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Myomectomy

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MYOMECTOMY 

 

What is a myomectomy?

A myomectomy is a surgical procedure to remove uterine myomas or fibroids. 

 

How is a myomectomy performed?

There are two main ways of performing a myomectomy, through a laparotomy (open incision, similar to the one used in a caesarean section) or a laparoscopy (keyhole surgery). The removal of the fibroids is done in a similar way regardless of the way the operation is performed. The surgeon makes an incision on the uterus, dissects around the fibroid, removes it and then sutures the wound on the uterus with dissolvable sutures. If there are more than one fibroid, they can either be removed through the same uterine cut or through a different one depending on the position in relation to the other fibroid.

 

What are the differences between an open and a laparoscopic myomectomy?

The removal of the fibroids is virtually the same. The difference is the mode of access. A laparoscopy uses smaller incisions and causes less surgical trauma. Potential benefits are: less post-operative pain, less time in hospital, prompter return to normal activities and better cosmetic results from smaller scars.

 

How do I know if I can have a laparoscopic myomectomy?

It depends on the number, size and position of the fibroids as well as the surgeon's experience and preference. The rule of thumb in most cases is up to 5 fibroids no bigger than 8 cm each. Each case is then assessed individually, on it's own merits. For example, a single fibroid with a 10 cm diameter can be removed laparoscopically as well as six or seven small ones; a large fibroid attached to the uterus by a small stalk is easier to remove than a smaller fibroid embedded into the uterine wall and near large arteries.

 

Do I need a myomectomy if I have fibroids?

Not necessarily. Most fibroids do not require any treatment. Treatment is indicated either when symptoms such as bleeding and pressure are present or when fibroids are too big or have grown too fast. Each case is different and things may change over time. You should always start with a discussion with your doctor.

I have fibroids and I am planning to fall pregnant. Do I need to have them removed?

Again, not necessarily. If you can fall pregnant with the fibroids that is usually the preferable option. They only need to be removed if they are making you infertile or causing miscarriages. The same general surgical indications such as bleeding, size, etc should also be taken into account.

 

How do I know if I should I have a myomectomy or a hysterectomy?

Both operations are used to treat fibroids. As the names say, a myomectomy removes the fibroids and preserves the uterus while a hysterectomy removes the whole uterus. The two options work well to remove the fibroids and reduce symptoms. Several factors can influence the decision, but ultimately it comes down to the individual woman's choice. A woman may chose to preserve the uterus because she wants to preserve her ability to fall pregnant, because she still wants to have periods or simply because of personal preference.

Are there any advantages to having a hysterectomy?

Removing the uterus is guaranteed to stop excessive bleeding as there are no more periods. In addition, it avoids the growth of other fibroids requiring more surgery in the future. It is seen as a more definitive treatment. 

 

What are the advantages of a myomectomy?

The most obvious is the preservation of a woman's fertility and the ability to fall pregnant. It should be chosen by women who intend to have children or want to keep their options open, as well as by any woman who wants to preserve the uterus.

 

What are the surgical risks of a myomectomy?

The most important surgical risks include:

 

Bleeding

Myomectomies usually bleed more than hysterectomies. If the bleeding is excessive, it may require a blood transfusion. This happens in about 1% of cases.

 

Infection

This is a possibility in any surgical procedure. Surgeons takes several measures to avoid infection including using sterilized instruments, gowns, gloves, etc and using antibiotics. A surgical infection may require prolonged hospitalization and the use of more antibiotics.

 

Damage to other organs

As with any procedure done in the pelvis, there is a possibility of injury to the bowel, bladder, ureter and large vessels. Again, all care is taken to prevent it from happening. If it does, it may be a small and simple to fix situation like a small cut to the bladder, or a more serious complication like a perforation to the bowel. Odds of a serious complication are in the order of 1/1000.

 

Hysterectom

Whenever the surgeon sets up to perform a myomectomy it may be the case that it ends up in a hysterectomy. This is a rare event, in the order of 1/300 procedures. The most common reason is the fact that the uterus starts to bleed and there is no way of stopping the bleeding other than doing a hysterectomy. The hysterectomy is then seen as a life saving measure. This possibility needs to be discussed before the procedure. Although rare, it may have serious emotional consequences for the woman.

 

Adhesions

Operations cause scars. External scars can be seen on the skin, internal scars present in the form of adhesions or fibrous connections between internal organs. When formed between the ovaries and Fallopian tubes, these internal scars may interfere with fertility.

 

Uterine wall "weakness"

The uterine scar, where the incision to remove fibroids was made, may create a point of tissue thinning or fibrosis. This can become a problem during labour as it may break (uterine rupture). Depending on the size and position of the scar, your surgeon may recommend that you have a caesarean section if you fall pregnant. The same usually applies to women who have had more than one previous caesarean section.

  

Can I fall pregnant after a myomectomy?

You certainly can and this is one of the most common reasons why a myomectomy is chosen instead of a hysterectomy.

 

Do I need to have a caesarean section if I become pregnant after having had a myomectomy?

It depends on the size and position of the incision made on the uterus to remove the fibroids. If the fibroid(s) was big enough to warrant surgery, the odds are that you will need a caesarean. The best person to assess this need is the surgeon who performed the myomectomy, so make sure you ask.

 

How long do I need to stay in hospital?

Usually one or two days after a laparoscopic myomectomy and two to three days after an open myomectomy.

 

How long do I need to recover from the operation?

Return to work and everyday activities happens between two and three weeks for a laparoscopic myomectomy and four to six weeks after an open myomectomy.

 

Are my ovaries going to be removed during the myomectomy?

No. The ovaries are preserved both in the case of a myomectomy and of a hysterectomy for fibroids. Fibroids are uterine nodules and do not interfere with the ovaries.