الفهرس 
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Abstract
SUMMARY
F
ibroids are tumor of the smooth muscles and the connective tissues of the uterus.
It is the most common benign pelvic tumor affecting about 20% of women above 35 years of age. The diverse symptomatology of fibroids can be attributed to size, number and location of the tumors. The common symptoms include menorrhagia, infertility, abdominal mass and pressure effects.
Recent advances have increased the treatment options available however surgery remains the main stay of treatment especially in symptomatic patients. The most serious complication during abdominal myomectomy is severe intraoperative hemorrhage. Uncontrolled hemorrhage may necessitate hysterectomy. Thus several methods are employed to decrease blood loss during myomectomy operation.
This study compared the effect of Preliminary Uterine artery ligation and peri-cervical tourniquet on blood loss during myomectomy operation. The study was conducted in Ain Shams University Maternity Hospital where 100 patients fulfilling the criteria of the study were recruited from the gynecology outpatient clinic of the hospital.
After enrollment, an informed written consent was taken from all participants before recruitment in the study, and after explaining the purpose, possible risks and complications (including possibility of blood transfusion and the possible need for hysterectomy) of different procedures carried out in the study.
The patients were randomly categorized into two groups:
group A: Bilateral uterine artery ligation was done preliminary to myomectomy: The uterovesical fold of the peritoneum is opened and the bladder is pushed down.This moves the ureters laterally and prevents them being included in the suture. The uterine vessels are identified on either side and ligated
group B: The tourniquet method was used where the urinary bladder was dissected downwards from the lower uterine segment, and then a perforation was made in the posterior leaflet of the broad ligament bilaterally at the level of uterine isthmus. A tourniquet (using 16- inch Foley catheter) was passed through the perforation encircling the uterine arteries bilaterally. The Fallopian tubes and the ovaries were carefully excluded from the line of the tourniquet to avoid direct compression and necrosis. The tourniquet was released intermittently (at about 30 minutes interval) during the surgery and finally removed after the repair of the uterus.
Trans-abdominal myomectomy was performed by a team of skilled lecturers in obstetrics and gynecology in all patients according to the standard technique through transverse lower abdominal incisions (Pfannensteil incision).
Post-operative venous blood samples of hemoglobin and hematocrit levels were withdrawn from patients after 24 hours to avoid wrong results due to hemodilution by intravenous fluids in the first 24 hours.
Primary outcome:
- Difference between Pre and post-operative hemoglobin and hematocrit levels:
Postoperative hemoglobin and hematocrit levels were measured 24 hours after the operation via a venous blood sample.
Secondary outcomes:
- The need for postoperative blood transfusion:
It was indicated when intra-operative blood loss exceeds 15% of the patient’s estimated blood volume, which is equal to the patient’s weight in kilograms multiplied by 65).
There are several methods available to directly or indirectly measure blood volume, but all are impractical in routine clinical practice. The mean value for indexed blood volume (ᵢBV) in normal weight adults is 70 mL/kg for males and 65 mL/kg for females. Since ᵢBV decreases in a non-linear manner with increasing weight, this value can’t be used for obese and morbidly obese patients.
Blood transfusion can be guided by measuring allowable blood loss.
- The Estimated blood loss= estimated blood volume x (preoperative haematocrit - postoperative haematocrit) then divided by preoperative haematocrit.
- Need for conversion from myomectomy to hysterectomy:
It was indicated when there was uncontrolled intra-operative hemorrhage affecting the patient’s vital signs and not responsive to conservative measures, or when it was impossible to reconstruct the uterus because of the many defects left by the removal of multiple fibroids.
- Intra-operative or post-operative complications:
e.g. Bladder injury, hematoma formation or post-operative fever; temperature greater than 38°C within 24 hours after surgery.
- Operative time measured in minutes:
It was measured from the start of skin incision till skin closure
- Duration of hospital stay in days:
Decision of discharging the patient from hospital was taken by the surgeon who performed the operation based on patient’s wellbeing, i.e. easy ambulation, absence of anemia clinically and by measuring hemoglobin level, bowel motility and presence of clean and dry wound.
Shifting from applying method of decreasing blood loss intra-operatively to another alternative method, addition of another method and (or) conversion from myomectomy to hysterectomy should be justified and explained by the senior surgeon.
Elimination of bias:
- Laboratory samples were done in the same laboratory preoperative and postoperative.
The demographic features of the investigated research groups in which there was no statistical significant differences as regards age, BMI and parity, Also there was no statistical significant differences between the investigated research groups as regards myoma number & size and uterine size.
There was no statistical significant difference between the investigated research groups as regards preoperative hemoglobin (p value= 0.266). Hemoglobin reduction was statistically significantly lower among ligation research group (p value<0.001). Postoperative hemoglobin was statistically significantly higher among ligation research group (p value <0.001). Value of ligation over Tourniquet in limiting Hb reduction in which reduction difference mean ± SD =0.4±0.1, 95% CI=0.3–0.5.
There was no statistical significant difference between the investigated research groups as regards preoperative hematocrit (p value=0.360). Hematocrit reduction was statistically significantly lower among ligation research group (p value <0.001). Postoperative hematocrit was statistically significantly higher among ligation research group (p value <0.001). Value of ligation over Tourniquet in limiting HCT reduction in which reduction difference mean ± SD =1.1+/-0.1,95% CI=0.9–1.3.
The Estimated intraoperative blood loss was statistically significantly fewer among ligation research group
(p value<0.001). Value of ligation over Tourniquet in limiting blood loss in which blood loss mean ± SD =175.8±15.5, 95% CI=145.1–206.5.
Also, the Operation duration was statistically significantly shorter among ligation research group (p value <0.001). Value of clamping over Tourniquet in shortening operation duration in which Duration reduction Mean±SD=13.4±1.9, 95% CI=9.6–17.3.
Regarding Blood transfusion, it was statistically significantly less frequent among ligation research group
(p value=0.029). Postoperative analgesia was statistically significantly more frequent among ligation research group
(p value=0.037)