Abdominal and Laparoscopic Myomectomy

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.

More about surgery and recovery can be found at A Gynecologist's Second Opinion: http://www.gynsecondopinion.com/surgery.htm

What Is an Abdominal Myomectomy?
The most common method of removing fibroids is by making a four- to six-inch "bikini" incision on the abdomen just below the pubic hairline.

After inspecting the uterus to determine the number and position of the fibroids, the uterus is injected with pitressin, a solution that limits bleeding during the surgery. Then the covering of the uterus overlying the fibroid is cut (illustration 1), and the fibroids are separated and removed from the normal uterine muscle (illustration 2). In that fibroids push away normal uterine muscle as they grow (and do not destroy it), the normal uterine muscle can be sewn back together (illustration 3). This procedure takes about one to two hours, depending on the number, sizes and positions of the fibroids. Following surgery, a woman having an abdominal myomectomy may need to stay in the hospital for two to three days.

For information about recovery (and other issues) from women with fibroids, see: http://health.groups.yahoo.com/group/uterinefibroids/

New Pain Management Techniques Used Following Surgery
The first few days after surgery are the hardest, and research is always being done in an effort to ease postoperative discomfort. I use an innovative device to relive post-operative pain called "ON-Q". As we are finishing surgery two tiny plastic tubes are inserted underneath the incision. The tubes are connected to a tennis ball sized device that slowly and evenly pushes local anesthetic contained in the ball into the incision - exactly where you need it. The device is used for 3 days and then easily, and absolutely painlessly, removed. This device greatly reduces the need for injected pain medication which travels throughout the entire body and brain and causes the grogginess that often accompanies narcotics.

I also commonly prescribe another effective innovation called "Patient Controlled Analgesia" (PCA). With this method, a small bedside pump drips pain medication into your IV at a very controlled, slow, and steady rate. With this steady low level of medication, you should not develop significant pain and the total amount of medication necessary per day is much smaller than with shots. Therefore, you will not feel as groggy, and the pain relief is much better

Are Some Fibroids Too Big for a Myomectomy?
The short answer is NO. Some doctors and some managed-care organizations have policies stating that a myomectomy cannot be attempted if the uterus is bigger than a certain size (usually a three-month pregnancy size). Hysterectomy is the only option that they will offer. However, gynecologists who are skilled and experienced at myomectomy surgery can perform a myomectomy on just about any size uterus.(illustration 5) One of the risks of a myomectomy is bleeding from the uterus during surgery. However, there are a number of techniques that can be used to reduce bleeding. A medication can be injected into the uterus that causes the blood vessels in the muscle to constrict, and less blood will seep out of the incisions in the uterine wall. Or the doctor can place an elastic tourniquet around the lower portion of the uterus to decrease the blood flow to the uterus.

The placement and depth of the incisions on the uterus are also important. Making the incisions down to the area between the fibroid and normal muscle, where there are very few blood vessels, will reduce bleeding. Closing every incision quickly and tightly will promptly stop bleeding.

A cell saver is a surgical machine that suctions blood from the surgery site, washes it with sterile salt water, filters it and then gives the patient their own blood through her IV. Therefore, there is less need to give your own blood before surgery and less need for a blood transfusion, avoiding the risk of infection or transfusion reaction. Although I rarely need to use the cell-saver, I have it available outside the room for every myomectomy surgery. If needed, it takes only a few minutes to set up. For women who have very numerous, large fibroids, I set the cell-saver up right at the beginning of the surgery. If I need it, it is ready to go.

In a study of 91 women with fibroids larger than 16 weeks (ranging from 16 to 36 weeks), no one needed to have the surgery changed to a hysterectomy. Complications were very rare and, by using a cell-saver, very few women (7) required a blood transfusion. Many gynecologic surgeons don't have training in these techniques and so don't offer them. Ask your doctor and get some clarification on these issue and their experience with myomectomy surgery.

	The abdominal incision is stretched (muscles are NOT cut) to allow the entire uterus with fibroids to be easily seen. (higher resolution image)
	Largest fibroid (12 cm) is removed from uterus (higher resolution image)
	23 fibroids were removed from this woman's uterus (higher resolution image)
	The uterus reconstructed after removal of the fibroids (higher resolution image)

What Does the Incision for an Abdominal Myomectomy Look Like?
I am often asked what the incision will look like after an abdominal myomectomy. I always make a bikini incision (medical name is Pfannensteil incision after the doctor who developed it). The incision is about 1 inch above the pubic bone and 4-6 inches long, depending on the size of the fibroids. The tissue underneath the skin called the fascia is then cut to allow access to the abdominal cavity. I do not cut the muscles, but stretch them apart (they have a natural separation) in order to get to the uterus and fibroids. The incision heals nicely as can be seen in the photos.

