What is Myomectomy?

Myomectomy is a surgical procedure to remove uterine leiomyomas (benign growths of the uterine muscle), also known as fibroids, while retaining the uterus. It is also known as fibroidectomy.

Fibroids or fibromas are tumors of the female reproductive system. These are non-cancerous or benign tumors, except in very rare cases, where these could be cancerous. Size of the tumor may be as small as a pea or as large as a softball.

There are three main types of uterine fibroids:

Intramural fibroids – they grow within the muscular uterine wall and are the most common types
Subserosal fibroids – these project outside the uterus and appear as stalks
Submucosal fibroids – these occur in uterine lining, known as endometrium. They bulge into the uterine cavity

In some cases, the subserosal or submucosal fibroids are pedunculated, i.e. they are suspended from a stalk inside or outside the uterus.

Depending upon the location, size and number of fibroids, the specific type of myomectomy surgery would be recommended.

Why is Myomectomy Done?

Although fibroids are benign growths, they can still cause troublesome symptoms and may need to be removed. These include the following:

Menorrhagia or heavy menstrual bleeding leading to anemia or low hemoglobin
Pelvic pain and discomfort due to pressure on adjoining organs
Difficulty in becoming pregnant, especially in the event of a subendometrial fibroid
Urinary symptoms due to pressure on the bladder
Complications during pregnancy

In most cases, myomectomy will provide relief from these symptoms, although there may be recurrence later.

What are the types of Myomectomy?

The surgical approach usually depends on - Size, location, and number of fibroids.

Abdominal (Open) Myomectomy or Laparotomy– This procedure involves removal of fibroids through an abdominal incision. This surgery is reserved for large fibroids that are usually over 6 to 7 cms in size. Fibroids as large as 15 to 16 cms in size maybe removed through this approach.

The incision could be a horizontal or vertical cut, depending on the size of the fibroid. Open surgery helps the surgeon to view the pelvic organs which would otherwise be difficult to view, when a patient has large or multiple fibroids.

However, this procedure has the disadvantage of the necessity for a larger incision, general anesthesia, and risks like blood loss, pain, possible infection and longer recovery time.

This surgical procedure involves a hospital stay of about five to seven days and recovery period of six to eight weeks.

Hysteroscopy or Hysteroscopic Myomectomy – It involves removal of fibroids through the vagina. It is done for one or small multiple fibroids which are sub-mucosal and are projecting into the lumen of the uterus. Usually the fibroids are 2 to 3 cms in size.

There is no incision involved in this procedure. A long thin resectoscope (borrowed sometimes from urology department) with a telescope and light is passed through the vagina and cervix into the uterus.

The surgeon can look for fibroids and polyps through the hysteroscope lens. These are then removed using a heated wire loop followed by control of bleeding. The small pieces are evacuated and sent for biopsy.

The patients are discharged usually the same evening or the next day and the procedure can be done under regional anesthesia. The recovery time is about two to three days.

Laparoscopic or Robotic Myomectomy – In this procedure, the surgeon removes fibroids through small abdominal incision. Three to four small (less than 1 cm)incisions are used that are much smaller than an open procedure. There is less pain and blood loss after the procedure and early recovery. Usually this approach is taken for fibroids that are less than 5 to 6 cm and are projecting outside the uterus.

It generally involves only an overnight stay in the hospital.

Robotic myomectomy – is similar to laparoscopic myomectomy, except that the surgeon controls movement of instruments from a separate console.

How do you Prepare Before Myomectomy?

The week before surgery

Before the surgical procedure, routine preoperative tests would be conducted

Thorough history and physical examination by the gynecologist
Pregnancy test to rule out coincidental pregnancy
Blood pressure and ECG to check fitness of heart
Blood tests checking hemoglobin levels, blood group, liver and kidney function tests
Urine tests
Chest x-ray

Other imaging tests to confirm the size and location of uterine fibroids include:

Ultrasound: This test uses sound waves to get an image of the uterus to view and measure fibroids.

For this test, the technician makes the patient lie down and moves the ultrasound device over the abdomen or places it inside the vagina to get images of the uterus.

Ultrasound Test Helps to View & Measure the Size of Fibroids

Magnetic Resonance Imaging (MRI): This test gives details on size and location of fibroids. It helps identify the type of fibroids and thus, the treatment option.

