Last updated date: 05-Mar-2023
Originally Written in English
The most frequent benign tumor in women of reproductive age is uterine leiomyoma. It is most common in the middle and later reproductive years. The symptoms of uterine fibroids differ based on their size, location in the uterus, and kind. They are most typically encountered in menstruation women between the ages of 30 and 50. Uterine fibroids are more common in women who begin menstruating before the age of 12.
Minimally invasive surgery is getting increasingly common, and the frequency of myomectomy procedures performed using laparoscopy is growing.
Fibroids and Infertility
A small but considerable fraction of infertile women have uterine fibroids. However, the effect of leiomyoma on infertility is debatable. Fibroids are seen in roughly 5-10% of infertile individuals; however, they were determined to be the single identifiable cause in just 1-2,4% of infertile patients.
Buttram and Reiter discovered uterine fibroids as the sole cause of infertility in just 2.4% of their 10 years of experience. Panait Sirbu et al. discovered fibroids to be the only cause of infertility in 53.1% of patients.
Myomas can cause infertility through a variety of methods. The uterine contractility is disrupted, interfering with sperm and ovum transfer. The fibroid may impede the tubal ostia. Subserosal myomas may cause adhesions around the salpinges. Submucous and intramural fibroids with an intracavitary component might deform and expand the uterine cavity, affecting implantation.
Vascular abnormalities, endometrial inflammation, and vasoactive substance production all have an impact on implantability. Submucosal fibroids are related with a 70% drop in delivery rate, while intramural fibroids are associated with a 30% reduction. If a link between myomas and infertility can be established, therapy to improve fertility is recommended.
Types of Myomectomy Techniques
A variety of procedures are employed to remove the fibroid from the uterus. The procedure used may be determined by a number of criteria, including the location and size of the fibroids, as well as the woman's features. Among the several forms of myomectomy are:
- Laparoscopic Myomectomy is performed to remove the fibroids in the uterus. To examine into the abdomen, this method is conducted using a narrow telescopic-like equipment. Four to five incisions are made in the navel and lower abdomen during the surgery. Fibroids are shells that form outside the uterus to mend the uterine wound. Recovery takes around 2 to 3 weeks and needs one night in the hospital. Complications such as hemorrhage, internal organ damage, and infection are possible during this minimally invasive technique. For the excision of fibroids, robotic-assisted laparoscopic surgery is used, in which the robotic system translates the surgeon's hand movement outside of the patient's body and precise surgical movement within the belly.
- A vertical or horizontal incision in the abdominal wall is used to conduct abdominal myomectomy, commonly known as laparotomy. It gives the surgeon direct access to the patient's uterus and allows him to use typical surgical methods and tools. The patient is sedated, and complete recovery is predicted in 4 to 6 weeks.
- Hysteroscopic Myomectomy involves removing a submucosal fibroid from the inside wall of the uterus. In order to do surgery within the uterus, a narrow telescope-like tool is inserted through the cervix to see uterine activity. This treatment is only used for minor fibroid tumors. This technique is carried out in an operating room while the patient is sedated. Fluid overload, hemorrhage, scarring inside the uterus, and uterine perforation are some of the complications seen after this treatment.
What is Laparoscopic Myomectomy?
The removal of uterine fibroids while leaving the uterus intact is known as laparoscopic myomectomy. It is the primary treatment option for people who still want to procreate or want not to undergo a hysterectomy using a minimally invasive technique in which tiny incisions are made in the abdomen above the fibroid. Through these incisions, a camera and surgical equipment are placed to see and act on the uterus.
There are two kinds of such operations. The first is laparoscopic myomectomy (LM), and the second is laparoscopically-assisted myomectomy (LAM) . Enucleation, preparation of the myoma bed, and extraction are all performed completely laparoscopically during LM. LAM involves making a tiny 3 to 6 cm incision in the lower belly and suturing and extracting the myoma bed through this aperture. An abdominal incision retractor or LapDisc Mini is used in LAM.
Intracorporeal suturing is required in LM, increasing the difficulties of the procedure. Many laparoscopists have been trained in intracorporeal suturing procedures in recent years, boosting the number of LM operations. We report on our LM techniques in this publication.
Laparoscopy or laparotomy?
Laparoscopic myomectomy was initially documented in 1979 (for subserosal fibroids), and in the early 1990s, it was also performed for intramural myomas. Laparoscopic myomectomy is becoming one of the most popular surgical treatments performed on infertile people.
The existence of a subserosal or intramural fibroid that narrows the uterine canal, myomas larger than 3cm, and numerous fibroids are all indications. Numerous clinical investigations have demonstrated the viability of laparoscopic myomectomy. A consensus eventually arose that the maximum size should be 8-10cm, and the total number of fibroids should not exceed four.
