Laparoscopic versus Abdominal Myomectomy: Surgical and Post-Operative Outcomes in CHRACERH-Yaounde

Introduction: Fibroid benign tumour of the uterus can be operated either by laparotomy or laparoscopy. Laparoscopy is not well vulgarised in our settings. Objective: The main objective was to compare the surgical and post-operative outcomes of laparoscopic versus abdominal myomectomy. Methods: We performed a comparative analytical cross sectional study from 1st January 2016 to 31st March 2018 consisted of two groups: group 1 of women who underwent laparoscopic myomectomy (LM) and group 2 of women who underwent abdominal myomectomy (AM). The data collected was entered in Epi Info 7.2 version and exported to IBM SPSS Statistics version 22 for analysis. We used alpha error margin of 5% and confidence interval of 95%. Results: We enrolled 50 cases of myomectomy consisted of 33 (66.0%) files for AM and 17 (34.0%) files for LM. The clinical presentation of fibroid was similar in both groups. The main operation time (H) was (1.27 ± 0.13) for laparoscopy which is much less than (2.05 ± 0.07) for laparotomy group (p = 0.006). In AM group we had 04 post-operatory complications against zero complications in LM group but the difference was not statistically significant (p = 0.387). In the second look laparoscopy, the types of adhesions were not statistically significant (p = 0.471). Conclusion: Laparoscopic offers advantages compared to abdominal myomectomy.


Introduction
Fibroids are the most common benign tumours of the uterus with a prevalence of 70% to 80% in women [1]. Although only 25% to 30% of women are affected by symptoms like pelvic pain, pressure, heavy menses, recurrent pregnancy loss, and infertility, it remains the leading indication for hysterectomy and a common women's health concern [2] [3] [4] [5]. While hysterectomy remains the definitive treatment for fibroids, myomectomy, however, remains the gold-standard for women affected by symptoms of a fibroid uterus who desire uterine preservation [2]. Myomectomy has traditionally been managed by laparotomy and has demonstrated effective clinical outcomes for symptoms as well as fertility [2].
Laparoscopic myomectomy is an advanced laparoscopic skill that requires the ability to suture effectively and efficiently [5] [6]. The benefits of the laparoscopic approach are well known and have been found superior to laparotomic myomectomy in terms of less blood loss, diminished postoperative pain, fewer overall complications and faster recovery [1]. Operations through laparoscopy are mainly done for infertility in case of tubal obstruction, rarely for myomectomy in our milieu. It is in the view of promoting this route of surgery that we decided to conduct the study.

Methods
We carried out a comparative analytical cross sectional study with retrospective data collection of all cases myomectomy either through laparoscopy or laparotomy at CHRACERH from 1st January 2016 to 31st March 2018. The study population consisted of two groups: Group 1 made up of women who underwent laparoscopic myomectomy and group 2 composed of women who underwent laparotomy myomectomy. Group 1 consisted of women who underwent myomectomy via laparoscopy and group 2 women who underwent myomectomy via laparotomy. The number of fibroid excised during surgery less than or equals to 4 and the size of the largest fibroid/sum of the sizes of the fibroids less than or equals to 10 cm. We excluded in for both groups women who had myomectomy via laparoscopy converted to laparotomy due to difficulty performing laparoscopic myomectomy and also patients' medical records with incomplete information. The sampling technique was consecutive and non exhaustive sampling constitutes all patients' medical records that fulfil the eligibility criteria. Using Schesselman formula for the calculation of our sample size we had a minimum sample of 42 divided into 14 for LM and 28 for AM. In our study we definitely worked on 50 patients, 17 for LM and 33 for AM. The data collected will be en-

Ethical Consideration
We obtained ethical approval from the institutional ethical review board of the Faculty of Medicine and Biomedical Sciences. Authorization was also obtained from the director of study site. The identity and personal details of participants of the study were kept strictly confidential. Only the investigator was able to decipher those codes used in the questionnaires.

Limitations of Our Study
 The number and sizes of fibroid limit the laparoscopic management as compared to the laparotomy management which can remove many fibroids and large ones.  The patients were not randomized.
 Long-term data such as pregnancy and obstetric outcomes as well as recurrence rate, were not evaluated in our study.

Socio-Demographic Profile of the Population
Using the register of the theatre and hospitalization record, a total of 128 names were selected. All files in the archives were examined in the search for 128 files and appropriate cases (see inclusion criteria) selected for the study. Out of 128 files, 78 files were found in the archives among which we had 60 files for abdominal myomectomy, 18 files for laparoscopic myomectomy. We finally recruited 50 files into our study among which we had 33 (66.0%) files for abdominal myomectomy, 17 (34.0%) files for laparoscopic myomectomy giving an approximate ratio of one LM is to two AM. All the 50 files selected fulfilled the inclusion criteria. Any other files with missing information and did not conformed to the inclusion criteria were excluded.

