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Summary

Myomectomy is a surgery that is done to remove fibroids from the uterus (womb). Uterine fibroids are noncancerous outgrowths that develop inside the uterus. Depending on their location, uterine fibroids can be of several types namely, intramural, subserosal, submucosal, and pedunculated fibroids. A fibroid can cause severe symptoms and can also develop reproductive problems in women such as infertility

A myomectomy can be performed by one of three techniques, i.e., abdominal, laparoscopic, and hysteroscopic myomectomy. The length of hospitalisation and recovery period depends on the type of surgery. However, there is always a risk of regrowth of fibroids after the surgery.

  1. What is myomectomy?
  2. Why is myomectomy recommended?
  3. Who can and cannot get a myomectomy?
  4. What preparations are needed before myomectomy?
  5. How is myomectomy done?
  6. How to care for yourself after myomectomy?
  7. What are the possible complications/risks of myomectomy?
  8. When to follow up with your doctor?

A myomectomy is performed to remove non-cancerous (benign) tumours called fibroids from the wall of the uterus.

Fibroids, also called leiomyomas or uterine myomas, are growths of varying sizes, made up of muscle cells and other tissues. The exact cause of fibroid formation is unknown; however, it is often linked to a female reproductive hormone called oestrogen. Fibroids are common - they are seen in about one in every three women and in women aged 30 to 50 years. The following types of fibroids can develop in the uterus:

  • Intramural fibroids: They are the most common type and develop in the muscle wall of the uterus.
  • Subserosal fibroids: They develop outside the wall of the uterus.
  • Submucosal fibroids: They develop in the inner wall of the uterus.
  • Pedunculated fibroids: In this type of fibroid, a subserosal or submucosal fibroid is connected to the uterus by a narrow straw of tissue.

Fibroids can cause pain or heavy menstrual bleeding. They also cause difficulties with conceiving or in rare cases, can become infected.

Treatment for fibroids is not required if you do not develop symptoms. However, if you show symptoms, medications would be recommended as the first line of treatment. If your symptoms are severe and medications do not work, a myomectomy may be recommended.

A myomectomy is recommended if you have any of the following symptoms:

Doctors recommend this surgery in women with the presence of fibroids and the following conditions:

  • Excessive bleeding from the uterus along with anaemia
  • Acute or severe pelvic discomfort
  • Abnormal urinary frequency in the absence of urinary tract infection
  • Infertility

This surgery may not be recommended in the following conditions:

  • Women who have fibroids and their resultant symptoms, but do not desire to get pregnant or preserve the uterus
  • Women who may have endometrial cancer (cancer of the inner lining of the uterus) or uterine sarcoma (cancer in either the muscle or other tissue layers of the uterus)
  • During pregnancy
  • Women with fibroids who do not show any symptoms
  • If the surgeon suspects that the uterus cannot be reconstructed after the removal of fibroids

Your doctor may ask you to get an ultrasound scan along with some blood and urine tests before the surgery.

Tell your doctor if you are taking any medications. 

You need to consider the following things while going to the hospital on the day of the surgery:

  • Do not smoke, if you are a smoker, from the day before your surgery to 48 hours after the surgery.
  • Do not eat anything for 6 hours or drink water for 2 hours before the scheduled time of surgery.
  • Carry all the medications that you usually take to the hospital. 
  • Do not wear any nail polish, make-up, contact lenses or jewellery.

Before starting the surgery, the anaesthetist will check whether you are a suitable candidate to have general anaesthesia (medicines that make you fall asleep during the surgery). However, if you are not suitable, i.e., if you have lung, kidney, or heart disease, spinal or epidural anaesthesia will be used. The anaesthesia numbs a specific or large portion of your body but will keep you awake. 

The surgeon may perform this surgery by any of the following three methods depending on the number, size, and location of the fibroids:

Abdominal myomectomy: This is a major surgery, performed for removal of either large or numerous subserosal and intramural fibroids, or when the surgeon suspects cancer. Abdominal myomectomy involves the following steps:

  • You will be administered general anaesthesia.
  • The surgeon will make a large cut, approximately 12 cm or less, in your lower abdomen.
  • A cut is made on the uterus, and the fibroid is removed. Sometimes, a laser is used to cut the uterus to reduce bleeding
  • The uterus, abdominal wall, and skin are then stitched back.

Laparoscopic myomectomy: This type of surgery is preferred for women with a small number of subserosal fibroids. This surgery usually involves the following steps:

  • You will be administered general anaesthesia.
  • The surgeon will make 3 to 4 cuts, approximately 0.5 to 1 cm, in your lower abdomen. One cut will be made near your belly button, one each near your hips and one cut near your bikini line.
  • Your abdominal cavity will then be filled with carbon dioxide gas. This will help the surgeon view the inside of your abdomen properly.
  • The surgeon will insert a thin, lighted telescope (laparoscope) through an incision (cut) to look at the uterus and other adjacent organs.
  • More surgical instruments will be inserted into your abdomen through other incisions to remove the fibroids.
  • After removal of fibroids, your uterus will be closed.
  • The gas will then be emptied from your abdomen, and the cuts in your skin will be closed

Hysteroscopic myomectomy: This surgery is performed only for the removal of submucosal fibroids. Unlike other procedures, no incisions are required in hysteroscopic myomectomy. This surgery involves the following steps:

  • You will be given either local anaesthesia (loss of sensation in a particular body part but awake) or general anaesthesia.
  • Your cervix (neck of the uterus) will be stretched open using a number of cervical dilators (surgical instrument) of increasing size.
  • After sufficient stretching, the surgeon will insert an instrument called a hysteroscopic resectoscope, which is a rod-like device with a camera and light and a wire loop, through your vagina into the uterus.
  • This instrument is attached to a fluid system that distends the uterus to allow proper viewing of the fibroid.
  • An electric current is passed through the wire loop that is hung over the fibroid. This leads to fibroid being “shaved off”.
  • The fibroid is then pulled out through the vagina

The length of the surgery usually varies with the number of fibroids present and their size. It usually takes a few hours. The hospital stay required varies with the type of surgery that has been performed.

