Myomectomy (Myoma = fibroids, ectomy = removal) literally means surgical removal of fibroids. This is the procedure of choice for women who have symptomatic fibroids and do not wish to have a hysterectomy. Myomectomy can be performed either by key hole approach (laparoscopically) or by open abdominal approach (by making a larger surgical incision on the abdomen). Laparoscopic myomectomy offers many advantages compared to open abdominal surgery such as:
- Enhanced recovery
- Short hospital stay
- Cosmetically improved scar
- Reduced adhesions (scarring) from the procedure
- Comparable pregnancy rates
Laparoscopic myomectomy is an advanced laparoscopic procedure and the success depends very much on the experience and expertise of the surgeon.
Is laparoscopic myomectomy suitable for all fibroids?
Myomectomy can be performed as a hysteroscopic, open or laparoscopic procedure.
- Hysteroscopic myomectomy: Submucous (indenting on the cavity of uterus) fibroids less than 4cm in size and a safe distance away from the outer border of the uterus can be resected through a trans-cervical approach. In this day surgery procedure, a telescope is inserted through the neck of the womb (cervix) and fibroid is removed by this route. There are no incisions involved and the recovery is very quick.
- Laparoscopic myomectomy: This procedure is considered when the largest fibroid is less than 10cm in size and the total no of fibroids is less than 5. However, sometimes larger and more numerous fibroids can be removed by this route depending on individual circumstances. Generally, if estimated duration of surgery is expected to be less than three hours, a laparoscopic approach is used. Sometimes, it can also be used as a two or three stage procedure. Certain hormonal injections or tablets can be used to reduce the size of the fibroids to make the procedure easier.
- Open myomectomy: This approach is used when the fibroids are larger than 10cm and more numerous in number. A bikini-line incision is generally used, but occasionally a midline incision is required.
What preoperative investigations are required?
A consultation involving full history, assessment of symptoms and clinical examination are necessary along with an ultrasound scan. This scan will delineate the number, size and location of fibroids. Occasionally, an MRI scan may be required especially if adenomyosis is suspected. (Adenomyosis is a condition where uterus is enlarged due to infiltration of uterine lining into the muscle layer. It leads to heavy and painful periods and sometimes can be mistaken for a fibroid uterus).
What about preoperative medical treatment to shrink fibroids?
There are two medications available which can shrink fibroids preoperatively. GnRH analogues can be administered as a monthly or three-monthly intramuscular injection. This therapy usually leads to significant shrinkage in size of fibroids and can make even larger fibroids amenable for laparoscopic surgery. They have also been shown to reduce blood loss and surgical duration. The periods will usually stop while you are on these injections thus allowing the haemoglobin to build up. These injections sometimes can cause side-effects of hot flushes and night sweats. They can also make small fibroids undetectable at the time of surgery which may grow back afterwards. The use is therefore reserved in cases where there is anaemia due to heavy periods and when the fibroids are larger than 16 weeks of pregnancy.
A new medical treatment called Ullipristal Acetate has recently been licensed for preoperative use. This medication has similar effects to GnRH analogues with two exceptions, it is taken as a daily oral tablet and there are no side effects of hot flushes and night sweats. It is also licensed for three months compared to six months with GnRH analogues.
What incisions are made?
Generally 3 or 4 small incisions are made on the abdomen depending on the uterine size and other circumstances. One 12mm incision is made within the umbilicus and the remaining incisions are smaller (5mm).
What precautions are taken to reduce blood loss during surgery?
Pressure of gas used during laparoscopy reduces the amount of bleeding. Vasopressin (20U) diluted in 100ml of saline is injected into the capsule of fibroids. This causes of spasm of blood vessels and reduced bleeding. A harmonic scalpel is used which in addition to incising also seals the blood vessels at the same time. Planning and speed of surgery are essential to minimise bleeding from the procedure.
Is there a risk of blood transfusion or a hysterectomy?
Uterine fibroids have a lot of blood supply and are therefore prone to bleeding during removal. With precautions as mentioned above, bleeding is not a big problem and blood transfusion is rarely required (less than 10% chance with laparoscopic myomectomy). With meticulous planning, pragmatic decision-making and judicious use of blood transfusion, hysterectomy is almost never necessary as result of intra-operative bleeding.
How are the fibroids removed through such small incisions?
A special device called morcellator is used to cut the fibroid into smaller pieces which are then extracted out through a smaller incision.
How are adhesions prevented?
With laparoscopic approach, there is minimal tissue handling which reduces risk of adhesions. Saline irrigation is also constantly in use which prevents drying of tissues and blood clots from sticking to the tissues. Meticulous control of bleeding also is essential. Finally, adhesion prevention barrier such as Adept solution or Interceed is used at the end of the procedure.
What about future pregnancy and risk of uterine rupture?
Laparoscopic myomectomy is a safe procedure from this point of view. Your surgeon will be able to advise you if an elective (planned) Caesarean Section is indicated or if you will be able to have a normal delivery.
What about recovery?
You will stay in the hospital for 24-48 hours depending on how well you recover. You may be in some discomfort especially on moving, but this will be well-controlled with analgesia. You may have light vaginal bleeding and some shoulder pain. You will feel tired, but will be able to eat and drink normally, walk around and go to the toilet. You will be discharged from the hospital after 24-48 hours.
For the first three days after discharge, we recommend taking regular pain-killers. You could take short walks, wash and shower as normal and avoid lifting heavy loads. You should also get plenty of rest (8hours at night, two hours during the day). You will be seen at the end of first week for a post-operative review and suture removal.
You should gradually increase activity levels and should be able to return to work by four weeks. The key to enjoying your recovery period lies in planning in advance. So get all the DVDs that you want to watch and the books you have always wanted to read and the four weeks will pass quickly.