	Picture of the abdomen prior to surgery (higher resolution image)
	Picture of the incision (higher resolution image)
	Picture of the incision 2 weeks after surgery (higher resolution image)

Can a Myomectomy Be Performed During a Cesarean Section?
Experienced surgeons can safely perform a myomectomy in carefully chosen women during a Cesarean section. One study of twenty-five women who had myomectomies performed for fibroids between 2 and 10 cm, showed that although five women needed a blood transfusion, no one needed to have a hysterectomy. Another study found that less than 1% of women needed a transfusion and none required hysterectomy. The authors concluded that, in experienced hands, myomectomy may be safely performed in some women during Cesarean section.

What Is a Laparoscopic Myomectomy?
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 technique continues to evolve as new instruments are developed. Because of the small size of the incisions and the level of skill needed to correctly perform the surgery, this procedure is actually harder for a physician to perform and takes more skill and training than abdominal surgery.

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.

Laparoscopic Surgery

For laparoscopic myomectomy, a small scissors 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.

Laparoscopic Myomectomy

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.

Myomectomy should be performed only if appropriate indications exist. And since it is a technically difficult surgery, your physician should have the extra training and experience that it requires. When talking to your doctor or interviewing a gynecologic surgeon, it is your right to ask about qualifications:

• How were you trained to do this surgery?
• How many of these operations have you performed for women with a situation like mine?
• Have you had any complications?

Many gynecologists have not been trained to suture with laparoscopic instruments, and some may even say that laparoscopic surgery is not possible. It is often a good idea to get a second opinion from a gynecologist who performs laparoscopic myomectomies on a regular basis to see if this procedure is feasible for you (see below).

Following laparoscopic myomectomy, most women are able to leave the hospital the same day as surgery. For more extensive surgery, a one-day stay may be a good idea. Because the incisions are small, recuperation is usually associated with minimal discomfort. Since the abdominal cavity is not opened to air, bacteria are less likely to reach the area of surgery, and the risk of infection is very low. The intestines are not exposed to the drying effect of air, or the irritating effects of the sterile gauze sponges used to hold the bowel out of the way during abdominal surgery. As a result, the intestines usually begin to work normally again immediately after laparoscopic surgery. This avoids the one- or two-day delay before a person is able to eat following regular abdominal surgery. After laparoscopic myomectomy, women usually can walk the day of surgery, drive in about 1 week and return to normal activity, work, and exercise within two weeks.

Video of a Laparoscopic Myomectomy (graphic footage of actual surgery) Windows Media Format

Can Laparoscopic Myomectomy be Performed if You Want to Have Children?
The use of laparoscopic myomectomy for women who desire to have children is controversial. The concern is how well the uterus will be able to withstand the stress of labor after having been cut and repaired with laparoscopic techniques. Fewer women have gone through labor and delivery after having a laparoscopic myomectomy than the numbers of women going on to have children after an abdominal myomectomy. The uterine scar, however, appears to heal as securely with a laparoscopic myomectomy as with myomectomy done by laparotomy. While many women have gotten pregnant and delivered safely, some physicians may recommend Caesarean section for delivery to avoid the stress of labor on the uterus. There are now a number of studies showing the safety and success of laparoscopic myomectomy for women who wish to get pregnant. However, a study comparing laparoscopic myomectomy and standard myomectomy with regard to fertility, labor, and delivery has not yet been performed by the research community. Further study will be needed to clarify this issue.

How Can We Remove a Big Fibroid Through a Small Laparoscopic Incision?
Less than a decade ago, removing fibroids after laparoscopic myomectomy was a difficult and time-consuming task. However, a few years ago an electrically powered device, called a morcellator, was invented and now allows us to quickly cut up the fibroid and easily remove it from the abdomen. The device is a hollow tube with a sharp circular blade at the end that rotates quickly and takes small slices off the fibroid in a few seconds. A large fibroid can now be removed in about fifteen minutes. Therefore, we are now able to perform laparoscopic myomectomy on women with even large fibroids. This device has allowed a major advance in our laparoscopic technique.

	The silver end of the morcellator is sharp and rotates quickly to cut through the fibroid. (Higher Resolution Image)
	A portion of the fibroid has been removed by the morcellator. (Higher Resolution Image)

Which Fibroids Can Be Removed Laparoscopically?
The limits to laparoscopic myomectomy depend on a number of factors - the size(s), number and position of the fibroids, whether future fertility is desired, and the experience of the surgeon. Some of the issues are

1. How safe will the surgery be in terms of blood loss, time of anesthesia, and risk of injury to other organs.
2. Strength of the repair of the uterus if fertility desired.

Size: Many experienced laparoscopic surgeons are comfortable removing fibroids less than 8 cm (3.5 inches) in diameter. Depending on the position of the fibroid, I have removed fibroids as large as 15 cm, and the largest reported in the literature is 16 cm.

Number: It is actually easier to remove 1 large fibroid than 10 small ones, because each fibroid may require a separate incision which then needs to be sutured. Suturing laparoscopically is more tedious than through an abdominal incision and is a skill that takes many years to perfect. Many experienced laparoscopic surgeons are comfortable removing up to 5 fibroids, but more may be reasonable in some situations.

