Reviewer’s report
Title: 
Blood Loss from Transverse Versus Longitudinal Uterine Incision in Abdominal Myomectomy: A
Randomized Controlled Trial
Version: 
2 
Date: 
29 Mar 2020
Reviewer's report:
General comment:
Overall: nice study - well designed, interesting topic (understudied so far), easy to read and understand except
for Discussion. Tables and figures are nice and instructive. I have got a couple of advices, remarks and
comments (see bellow), most of them only minor problems, but one of them seems quite significant to me.
Specific comments:
1. Title (page 5 of 24): "Transverse Versus Longitudinal Uterine Incision in Abdominal Myomectomy: A
Randomized Controlled Trial". 
Once the study was so much focused on more or less just one outcome (blood loss), it should have been
probably expressed in the title. But this is just an idea for your consideration, not a command.
2. Background (page 7/24): "However, longitudinal incisions are associated with weaker scars and higher
incidence of uterine rupture in subsequent pregnancies compared to transverse uterine incisions." 
Not sure if this only report and furthermore not in the patients with myomectomy (but with C Sections) can
give us such a definite statement.
3. Material and Methods - Recruitment (page 8/24): "Criteria for inclusion in the study were as follows; single
myoma measuring 5-10 cm in diameter, …"
And here goes my biggest problem with the whole study. How patients with single myomas smaller than 10 cm
could be candidates for open procedure??? Especially when it is proclaimed that the study and procedures were
performed in the university setting. I would accept if it would be between 8 and 12 cm for instance or for
multiple myomectomy cases. To me it at the edge of the ethics but OK, once it has been approved by local
ethical board it should be at least thoroughly explained / discussed in Discussion section.
Fortunately, mean myoma size like 8 cm in both groups (shown in Table 1) looks a bit more appropriate for
open myomectomy than the interval between 5 and 10 cm as it has been stated for inclusion.
4. Material and Methods - Recruitment (page 8/24): Criteria for inclusion again: "… causing uterine pressure-
related symptoms, infertility or recurrent pregnancy loss in women, between 20 and 35 years of age, with BMI
between 18.5-29.9 kg/m2."
But not a word of bleeding symptoms (which is the only one really specific for uterine fibroids patients) or
fibroids location (which is in many times weigh more significant predictor for intraoperative bleeding, i.e. the
studied primary outcome, than the size). Later AUB (as well as typing of myomas according to FIGO) is
correctly mentioned as one of the main clinical causes for surgery (Table 1).
Good point with exclusion of obese patients on the other hand.
5. Material and Methods - Intervention (page 8/24): We do not know anything about the type of laparotomy
incision. Pfannenstiel, i.e. transverse suprapubic I would suppose?
6. Material and Methods (page 7-9/24): I miss the explanation how the post-op pyrexia was defined.
7. Results (page 9-10/24): "Only one case needed postoperative blood transfusion, due to anemic symptoms
after an estimated blood loss of 1000 ml, in the longitudinal incision group, …"
But Table 2 is showing us the range of blood loss (in the „longitudinal group") between 387 to 582 mL. Or
did I misunderstand something?
8. Results (page 10/24): "… the amount of blood lost …"
The blood loss was certainly meant but I would rather recommend "the amount of blood" or even better "the
amount of liquid" because as we all know it is never the pure blood contained in the drain.
9. Discussion (page 10/24): "The primary research outcome of the current research study was to statistically
compare the intraoperative blood loss in the two research categorical groups."
It is 3 times "research" in one sentence. Sound a bit too many to me. The whole 1st paragraph of discussion
should be rewritten, as well as the last one (with strong and weak points of the study). A discussion should be
composed from sentences not the keywords only.
10. Discussion (page 10/24): The authors repeatedly refer to the study comparing the same outcomes but using
laparoscopy for myomectomy (Morita et al, 2004). Did authors tried to acknowledge if these surgeons had
used the same eliptoid kind of uterine incision or some other trick to make the blood loss lower in the
longitudinal group? This would be very interesting to know and also discuss in this part of the paper. 
11. Discussion (page 11/24): "As regards the operative time, there was no significant difference between both
procedures, although the mean time for myomectomy via laparoscopic approach is usually longer than
abdominal myomectomy due to more meticulous operative skills."
I hopefully understood what authors were trying to say but not everyone would have to understand. It is often
unclear when they compare their 2 sub-groups and when open myomectomy with laparoscopic one. Sadly, the
whole Discussion section seems to be the weakest part of the text. 
12. Discussion (page 11/24): Disagree with the strength number 1, which seems to me obvious and standard in
such a study. Maybe if it would be stated like homogeneity of the groups (only patients with single, similar size
myomas included) it would impress better.
First such comparison in scientific literature (regarding open myomectomy) could be proclaimed as a strength
and low number of patients (to prove statistical significance in different IBL for instance) could be added as
anothert limitation. 
13. Conclusion (page 11/24): Would recommend to add "open" here to myomectomy. 
14. Abbreviations (page 11/24): IBL could be added for intraoperative blood loss.
15. 
Table 1 (page 16/24): FIGO sub-classification has been used by the authors and this should be written
somewhere (at least at the legend) and not only as a reference to literature source number 13. Type 2-5 sounds
clearer to me than the term "hybrid myomas" so I would probably recommend to use the first one. Not
everyone is familiar with the latter term.
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.
Yes
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.
I recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following questions:
1
. 
Have you in the past five years received reimbursements, fees, funding, or salary from an organisation
that may in any way gain or lose financially from the publication of this manuscript, either now or in the
future?
2
. 
Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from
the publication of this manuscript, either now or in the future?
3
. 
Do you hold or are you currently applying for any patents relating to the content of the manuscript?
4
. 
Have you received reimbursements, fees, funding, or salary from an organization that holds or has
applied for patents relating to the content of the manuscript?
5
. 
Do you have any other financial competing interests?
6
. 
Do you have any non-financial competing interests in relation to this paper?
If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your reply
is yes to any, please give details below.
I declare that I have no competing interests' below.
I agree to the open peer review policy of the journal. I understand that my name will be included on my report
to the authors and, if the manuscript is accepted for publication, my named report including any attachments I
upload will be posted on the website along with the authors' responses. I agree for my report to be made
available under an Open Access Creative Commons CC-BY license
(
http://creativecommons.org/licenses/by/4.0/
). I understand that any comments which I do not wish to be
included in my named report can be included as confidential comments to the editors, which will not be
published.
I agree to the open peer review policy of the journal