Conservative Myomectomy

Myomectomy is an operation in which only the myoma, and not the entire uterus, is removed, which saves the woman the opportunity to have children. There are several ways to perform myomectomy: hysteroscopic, laparoscopic and abdominal (normal).

Hysteroscopic myomectomy

Hysteroscopic myomectomy is used only for fibroids located directly under the mucous layer of the uterine cavity and protruding into its lumen. In this case, do not resort to the cut. The doctor inserts a special instrument (resectoscope) through the vagina and neck into the uterus and removes the node. Usually this procedure is performed under anesthesia.

Preoperative therapy with one of the basic drugs (3-6 months) is also recommended.

Indications:

  1. submucous node location;
  2. leg leiomyoma;
  3. meno- and metrorrhagia leading to anemia;
  4. miscarriage and infertility;

Contraindications:

  1. the depth of the uterine cavity is more than 12 cm;
  2. suspected hyperplasia or endometrial adenocarcinoma;
  3. infection of the upper and lower genitalia;
  4. severe diseases of the liver, kidneys and heart (risk of hypervolemia);
  5. suspected leiomyosarcoma;

 

Complications:

  • damage to the main vessels and organs of the abdominal cavity with the introduction of trocars, complications of anesthesia, respiratory disorders, TE, etc.
  • with laparoscopic myomectomy, postoperative bleeding from the uterus or bed of the myomatous node is possible,
  • there is a risk of developing intraoperative complications that require immediate hysterectomy – removal of the uterus.
  • hematomas in the uterine wall with inadequate layer-by-layer closure of defects, infectious complications.
  • damage to the ureters, bladder and intestines more often occurs with a low or interstitial location of the myomatous nodes.
  • perhaps the occurrence of hernias of the anterior abdominal wall after the extraction of macrodrugs through it.
  • it should be noted that the scars remaining on the uterus after this kind of surgical intervention require increased attention during pregnancy and childbirth in these patients.
  • relapses after laparoscopic removal of fibromatous nodes occur in 33% of women within 2 years.

With the traditional technique of gynecological surgery, skin sutures are removed on days 6-8, depending on the type of intervention, they are discharged from the hospital 10-15 days after the operation. Disability is restored after 1.5 – 2 months.

Laparoscopic myomectomy

Laparoscopic myomectomy is performed in the presence of subserous or intramuntral nodes. Small puncture cuts are made on the abdomen in the navel to insert a laparoscope into the abdominal cavity with a miniature video camera attached to it and 2-3 others in the lower abdomen, through which special surgical instruments are introduced into the abdominal cavity to remove the tumor. The operation is performed under general anesthesia.

The purpose of the operation is the removal of myomatous nodes with preservation of the reproductive and menstrual functions. Before the operation, a 6-month course of one of the basic drugs (goserelin, gestrinone) is prescribed to reduce the size of the nodes and reduce blood loss during surgery. Hormonal preoperative preparation is indicated for a fibroid site with a size of more than 4–5 cm. In case of subserous localization of the myomatous node on the leg, preoperative preparation is not carried out.

Indications for myomectomy

  1. Nodes on the stem and subserous localization.
  2. Miscarriage and infertility. The presence of at least one myomatous node with a diameter of more than 4 cm with the exclusion of other causes of miscarriage and infertility.
  3. Meno- and metrorrhagia leading to anemia. The main reason is cavity deformation and impaired uterine contractility.
  4. Rapid growth and large sizes of myomatous nodes (more than 10 cm).
  5. Pelvic pain syndrome resulting from circulatory disorders in the myomatous nodes.
  6. Violation of the function of neighboring organs (bladder, intestines) due to their mechanical compression by the tumor.
  7. The combination of uterine fibroids with other diseases requiring surgical treatment.

 Absolute contraindications

General contraindications for laparoscopy are diseases in which a planned operation can be life-threatening for the patient (diseases of the CVD and respiratory system in the decompensation stage, hemophilia, severe hemorrhagic diathesis, acute and chronic liver failure, diabetes mellitus, etc.).

Suspected genital malignancy.

The size of the myomatous node is more than 10 cm after hormonal preparation.

The literature discusses the size of the myomatous node, which allows for conservative myomectomy with laparoscopic access. According to many domestic and foreign authors, the size of the myomatous node should not exceed 8 – 10 cm, since with a larger value of the myomatous nodes after husking, difficulties arise in their removal from the abdominal cavity. With the introduction of electromechanical morcellators into practice, it became possible to remove myomatous nodes up to 15-17 cm in size.

Many interstitial nodes, the removal of which will not allow to preserve the reproductive function. According to some surgeons, laparoscopic myomectomy can be performed for patients with a number of nodes not exceeding 4. In cases of a larger number of nodes, a laparotomy is necessary.

With multiple uterine myoma, it is necessary to generally assess the possibility of conservative surgery due to the high frequency of relapses (30% or more), while single fibroids relapse only in 10-20% of cases.

It should also be borne in mind that the relativity of contraindications often depends on the qualifications of the surgeon. Relative contraindications, according to some surgeons, include obesity of the II-III degree and pronounced adhesions after previous glancing.

Technique for the operation

Most gynecological interventions, except for volumetric ones (hysterectomy, myomectomy), are performed from three trocar punctures. A 10 mm trocar for a laparoscope is inserted through the navel, two 0.5 cm trocar for tools (scissors, clamps, biopsy forceps, needle holder, etc.) are inserted into the lower abdomen. Tools make the necessary manipulations – stopping bleeding, resecting a part of an organ, removing pathological formations, suturing. 0.5 cm trocar wounds are sealed with a plaster, an intradermal suture with an absorbable thread is applied to wounds 1 cm in size. A number of gynecological interventions are currently being performed by an even more gentle technique – micro-laparoscopic. The operation is usually performed under general anesthesia, although simple procedures (diagnosis, sterilization) in some hospitals are performed under combined local anesthesia

Duration of hospitalization, postoperative regimen

After a laparoscopic operation, bed rest is prescribed on the first day before evening because of anesthesia, in the evening you can drink fluids, turn around and sit down in bed. The next day, you are allowed to get up and walk, eat. Sutures, as a rule, are not removed, discharge is carried out 2-5 days after the intervention. During the first two weeks after surgery, washing in the shower, after washing – treating wounds with iodine solution or 5% potassium permanganate solution. Normal work and physical work is possible in 2-3 weeks.

Full recovery of disability is largely due to the presence of concomitant pathology (hypertension, diabetes mellitus, obesity) and the severity of anemia before surgery, and usually corresponds to the 12-21st day after surgery. Sexual life is possible about a month after the operation. In the future, routine gynecologist follow-up with preventive examinations and ultrasound is necessary once every 6-12 months.

Abdominal myomectomy

This is a surgical operation in which one incision is made on the abdomen in order to open access to the uterus, another incision is made on the uterus itself. This operation is performed under general anesthesia and requires the patient to be in the clinic for the next few days.

Positive sign:

  • preservation of the organ is possible if the patient wants to maintain fertility.

Minuses:

  • the postoperative recovery period lasts about 6 weeks; general anesthesia is needed;
  • postoperative adhesion formation in the pelvis;
  • relapses (re-formation of myomatous nodes) from 10 to 27%.