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Many women have benign tumors in their uterus called myomata uteri or fibroids. These myoma may be silently present and cause no problems. In many women, however, fibroids can cause excessive and frequent menstrual periods, pelvic pain, infertility, and recurrent pregnancy loss.
Severe anaemia can result from excessive uterine bleeding. Other symptoms can include pelvic pressure on the woman's bladder or rectum which may result in frequent urination or constipation. Some women will experience pain during sexual intercourse (due to an enlarged uterus).
What is a Myomectomy?
Myomectomy is a procedure in which uterine fibroids are surgically removed from the uterus. Uterine fibroids (also known as myomas) affect 30% of women. While many fibroids do not need treatment, others can cause abnormal uterine bleeding, pressure, pain, or other symptoms.
Removing the entire uterus (hysterectomy) is frequently done to treat fibroids, but many women are looking for alternatives to hysterectomy if they wish to have children or simply do not want to lose their uterus. Unfortunately, many gynecologists are hesitant to recommend myomectomy. As with any procedure, there are both advantages and disadvantages to myomectomy. This site will provide information to help you make an informed decision.
There are numerous ways that doctors perform a myomectomy. The type, size, and location of your fibroids determine which of the following myomectomies might be recommended.
- Laparotomy (Abdominal Myomectomy)
- Laparoscopic Myomectomy
- Hysteroscopic Myomectomy
- Laparoscopic Myomectomy with Mini-Laparotomy
- Laparoscopic Assisted Vaginal Myomectomy (LAVM)
In short, laparoscopic myomectomy does a pretty good job of taking out pedunculated subserosal fibroids through the belly button along with a few other "stab" locations in the abdomen, hysteroscopic myomectomy is for submucosal fibroids that can be removed vaginally, and laparotomy takes care of all fibroids no matter their location, size, or number. Laparoscopic Myomectomy with Mini-Lap allows for the removal of slightly larger subserosal fibroids than what the laparoscope alone can handle -- but is a relatively small 3" incision or less in the abdomen. LAVM allows for the laparoscopic removal of subserosal fibroids from the uterus with the total removal of fibroid material through a vaginal incision.
Clearly, any myomectomy involving the use of laparoscope or hysteroscope requires an endoscopic surgeon with a little more skills underneath his/her belt than what is acquired from most medical schools today.
What are the advantages and disadvantages of laparoscopic myomectomy?
The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions rather than large ones are used. It is important to understand that even a laparoscopic myomectomy is real surgery, and often requires several weeks of recovery. Another major factor in recovery time is motivation; I have found motivation can be just as important in recovery as the type of surgery.
One concern when there are multiple fibroids is of leaving smaller myomas behind. Often it is necessary to feel the uterus to find the smaller myomas; these likely would be left behind during a laparoscopic myomectomy. To summarize, I think laparoscopic myomectomy is best for pedunculated and superficial myomas. When there are deep myomas and a large number of myomas, I think that it is possible to repair the uterus better by doing an abdominal myomectomy
Who benefits from a Myomectomy?
Myomectomy should be performed when infertility is an issue and you have not been able to get pregnant or hold onto a pregnancy because of the presence of uterine fibroids. If you donít happen to want a hysterectomy you are just plain out of luck because myomectomy is for women who want to get pregnant. Well, not exactly.
Many gynaecologists will perform a myomectomy when the patient chooses to keep her uterus for reasons other than future pregnancy. So, under those circumstances, the ideal patient for this procedure meets three basic requirements:
- They have fibroids
- The fibroids are symptomatic
- There is no cancer.
Advantages of Laparoscopic Myomectomy
Small incisions and less scarring
Gentler handling of the body tissues and organs during the operation
Less postoperative pain
Less postoperative narcotic use for pain relief
Faster overall recovery with an earlier return to normal activity
Technique of Laparoscopic Myomectomy
Preoperative preparation involves a shave and a small enema. Fasting for 6 hours preop is required.
A general anaesthetic is administered.
The laparoscope and other instruments are introduced as described.
The fibroid is visualised. A cut is made in the uterus and the fibroid is freed from the uterine muscle.
The incision in the uterus is repaired with sutures.
The fibroid is removed, usually by cutting it up into small pieces to get it out of the small incisions.
The wounds are closed.
Immediate post operative recovery involves an average of 2 days in hospital. 2 in 5 patients can go home late the next day after surgery. 8 patients of every 10 are home in 2 days. Patients are welcome to rest in hospital for as long as they need to. One in 5 patients will only need tablets and not injections for postoperative pain relief. If injections are required about 2 are needed on average. Patients will be given as much pain relief as they request to make sure they are comfortable. A low grade temperature is common in the first few days after surgery. The first few days at home should be taken very easily. The patient should have someone to help. Plenty of rest and fluids are advisable. Exercise your calf muscles to prevent clots. Oral pain relief eg. Panadeine/Panadol may be needed, especially at night.
Graded recovery over the next few weeks will occur. Gentle increasing exercise is helpful. Driving is permissible. Expect to tire easily. Bowel discomfort and some cramps are common. Return to normal activity occurs at about 2-3 weeks for many patients. All patients should individually assess their recovery rate. Some may need more time off work than others and certificates will always be provided. It is important not to have intercourse for 6 weeks postoperatively.
Risks of Myomectomy
These risks apply to myomectomy, whichever method is used to approach the uterus.
Infection. Infection rates are low as preventative antibiotics are used at and after the surgery. In hospital rates are 1-2%.
Bleeding. At the time of the operation some blood will be lost. Rarely this can be serious and require some emergency treatment such as transfusion.
Damage to bowel, bladder and ureter. These structures are very close to the uterus and can be damaged as the fibroid is removed. The risks are about 1 in 250-300 cases. Damage detected at the time of surgery is repaired immediately and will often not have serious consequences. Sometimes the injury can be undetected or develop over several days after surgery eg. where a burn is made to stop bleeding.
Deep Venous Thrombosis or Pulmonary Embolus. A clot can form in the leg or pelvic veins and travel to the lungs. The complication will happen in about 1 in 400-500. This is serious and can rarely be fatal. Tell your doctor if this has happened to you before or if you have a family history. During the surgery a number of precautions are taken to prevent these conditions. Early mobilisation after laparoscopic surgery may also reduce the risk compared to larger incision operations.
Other risks of laparoscopy. As described in the information on laparoscopic surgery.
Conversion to open myomectomy. During the course of the operation the doctor may decide your case is not suitably safe for a laparoscopic approach. A conventional myomectomy as could be done elsewhere will then be performed. The risk of this is 10 in 100 cases.
Adhesions (scarring) are a common complication of myomectomy. These may stick to tubes, ovaries, bowel and uterus. They can cause pain or infertility. They may be reduced by performing another laparoscopy to free them up 10 -14 days post surgery.
Uterine rupture in pregnancy can occur if the scar in the uterine wall gives way in labour. Caesarean Section is often the safest mode of delivery after large fibroids have been removed from the uterus.
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