  • Abdominal myomectomy: You may require 1 to 4 days of hospitalisation.
  • Laparoscopic myomectomy: It is an outpatient or same-day surgery, .i.e., you will be discharged on the day of surgery itself, or you may require 1 day of hospitalisation.
  • Hysteroscopic myomectomy: It is an outpatient procedure. You will be discharged after a few hours of observation after surgery.

After the surgery

You can expect the following in the hospital after the myomectomy surgery:

  • You will be kept under observation where your pulse, temperature, blood pressure, respiration and vaginal discharge will be noted.
  • You may have an intravenous (IV) catheter placed in your arm to supply fluids to your body.
  • Perform cough, breathing, and leg exercises every hour when you are awake.
  • You would be made to walk the same day after surgery.
  • You may have a catheter inserted into your bladder through the urethra to drain off urine. It would be attached for about 24 hours following surgery.
  • Tell the nurse if you need a painkiller.
  • You would be made to wear compression stockings, and a heparin injection (blood-thinner medicine) would be given to you. Both of these help prevent the development of clots in the lungs and legs after surgery

The time of recovery from this surgery depends on the type of surgery:

  • Abdominal myomectomy: 4 to 6 weeks
  • Laparoscopic myomectomy: 1 to 2 weeks

Hysteroscopic myomectomy: Up to 2 weeks

After getting back from the hospital, you need to follow the below-mentioned suggestions at home to look after yourself during the recovery period:

  • Take maximum rest for 2 weeks.
  • Take all the medicines promptly as prescribed by your doctor.
  • Avoid standing for more than a few minutes at a time.
  • Try walking for 10 minutes every day after the initial 2 weeks after surgery, unless restricted by the doctor.
  • You can resume your work life after the recovery period depending on the type of surgery.

Undergoing myomectomy could benefit you by:

  • Providing relief from symptoms such as discomfort, pain and heavy menstrual bleeding.
  • Keeping the uterus and other reproductive organs intact after the surgery, which can increase your chances of conceiving again.

When to see the doctor?

You should call the doctor immediately if you see any of the following symptoms:

  • Excessive bleeding from the vagina.
  • Redness, swelling, or increasing pain at the site of incision.
  • Abnormal discharge from the incision site.

The risks associated with this surgery include:

  • Infection of the ovaries, uterus, and fallopian tubes (tubes connecting the ovaries to the uterus)
  • Regrowth of fibroids
  • Injury to the uterus from cuts made in the surgery can cause infertility (rare)
  • Injury to the bowel or bladder (rare)
  • The cuts made in the uterus during surgery may open during delivery or in late pregnancy period (rare)
  • You may require an additional surgery called hysterectomy (a procedure to remove the uterus) if removal of the fibroids during the myomectomy causes heavy bleeding that cannot be resolved without performing a hysterectomy (rare)
  • Blood clots may develop in your lungs or legs (rare)

Depending on your surgery, your doctor will let you know when to return for a follow-up before you are discharged from the hospital.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

References

  1. Better health channel. Department of Health and Human Services [internet]. State government of Victoria; Myomectomy
  2. National Cancer Institute [Internet]. Bethesda (MD): U.S. Department of Health and Human Services; NCI Dictionary of Cancer Terms
  3. National Health Service [internet]. UK; Fibroids
  4. MedlinePlus Medical Encyclopedia [Internet]. US National Library of Medicine. Bethesda. Maryland. USA; Uterine Fibroids
  5. Chung Shan Medical University Hospital [Internet]. Taiwan; Gynecologic Myomectomy
  6. Brighton and Sussex University Hospitals [internet]: NHS Foundation Trust. National Health Service. U.K.; Open laparoscopic myomectomy
  7. Hernandez A, Sherwood ER. Anesthesiology principles, pain management, and conscious sedation. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 14.
  8. Cohen NH. Perioperative management. In: Miller RD, ed. Miller's Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 3.
  9. Stanford Health Care [internet]. Stanford Medicine. Stanford Medical Center. Stanford University. US; Types of Myectomy
  10. American Society of Anesthesiologists [Internet]. Washington D.C. US; Types of Anesthesia
  11. Central Manchester University Hospitals [Internet] [internet]: NHS Foundation Trust. National Health Service. U.K.; Myomectomy
  12. UCSF health: University of California [internet]. US; Myomectomy
  13. Buckinghamshire Healthcare [internet]: NHS Foundation Trust. National Health Service. U.K.; Transcervical resection of fibroids
  14. Guys' and Thomas' Hospital [internet]: NHS Foundation Trust. National Health Service. U.K.; Abdominal myomectomy
  15. UW Health: American Family Children's Hospital [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; Myomectomy
  16. Royal Berkshire Hospital [internet]: NHS Foundation Trust. National Health Service. U.K.; Myomectomy (fibroid surgery)

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