Chapter 7 Myomectomy
GENERAL PRINCIPLES
Definition
■ Abdominal myomectomy is performed via a laparotomy incision and is also
referred to open myomectomy. It is the surgical removal of uterine
leiomyomas which leaves the uterus intact. Reproductive-aged patients
continue to have menstrual cycles and are able to theoretically able to
conceive following abdominal myomectomy.
■ Uterine leiomyomas are also called uterine fibroids, myomas, or
fibromyomas. They are benign proliferative, unicellular, wellcircumscribed, pseudoencapsulated, benign growths composed of smooth
muscle and fibrous connective tissue. They are the most common benign
growth of the uterus.
■ The pathogenesis of leiomyomas remains unknown. However, several
pathogenic theories may be associated with uterine fibroids including
genetic predisposition, epigenetic factors, estrogens, progesterone, growth
hormone factors, cytokines, chemokines, and extracellular matrix
components.
Differential Diagnosis
■ Adenomyosis
■ Adenomyoma
■ Leiomyosarcoma
■ Diffuse leiomyomatosis
■ Extrauterine pelvic tumors
■ Ovarian mass
■ Pregnancy
Anatomic Considerations
■ Leiomyomas are unique and symptoms vary among women. The prevalence
of uterine fibroids may approach 60% to 80%; however, the majority of
women are asymptomatic.
■ Asymptomatic women should be reassured and followed clinically.■ Thirty percent of women with fibroids may have significant symptoms.
■ The size of leiomyoma may range from a few millimeters to more than 20
cm.
■ The number of leiomyoma also varies. Most patients have fewer than 10
leiomyomas; however, several case reports of patients with more than 100
leiomyomas removed by abdominal myomectomy have been reported.
■ The weight of each leiomyoma varies. The largest removed by case report
was 65 kg.
■ Uterine fibroids may impact fertility via the following mechanisms:
■ Mechanical blockage of the fallopian tube
■ Abnormal vascularization of the uterus
■ Abnormal endometrial development
■ Chronic intracavitary inflammation
■ Increased uterine contractions
■ Distortion of the endometrial cavity
■ The FIGO classification system characterizes the variable anatomic
locations of fibroids.
■ These benign growths may be located within various regions within the
uterus and cervix including endocervical, intracavitary, submucosal,
intramural, transmural, subserosal exophytic, pedunculated serosal,
parasitic, and may prolapse through the cervix into the vagina.
■ Intramural fibroids are the most common location of fibroids. They
reside in the myometrium. They may be of varying size and number.
Proliferation of fibroids is associated with potential distortion of the
endometrial cavity or the external serosal surface.
■ Submucous leiomyomas are commonly referred to as intracavitary
fibroids. They are variably located within the endometrial cavity.
■ If they grow, they may efface the cervix and be seen in the internal
cervical os.
■ Complete protrusion and prolapse through the cervix may occur such
that the leiomyoma is seen dilating the ectocervix and be present
within the vagina. Vaginal myomectomy is ideal for prolapsing
leiomyomas.
■ Intracavitary fibroids may be associated with intense pelvic cramping,
leukorrhea, foul-smelling vaginal discharge, or aberrant menstrual
bleeding.
■ Intracavitary fibroids can be treated with hysteroscopic resection or
hysteroscopic morcellation.
■ Subserous leiomyomas grow on the outer uterine surface leading to an
irregular surface contour of the uterus.■ They may develop a pedicle of varying width.
■ Fibroids attached to a stalk are mobile and may cause torsion with
acute abdominal or intermittent abdominal pain. Fever may occur if
complete torsion and necrosis of the fibroid occur.
■ Most are asymptomatic and do not cause adverse pregnancy outcomes.
■ Exophytic fibroids may also attach to other peritoneal organs and
develop a collateral blood flow. They are called parasitic fibroids.
■ The more common attachments of parasitic fibroids include bowel,
omentum, and mesentery. Because these lesions are mobile, they may
also be confused with an adnexal mass or abdominal mass of unknown
etiology.
■ If they involve the broad ligament they are called intraligamentary
leiomyomas. This anatomic variant is associated with deviation of the
ureter. Much care must be taken when performing abdominal
myomectomy with intraligamentary leiomyomas to prevent transection
of the ureter.
■ The size, number, and location of fibroids are unique to each patient and
may be associated with a variety of clinical presentations including
menstrual dysfunction, bulk symptoms, pelvic pain, increased abdominal
girth, infertility, or pregnancy-related complications.
