Myomectomy: A Uterus-Preserving Guide to Fibroid Removal

Submucosal Fibroids: These are the most symptomatic type of fibroids, even when they are very small. They grow just underneath the endometrium and protrude into the uterine cavity. By distorting the cavity and exposing a large surface area, they can cause extremely heavy and prolonged menstrual bleeding, as well as problems with fertility by interfering with the implantation of an embryo. 

Intramural Fibroids: These are the most common type. They grow within the muscular wall of the uterus, the myometrium. As they grow larger, they can expand the uterus, much like a pregnancy, leading to "bulk-related" symptoms such as pelvic pressure, a feeling of fullness, frequent urination from pressure on the bladder, and constipation from pressure on the rectum. 

Subserosal Fibroids: These fibroids grow on the outer surface of the uterus and protrude outwards into the pelvic cavity. They do not typically affect the menstrual flow but can cause significant bulk symptoms or pain if they grow very large or press on adjacent organs. 

Pedunculated Fibroids: These are a subtype of submucosal or subserosal fibroids that are attached to the uterus by a thin stalk or "pedicle." A pedunculated fibroid can sometimes twist on its stalk torsion, cutting off its own blood supply and causing sudden, severe pain. 

The Procedure: The surgeon makes a single, larger incision in the abdomen to directly access the uterus. This is typically a horizontal "bikini cut" incision, though a vertical incision may be necessary for very large fibroids. The surgeon then makes an incision in the uterus directly over the fibroid, carefully shells the fibroid out from the surrounding uterine muscle, and then meticulously repairs the uterine wall in multiple layers to ensure a strong and secure closure. 
 

Indications: An abdominal myomectomy is the preferred approach for women with very large fibroids, multiple fibroids in various locations, or fibroids that are located deep within the uterine wall. It gives the surgeon the best direct access and tactile feedback, which is crucial for removing large tumors and ensuring a robust uterine repair. 

The Procedure: The surgery is performed through several small keyhole incisions in the abdomen. The abdomen is inflated with carbon dioxide gas, and a laparoscope, a thin camera, is inserted to provide a magnified view. The surgeon uses specialized, long instruments to perform the myomectomy. The fibroid is shelled out, and the uterine incision is repaired with sutures, all from inside the abdomen. 

The Morcellation Step: To remove the large fibroid from the body through the small incisions, the surgeon must use a device called a morcellator to cut the fibroid into smaller pieces within a special containment bag before it is extracted. 

Indications: Laparoscopic myomectomy is an excellent option for certain types of subserosal and intramural fibroids that are not excessively large. 

The Technology: The surgeon operates from a console in the operating room, controlling highly precise, wristed robotic arms to perform the dissection and suturing. 

The Advantage: The robotic system provides the surgeon with a magnified, 3D high-definition view and instruments that have a greater range of motion than the human wrist. This can be a significant advantage for performing the complex, multi-layered suturing required to repair the uterine wall after a deep fibroid is removed, potentially leading to a stronger and more secure closure than can be achieved with standard laparoscopy. 

The Procedure: This is performed for submucosal fibroids that protrude into the uterine cavity. A specialized instrument called a hysteroscope, which is a thin telescope with a camera, is passed through the vagina and cervix and directly into the uterus. The uterine cavity is filled with fluid to provide a clear view. The surgeon then uses an electrified loop or a special tissue removal device, passed through the hysteroscope, to shave off and remove the fibroid from the inner wall of the uterus. 

The Advantage: This is the least invasive type of myomectomy, with a very quick recovery time, as there are no external or internal incisions. 

Comprehensive Evaluation: Your journey begins with a thorough evaluation by your gynaecologist. This will include a pelvic exam and a detailed imaging study, usually a pelvic ultrasound or an MRI, to map the exact size and location of all your fibroids. 
 

Medical Optimization: In some cases, if you have very large fibroids or are very anemic, your doctor may prescribe a course of medication, such as a GnRH agonist, for a few months before your surgery. This medication can temporarily shrink the fibroids and stop your periods, allowing you to build up your blood count before the operation. 

Anesthesia: A myomectomy is performed under general anesthesia, except for a hysteroscopic myomectomy which can sometimes be done with a spinal block or sedation. 

The Surgical Procedure: The surgeon will perform the specific type of myomectomy that was planned. This is a meticulous and often challenging procedure, as the goal is to carefully remove the fibroids while minimizing blood loss and ensuring a strong, multi-layered repair of the uterine wall. The surgery can take anywhere from one to four hours or more. 

Hysteroscopic Myomectomy: The recovery is very quick. You will go home the same day and can typically return to normal activities within a day or two. 

Laparoscopic or Robotic Myomectomy: You will typically stay in the hospital for one to two nights. Recovery is much faster than with an open surgery, and you can often return to a non-strenuous job in about two to four weeks. 

Abdominal Myomectomy: This is a major abdominal surgery with a longer recovery. You will stay in the hospital for about three to five days. You will have significant restrictions on your activity, with no heavy lifting for at least six weeks. A full recovery can take six to eight weeks.