Design: Case report of perioperative strategies.

Setting: Laparoscopic myomectomy in a a tertiary hospital.

Patients or Participants: A 33-year-old nulliparous woman, with abnormal uterine bleeding and dysmenorrhea, not responsible to medical treatments and desiring future pregnancy. The MRI shows a myometrial transmural nodule in the cervical and anterior uterine wall, measuring 8.3 x 8.2 x 8.1 cm with restricted weighted diffusion and areas of hyaline and cystic degeneration, suggestive of atypical leiomyoma.

Interventions: Preoperative vaginal use of 400mcg of misoprostol, one hour prior to the laparoscopic procedure. Intraoperatively, the uterine arteries were bilaterally identified laterally to the ureters, after opening the posterior leaf of the large ligament and clamped. Both utero-ovarian ligaments and round ligaments were also clipped, reducing uterine blood supply. Diluted Vasopressin was injected into the anterior myometrium. A transverse incision was performed with careful identification of leiomyoma pseudo-capsule and cauterization of its vessels. After myomectomy, a hemostatic 2.0 barbed suture closure was performed, and a oxidized regenerated cellulose hemostatic barrier was applied covering the incision. Clips were removed.

Measurements and Main Results: The surgery lasted 200 minutes with a total blood loss of 255 ml. Hemoglobin dropped from 12,9 g/dL to 11,8 g/dL. The nodule measured 14,5 cm and histological analysis reported a typical leiomyoma. The patient was discharged the following day

Conclusion: Laparoscopic myomectomy is associated with longer operating hours and more intense blood loss than hysterectomy. Misoprostol, temporary uterine artery clamping, and intramyometrial vasopressin injection are associated with lower blood loss. Barbed suture decreases operative time. Our case shows how the combination of strategies contributes to a successful post-operative result.