Myomectomy

1 in 5 women have fibroids, however most of them are harmless and having no symptoms. The doctor advises a myomectomy surgery if the woman is having fibroids in the uterus and shows symptoms that are problematic and interfere in the day to day life. Following are the reasons to go for myomectomy instead of hysterectomy procedure.

• Restoring the uterus
• Planning a pregnancy or bearing children in the future
• If the fibroids in the uterus are causing a problem or interfering with fertility.

There are 3 types of procedures to get rid of the fibroids and usage of the type of procedure usually depends upon the location, size, and number of the fibroids present.

• An abdominal Myomectomy is a suitable option if the patient has large uterine fibroids present.
• Laparoscopic myomectomy is advised if the fibroids are smaller in size and fewer in number.
• Hysteroscopic myomectomy is recommended if the fibroids are present inside the uterus but smaller in size.

Myomectomy is a safe surgical procedure but does pose some complications. Some of these complications are as mentioned below.

• Excessive loss of blood –Doctor may consider giving injections a month prior to reduce blood loss during the surgery. Many women are anemic or have very low blood count, and hence, they are at an increased level of risk due to excessive blood loss. In such cases, the doctor suggests various ways to increase the blood count before the myomectomy surgery. During the surgery, the surgeons also take several measures to reduce the amount of blood loss. This can be done by injecting some medicines near the fibroids to clamp down the blood vessels or by blocking the blood flow from the arteries present in the uterus.
• Scarring of the tissue – After the surgery, the incisions made to remove the fibroid may form scar tissue, and this can lead to adhesions inside the body. These adhesions outside the uterus might entangle the surrounding structures and result in blockage of the fallopian tubes or a trapped intestine loop. In rare cases, these adhesions may be formed inside the patient’s uterus and lead to Asherman’s syndrome which refers to light mensural periods and problem in the fertility. The laparoscopic myomectomy causes lesser adhesions as compared to abdominal myomectomy, which is also known as laparotomy.
• Childbearing complications – The surgical procedure of myomectomy may cause some risk during delivery if the woman is pregnant. If during the myomectomy surgery, the surgeon has to make a large and deep incision in the uterus wall, then the doctor who does the delivery of the child may suggest a C-section (cesarean) surgery, in order to prevent the uterus walls to rupture during the labor. This is though a very rare complication observed during the pregnancy.
• Rare chance of hysterectomy – In some rare cases, if the bleeding is excessive and uncontrollable or if any other abnormalities are observed during the surgery apart from fibroids, then the surgeon might opt for hysterectomy surgery.

Some of the steps, advised by the doctor, to prevent possible complications associated with myomectomy surgery, are as mentioned.

• Iron supplements – If the patient is anaemic and has encountered heavy blood flow during the menstrual cycle, then the doctor advises to take some iron supplements in order to rebuild the blood count before the myomectomy surgery.
• Hormonal treatment – Hormonal treatment before the surgery is another method for curing the anemia. The doctor may suggest some birth control pills, gonadotropin-releasing hormone (Gn-RH) agonist or some other hormonal medicines to reduce the excessive blood loss during the menstruation cycle. When Gn-RH agonist is given as a therapy, it obstructs the production of progesterone and estrogen. This results in stopping of the menstruation and hence, rebuilding the blood count or hemoglobin level and iron in the patient's body. One to understand the benefits are transect.
• Fibroid shrinkage therapy – Some therapies like Gn-RH agonist can also help in shrinking the uterine fibroids and uterus. This makes it easy for the surgeon to opt for a minimally invasive technique e.g. horizontal, small incisions rather than large vertical incisions or a laparoscopic myomectomy instead of open surgery. In many patients, the Gn-RH agonist may also lead to the symptoms of menopause which includes night sweats, hot flashes, and dryness in the vagina. However, all these symptoms are temporary and they will stop when the patient stops taking the medications. This treatment usually occurs several months before the surgery.

The studies suggest that the Gn-Rh agonists are not suitable for all the women and the doctor should take the decision on the prescription of Gn-Rh agonists, after reviewing the actual problem and condition of the patient. However, the Gn-RH agonist does help to shrink the fibroid by softening it and finally making the removal process easier.

Some of the other risks associated with the Myomectomy surgery are as mentioned.

• Heavy bleeding – just like any other surgery
• Infections
• Breathing difficulty

After waking up from the effect of general anesthesia some patients might face some of the following problems:

• Nausea
• Vomiting
• Uneasiness
• Dizziness
• A temporary state of confusion
• A feeling of cold or shivering

The doctor will discuss the myomectomy surgery with the patient in detail, along with its benefits and risks.

Before the procedure:

Some points to be taken into consideration, before the surgery, are as mentioned.

