Myomectomy

Generality

Myomectomy is the surgical procedure by which uterine fibroids are eliminated. This surgery is taken into consideration when uterine fibroids are symptomatic and bothersome.

The preparation for myomectomy is very simple; furthermore, if the doctor's instructions are scrupulously followed, it is rare for complications to arise.

Figure: types of fibroid to the uterus

There are essentially three surgical techniques that doctors can adopt: laparoscopy, laparotomy and hysteroscopy.

The results are satisfactory, even if there is a risk of recurrence.

What is myomectomy?

Myomectomy is a surgical procedure aimed at removing uterine fibroids .

A uterine fibroid (otherwise known as leiomyoma or uterine myoma ) is a benign tumor of the uterus, which can form on the inner side or on the outside of the organ.

NB: a benign tumor is an abnormal mass of proliferating cells which, unlike what happens in the malignant tumor, is neither infiltrating nor metastasizing (ie it does not give metastasis).

MAIN CHARACTERISTICS OF UTERINE FIBROMES

Uterine fibroids are considered the most common tumors of the uterus. Similar to nodules, they consist of a small number of muscle cells and a large amount of fibrous tissue.

The size of the fibroids is extremely variable: there are, in fact, uterine fibroids of a few millimeters and fibroids in the uterus even 20 centimeters large.

The appearance of one or, more often, a series of uterine fibroids alters the structure of the uterus and reduces its contractile capacity (loss of muscle contractility is a natural consequence of the greater presence of fibrous tissue).

Uterine fibroids may be asymptomatic (ie not cause any obvious symptoms) or cause of:

Abundant menstruation and longer menstrual cycle
Anemia due to more abundant menstruation (NB: the pathological deficiency of hemoglobin is called anemia)
Pain and discomfort in the pelvic area
Abdominal swelling and heaviness in the lower abdomen
Constipation
Pain in urination
Pain during sexual intercourse
Reduced fertility and greater possibility of spontaneous abortions

When you run

Myomectomy is practiced when uterine fibroids are symptomatic (ie they cause one or more symptoms) and do not allow the affected woman to lead a normal life. Specifically, the situations for which removal of fibroids from the uterus is most required are:

A condition of persistent anemia that does not respond to any alternative treatment.
The presence of pain or a sense of heaviness in the lower abdomen continues and that it is not possible to alleviate in any other way.
An excessive difficulty in getting pregnant.

Myomectomy is preferable to hysterectomy (that is, to complete uterus removal surgery), because it preserves the uterus by allowing the woman who is operated on in childbearing years to have children in the future.

risks

Myomectomy is safe. However, there is still surgery, so it is not completely risk-free. The most known complications are:

Excessive blood loss (bleeding) . The uterus is a very vascularized organ and the appearance of fibroids further increases the number of blood vessels present. Therefore, a surgical incision made on a uterus under these conditions could result in significant blood loss.
To prevent or reduce bleeding, surgeons often "pinch" the uterine arteries momentarily and inject coagulant drugs, in such a way as to slow down the flow of blood at the point to be operated.
Worsening of anemia status . It is due to excessive blood loss.
Scar tissue formation . The incisions and surgical sections provided by the operation can lead to the formation of intra-abdominal adhesions (or adhesions). The latter are bands of fibrous tissue, which are created as a result of the healing process and which affect the normal anatomy of the internal organs.
Increased risk of complications during post-surgery pregnancies . After myomectomy, the uterus becomes more fragile and, if you are pregnant, it may break at the time of labor. To avoid this inconvenience, the doctor uses the caesarean section.
Need to resort to hysterectomy . If the blood loss from the uterus is consistent and you cannot stop in any way, the doctor may be forced to remove the uterus.

WHAT ARE THE USEFUL STRATEGIES TO AVOID SERIOUS HEMORRHAGES?

To limit blood loss and related effects (anemia), in view of a future myomectomy, the doctor may prescribe:

A gonadotropin-releasing hormone (Gn-RH) agonist or contraceptive pill, in order to regulate the menstrual cycle and minimize the amount of blood lost through menstruation.
NB: an agonist, in pharmacology, is a competitor of the natural molecule.
A drug therapy capable of reducing the volume of uterine and uterine fibroids . In these conditions, the organ on which to intervene becomes smaller, so that the incision to be made becomes smaller.
The drugs used are, once again, the agonists of Gn-RH; these, in fact, produce a sort of "temporary menopause": the patient, in fact, feels hot flashes, night sweats, vaginal dryness, etc.
However, it must be specified that this drug therapy has no effect on all women: in some, in fact, the fibroids take on an appearance indistinguishable from the rest of the uterus, so they are no longer recognized at the time of the operation.

