Mr Stephen Quinn
 

MB MS BSc MSc MD MRCOG

Laparoscopic Myomectomy Procedure for Treating Fibroids

Myomectomy is a surgical procedure to remove the uterine fibroids, generally via the abdomen, without removing the womb (uterus).


Laparoscopic Myomectomy Surgery for Fibroids

The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions are used rather than one larger incision. The disadvantage is that only small fibroids can be removed by laparoscopic myomectomy and it is not recommended if there are many fibroids or if the fibroids are deeply embedded in the uterine wall.

 

Laparoscopic surgery is usually performed under general anaesthesia. The procedure can take one to three hours, depending on the number, size, and depth of the fibroids within the muscle wall. Following laparoscopic myomectomy many women are able to leave the hospital the next day, although a two-night stay may be necessary. Because the incisions are small, recovery is usually associated with minimal discomfort. After laparoscopic myomectomy, women usually return to normal activity within ten to fourteen days.


Laparoscopic Myomectomy Procedure

During this procedure a laparoscope (a thin fiber-optic device that transmits light and a video image) is inserted through a small incision, usually in the navel, to view the uterus. The image from the camera attached to the end of the laparoscope is seen on a video monitor. Two or three small (0.5-1.5cm) incisions are made below the public hairline and instruments are inserted through these incisions to perform the surgery. The fibroids are detached from the uterus and removed. Following removal of the uterine fibroids, the openings in the uterus are stitched closed with the use of specially designed instruments. 



Risks of Surgery

  • Excessive bleeding during the operation requiring blood transfusions.
  • Anaemia due to blood loss during the operation and post-operation.
  • Adverse reactions due to anaesthetics.
  • Puncture of bowel or bladder during surgery.
  • Opening of the womb or bowel during operation.
  • If a large fibroid is removed, the wall of the womb may be weakened leaving a deep wound.
  • Blood clot in legs (deep vein thrombosis) or sometimes, part of this clot can break off and travel to the lungs (known as PE). This can cause shortness of breath or even occasionally be fatal.
  • Wound infection.
  • Pelvic adhesion that can cause pain and/or bowel blockage, which may require surgery in the future to correct this.
  • Risk of conversion to hysterectomy (although this is very low).
  • A keyhole (laparoscopic) myomectomy may be converted into an open abdominal procedure for effectiveness and safety reasons.
  • Eventual re-growth of fibroids. Re-treatment rates for over 5-10 years are 10% for single myomectomy and 25% for multiple myomectomy. For laparoscopic (keyhole) myomectomy, symptoms can recur in up to 2 in 5 cases within 5 years.
  • Special precautions in pregnancy: consideration for the need for caesarean section delivery.
  • There have been concerns in recent years regarding the risks of morsellating uterine fibroids at key-hole surgery. This is due to the potential risk of a fibroid being mistaken for a type of malignant tumour known as a leiomyosarcoma. When tumours such as these are morsellated there can be a worse prognosis for the disease. These are very rare tumours (approx. 1 in a 1000 of cases where fibroids were operated on) and for that reason the risks are currently judged to be low.
     

What happens on the day, and before the operation?


  • You will be taken to a waiting room where a nurse will check you in.
  • Your surgeon may request a portion of your pubic hair shaved before the operation.
  • An anaesthetist will meet you to go through the type of anaesthesia applicable for your case with you and ask questions on previous operation(s) if you had any and your family's.
  • Also, he/she will give you warnings on possible side-effects and a chance to ask questions. Don't forget to mention any previous operation(s) you had and any side-effects. If you never had an operation under general anaesthesia, tell him/her about your family's operation(s).
  • In the pre-op room, an intravenous line is inserted for drugs to be given.
  • You will be moved to the operating theatre where various monitors will be connected to help to care for you while you are anaesthetised.
  • The anaesthetist will put you to sleep. A tube may be put into your mouth to help you to breathe and taken out at the end of the operation.
  • The anaesthetist will stay with you throughout to make sure that you remain safe.

What happens DURING the operation?


Generally speaking, the surgeon performs the following:

  • Insert a catheter into the womb (uterus). Carbon dioxide gas is pumped in to inflate the abdomen to create the space for him/her to work.
  • Make a small incision (cut) in the navel.
  • Insert the laparoscope (a specialised endoscope with fibre optic tube attached to a viewing device) into the womb to examine the abdomen.
  • Make two or 3 additional incisions in the abdomen. He/she will insert a special laparoscope through these incisions to find each fibroid and remove it surgically.
  • After removing the fibroids, they are cut into pieces by special instruments and removed, and if necessary, the wall of the womb is repaired.
  • When the removal of fibroids is completed, as much gas as possible is removed.
  • Close up all incisions with either stitches or clamps/staples at the end of the operation.

The whole operation can take several hours to complete, depending on the size and location and number of fibroids to be removed. Keyhole procedure in some cases takes longer than open abdominal surgery.

When the operation is over, the anaesthetist will bring you back to consciousness. You will then be moved to the recovery room where you are being watched by the anaesthetist and given oxygen. You will continue to wake up, feel drowsy and weak for a little while. Specially trained nurses will care for you in the recovery room until you are fine to move to the ward.


What happens after surgery?


When you wake up from the operation, you will notice that you have the following:

  • An oxygen mask to help you breathe.
  • A drip in the arm to give fluids, blood, plasma.
  • A temporally bladder catheter.
  • You may have a drain from the wound.

Generally


  • You will feel extremely tired and sleepy.
  • If you have a keyhole (laparoscopic) myomectomy, it is likely that you feel some shoulder-tip pain and/or abdominal bloating or pain due to the carbon dioxide gas used in the operation.
  • For the next few days, you may be given anticoagulant injection to prevent DVT such as Clexane.
  • Tell your nurses as soon as you pass wind or a bowel motion because this shows that your digestive system is getting back to normal. If you do not open your bowel after two days, you will be given suppositories to help.
  • The urinary catheter will be removed once you are able to use the toilet.

Going home

Depending on your speed of recovery, you are going hone within 3 to 7 days after open abdominal surgery and in a day or two after keyhole procedure. You will normally be given an appointment to be seen in the clinic in 6 weeks.


Care At Home Guide

  • The pinkish/brown vaginal discharge continues for 10-14 days post-op. This is normal as part of the healing process.
  • Keep the wound (incision site) clean and dry. There is no need to put any dressing over it. The key objective here is to avoid infection for healing to take place.
  • If you have concerns at home please contact St Mary’s Hospital, Lindo Wing for advice or call 07551368653

References

www.britishfibroidtrust.org.uk/myomectomy.php

BSGE