The uterine rupture during pregnancy or labor should be addressed as a substantial risk following myomectomy. Excessive coagulation, uterine fistulas, intramurally produced hematomas, and the improper suture size are all factors that contribute to this. Multilayer and uterine suturing are permitted in laparotomies provided they are optimally closed following enucleation. Laparoscopic surgeons are attempting to use multilayer procedures rather than single layer approaches to prevent uterine rupture.
Other risks associated with laparoscopic myomectomy include embolism, thrombosis, intestine injury, ureteral injury, urinary bladder injury, excessive bleeding, and fistula.
When opposed to laparotomy, laparoscopic myomectomy offers benefits. Women experienced less post-operative discomfort, a quicker recovery time, a shorter hospital stay, and less ileus time. Dubuisson performed a second-look laparoscopy and observed a 35.6% adhesion rate after laparoscopic myomectomy and a 90% adhesion rate after laparotomy. The prevalence is higher in posterior uterine incisions.
Who is an Ideal Candidate for a Laparoscopic Myomectomy?
Myomectomy is a successful technique for relieving the discomfort caused by fibroids. The following are some of the advantages of myomectomy:
- Relief from fibroid symptoms
- Protection of healthy tissue, including the uterus and ovaries
During a laparoscopic or robotic myomectomy treatment, many fibroids, including big fibroids, can be removed. To arrange the myomectomy, your surgeon will do a thorough examination and discuss your MRI with you.
For fibroids that protrude considerably into the cavity of your uterus, a hysteroscopic myomectomy can be done. This form of fibroid is often removed before to pregnancy. An abdominal myomectomy may be necessary based on the size or number of fibroids.
you will have a detailed assessment by a team of fibroid specialists to determine if you are a viable candidate for laparoscopic or robotic myomectomy.
How to prepare before the Laparoscopic Myomectomy procedure?
Fasting, or not drinking fluids or eating anything in the hours preceding surgery, is required. Before the procedure, the doctor's instructions must be followed. If the patient is already on medicine, it is best to talk with the doctor about whether or not to continue the drug.
Check with your doctor to see if the anaesthetic is general or spinal. General anesthesia is used for laparoscopic, robotic, abdominal, and some hysteroscopic myomectomy procedures during which the patient is unconscious. Spinal anesthesia is used to numb the nerves in the lower portion of the body during various hysteroscopic myomectomies.
Because fibroids interfere with fertility, laparoscopic myomectomy is difficult but offers advantages such as shorter hospitalization, less surgical discomfort, less febrile morbidity, faster recovery, and less blood loss. Laparoscopic myomectomy also reduces the likelihood of postoperative adhesion development. This operation also reduces the likelihood of trouble in future pregnancies owing to uterine rupture.
What to Expect During a Myomectomy?
If you are considering a myomectomy, you will visit with one of our surgeons. The appointment will involve a physical examination as well as a battery of tests. To reduce the risks of myomectomy surgery, your doctor may advise you to undertake the following:
- Iron supplements to correct iron deficiency anemia
- Medications to correct anemia
- Medications to shrink fibroids
You will be given general anesthetic prior to the procedure. Three or four tiny incisions will be made in your lower abdomen by your surgeon. After that, your surgeon will insert a laparoscope via one of the incisions. A laparoscope is a slender, illuminated tube with a camera attached to one end. Small instruments will be inserted into the other incision locations and utilized to carry out the procedure. If the operation is being performed robotically, your physician will use robotic arms to manipulate the tools remotely.
Your surgeon may need to break your fibroids into little pieces and place them in a bag before removing them via a small incision in the abdominal wall. Your surgeon may have to create a bigger incision in your abdomen if they are too large. Outpatient laparoscopic and robotic myomectomy procedures are most often done. You should be able to leave the hospital within a few hours of the surgery being completed.
What are the risks involved in Laparoscopic Myomectomy?
Even though Laparoscopic Myomectomy has low complications and risks involved, it might occur that sometimes unique challenges are faced in some cases. Some of the risks involved in the procedure include:
- Excessive blood loss which is higher with the larger uterus. Women already have low blood counts as a result of severe monthly bleeding (anemia). Because of the increased risk of blood loss, doctors always recommend ways to boost the blood count before undergoing surgery. Doctors go above and beyond to prevent severe bleeding, including injecting medicines near fibroids to constrict blood vessels and limit flow from the uterine arteries.
- There can be a certain risk during pregnancy. Doctors might consider conducting cesarean birth (C-section) if there has been a deep cut in the uterine wall. This is done to avoid uterine rupture during childbirth, which is a relatively rare pregnancy problem. Fibroids have been linked to pregnancy problems.
- If the bleeding is uncontrolled and additional abnormalities are discovered in addition to fibroids, the surgeon may perform a hysterectomy and remove the uterus.
- There is a small probability that the malignant growth will spread and be misdiagnosed as fibroids. If the tumor is removed by a small incision, it may break up into little fragments and disseminate throughout the body. This possibility and risk increase as women age and after menopause.