For this test, the patient will be placed inside a narrow tube, which may make the patient feel claustrophobic. The MRI machine makes loud clicking noises and the doctor would suggest wearing ear plugs to block these noises.

Before myomectomy, you must discuss with surgeon the following points:

Inform surgeon about the vitamins, dietary supplements or any other over-the counter medications being consumed
Ask your surgeon whether routine medications should be continued or not, before surgery
Consult surgeon if warfarin or blood thinning agents are being consumed and if they can be continued
Understand from the surgeon the type of anesthesia- some patients may need general anesthesia, whereas some may need spinal anesthesia
Be aware of the pain medications which could be prescribed during and after the surgery and the period for which these need to be consumed

Treatment with Gonadotropin-releasing hormone analogue (GnRH-a) injection before Surgery

For large fibroids a course of 2-3 injections over a period of three months of GnRHa (once a month) before myomectomy helps shrink the fibroids and reduces the risk of excessive bleeding during the surgery.

Day before and the morning of surgery

You should be admitted to the hospital one day prior to the surgery
Overnight fasting is required and intravenous fluids may be administered, if required
You can have a normal bath in the morning and wear the hospital gown provided to you
You will be shifted to the operating room, one or two hours before the surgery
Depending on the type of myomectomy, the surgery would be performed under general or spinal anesthesia

What Happens During the Surgery?

Once inside the operating room, the patient will be transferred to the operating table and the anesthetist will administer either general anesthesia or spinal anesthesia.
During general anesthesia, the patient will be asleep and will remain unaware of the operation. Under spinal anesthesia, the lower half of the body alone will be numb so that the patient does not feel the pain. However, she remains awake and aware of the procedure.
The patient will be connected to a monitor which continuously checks the vital parameters such as heart rate, blood pressure and respiratory rate.
The surgeon will begin the procedure which may be an open myomectomy, hysteroscopic myomectomy or a laparoscopic procedure as described above.
Once the fibroid/fibroids are removed, the wound is closed and a bandage applied over the wound.

What Happens after Myomectomy?

Recovery in hospital

After the myomectomy surgery, the patient would gradually recover from the anesthetic effect and will wake up feeling a bit drowsy and will be transferred to the postoperative recovery room.
In the recovery room, the nurse will monitor the vital parameters and observe the patient closely for an hour or two.
Once the patient is stable, she will be taken back to her room.
Intravenous fluids will be given to maintain hydration and painkillers administered for relief of pain.
A urinary catheter may be in place for passage of urine until the patient is ambulant, usually until the following day.
Thromboprophylaxis will be given for a few days to prevent deep vein thrombosis or pulmonary embolism following surgery.
Liquid diet may be allowed on the day after surgery and if tolerated, soft solids may be given with gradual introduction of normal diet.
Some vaginal discharge may be present for a few days following the surgery.
Once the patient’s general condition is normal, she may be discharged.

Recovery at home

After being discharged from the hospital, the patient must take appropriate care at home, to recover from the surgery. The general suggestions advised by the surgeon would include:

Adequate rest for two weeks
Avoid standing for more than few minutes at a time, avoid lifting weights and straining
Strictly follow regimen of antibiotics and other drugs, including pain medications, as suggested by the surgeon
If excessive vaginal bleeding or discharge or bleeding from the wound is observed, the physician or surgeon must be consulted immediately
A followup visit will be necessary in a week to remove the sutures and to review the patient’s progress and recovery.

What are the Risks of Myomectomy?

Myomectomy has low risk of complications, as compared to other surgical procedures. The risks and complications could include the following:

Excessive blood loss which may rarely necessitate removal of uterus
Scar tissue formation and adhesions
Pelvic inflammatory disease involving the fallopian tubes and ovaries
Wound infection

Rupture of uterine scar during a later pregnancy or delivery

How to Avoid Potential Surgical Complications?

The surgeon may recommend the following measures to reduce or avoid complications:

Iron supplements - to build up the blood count in anemic patients, before surgery
Hormones - The doctor may prescribe hormonal medications to reduce menstrual flow.
Treatment to shrink fibroids - Some hormonal medications like Gonadotrophin releasing hormones (GnRH) can shrink fibroids which in turn help the surgeon to make a minimal incision and thus, a minimal invasive surgery approach
Medications to reduce bleeding – The use of misoprostol in vagina and the injection of vasopressin into uterine muscle are both effective, in reducing bleeding during myomectomy.