Preparation

Myomectomy is a surgical procedure that involves general anesthesia or spinal anesthesia, therefore, before it can be performed, the woman must be subjected to the following clinical controls:

Accurate physical examination
Complete blood analysis
Evaluation of clinical history (diseases suffered in the past, possible allergies to anesthetic drugs, medicines taken at the time of checks, etc.)
Electrocardiogram

If there are no contraindications of any kind, the doctor will explain to the patient everything that the operation requires, including the pre- and post-operative recommendations, the type of anesthesia expected, the surgical technique used, the expected duration of the operation and the timing of recovery.

PRE- AND POST-OPERATIVE RECOMMENDATIONS

For the entire operation to proceed smoothly, the patient is required to:

Before myomectomy, discontinue any possible pharmacological use of antiplatelet agents (aspirin), anticoagulants (warfarin) and anti-inflammatory drugs (NSAIDs); this interruption is necessary because these drugs, by reducing the coagulation capacity of the blood, predispose to serious bleeding.
On the day of myomectomy, appear at full fasting at least the previous evening, as general anesthesia or spinal anesthesia is expected.
After surgery, be accompanied home by a family member or friend .

Procedure

The surgeon, based on the number, location and characteristics of uterine fibroids, can perform the surgery of myomectomy in laparotomy ( abdominal or traditional myomectomy ), in laparoscopy ( laparoscopic myomectomy ) or in hysteroscopy ( hysteroscopic myomectomy ).

ABDOMINAL MYOMECTOMY

Surgery performed in laparotomy involves opening the abdomen through an incision of several centimeters on the belly. This makes the invasive procedure and the post-operative phase very long.

Figure: laparoscopic myomectomy. From the site: en.wikipedia.org

Abdominal myomectomy, which involves general anesthesia, is indicated for uteri covered with several large fibroids. The incision on the abdomen can be horizontal or vertical, depending on the position and characteristics of the fibroids.

At the end of the procedure, the surgeon closes the patient's abdomen with stitches.

MYOMECTOMY LAPAROSCOPIC

Laparoscopy is a minimally invasive surgical technique that allows you to work without the practice of large skin incisions; the intervention, in fact, foresees two or three small incisions, which serve the surgeon to introduce the laparoscope (a device equipped with light and a camera) and surgical instrumentation.

Laparoscopic myomectomy, which requires general anesthesia, is suitable for uteri with at most two fibroids; these, moreover, must measure no more than 5-6 centimeters and be located on the outer wall of the uterus (subsosiera).

Robotic myomectomy

Robotic myomectomy is a laparoscopy operation in which the surgeon, instead of operating in person, drives a robotic instrument equipped with mechanical arms, which, in fact, replace his hands. This allows a high precision of the intervention.

HYSTEROSCOPIC MIOMECTOMY

Hysteroscopic myomectomy is a minimally invasive surgical technique, which is performed by introducing a special instrument called a resectoscope into the uterus through the vagina and cervix.

The resectoscope, in addition to having a light and a camera connected to an external monitor, is equipped with a source of electrical discharges: these discharges serve the surgeon to eliminate the tissue that constitutes uterine fibroids.

Hysteroscopic myomectomy is appropriate for medium to large uterine fibroids and the submucosal type. It can be performed under general anesthesia or spinal anesthesia.

IS IT POSSIBLE TO WORK IN PREGNANCY?

Pregnancy can stimulate the appearance of fibroids. These, in general, are removed some time after the birth, but it can happen, on some rare occasions, that they must be eliminated shortly before the birth of the child.

Post-operative phase

The post-operative phase depends on the type of intervention:

Abdominal myomectomy : since it is a very invasive procedure, it may take several days, even 3 or 4 days. Expected recovery time: 4-6 weeks.
Laparoscopic myomectomy : requiring general anesthesia, it requires the patient to spend at least one night in the hospital, for very precautionary reasons. Estimated recovery time: 2-3 weeks.
Hysteroscopic myomectomy : if performed under spinal anesthesia, the patient can be discharged a few hours after surgery. Recovery times are very short: one week, except for complications.

AFTER HOW LONG FROM THE INTERVENTION CAN YOU HAVE A PREGNANCY?

After a myomectomy, the uterus needs about 3 months to completely heal: doctors therefore recommend that you wait at least 90 days before becoming pregnant.

Results

The results of myomectomy are quite satisfactory.

Very often, in fact, the symptoms caused by fibroids disappear and fertility increases. However, it is possible that after a few months recurrences appear (ie the fibroids reform) and that a second myomectomy operation is necessary.