• The doctor takes a complete medical history and physical examination test, of the patient, before performing the surgical procedure. The patient may be asked about the age and if planning any pregnancy, any past surgeries, allergies to any medicines, previous personal history and family history of fibroids or uterine problems. In the physical examination, the doctor examines the patient very carefully by slightly pressing around the lower abdomen to see if the large fibroids can be felt or for any other concerning signs and symptoms.
• The doctor also advises some tests such as some blood investigations, before the surgery.
• The patient is advised to inform the doctor if he/she is taking any blood thinning medications or any supplements. Accordingly, the doctor would decide if the medication is to be stopped or can be continued. The patient is also advised to inform the doctor is he/she is diabetic and is taking insulin.
• The patient is advised to inform the doctor about any past allergies or surgeries, if any.
• The patient is advised to quit smoking as it delays the healing process after the treatment. The patient is also asked to avoid alcohol.
• The patient is also advised not to eat or drink after midnight before the day of the procedure or 6-8 hours before the procedure.
• The patient is advised to empty the urinary bladder and bowel, before the surgical procedure.
• The patient is asked to change into the hospital gown and is asked to remove any jewellery or the electronic gadgets.

Depending upon the location, number and size of the uterine fibroids, the surgeon may opt for any of the following mentioned techniques:

• Abdominal myomectomy – In this method, the surgeon makes a large incision on the abdomen to open it and assess the uterine fibroids through the abdomen. In this procedure, the surgeon enters the patient’s pelvic cavity by making one or two incisions, as mentioned.
• Horizontal bikini-line incision – This is an inch long (approximately 2.5 cm) incision and is made above the pubic bone of the woman. This horizontal incision is usually like the natural lines on the skin and results in a less painful procedure and with a thinner scar as compared to the vertical incision. However, if the patient has a large fibroid, the surgeon suggests not to go for horizontal incision as it restricts the access to the pelvic cavity.
• Vertical incision – In this procedure, the incision starts from the mid part of the patient's abdomen i.e. from the umbilicus to the pubic bone (just above it). This method provides greater access to the surgeon and reduces the excessive amount of bleeding. However, this method is used very rarely, especially in cases if the patient's uterus is so big that it extends up to or past the umbilicus.

• Laparoscopic myomectomy – Laparoscopic myomectomy or robotic myomectomy are both minimally invasive techniques and in these techniques, the surgeons remove the fibroids by accessing it through various small-sized incisions.

During the laparoscopic myomectomy, the surgeon makes a small incision near or in the umbilicus of the patient. Then a laparoscope (a fine tube with a camera) is inserted into the patient’s abdomen through this incision. Some other incisions are then made on the lower abdomen to insert small surgical instruments with the help of which the surgeon operates. In a robotic myomectomy, the surgical instruments are inserted through these small incisions but the surgeon controls their movements from a sperate remote or console.

The uterine fibroid is then broken into smaller pieces and taken out through one of the small incisions. In some rare cases, these fibroid pieces are extracted from an incision made in the vagina which is known as colpotomy.

The robotic incisions are smaller than the laparoscopic myomectomy incisions. These smaller incisions in turn result in very less pain, minimal loss of blood and resultantly, the patient is able to return to normal activities more quickly as compared to laparoscopic myomectomy.

• Hysterectomy myomectomy – This procedure is recommended if the fibroids cause a bulging in the uterus. In this procedure, the surgeon accesses through the vagina and cervix and removes the fibroids. The surgeon uses a lighted, small instrument known as a resectoscope which resects or cuts the tissue with the help of a laser beam or electricity. This is done through the vagina, then the cervix and finally uterus. The surgeon usually inserts a clear liquid, a salty sterile solution into the uterus to cause expansion of the uterine cavity, which further helps in proper examination of the uterus walls. The fibroid is then shaved until it properly aligns with the uterine surface. The removed tissue is washed with the help of the clear solution, which was used to expand the cavity of the uterus. In rare cases of complicated hysterectomy myomectomy surgery, the surgeons make a small incision to insert a laparoscope to clearly view the uterus and surrounding organs.

After the procedure:

• Patient might experience some pain for initial few days after the surgery but the doctor will prescribe some oral painkillers to reduce the pain.
• The doctor will also explain about the strict diet to be followed for some time after the myomectomy in order to promote fast recovery.
• The patient is advised not to perform any strenuous exercises like lifting heavy weights or climbing stairs.
• The doctors ask the patient not to use tampons and have sexual contact during the period of recovery.
• Some patients might observe some blood spotting for a few days initially which will disappear after almost a week.

• The successful myomectomy surgery helps the patients to get relieved from the heavy bleeding, frequent urination, and pelvic pain and pressure.
• Once the fibroids are removed, the patient’s fertility state also improves along with pregnancy outcome.

Q1. Can a woman plan pregnancy after myomectomy surgery?

A1. Yes, the woman who has undergone the myomectomy surgery can plan a pregnancy within one year after the surgery. The patient is advised to wait for approximately 3 months after the surgery date to give proper time for the uterus to heal.

Q2. How much time does the recovery take for all the myomectomy techniques?

A2. The recovery period for each technique is as mentioned.

• Abdominal myomectomy – The recovery period is of approximately 4 to 6 weeks.
• Laparoscopic or robotic myomectomy - The recovery period is around 2 to 3 weeks.
• Hysterectomy myomectomy – The recovery period is less than 7 days.