LAPAROSCOPIC MYOMECTOMY
What is a myomectomy
A myomectomy is a surgical operation to remove fibroids, while preserving the uterus. Fibroids are common benign growths and could cause symptoms including heavy and painful periods, pressure and infertility. Myomectomy is the best treatment option for women with fibroid symptoms and want to have children in the future.
How is myomectomy performed?
All myomectomy operations are performed under general anaesthesia. The procedure can be performed in several different ways, depending on the size, number and location of fibroids. Fibroids could grow into the cavity (submucous fibroids), into the wall (intramural fibroids) or outwards from the wall of the uterus (subserous) fibroids. Submucous fibroids are usually removed by keyhole surgery through the cervix (hysteroscopic myomectomy). This involves no cuts.
Intramural and subserous fibroids are removed through keyhole (laparoscopic myomectomy) or a larger incision on the abdomen (open myomectomy). Some large submucous fibroids would also require laparoscopic or open myomectomy.
At Gynaecare clinics, our expert gynaecologist will perform a detailed pelvic ultrasound scan at your first appointment, accurately measuring and mapping your fibroids, to determine the safest and most effective surgical procedure. His expertise in all forms of surgery means all three surgical options are available to you.
Laparoscopic Myomectomy
Four small incisions are made into the abdomen. Three of these are 5 mm in size and a 10-12 mm additional incision is utilised. A telescopic camera and instruments are inserted through the incisions for the surgery.
A diluted solution of Vasopressin is injected into the womb, reducing its blood supply temporarily in order to minimise blood loss. A special ultrasound incision instrument (Harmonic scalpel) is then used to cut out the fibroids. The uterus is repaired with dissolvable sutures, before fibroids are cut into smaller pieces to allow easy removal through the small incisions. This can be done using an instrument called a morcellator. The skin incisions are then closed.
Most patients will spend a night in hospital with discharge home within 12-24 hours after surgery, and two to four weeks recovering at home. After the procedure, you will have small scars on your skin where the incisions were made.
Can all fibroids be removed by laparoscopic myomectomy?
Not all fibroids can be removed by a laparoscopic myomectomy. If the fibroids are too large, or numerous or deeply embedded in the uterus, then an abdominal myomectomy may be necessary. In our practice, 4% of cases may switch from a laparoscopic myomectomy to an abdominal myomectomy.
What are the advantages of this type of surgery?
Laparoscopic myomectomy uses small cuts on the abdomen, minimising trauma, and therefore post-operative pain. Recovery from laparoscopic surgery is much quicker, with most patients discharged home within 12-24 hours following the operation. The recovery period at home is also much quicker with return to normal activities in a much shorter time.
The magnification provided by the laparoscopy camera gives much better views of the pelvic structures, ensuring cleaner cuts, much less blood loss and much lower post operation infection risks.
The small 0.5 – 1 cm cuts have a much better cosmetic appearance compared to a 10 cm cut required for abdominal myomectomy.
Mr Ogutu is an expert laparoscopic surgeon, is one of a few in the region performing laparoscopic myomectomy procedure, with excellent results.
Is this procedure safe?
Particularly good research evidence confirms that laparoscopic myomectomy is safe and effective. It has added benefits compared to open myomectomy including:
- Less post-operative pain
- Shorter hospital stays (1-2 days compared to 3-4 days with abdominal myomectomy)
- Quicker recovery
- Lower complication risks (less blood loss, lower infection risk etc)
- Better cosmetic appearance of abdomen after surgery
What are the risks of morcellation?
- Small pieces of benign (non-cancerous) fibroid tissue could be left inside your abdomen. These may then attach to the internal organs in your abdomen where they can continue to grow. You may then require additional surgery to remove these fibroids. The risk of this happening is thought to be 1 in 120 (uncommon) to 1 in 1200 (rare).
- Morcellation of uterine tissue or a fibroid that could contain an unexpected cancer called uterine sarcoma.
The risk of unexpected uterine sarcoma in fibroids depends on your age and is higher around the time of and after your menopause. Various studies have quoted this risk as ranging from:
- 1 in 65 to 1 in 278 (if you are over 60 years of age),
- 1 in 158 to 1 in 303 (if you are between 50 and 59)
- 1 in 304 to 1 in 1250 (if you are younger than 50).
While these studies do not give us exact risk figures, they do tell us that the risk increases significantly with age. If you are over 50 years of age, your risk is higher and continues to increase as you get older.
If an unexpected uterine sarcoma is morcellated then it can potentially cause the cancer to spread and worsen your chances of survival.
If you have large, rapidly growing fibroids, with high blood flow and are over 50 years of age, post-menopausal, then there is an increased risk of the fibroid potentially being cancerous. In these cases, it will be safer to perform an abdominal myomectomy as risk of spread is much lower.
Abdominal Myomectomy
Also known as an “open” myomectomy, it involves a 7-10 cm incision through the skin on the lower abdomen, known as a “bikini cut,” and removing the fibroids from the uterus. The uterine muscle is then sewn back together using several layers of stitches. You will be asleep during the procedure.
Most women will spend two nights in the hospital and four to six weeks recovering at home.
Hysteroscopic Myomectomy
Only fibroids growing into the cavity of the uterus (submucosal fibroids) can be removed by hysteroscopic myomectomy.
This is an outpatient surgical procedure, performed under general anaesthetic. There are no cuts involved and therefore no scars on your skin after the procedure.
A long, slender “telescope” is placed through the cervix into the uterine cavity. Fluid is introduced into the uterine cavity to lift apart the walls. Instruments passed through the hysteroscope are used to shave off the submucosal fibroids.
You will be discharged home after 3-5 hours of observation in the recovery room. You may experience cramping and light bleeding after the procedure. Typical recovery involves one to four days of resting at home.
Will I always require a caesarean section after myomectomy?
Most women will safely delivery vaginally after myomectomy. However, removal of fibroids from the uterus may weaken the uterus, depending on how deep the fibroids are embedded.
After your myomectomy, we will confirm the depth and number of fibroids removed. If we suspect potential weakness, we will advise you to have a planned caesarean section in order to minimise the risk of uterus further weakening and potentially coming apart during labour.
We will provide a detailed report to share with your obstetricians, including our recommendations for your safe delivery.
For more information about how we can help you, have a look at our Fibroid Package.
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