- After surgery, there can be adhesions – Scarring caused by an incision into the uterus to remove fibroids. Because of the adhesion established within the uterus, there is a possibility of light menstrual cycles and trouble with fertilization. Adhesion is more likely in laparoscopic myomectomy.
There is a potential that new fibroids will form following the myomectomy treatment. The risk is higher in younger women than in individuals nearing menopause or with few fibroids.
How can one prevent possible surgical complications?
Doctors recommend below preventive measures to minimize the risk of myomectomy surgery –
- Heavy menstrual periods can cause iron deficiency anemia. Usage of vitamins and iron supplements to allow build up the blood count during the surgery.
- GnRH agonist medication is used to reduce the fibroid, allowing the surgeon to employ a less invasive technique during surgery. Night sweats, hot flashes, vaginal dryness, and menopause may result with this treatment. These issues and discomforts are resolved after the drug is administered.
- Another method of preventing anemia and surgical complications is to use hormone therapy. Doctors suggest GnRH, or gonadotropin-releasing hormone agonist, birth control tablets, and other hormonal drugs to reduce or halt menstrual flow. These medications interrupt menstruation by blocking the synthesis of progesterone and estrogen, enabling the body to generate hemoglobin and iron reserves.
What to Expect During Recovery?
Laparoscopic myomectomy is a surgical procedure used to remove one or more fibroids. Your doctor will insert a lighted tube (scope) and other instruments into small wounds (incisions) in your abdomen. The fibroids were subsequently removed by the doctor. For many days following surgery, you may experience abdominal pain. Your stomach may also be bloated. For a few days, you may notice a change in your bowel motions. You may also have cramps throughout the first week.
It is typical to experience some shoulder or back ache. This is due to the gas the doctor injected in your stomach to let him examine your organs more clearly. Your doctor may prescribe pain relievers. You might be out of commission for 1 to 2 weeks. It is critical not to carry anything heavy for at least a week. Your doctor may talk to you about when you can have sex and when it's safe to attempt to become pregnant.
For a few weeks, you may experience a dark or reddish-brown vaginal discharge, as well as minor vaginal bleeding or spotting. This is typical. Your first two periods may begin early or late. They might be a lot more painful or heavier than normal.
This care sheet will give you an estimate of how long it will take you to recuperate. However, everyone recovers at their own speed. Follow the actions outlined below to get better as soon as possible.
How can you care for yourself at home?
- Rest when you feel tired.
- Be active. Walking is a good choice.
- Allow your body to heal. Don't move quickly or lift anything heavy until you are feeling better.
- Ask your doctor when it is okay for you to have sex or use tampons. Do not douche.
- Hold a pillow over your incisions when you cough or take deep breaths. This will support your belly and may help to decrease your pain.
- Do breathing exercises at home as instructed by your doctor. This will help prevent pneumonia.
- You can eat your normal diet. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken, toast, and yogurt.
- Avoid constipation and straining if your bowel motions are irregular shortly after surgery. Consume lots of water. Fiber, a stool softener, or a moderate laxative may be recommended by your doctor.
- Be safe with medicines. Read and follow all instructions on the label.
- If the doctor gave you a prescription medicine for pain, take it as prescribed.
- If you are not taking a prescription pain medicine, ask your doctor if you can take an over-the-counter medicine.
- Your doctor will tell you if and when you can restart your medicines. You will also get instructions about taking any new medicines.
- If you take aspirin or some other blood thinner, ask your doctor if and when to start taking it again. Make sure that you understand exactly what your doctor wants you to do.
- If you have strips of tape on the cut (incision) the doctor made, leave the tape on for a week or until it falls off.
- If you have skin adhesive on the incision, leave it on until it falls off. Skin adhesive is also called liquid stitches.
- Wash the area daily with warm, soapy water, and pat it dry. Don't use hydrogen peroxide or alcohol. They can slow healing.
- You may cover the area with a gauze bandage if it oozes fluid or rubs against clothing.
- Change the bandage every day.
- Keep the area clean and dry.
- If you wish to attempt to get pregnant quickly, see your doctor. When it is safe to do so, your doctor will advise you. If you don't want to get pregnant, discuss birth control with your doctor.
- Dress in loose, comfy clothes. Avoid anything that exerts pressure on your stomach for a few weeks.
- You may have some vaginal bleeding. If necessary, use sanitary pads.
- To alleviate pain, you might apply a heating pad to your stomach.
Although laparoscopic myomectomy is a minimally invasive surgery, it is the primary treatment choice for people who want to conceive but do not want to undergo a hysterectomy. Small incisions are made in the abdomen over the area where the fibroid is. If you have smaller and fewer fibroids, laparoscopic myomectomy may be preferable. If you have tiny fibroids inside your uterus, a hysteroscopic myomectomy may be preferable.