparoscopic Myomectomy
LM is a surgical procedure in which the myomectomy is
performed entirely by laparoscopic technique, without a
minilaparotomy incision. Numerous trials have shown
several advantages of LM versus abdominal myomectomy.
In 1 meta-analysis, which included 6 RCTs involving 576
patients, LM was associated with decreased recovery time
and lower postoperative pain. The EBL was also signifi-
cantly less, and the technique was associated with fewer
complications. Operating time, however, was longer with
LM [16]. Tinelli et al [17] confirmed the above findings by
showing EBL was significantly less (p , .0001) for patients
treated with LM as compared with abdominal myomectomy.
Laparoscopic-Assisted Myomectomy
Laparoscopic-assisted myomectomy is a variation on the
traditional LM. This technique uses a minilaparotomy inci-
sion to help facilitate the LM. The incision can be used
to assist with myoma enucleation, uterine defect closure,
and/or morcellation. Laparoscopic-assisted myomectomy
may be used for submucosal myomas that cannot be properly
treated by hysteroscopic excision, intramural, or subserosal
myomas. A benefit of the minilaparotomy is that it facilitates
palpation of any uterine defect, and this technique is espe-
5
cially favorable when entry into the endometrial cavity is
planned. In comparison with a traditional abdominal laparot-
omy, Nezhat et al [18] found laparoscopic-assisted myomec-
tomy to reduce hospital stay. Kalogiannidis et al [19] found
laparoscopic-assisted myomectomy could significantly
reduce operative time by an average of 15 minutes
(p 5 .01) with less EBL (p 5 .03).
Robotic-Assisted LM
Robotic-assisted LM (RALM) involves the use of the da
Vinci robotic surgical system (Intuitive Surgical Inc., Sunny-
vale CA), which provides increased surgical dexterity during
minimally invasive myomectomy and permits greater accu-
racy with the layered closure of uterine defects. Several
studies have compared RALM with LM with overall clear ad-
vantages over LM. However, Gargiulo et al [20] noted that
RALM had a significantly longer operating time (mean differ-
ence, 76.8 minutes) and a higher EBL (mean difference,
24.2 mL). In contrast, a more recent retrospective case-
control study noted that EBL was higher for those that under-
went LM (232.7 vs 138.4, p 5 .006) [21]. A meta-analysis
comparing RALM with both abdominal myomectomy and
LM found a significantly decreased EBL in robotic cases
versus abdominal cases, but no difference was found in
EBL when the 3 modalities were compared [22]. Overall, lit-
tle consensus has been reached over whether or not RALM
has any advantage over of LM in reducing EBL, and no
RCTs have been performed to date comparing these 2 surgical
methods. The lack of consensus among these studies may be
due to variations in surgeon experience with the da Vinci sys-
tem and differences in number, size, and location of myomas.
Uterine Artery Occlusion
A more radical approach to reducing blood loss during a
myomectomy is to temporarily or permanently occlude or
ligate the uterine arteries before the procedure. Liu et al
[23] showed in a nonrandomized trial that premyomectomy
uterine artery ligation significantly decreased intraoperative
EBL (mean decrease, 200 mL). Myoma recurrence rates
were also lower in the uterine artery occlusion group by
2 months (0% vs 19.4%) with no significant impact on
fertility [23]. Alborzi et al [24] further confirmed these re-
sults, showing uterine artery occlusion before LM resulted
in a lower EBL (mean difference, 229 mL; p 5 .0001) and
blood transfusion requirement. Another important finding
in this study was the lack of impact on subsequent fertility
(35% vs 35.7%; p 5 .966) and live birth rates (28.5% vs
30%; p 5 .63). A potential drawback of this technique is pro-
cedure prolongation, which was noted to be approximately
17 minutes [24].
Uterine artery embolization is theoretically another
approach that could be used to limit blood loss during a myo-
mectomy; however, no studies to date have looked at this
modality intraoperatively. The work of McLucas and
Voorhees [42] focused on using uterine artery embolization
preoperatively for both hysteroscopic and laparoscopic
6 Journal of Minimally Invasive Gynecology, Vol -, No -, -/- 2016
myomectomies, with 72% of patients reporting symptomatic
improvement at an average of 4.7 months after surgery.
Unfortunately, there was no elaboration regarding the effects
of embolization on reducing intraoperative blood loss. This
could be an avenue for future research.
