J Minim Invasive Gynecol. 2025;32(2):113-132. doi: 10.1016\/j.jmig.2024.08.004 <\/a>
While minimally invasive surgical approaches for myomectomy reduce morbidity compared to open surgery, intraoperative bleeding remains a major challenge, and no consensus currently exists on the optimal strategies to mitigate this risk. \u00a0This recent AAGL guideline assesses strategies for minimising blood loss during minimally invasive surgery, drawing on evidence from 32 randomized controlled trials and 18 observational studies: evaluating both preoperative medical therapies and intraoperative techniques.<\/p>\n\t\t\tFINDINGS (with gradings) <\/h3>\t\t\t\n\t\t\tPreoperative Medical Adjuncts<\/h3>\t\t\t\n\t\t\t\t
GnRH Agonist (Leuprolide acetate):<\/u><\/em> The preoperative use of GnRH agonists, for 3 months prior to laparoscopic myomectomy has been associated with a statistically significant reduction in intraoperative blood loss<\/em><\/strong>. A meta-analysis, including two RCTs and one observational study reported a mean reduction in blood loss of 75.35 mL (95% CI: -138.06 to -12.64 mL, p<\/em> = 0.02), although the clinical magnitude of this benefit may be modest. (Grade B evidence; moderate recommendation). <\/em><\/strong><\/p>\nMisoprostol (Prostaglandin):<\/u><\/em> Preoperative administration of misoprostol, either vaginally (400\u202f\u00b5g) or rectally (200-600\u202f\u00b5g), has been shown to significantly reduce blood loss<\/em><\/strong>, with a mean difference of -127.5\u202fmL (95% CI -194.7 to -60.3\u202fmL; p\u202f<\u202f0.01), based on two high-quality RCTs and one lower-quality study. One additional RCT suggests that adding misoprostol to vasopressin may offer modest further blood loss reduction (-67\u202fmL). (Grade B evidence; moderate recommendation).<\/em><\/strong><\/p>\n\t\t\tIntraoperative Medical Adjuncts<\/h3>\t\t\t\n\t\t\t\t
Epinephrine:<\/u><\/em> Intra-myometrial epinephrine has been shown to modestly reduce surgical blood loss<\/em><\/strong> (mean difference -78.62\u202fmL; 95% CI -95.26 to -61.98\u202fmL; p\u202f<\u202f0.01). Additional benefits include reduced surgical difficulty, shorter enucleation time, and less postoperative analgesic use. No significant complications were reported.\u00a0 (Grade B; moderate recommendation).<\/em><\/strong><\/p>\nVasopressin:<\/u><\/em> Intra-myometrial vasopressin has been shown to significantly reduce surgical blood loss<\/em><\/strong>, with a mean difference of -103.68\u202fmL (95% CI -150.74 to -56.62\u202fmL; p\u202f<\u202f0.01), based on two low-risk RCTs and two non-RCTs. Additional benefits included reduced operative time, lower transfusion rates, and less postoperative haemoglobin drop. Although commonly used by surgeons as first line for prevention of bleeding, the current evidence does not confirm superiority over alternative agents. (Grade B; Moderate recommendation).<\/em><\/strong><\/p>\nOxytocin: <\/u><\/em>Evidence supporting the use of oxytocin at the time of induction is limited but promising. A single RCT with low risk of bias demonstrated a significant reduction in intraoperative blood loss <\/em><\/strong>(mean 269.5\u202fmL vs 445\u202fmL; p\u202f<\u202f0.05) and transfusion rate (6.7% vs 36.7%; p\u202f=\u202f0.01) compared to placebo. Further research is required; however, these results are promising for future use. (Grade B; Moderate recommendation).<\/em><\/strong><\/p>\nTranexamic Acid:<\/u><\/em> A single, well-designed RCT involving 60 patients found no significant reduction in intraoperative blood loss <\/em><\/strong>with intravenous tranexamic acid (15\u202fmg\/kg pre-incision), indicating limited efficacy in laparoscopic myomectomy. Overall, moderate-quality evidence suggests tranexamic acid does not significantly reduce blood loss, which is interesting, considering many gynaecologists would utilize it during high-risk gynaecological procedure.\u00a0 (Grade B; Weak recommendation).<\/em><\/strong><\/p>\n\t\t\tIntraoperative Surgical Interventions<\/h3>\t\t\t\n\t\t\t\t
Electrosurgical Energy Devices:<\/u><\/em> Intraoperative energy devices, including ultrasonic shears, electrosurgical vessel sealing systems (e.g., Ligasure, PK Forceps), and CO\u2082 lasers, were evaluated. However, all studies were subject to high or critical risk of bias due to factors such as co-interventions, unbalanced surgeon experience, and non-standardised outcome measures. No meta-analysis could be performed due to heterogeneity and methodological limitations. Overall, current evidence is insufficien<\/em>t<\/strong> to support the superiority of any specific energy device in minimizing intraoperative blood loss. (Grade C; Strength of Recommendation: No Recommendation).<\/strong><\/p>\nUterine Artery Occlusion:<\/u><\/em> Uterine artery occlusion (UAO), whether temporary or permanent, has been shown to significantly reduce intraoperative blood loss<\/em><\/strong> during laparoscopic or robotic-assisted myomectomy. In a meta-analysis of 13 studies (including 2 RCTs and 13 observational studies), UAO was associated with a mean blood loss reduction of 126.84 mL (95% CI -169.16 to -84.51 mL; p < 0.01), with findings consistent across sensitivity analyses despite high heterogeneity (I\u00b2 = 98.54%). No increase in perioperative complications or operative time was observed. (Grade B; Moderate Recommendation).