Myomectomy
Introduction
Myomectomy is the removal of fibroids while preserving the uterus. The most common risk of myomectomy is bleeding from the uterus and special techniques should be used to decrease the risk of blood transfusion and avoid hysterectomy.
Regardless of the approach used, surgeon’s skill is extremely important to ensure that the procedure is performed safely especially in patients with large fibroids.
Most gynecologists will offer abdominal myomectomy, which is the removal of fibroids using a large incision through the abdominal wall. Typically, a horizontal or vertical large 12 cm wide incision is made and the layers of the abdomen are opened until the uterus is reached. The fibroids are then removed and uterine muscle is sutured.
The advantages of this approach are mainly for the comfort of the surgeon, not for the patient. Fibroids are readily accessible and this approach can be used to address fibroids of any size, number, and location.
Unfortunately, there are many disadvantages for the patient. Of all the approaches to fibroid removal, the abdominal approach results in the greatest amount of pain, longest hospital stay, largest incision size, and longest recovery time. After an abdominal myomectomy, patients require a hospital stay of 2-3 days. Recovery time is 6-8 weeks long. The risk for complications such as wound infection, adhesion formation, and future hernias, are all significantly greater.
Laparoscopic Myomectomy
Laparoscopic myomectomy is the removal of fibroids using very small incisions, usually only 0.5-1.5cm each. Typically, a camera is placed through the navel and the abdomen is inflated with air to allow the surgeon to see inside. Depending on the location and size of the fibroids, 2-3 additional incisions are made in the lower part of the abdomen, through which specialized instruments are passed. The fibroids are shelled out, and the uterus is sutured closed with laparoscopic equipment. The fibroids are then removed through a device called a laparoscopic morcellator.
The benefit of the laparoscopic approach is that patients are often able to go home the same day, pain is minimized, and most patients return to work within 1-2 weeks.
The disadvantage of laparoscopic myomectomy is that the surgeon can’t palpate the uterus and fibroids directly making it more likely to miss smaller sized fibroids or fibroids that are very deep in the muscle layer. Access to fibroids that are deep within the uterus is much more difficult with this approach. For women with multiple fibroids or large fibroids, this approach is also very time-consuming, meaning prolonged exposure to anesthesia. Because of difficulty with visualization and blood loss, this is not a safe option for massively large fibroids.
Laparoscopically-assisted Abdominal Myomectomy(LAAM) and Bilateral Uterine Artery Ligation (BUAL)
This innovative approach offers what we consider to be “the best of both worlds,” combining all the advantages of the abdominal and laparoscopic approaches while minimizing the disadvantages. A camera is placed through the navel, and the uterus is surveyed. If there are adhesions from prior surgery, endometriosis or cysts that need to be removed, this can be accomplished at this time. In order to avoid large amount of blood loss during the removal of fibroids, we either temporarily or permanently (large uterus only) block some of the blood supply to the uterus. This procedure is called Bilateral Uterine Artery Ligation (BUAL). Permanent blockage of the uterine arteries is done only in a very large uterus in order to avoid extreme bleeding and potential hysterectomy. Large, medium, or the smaller uterus only requires placement of the tourniquet at the base of the uterus to block blood flow. The tourniquet is removed at the end of the surgery restoring normal flow. In order to remove the fibroids a 4cm horizontal or vertical (large uterus only) incision is made above the pubic bone, usually near the top of the hairline. The layers of the abdomen are entered until the uterus is reached. Each fibroid is then removed and uterine muscle sutured. With this approach, the incision size is kept as small as possible while having direct access to the uterus. Fibroids of any size, number, and location can be addressed with this approach. Most patients can go home the same day of surgery and recovery time is approximately 2 weeks.