Vascular Clips
The effect of bilateral temporary occlusion of the uterine
arteries with vascular clips during LM was studied in an
RCT [25]. Patients in the experimental group had both uter-
ine arteries temporarily occluded during the surgery using
titanium Yasargil vascular clips (Aesculap Inc., Center
Valley, PA). These clips are inserted through a 10-mm trocar,
opened by alligator forceps, and placed over the uterine ar-
teries. Patients in the control group had no intervention.
The results showed a statistically significant lower decrease
in hemoglobin when using the vascular clips (1.2 g/dL vs
1.45 g/dL; p , .05). No transfusions or major complications
occurred as a result of vascular clip placement, and there was
no change in duration of hospital stay. However, the surgery
required on average an extra 15 minutes for clip placement
on the uterine arteries. Another similar but more recent study
confirmed that mean EBL was significantly lower in the
group receiving vascular clips to transiently occlude the
uterine arteries during surgery (109 6 73.28 mL vs
203.4 6 152.39 mL; p , .05) [26].
These studies demonstrate that vascular clips provide a
safe and effective tool to reduce EBL during myomectomy.
Moreover, vascular clips are particularly beneficial because
the surgeon controls the duration of reduced blood supply
and there are no systemic side effects, which can occur
with some of the aforementioned medical interventions.
The clips may be removed after completion of the procedure,
allowing an immediate return of the physiologic blood sup-
ply. This is in contrast to vasopressin injection, in which the
duration of action is not completely controlleddthe vaso-
constrictive effect may last longer than anticipated and
lead to potential postoperative hemorrhage. Additionally,
systemic side effects may result if vasopressin is incorrectly
injected directly into a blood vessel [25,43]. For these
reasons vascular clips may be more advantageous. Finally,
a subsequent longitudinal study followed patients who had
undergone transient uterine artery occlusion with vascular
clamps over 4 years prior and once again found no impact
in pregnancy outcomes [43]. More recently, Donat et al
[44] demonstrated the combination of vascular clips and
bulldog clamps to occlude the uterine arteries in a patient
who declined blood products and thereby decreased the
potential transfusion requirement.
Pericervical Tourniquet
The use of a pericervical tourniquet was found to signif-
icantly reduce EBL during myomectomy in multiple studies.
Although different methods were used for the pericervical
tourniquet, the results remained consistent in favor of tourni-
quet placement [27]. In addition, pericervical tourniquet use
was also associated with decreased transfusion rates
compared with control subjects. There was no significant
effect on surgical time or postoperative morbidity.
Randomized studies have also compared tourniquet use
with vasopressin and uterine artery ligation for reducing
EBL during myomectomy [45,46]. Fletcher et al [46]
concluded that vasopressin resulted in a lower EBL than
the Foley catheter tourniquet (287.3 mL vs 512.7 mL;
p 5 .023). Similarly, Helal et al [45] found that uterine artery
ligation resulted in a lower EBL compared with tourniquet
(433.80 6 285.21 vs 823.23 6 237.33 mL; p , .001).
Finally, an RCT by Taylor and Magos [47] investigated the
impact of triple tourniquets during abdominal myomectomy.
In this study women randomized to the treatment group
(n 5 14) had a number 1 polyglactin suture ligation of the
uterine arteries at the level of the cervix and polythene tour-
niquets placement to transiently occlude the ovarian arteries.
The women in the control group (n 5 14) did not receive
tourniquets. This study found a significant decrease in blood
loss in the tourniquet group (489 mL 6 362 vs 2359 6 1241;
p , .0001), which also translated to a significantly lower
transfusion requirement (1 patient vs 11; p 5 .0003). In sum-
mary, pericervical tourniquets and uterine artery ligation
have been shown to decrease EBL and need for transfusion
during myomectomy. This relatively simple technique is
likely best used as an adjunct to other hemostatic techniques.
Electrosurgical Methods
Electrosurgical methods are a common tool for hemosta-
sis in a wide variety of open and minimally invasive sur-
geries. In general, these methods include monopolar,
bipolar, and ultrasonic electrosurgical devices. With all
forms of energy devices, there is risk associated with thermal
injury of tissues adjacent to but not directly contacted by the
device. Several studies have evaluated the degree of thermal
spread from the above devices, and most showed signifi-
cantly increased spread with monopolar electrosurgery
[48]. In addition, monopolar electrosurgery carries a risk
of ‘‘capacitative coupling,’’ when a defect in the insulation
of a monopolar device leads to induction of a current in
neighboring tissue. Limited data are available on the utility
of specific electrosurgical methods in reducing blood loss
during myomectomy. A study of individuals undergoing
open myomectomies compared 67 patients in which bipolar
electrosurgery and 42 cases in which monopolar surgery was
used [28]. A small but not statistically significant difference
was noted in EBL for the bipolar compared with monopolar
surgeries (159.94 6 50.59 mL vs 104.47 6 50.55 mL). An
RCT investigated the utility of an ultrasonic device, the har-
monic scalpel, versus electrosurgery with bipolar forceps
and dilute epinephrine on LM operative time, hemostasis,
and surgical outcomes [29]. This study found a significant
positive impact of the harmonic scalpel on total operative
time (71.8 6 26.7 vs 88.8 6 35.5; p 5 .000), intraoperative
blood loss (135.2 6 89.1 vs 182.8 6 116.8; p 5 .004), length
of hospitalization, and postoperative pain. Importantly, the
Hickman et al. Hemostatic Techniques for Myomectomy
harmonic scalpel was not associated with increased surgical
difficulty. Whether or not other types of electrosurgical
devices significantly affect EBL requires further research.
