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).
How is an open myomectomy performed?
Open myomectomy is carried out when the fibroids are larger than 10cm and more numerous in number. A bikini-line incision is generally used, but occasionally a midline vertical 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?
Gonadotropin Releasing Hormone (GnRH) analogues can be used to shrink the size of fibroids. These medications are used only in certain situations where bikini incision is not adequate and shrinking the fibroids may make them small enough to be removed through a bikini incision.
What risks are associated with open myomectomy?
Infection, bleeding, injury to surrounding organs and thromboembolism (blood clot in legs or chest) are associated with this procedure. A shot of intravenous antibiotics is given at the beginning of the procedure and aseptic precautions are followed to minimise risk of infection. Bleeding is a common risk and with careful technique this risk is reduced (detailed in the next answer). Risk of injury to surrounding organs is minimal especially if you haven’t had any operations before.
Thromboembolism (blood clot) is a risk due to reduced mobility and pelvic lump slowing down pelvic circulation. Special stockings are used along with calf-pumps to keep circulation active. Special blood thinning injections are given to reduce this risk further.
There is also a risk of recurrence of fibroids. However, we would expect you to get a five-year window at least before a further procedure is required. Timing of the operation in terms of your pregnancy planning is therefore critical. Adhesions (scar-tissue) formation is also a risk and meticulous control of bleeding and minimal tissue handling is essential. Adhesion prevention barrier such as Adept solution or Interceed is used at the end of the procedure.
Open myomectomy often means larger uterine incisions to remove large fibroids. This can compromise strength of the uterine wall and it may be necessary to have an elective caesarean section during subsequent pregnancies. Your surgeon will be able to advise you after surgery.
What precautions are taken to reduce blood loss during surgery?
A tourniquet is used to block blood supply from the uterine and ovarian vessels. 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 diathermy 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. Additionally, a cell-saver can be used to collect blood lost during the surgery and re-transfuse after purification.
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 Open Myomectomy). With meticulous planning, pragmatic decision-making and judicious use of blood transfusion, Hysterectomy is rarely needed as result of intra-operative bleeding. Nowadays, Uterine Artery Embolisation can also be used to stop the bleeding thus reducing the risk of hysterectomy further.
What about recovery?
You will stay in the hospital for 3-5 days after surgery. Epidural or Patient-Controlled Analgesia is used for pain relief. Intravenous drip, any drains and catheter are removed on the second post-operative day. You are able to eat and drink straightaway. Early mobilisation is encouraged to minimise risk of thrombo-embolism. You will also be given special stockings and special injections to thin your blood to reduce this risk further.
After discharge, you should gradually increase activity levels and should be able to return to work by six 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 six weeks will pass quickly.