Reviewer’s report
Title: 
Blood Loss from Transverse Versus Longitudinal Uterine Incision in Abdominal Myomectomy: A
Randomized Controlled Trial
Version: 
3 
Date: 
18 May 2020
Reviewer's report:
The manuscript is very interesting and contains notions that many surgeons should reflect on, starting with the
way to incise and suture the uterus to remove a fibroid.
I have reviewed the many comments from previous reviewers; some are rightly focused on the study
methodology.
In my opinion, the radiological discussion on the vascular course of the myometrium vessels is excessive and
would have to be reduced substantially. So, we lose sight of the innovative importance of the manuscript and
focus only on anatomical and not biological reasoning.
Instead, it is necessary to restore the biological rationale of the intracapsular removal of the fibroids (which the
authors rightly reported previously, with adequate bibliography), which must be resumed in the discussion (it
is not the way to incise and / or suture the myometrium, but it is how it is correctly enucleated the fibroid from
the myometrium).
I therefore believe that the discussion of the biological rationale of intracapsular myomectomy, with the
correct bibliographical references previously deleted, should be restored in the discussion.
It would therefore be useful to discuss the biological reasoning of myomectomy, to be carried out according to
biological rationale.
It is therefore true that no study to date has compared the obstetric quality of the scars of intracapsular
myomectomy with those of the conventional surgical approach, as there is no rational comparison. Is it better
to remove myoma with healthy tissue on it (pseudocapsule) than myoma without healthy tissue on it?
To remove a myoma, the overlying myometrium must always be incised with the inevitable lesion of the
pseudocapsule during the incision to reach the myoma.
Unfortunately, in the literature there are no net biological limits for the maximum accepted damage to the
pseudocapsule, but only electrical limits (not more than 30 watts, before electrical damage to the muscle fibers
occurs).
It is not known whether the whole pseudocapsule should be preserved or even a smaller part would be
sufficient to provide the postulated growth mediators to stimulate healing of the myometrium, but it is also
true that the greater pseudocapsule is preserved, the healthier tissue there is to begin myometrial scarring.
It is true that, during intracapsular myomectomy, electrical resection of the intracavitary part will also reset
part of the overlying pseudocapsule, but if the technique is performed "pseudocapsule sparing", the greatest
amount of tissue or neurovascular bundle is preserved.
The surgical concept, although young, has already been widely approved by the scientific community, since
there are now over 40 papers in the literature and various book chapters, so the discussion of the manuscript
must make use of this part of biological rationale.
I agree that the choice of the well-established elliptical incision was governed by the surgeons' preference and
was rationalized in simple words (since it is believed that it does not affect the primary outcome of the study,
intraoperative blood loss), but it is also necessary to understand that the removal of healthy tissue attached to
the myoma could be a biological bias in the subsequent cicatricial phase.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you recommend an additional statistical
review?
If an additional statistical review is recommended, please specify what aspects require further assessment in
your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
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