Position: The easiest fibroids to remove are those that are outside the uterus on a stalk (subserosal pedunculated). Once the stalk is cut, the fibroid can be cut up into small pieces with a specially designed instrument called a morcellator and brought out of the abdomen through a small incision. The deeper the fibroid is into the uterine muscle wall, the more difficult it is to remove, and the more suturing needs to be done to repair the muscle wall. Other considerations regarding position include how close the fibroids are to the fallopian tubes (if fertility is desired) or to the uterine blood vessels, and whether there is any risk of damage to these areas. Skill, experience and judgment of the surgeon all come together here.

Fertility: If future fertility is desired, then the strength of the uterine wall repair is important. While this issue has not been fully studied, my feeling is that if there is going to be a large area of the wall that needs to be repaired and it is right up against the uterine cavity, then the repair is probably stronger if done through an abdominal incision with standard surgical instruments. If the fibroid is not large or not near the cavity, then laparoscopic surgery can be performed. Or, if future fertility is not desired, then the size of the fibroid and proximity to the cavity is not important and laparoscopic surgery can almost always be performed. MRI is a very helpful test that allows me to see the exact size, number and position of all the fibroids, so I always get an MRI before laparoscopic surgery. I like to show the MRI to the patient so that she can appreciate what the issues are and so we can discuss what is in her best interest.

These are the reasons why different gynecologists will give different opinions about whether laparoscopic myomectomy is feasible and appropriate - it is complicated. And, to a large degree, opinions will be based on the surgeon's experience, skill and comfort doing laparoscopic myomectomy.

Can Myomectomy Lead to Scar Tissue?
Any surgery can cause scar tissue to form. Your body makes new tissue as part of the healing process to help connect things back together. This new tissue is called scar tissue or adhesions. Unfortunately, this natural defense can work against us when it occurs internally after surgery, because scar tissue may stick to and pull the normal tissue around it, sometimes causing pain. Scar tissue near the fallopian tubes or ovaries may decrease fertility by making it difficult for the egg to travel to the fallopian tube.

One of the major benefits of laparoscopic surgery is the principle that it causes fewer adhesions than abdominal surgery. A group of Italian doctors recently performed laparoscopy on a group of women a few months after they had fibroids removed by either laparoscopy or traditional abdominal surgery. The number of women studied was small (thirty-two), but the doctors found fewer and thinner adhesions in the women who had laparoscopic surgery. Further studies need to be performed, but this information is encouraging for women wishing laparoscopic surgery.

Can Adhesion Barriers Prevent Scar Tissue?
Another new advance in surgery has been the use of special substances, called adhesion barriers, which help prevent the formation of scar tissue after surgery. Small sheets of cloth-like material can be wrapped around the raw areas from surgery and the material prevents nearby tissue such as the intestines from sticking to the surgery sites. After a few weeks, the material dissolves, leaving the newly healed surgery sites fairly free of adhesions. While the barriers are not perfect, they have been shown to help reduce the formation of adhesions.

	This adhesion barrier looks and feels like a silky piece of gauze. (Higher Resolution Image)
	When placed over the uterus and sprinkled with sterile water, the adhesion barrier sticks to the uterus and prevents other organs from sticking to the sutured area. (Higher Resolution Image)

I am including an abstract of an article about one adhesion barrier, called Seprafilm:

What are the risks of abdominal myomectomy?
Some studies suggest that there may be less risk of intraoperative injury with abdominal myomectomy compared to abdominal hysterectomy. One study of women having surgery for fibroids showed that operating times were slightly longer in the myomectomy group, but blood loss was slightly more in women who had a hysterectomy. The risks of severe complications such as severe bleeding, fever, life-threatening problems or need for readmission to the hospital were the same for both groups of women. However, 13% of women in the abdominal hysterectomy group had a complication, including 1 bladder injury, 1 ureteral injury, 3 bowel injuries, 8 women who had nausea, vomiting and slow return of bowel movements, and 6 women with pelvic infections. In contrast, complications occurred in only 5% of the abdominal myomectomy patients, including 1 bladder injury, 2 women who needed another operation for a bowel obstruction and 6 women who had nausea, vomiting and slow return of bowel movements. The authors concluded that myomectomy should be considered a safe alternative to hysterectomy.

Reference List

1. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994;83:414-8.

2. Hillis SD, Marchbanks PA, Peterson HB. Uterine size and risk of complications among women undergoing abdominal hysterectomy for leiomyomas. Obstet Gynecol 1996;87:539-43.

3. Sawin SW, Pilevsky ND, Berlin JA, Barnhart KT. Comparability of perioperative morbidity between abdominal myomectomy and hysterectomy for women with uterine leiomyomas. Am J Obstet Gynecol 2000;183:1448-55.

4. West S, Ruiz R, Parker WH. Abdominal myomectomy in women with very large uterine size. Fertil Steril 2006;85:36-9.

5. Roman AS, Tabsh KM. Myomectomy at time of cesarean delivery: a retrospective cohort study. BMC Pregnancy Childbirth 2004;4:14.