Myomectomy
Encyclopedia
Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyoma
s, also known as fibroids. In contrast to a hysterectomy
the uterus
remains preserved and the woman retains her reproductive potential.
Patients have many options in the management of uterine fibroids, including: observation, medical therapy (such a GNRH agonists), hysterectomy
, uterine artery embolization
, and high-intensity focused ultrasound ablation. Despite these many options, the surgical approach of selected fibroid removal remains an important choice for those women who want or need to preserve the uterus for reproduction.
with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes four to six weeks.
the uterus is visualized and its fibroids located and removed. Morcellators are available to shred larger fibroids so that they can be removed through the small portholes of laparoscopy..
Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm.
a limited numbers of myomectomies have been performed.It has not been proven that results are superior to laparoscopy.
removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. However, also larger lesion have been treated by hysteroscopy. Recovery after hysteroscopic surgery is but a few days.
, the risk of adhesion
or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section.
It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy.
There is some suggestion that myomectomy surgery is associated with a higher risk of uterine rupture
in later pregnancy.
to gain access to the baby.
Uterine fibroids
A uterine fibroid is a benign tumor that originates from the smooth muscle layer and the accompanying connective tissue of the uterus.Fibroids are the most common benign tumors in...
s, also known as fibroids. In contrast to a hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
remains preserved and the woman retains her reproductive potential.
Indications
The presence of a fibroid does not mean that it needs to be removed. Removal is called for when the fibroid causes pain or pressure, abnormal bleeding, or interferes with reproduction.Patients have many options in the management of uterine fibroids, including: observation, medical therapy (such a GNRH agonists), hysterectomy
Hysterectomy
A hysterectomy is the surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total or partial...
, uterine artery embolization
Uterine artery embolization
Uterine artery embolization is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body...
, and high-intensity focused ultrasound ablation. Despite these many options, the surgical approach of selected fibroid removal remains an important choice for those women who want or need to preserve the uterus for reproduction.
Procedure
A myomectomy can be performed in a number of ways, depending on the location and number of lesions and the experience and preference of the surgeon.Laparotomy
Traditionally a myomectomy is performed via a laparotomyLaparotomy
A laparotomy is a surgical procedure involving a large incision through the abdominal wall to gain access into the abdominal cavity. It is also known as coeliotomy.- Terminology :...
with a full abdominal incision, either vertically or horizontally. Once the peritoneal cavity is opened, the uterus is incised, and the lesion(s) removed. The open approach is often preferred for larger lesions. One or more incisions may be set into the uterine muscle and are repaired once the fibroid has been removed. Recovery after surgery takes four to six weeks.
Laparoscopy
Using the laparoscopic approachLaparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
the uterus is visualized and its fibroids located and removed. Morcellators are available to shred larger fibroids so that they can be removed through the small portholes of laparoscopy..
Studies have suggested that laparoscopic myomectomy leads to lower morbidity rates and faster recovery than does laparotomic myomectomy. As with hysteroscopic myomectomy, laparoscopic myomectomy is not generally used on very large fibroids. A study of laparoscopic myomectomies conducted between January 1990 and October 1998 examined 106 cases of laparoscopic myomectomy, in which the fibroids were intramural or subserous and ranged in size from 3 to 10 cm.
Robotic surgery
Using the da Vinci Surgical SystemDa Vinci Surgical System
The Da Vinci Surgical System is a robotic surgical system made by Intuitive Surgical and designed to facilitate complex surgery using a minimally invasive approach...
a limited numbers of myomectomies have been performed.It has not been proven that results are superior to laparoscopy.
Hysteroscopy
A fibroid that is located in a submucous position (that is, protruding into the endometrial cavity) may be accessible to hysteroscopicHysteroscopy
Hysteroscopy is the inspection of the uterine cavity by endoscopy with access through the cervix. It allows for the diagnosis of intrauterine pathology and serves as a method for surgical intervention .-Method:...
removal. This may apply primarily to smaller lesions as pointed out by a large study that collected results from 235 patients suffering from submucous myomas who were treated with hysteroscopic myomectomies; in none of these cases was the fibroid greater than 5 cm. However, also larger lesion have been treated by hysteroscopy. Recovery after hysteroscopic surgery is but a few days.
Complications and risks
Complications of the surgery include the possibility of significant blood loss leading to a blood transfusionBlood transfusion
Blood transfusion is the process of receiving blood products into one's circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of the blood...
, the risk of adhesion
Adhesion
Adhesion is any attraction process between dissimilar molecular species that can potentially bring them in close contact. By contrast, cohesion takes place between similar molecules....
or scar formation around the uterus or within its cavity, and the possible need later to deliver via cesarean section.
It may not be possible to remove all lesions, nor will the operation prevent new lesions from growing. Development of new fibroids will be seen in 42-55% of patients undergoing a myomectomy.
There is some suggestion that myomectomy surgery is associated with a higher risk of uterine rupture
Uterine rupture
Uterine rupture is a potentially catastrophic event during childbirth by which the integrity of the myometrial wall is breached. In an incomplete rupture the peritoneum is still intact. With a complete rupture the contents of the uterus may spill into the peritoneal cavity or the broad ligament...
in later pregnancy.
Myomectomy during pregnancy
Leiomyomata tend to grow during pregnancy but rarely interfere with the growing pregnancy directly. Generally, surgeons tend to stay away from operative interventions during the pregnancy because of the risk of haemorrhage and the concern that the pregnancy may be interrupted. Also, after a pregnancy, myomas tend to shrink naturally. However, in selected cases myomectomy may become necessary during pregnancy, or also at the time of a caesarean sectionCaesarean section
A Caesarean section, is a surgical procedure in which one or more incisions are made through a mother's abdomen and uterus to deliver one or more babies, or, rarely, to remove a dead fetus...
to gain access to the baby.