Para-Clinical Diagnosis of Fibroid in Study Population
The distribution of the FIGO types on U/S was different (p < 0.001) with FIGO type V being the most represented in AM group 18 (54.5%) patients and FIGO type V and VI being the most represented in LM group 08 (47.1%) patients.
The size of the largest fibroid was different in the two groups (p = 0.026). It ranges from 2.0 cm to 7.8 cm in LM group with an average 5.00 cm ± 1.76 and from 3.4 cm to 9.8 cm in AM group giving an average of 6.10 cm ± 1.52. The most represented largest size of the fibroid in the LM group was 4.3 cm and in the AM group was 5.0 cm.

Post-Operative Outcomes of the Study Population
There was 01 (3.0%) post-operative transfusion of 2 units of blood in AM group Open Journal of Obstetrics and Gynecology against no transfusion in LM group. The difference was not statistically insignificant (p = 0.542).
There was a significant difference in the mean duration of hospitalisation in both groups (p ≤ 0.001). The duration of hospitalisation varied from 03 days to 08 days in AM group with the average of 5.74 days ± 0.06 and from 02 days to 05 days in LM group giving an average of 3.77 days ± 0.17. Most of the patients (41.2%) in LM group were discharged between 3 rd and 5 th day of post operation while in the AM group, most of the patients (69.7%) were discharged between the 5 th day and 8 th day of post operation. After surgery 04 (12.1%) patients in AM group and non in LM group. The complications included; bleeding from incision site, internal bleeding, severe anaemia and wound infection. The difference was not statistically significant (p = 0.387). There was a difference in type of peritoneal adhesions which was not statistically significant. Lastly LM was more expensive than AM (p ≤ 0.001).  (Table 1). On ultrasonography, the FIGO types were significantly different (p < 0.001): Type V and VI 08 (47.1%) patients in LM group and Type V 18 (54.5%) patients in AM group (Table 2). This is similar to a study carried out by Innie Chen et al. in 2011 [5] who reported difference in the subserosal fibroid in the two groups (p = 0.001). The number of fibroids (mean ± SD) was similar in both groups (p = 0.772): 3.12 ± 1.05 in LM group and 3.27 ± 2.05 in AM group (Table 3). This was also similar with the study obtained by Nicel et al. in 2014 [7] that showed the number of fibroids was the same in the two group pre-operatively (p = 0.232). Renisavljevic et al. 2012 [8] in their study conclude that there was no difference in the number of fibroids on U/S in the two groups

Discussion
The size of largest fibroid (cm) (mean ± SD) diagnosed with ultrasound was different on both groups (p = 0.026): 5.00 cm ± 1.76 in LM group and 6.10 cm ± 1.52 in AM group. In both groups, the surgical outcomes some differences. The number of fibroids (mean ± SD) found during surgery was similar in both groups (p = 0.556): 3.00 ± 1.27 in LM group and 3.30 ± 1.90 in AM group. There was a difference in the size of the largest (cm) fibroid (mean ± SD): 5.34 ± 1.65 cm in LM group and 7.53 ± 4.62 cm for AM group which was not statistically significant (p = 0.064) ( Table 2). Barakat et al. in 2011 [9] in their study stipu-   [8] in their study also reported that the average blood Open Journal of Obstetrics and Gynecology  [11] who reported the average blood loss for LM 246 ± 161 ml and 351 ± 219 ml for laparotomy group (p = 0.03) which was statistically significant. Also Wang et al. [12] in 2018 in a meta-analysis: robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids concluded that there was a significant less amount of blood in robotic assisted laparoscopic myomectomy compared to laparotomy myomectomy. The mean operation time (H) (mean ± SD) was 1.27 ± 0.13 for LM group which was significantly less than 2.05 ± 0.07 for AM group (p = 0.006) (  [15] also arrived at the same conclusion that length of hospital stay was shorter for LM group compared to AM group. There were zero post-operative complications for LM groups and 04 (12.1%) for AM group and therefore could not be statistically compared (p = 0.387) (

Conclusion
Per-operative laparoscopic myomectomy was superior to abdominal myomectomy in terms of shorter duration of surgery and decrease blood loss.
Post-operatively laparoscopic myomectomy was advantageous over abdominal