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Laparoscopic Myomectomy Surgery

What is a myomectomy?

Myomectomy means the surgical removal of just the fibroid, with reconstruction and repair of the uterus. There are now a number of techniques used to perform myomectomy: through an abdominal incision, vaginal incision, with a laparoscope, or with a hysteroscope. Myomectomy relieves symptoms in more than 75% of women. “The restoration and maintenance of physiologic (normal) function is, or should be, the ultimate goal of surgical treatment”, said Victor Bonney, an early advocate of abdominal myomectomy, in 1931. However, women are often told that myomectomy is not appropriate for them because hysterectomy is safer, is associated with less bleeding or that uterine muscle cancer (sarcoma) may be present. However, recent studies dispute all of those claims.

Studies show there may actually be less risk of complications during myomectomy than during hysterectomy. One study of women who had myomectomies and women who had hysterectomies for fibroids of the same sizes (about 4 months pregnancy size) found surgery took slightly longer in the myomectomy group (200 v. 175 min), but there was more blood loss in the hysterectomy group. The risks of bleeding, fever, life-threatening complications, need for another surgical procedure or re-admission to the hospital were not different. The authors of the study concluded that there was no difference in complications and with an experienced surgeon myomectomy is a safe alternative to hysterectomy.

Laparoscopic myomectomy surgery:

Only certain fibroids can be removed by a laparoscopic myomectomy. If the fibroids are large, numerous or deeply embedded in the uterus, then an abdominal myomectomy may be necessary. Also, sometimes during the operation it is necessary to switch from a laparoscopic myomectomy to an abdominal myomectomy.
You will be asleep during the procedure, which is performed in the operating room. First, four one-centimeter incisions are made in the lower abdomen: one at the navel (belly button), one below the bikini line (near the pubic hair) and one near each hip. The abdominal cavity is then filled with carbon dioxide gas. A thin, lighted telescope, called a laparoscope, is placed through an incision, allowing doctors to see the ovaries, fallopian tubes and uterus. Long instruments, inserted through the other incisions, are used to remove the fibroids. The uterine muscle is sewn back together. At the end of the procedure, the gas is released and the skin incisions are closed.

Most women spend one night in the hospital and two to four weeks recovering at home. After the procedure, you will have small scars on your skin where the incisions were made.

What are the symptoms?

Surprisingly most fibroids up to the size of an orange cause no symptoms. Their mere presence is not a reason to treat them. Only about a quarter of women with fibroids will experience any symptom. These may include:

• Heavy and painful periods- Periods may last more than seven days and menstrual flow may be very heavy.

• Pain during sexual intercourse,

• Infertility- Large intramural fibroids may be the cause of longstanding infertility if all other causes have been excluded.

• Urinary or bowel symptoms caused by local pressure due to the fibroids.

• Complications in pregnancy like miscarriage, premature labour

• Pain in the pelvis-The pressure of large fibroids on other organs may cause pain in the pelvis. Pain may also occur if the stalk of a fibroid twists, cutting off blood supply to the fibroid. Rarely, a fibroid may become infected and cause pain.

• Very rarely, a fibroid can undergo malignant change, particularly if the fibroid is very large or rapidly increases in size.

Surgical method of myomectomy

• Hysteroscopy myomectomy surgery: It is a procedure in which lighted viewing instrument is inserted through the vagina into the uterus. It is performed to remove fibroids from the inner wall of the uterus that have not grown deep into the uterine wall. This surgery doesn’t require night stay at hospital and requires two weeks to recover.

• Laparoscopy myomectomy surgery: In this procedure lighted viewing instrument is through one or two small cuts in the abdomen. It is performed to remove one or two fibroids that are grown outside the uterus. This surgery might require a stay of 1 night at the hospital and requires a one or two week stay to recover.
  

• Laparotomy myomectomy surgery: In this procedure a large incision is done to remove the fibroids from the uterus. It is performed to remove large fibroids that are grown deep inside the uterine wall. This surgery usually requires a stay of 1 to 4 days at hospital and requires four to six weeks to recover.

• The choice of method for the surgery depends on the size, location and number of fibroids.

Laparoscopic myomectomy surgery procedure:

Laparoscopic surgery is usually performed as out-patient surgery under general anesthesia and has absolutely revolutionized gynecologic surgery because of the short hospital stay and quick recovery. The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline and instruments are passed through these small incisions to perform the surgery. Because the incisions are smaller, patients can enjoy faster recovery times and smaller scars.