<\/strong><\/p>\nUterine Artery Occlusion<\/u>: (When Vasopressin Already Used): <\/em>A meta-analysis of these studies demonstrated no statistically significant reduction in intraoperative blood loss<\/em><\/strong> when uterine artery occlusion (either bipolar occlusion or suture ligation techniques) was added to vasopressin use (mean difference -30.74 mL; 95% CI -71.01 to 9.53 mL; p<\/em> = 0.13), with substantial heterogeneity noted (I\u00b2<\/em> = 80.3%). Thus there is moderate-to-low quality evidence for this combination and its routine use is not recommended (Grade C; Strength of Recommendation: Weak).<\/em><\/strong><\/p>\nBarbed Suture:<\/u><\/em> Barbed sutures have been widely adopted in myomectomy due to their potential to expedite suturing. Eight studies, including seven observational and one RCT, provided data suitable for meta-analysis, which showed that barbed sutures were associated with a statistically significant but clinically modest reduction<\/em><\/strong> in blood loss (mean difference -36.46 mL; 95% CI -59.70 to -13.21 mL; p<\/em> < 0.01), with considerable heterogeneity across studies (I\u00b2<\/em> = 92.59%). Importantly, nine studies reported significant reductions in operative time with barbed sutures<\/em><\/strong>, ranging from 7 to 58 minutes. Complication rates and postoperative adhesions were similar between barbed and conventional suture groups. Overall, their primary benefits may lie in the technical convenience and operative efficiency rather than haemostatic advantage (Grade C; Strength of Recommendation: Weak).<\/em><\/strong><\/p>\n\t\t\tConclusions<\/h3>\t\t\t\n\t\t\t\t
This guideline reinforces several practices already employed by surgeons while prompting critical appraisal of others.<\/p>\n
This guideline highlights moderate-level evidence (Grade B) for most effective agents such as vasopressin, epinephrine, oxytocin, misoprostol, and leuprolide, all of which demonstrated efficacy in reducing intraoperative bleeding. GnRH analogues are often only selectively used when patients wish to delay surgery or to pre-shrink very large lesions for access. Preoperative misoprostol may be administered by some clinicians to promote uterine contraction, while vasopressin infiltration remains a near-universal intraoperative strategy for many surgeons. Oxytocin appears promising, but further research is required.<\/p>\n
However, common interventions such as tranexamic acid and barbed sutures are supported only by weak evidence. Although tranexamic acid (TXA) is often administered at induction, the guideline’s findings challenge its efficacy, suggesting that continued use warrants reconsideration.<\/p>\n
Most surgeons commonly employ multilayer barbed suture closure as a standard in nearly all cases. This guideline continues to support current practices, such as vasopressin use and barbed suturing for technical ease but invites thoughtful reflection on the use of TXA and reinforces evidence-based tailoring of haemostatic strategies to individual cases.<\/p>\n\t\t\t
Summary Table<\/h3>\t\t\t\n\t\t\t\t![\"summary-aagl-guideline-laparoscopic-myomectomy-table-001\"](\"https:\/\/escope.ages.com.au\/july-2025\/wp-content\/uploads\/sites\/10\/2025\/07\/summary-aagl-guideline-laparoscopic-myomectomy-table-001.avif\" "\\"summary-aagl-guideline-laparoscopic-myomectomy-table-001\\"")
\n\t\t\tAuthors<\/h3>\t\t\t\n\t\t\t\t![\"Dr](\"https:\/\/escope.ages.com.au\/july-2025\/wp-content\/uploads\/sites\/10\/2025\/07\/escope-author__dr-saima-hamid-wani-001.avif\" "\\"Dr")
\n\t\t\t\t
Dr Saima Hamid Wani<\/p>\n\t\t\t\t![\"Dr](\"https:\/\/escope.ages.com.au\/july-2025\/wp-content\/uploads\/sites\/10\/2025\/07\/escope-author__dr-basia-lowes-001.avif\" "\\"Dr")
\n\t\t\t\t
Dr Basia Lowes<\/p>\n\n","protected":false},"excerpt":{"rendered":"
In this eSCOPE Journal Club we bring you a summary of the 2025 \u2018hot off the press\u2019 AAGL guideline, highlighting techniques for blood loss minimization during laparoscopic myomectomy. \u00a0Although not your traditional journal club critique, we felt this review would be invaluable to keep your everyday clinical practice up to date.\u00a0<\/p>\n","protected":false},"author":1,"featured_media":72,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"","ast-site-content-layout":"full-width-container","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[1],"tags":[],"class_list":["post-236","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorised"],"acf":[],"_links":{"self":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/236","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/comments?post=236"}],"version-history":[{"count":6,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/236\/revisions"}],"predecessor-version":[{"id":252,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/posts\/236\/revisions\/252"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/media\/72"}],"wp:attachment":[{"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/media?parent=236"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/categories?post=236"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/escope.ages.com.au\/july-2025\/wp-json\/wp\/v2\/tags?post=236"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}