The powerful hemostatic devices are one of the milestones for successful laparoscopic surgery

Abstract

Uterine fibroids are the most common benign uterine tumors, and the choice of treatment depends on the patient's age, the reason for treatment, the issue of fertility preservation, and the patient's preference.1 Uterine fibroids, undoubtedly, are one of the most frequently used indications for surgery, especially laparotomy,2 and uterine fibroids also contributed to the most frequent cause of hysterectomy.3 However, organ-preservation concept has been widely accepted in the modern medicine4; therefore, there are many strategies developed for minimizing the invasiveness of surgery (robotic, laparoscopic surgery, hysteroscopic surgery, etc.)5,6 and minimizing the needs for operation (medicine treatment, uterine artery embolization, etc.).7,8 It is very important to further improve the quality of life and outcome of uterine fibroid treatment, and of most importance, preservation of the future fertility ability is always considered. Among these treatments for uterine fibroids, myomectomy, a very popular and well-done procedure for the maintenance of future fertility, is still a complicated surgery when a minimally invasive approach is used. Therefore, any technique or instrument to minimize the surgery-related trauma, decrease surgery-related blood loss and improve the performance during operation is welcome.9,10 We are glad to learn that Dr. Huang's study published in this issue of the Journal of the Chinese Medical Association attempted to clarify the role of different hemostatic devices in the laparoscopic myomectomy.11 The authors enrolled 817 women in the Chang Gung Memorial Hospital at Linkou between January 1997 and September 2015, to study the perioperative and postoperative outcomes during laparoscopic myomectomy.11 These women were treated with the different coagulation systems, including conventional electrosurgery, LigaSure (Valleylab, Boulder, CO) and Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH).11 The authors found that the operator used the latter two devices (LigaSure and Harmonic Scalpel) to perform laparoscopic myomectomy for these women with uterine fibroids, resulting in not only removing the larger number of uterine fibroids but also obtaining heavier weight of uterine fibroids, compared with the use of conventional electrosurgery device,11 although both instruments needed much more operative time and contributed to much more blood loss.11 This study was interesting and worthy of discussion. First, it is unfair to claim that the use of LigaSure and Harmonic Scalpel instruments resulted in the increased operative time and increased blood loss, because more tumors were removed in both groups and it was possible that more complicated operation was done in the both groups. Therefore, the explanation of results should be careful. Laparoscopic myomectomy is a relatively complicated surgery, which might be varied greatly from ease to difficulty. For example, the subserous-type uterine fibroids might be easily removed. In fact, the location of the tumor, the size of the tumor and the characteristics of the tumor, and many others are all critical determents for the difficulty of laparoscopic myomectomy. What is the better way to show the authors' data? Our opinion is that we can use the following calculation (blood loss [ml]/weight of the removed fibroids [gm]) to show the data. We find that per gm of fibroid removed result in the blood loss ranging from 0.83 ml to 1.21 ml and per gm of fibroid removed needed the operative time ranging from 0.48 min to 0.65 min. These presented data might be more reasonable, since the blood loss was positively correlated with operative time, suggesting that the more operative time needs, the more blood loss occurs in Dr. Huang's study.11 All suggested that either tumor behavior (location and size) or technique and/or instruments might be the most important factor for the success of operation. That is to say that the gold standard to minimize surgery-related complication is “a