Laparoscopic surgery differs from traditional surgery in a few key ways: during laparoscopic surgery, the surgeon is not looking into the abdomen directly through a large incision across the abdomen, but performs the surgery while looking at a large video monitor suspended over the patient’s abdomen. The surgery, and especially the suturing of the uterus that is necessary during a laparoscopic myomectomy, requires a great deal of hand-eye coordination and dexterity, as well as knowledge of pelvic anatomy in order to be successful.

For laparoscopic myomectomy, a small scissors-like instrument is used to open the thin covering of the uterus. The fibroid is found underneath this covering, grasped, and freed from its attachments to the normal uterine muscle.

After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. New morcellators allow the easy removal of even large fibroids. The openings in the uterus are then sutured closed using specially designed laparoscopic suture holders and grasping instruments. Laparoscopic suturing with small instruments, in particular, requires special training and expertise. The entire procedure can take one to three hours, depending on the number, size, and position of the fibroids.

Advantage of having laparoscopic myomectomy

Laparoscopic myomectomy is removing the fibroids by using laparoscopic surgical techniques. Laparoscopic surgery is a minimally invasive procedure, usually performed as outpatient surgery under general anesthesia. It has revolutionized gynecological surgery because of a shortened hospital stay, better cosmetic appearance, and quick recovery. In laparoscopic surgery, surgeons use electronic eyes (a highly sensitive video camera) instead of their own eyes to do surgery. With a very bright light from a laparoscope directly shining over the surgical field, the operative site is greatly magnified onto several high resolution TV monitors. Heightened visibility of the operative field affords the surgeon to identify and dissect within the right surgical planes more precisely and easily, thus avoiding unnecessary tissue trauma and greatly reducing blood loss during surgery.

Because the incisions are small, recuperation is usually associated with minimal discomfort. Since the abdominal cavity is not opened, bacterial contamination is minimized, and the risk of infection is low. The intestines are not exposed to the drying effect of air or the irritating effects of the sterile gauze pads used to hold the bowel out of the way during the abdominal surgery. As a result, normal functioning of the intestines return almost immediately after the surgery. This not only spares the patient postoperative gas pain, it also avoids days of delay before a person is able to eat. After laparoscopic myomectomy, women usually return to normal activity, work, and exercise within 7-10 days.

• Small incisions and less scarring

• Gentler handling of the body tissues and organs during the operation

• Less postoperative pain

• Less postoperative narcotic use for pain relief

• Shorter hospitalization

• Faster overall recovery with an earlier return to normal activity

• Technique of Laparoscopic Myomectomy

• Preoperative preparation involves a shave and a small enema. Fasting for 6 hours preop is required.

• A general anaesthetic is administered.

• The laparoscope and other instruments are introduced as described.

• The fibroid is visualised. A cut is made in the uterus and the fibroid is freed from the uterine muscle.

• The incision in the uterus is repaired with sutures.

• The fibroid is removed, usually by cutting it up into small pieces to get it out of the small incisions.

• The wounds are closed.

Recovery

Immediate post operative recovery involves an average of 2 days in hospital. 2 in 5 patients can go home late the next day after surgery. 8 patients of every 10 are home in 2 days. Patients are welcome to rest in hospital for as long as they need to. One in 5 patients will only need tablets and not injections for postoperative pain relief. If injections are required about 2 are needed on average. Patients will be given as much pain relief as they request to make sure they are comfortable. A low grade temperature is common in the first few days after surgery. The first few days at home should be taken very easily. The patient should have someone to help. Plenty of rest and fluids are advisable. Exercise your calf muscles to prevent clots. Oral pain relief eg. Panadeine/Panadol may be needed, especially at night.

Graded recovery over the next few weeks will occur. Gentle increasing exercise is helpful. Driving is permissible. Expect to tire easily. Bowel discomfort and some cramps are common. Return to normal activity occurs at about 2-3 weeks for many patients. All patients should individually assess their recovery rate. Some may need more time off work than others and certificates will always be provided. It is important not to have intercourse for 6 weeks postoperatively.

Cost of myomectomy surgery (laparoscopic)

• The cost of the operation varies a great deal. Different countries have different rates. The operation needs an expert surgeon and the cost of the surgery will depend a lot on the surgeon's fees. The more experienced he is, the higher his charges will be. This operation also needs hospital stay of four to five days. The charges will depend on the hospital also. The operating room charges, the recovery room charges, the anesthetics charges, medicines, check ups, pre and post consultations all cost money.
  

• Most health insurance companies cover the myomectomy surgery. However, this has to be discussed in advance. Myomectomy surgery is considered a health related operation and hence there is insurance cover for it.
  

• India is the most favorable destination when it comes to laparoscopic surgery at low cost without compromising the quality.