Barbed Suture
Unidirectional and bidirectional barbed sutures have been
used in LM since 2008. This type of suture contains small
barbs in a helical array that holds in tissue and eliminates
the need to tie surgical knots [30]. As such, the barbed suture
has been shown to decrease suturing time and maintain
adequate tension of the suture line during its use. These fac-
tors are advantageous in LM, because they typically lead to a
lower EBL. Alessandri et al [31] performed an RCT of LM
with or without unilateral barbed sutures. The control group
received standard continuous sutures with intracorporeal
knots, and the experimental group received knotless barbed
sutures. Both groups started with similar mean preoperative
hemoglobin concentrations (10.6–11.7 g/dL and 10.8–
12 g/dL, respectively; p 5 .508); however, EBL was signif-
icantly lower in the experimental as compared with the con-
trol group (DHb 5 .5–.7 versus .7–1.1; p 5 .004).
Additionally, the time required to suture the uterine wall
was significantly shorter in the experimental group than
the control group (9.6–13.4 vs 15.7–19.1 minutes;
p , .001). These results support the use of barbed sutures
to decrease EBL in LM. Tulandi and Einarsson [30] per-
formed a meta-analysis evaluating the efficacy of barbed
versus standard suturing in LM. A comparison of 3 studies
was performed, and similarly it was found that uterine
closure with barbed sutures resulted in a significant decrease
in total operating and suturing time. EBL was also signifi-
cantly lower, but it is important to note that the decreased
blood loss could have been attributed to other potentially
confounding factors of the surgery, such as the number of
myomas removed, length and number of uterine incisions,
and/or use of any other medical interventions (such as
vasopressin or GnRHa) to decrease EBL [30].
Loop Ligation of Myoma Pedicle
The process of ligating the myoma pseudocapsule was
shown to be effective in reducing EBL in LM, especially
when combined with injection of vasopressin to constrict
the myometrial blood vessels. This involves making a verti-
cal incision on the most prominent portion of the myoma
using a monopolar electrode, and after two-thirds of the
tumor is enucleated, a loop at the basal part of the myoma
is made using a Roeder knot. This loop is tightened until
the pseudocapsule is fully removed, causing complete occlu-
sion of blood vessels in the pseudocapsule [32]. Zhao et al
[32] performed an RCT dividing 105 patients into 3 groups:
loop ligation with vasopressin, vasopressin alone, and
neither loop ligation nor vasopressin. They found that EBL
(58.67 6 27.53 mL vs 224.35 6 131.17 mL vs
363.68 6 147.83 mL, respectively; p , .001), postoperative
hospital stay (3–5 days vs 3–7 days vs 4–7 days,
respectively; p , .001), number of blood transfusions
7
(0 vs 1 vs 5, respectively; p 5 .024), and number of conver-
sions to laparotomy (0 vs 3 vs 6, respectively; p 5 .038) in
the group receiving loop ligation with vasopressin was
significantly lower than in the other groups. This study indi-
cated that compared with no treatment, loop ligation of the
myoma pedicle during myomectomy also reduced EBL.
Further, the combination of loop ligation with vasopressin
injection was the most effective in reducing EBL.
Conclusions
A variety of preoperative and intraoperative options are
available to help decrease blood loss, transfusion require-
ments, change in postoperative blood count, and length of
hospitalization. Using an evidence-based approach to
myomectomy, regardless of type of surgical method
(open vs minimally invasive), can have a profound impact
on surgical outcomes. It is also important to note that
many of these techniques may be used together, thereby hav-
ing an additive effect on decreasing intraoperative blood
loss. Finally, use of these techniques becomes especially
important in patients who are anemic before the surgical
intervention, at increased risk of intraoperative blood loss,
or who decline the use of blood products.
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