Reducing blood loss at open myomectomy using triple tourniquets: A randomised controlled trial

Abstract

aObjectives To evaluate triple tourniquets in controlled conditions and for the first time to investigate the hypothesis that leaving a semi-permanent tourniquet around the uterine artery reduces post-operative bleeding from the uterine incisions. Design A randomised controlled trial.Setting Two University teaching hospitals.Population Twenty-eight patients with symptomatic fibroids and uterine sizes ranging from 14 to 24 weeks of gestation undergoing open myomectomy. Methods A number 1 polyglactin suture was tied around the cervix to occlude the uterine arteries, and polythene tourniquets were tied around the infundibulopelvic ligament to obstruct the ovarian vessels. At the end of the procedure, the ovarian ties were released but the uterine artery suture remained in situ. Main outcome measures Intra-operative blood loss, post-operative blood loss, blood transfusion rates, operative morbidity, uterine blood flow and ovarian function. Results There was significantly less blood lost in the tourniquet group than in the control group (difference between means 1870 mL, 95% CI 1159 -2580 mL, P < 0.0001; transfusion rates of 7% and 79%, P ¼ 0.0003). The volume in the pelvic drain 20 min post-operatively and after 48 hours failed to reach statistical significance between the two groups (P ¼ 0.10 and P ¼ 0.165). There were no differences in uterine artery Doppler resistance indices at five days (P ¼ 0.54), six weeks (P ¼ 0.47), three months (P ¼ 0.49) and at six months (P ¼ 0.18). Day two serum FSH concentrations after surgery were unchanged (P ¼ 0.45), compared with baseline values. Conclusions Triple tourniquets are effective in reducing bleeding and transfusion rates. There appears no obvious adverse effect on uterine perfusion or ovarian function.

Prospective randomised trial comparing gonadotrophin‐releasing hormone analogues with triple tourniquets at open myomectomy

“…4 Briefly, the tourniquet group had a small incision made into the broad ligament through the avascular space just inferior to the insertion of the round ligament, fallopian tube and ovarian ligament into the uterus on each side. A number 1 polyglactin suture (Vicryl) was threaded through the incisions and tied around the cervix above the level of the bladder to occlude the uterine arteries; we no longer open the uterovesical fold as a matter of routine unless the dome of the bladder is high and requires dissection off the cervix.…”

“…2 The use of tourniquets to temporarily occlude the uterine blood supply at myomectomy has a long history, 1,3 and we have shown previously in a randomised controlled trial that 'triple' tourniquets (tourniquets applied to the uterine and ovarian vessels) are highly effective. 4 An alternative approach to reducing operative haemorrhage at myomectomy involves pre-treating women with gonadotrophin-releasing hormone (GnRH) analogues. 5 A recent survey of UK consultant gynaecologists showed that 87% use this approach in contrast to a smaller percentage who use other methods to limit bleeding (35% use myomectomy clamps, 23% tourniquets and 19% use vasoconstrictors).…”

Embolização das artérias uterinas com partículas de PVA-PVAC esférico como preparo para posterior ressecção cirúrgica de miomas

“…Therefore, many techniques are proposed to reduce the bleeding, whether by the use of mechanical tourniquets in uterine vessels and pelvic infundibulum, or with chemical tourniquets, such as vasopressin and epinephrine 7 . In this regard, UAE also present advantages as a preoperative procedure, since as well as progressively reducing the size of myomas, it decreases vascularization of tumors and hence bleeding during surgery 8 .…”

Successful removal of 36 fibroids from a uterus: case report

“…This might be possible through meticulous surgical steps of this procedure and decreasing blood flow to the uterus by taking different measures like use of uterine tourniquet and vasopressin [3,6,7,9,10]. Tourniquets are safe and inexpensive to use and can be of great benefit when large or multiple intramural fibroid must be removed as we applied tourniquet in this case.…”

“…For women who need their fertility, despite the introduction of new surgical and non-surgical techniques, open myomectomy remains the most likely treatment option [2,6] as it appears to increase pregnancy rate for these women [1].…”