■ Menstrual complaints may include heavy menstrual cycles, anemia and pica
as a result of heavy menses, irregular bleeding, postcoital bleeding,
dysmenorrhea, leukorrhea, and passage of large clots, chronic or acute
anemia.
■ Bulk symptoms may include increased abdominal girth, back pain, early
satiety and cosmetic complaints from abdominal distention, constipation,
urinary frequency, urinary urgency, urinary retention, unilateral or
bilateral ureteral obstruction, and varying degrees of hydronephrosis.
■ Pain including dysmenorrhea and dyspareunia.
■ Enlarging uterus may also lead to an inability to visualize the cervix,
making pap test, saline infusion sonography, and endometrial biopsy
difficult.
■ Reproductive-associated symptoms include infertility, recurrent
miscarriage, premature delivery, preterm delivery, and abdominal pain
during pregnancy due to leiomyoma degeneration.
■ Degenerative changes may be seen within the fibroid including:
■ Hyaline degeneration—this represents the most common type of
degeneration and is caused by excessive overgrowth of fibrous elements.
■ Cystic degeneration occurs after hyaline degeneration and results in
myxomatous changes with the development of multiple cystic cavities
within the fibroid.■ Necrosis occurs with impaired blood flow to the fibroid. This is most
often seen in pregnancy. The gross specimen when opened has a dull
reddish color and is due to aseptic degeneration associated with local
hemolysis.
■ Mucoid degeneration is associated with fibroid that are greater than 8
cm. This occurs more often with impaired arterial inflow to the fibroid.
■ Infectious degeneration is more often associated with pedunculated
leiomyomas.
■ Calcific degeneration more commonly seen in postmenopausal women.
■ Sarcomatous degeneration is rare and occurs in up to 1/300 women
undergoing surgery.
■ Women desirous of pregnancy and who have indications for surgery should
have the most minimally invasive uterine-sparing procedure performed by a
skilled gynecologist.
■ Size, number, and location of uterine leiomyoma determine which surgical
procedure may be recommended and surgical skill set required.
■ These factors influence surgical approach, specifically whether a vaginal,
hysteroscopic, abdominal, mini-laparotomy, laparoscopic, or robotic
myomectomy is advisable.
■ Individual characteristics of uterine fibroids also influence length of
surgery, surgical risks, intraoperative and postoperative blood loss,
infectious morbidity, complications, and risk of recurrence.
■ Surgical intervention may be indicated in patients with:
■ Failed medical therapy for the treatment of symptomatic disease
■ Intracavitary distortion leading to infertility or recurrent miscarriage
■ Unrelenting abdominal pain due to acute leiomyoma torsion,
degeneration, or vaginal prolapse
■ Failure of medical therapy for intractable or heavy menstrual dysfunction
■ While uncommon, obstruction of ureters, renal insufficiency, marked
hydronephrosis, or acute urinary retention may predispose to
intervention
■ Concern for leiomyosarcoma
Nonoperative Management
Hysterectomy has been the traditional therapy offered to women with uterine
fibroids, increasingly women are interested in less invasive therapy. Women
with minimal fibroid symptomatology are advised to consider “watchful
waiting” or monitoring that can include periodic clinical examination,
imaging, and journaling of their symptoms. The frequency of office visits and
testing should be based on clinical symptoms. Nonoperative management and
alternative to hysterectomy procedures such as uterine fibroid embolization(UFE) and endometrial ablation options are only for women who do not
desire future fertility but request uterine sparing procedures. Medical therapy
including hormonal therapy, levonorgestrel intrauterine device, tranexamic
acid, NSAIDs, and GnRH agonist therapy are well suited for women who wish
to retain their fertility.
However, quality-of-life (QOL) indicators must be considered in women
with uterine fibroids and clinicians inquire about them as they may help to
determine whether nonoperative management, watchful waiting, or surgical
intervention is needed. The patient should be queried about QOL-related
factors including:
■ Fears about her health
■ Impact on her relationships
■ Emotions
■ Sexual functioning
■ Body image
■ Loss of control
■ Hopelessness
A recent survey of 968 reproductive-aged women noted:
■ Patients waited 3.6 years before seeking treatment
■ 41% saw >2 health providers for diagnosis
■ 28% missed work due to leiomyoma symptoms
■ 24% believed that symptoms prevented career potential
■ 79% expressed desire for treatment that does not involve invasive surgery
■ 51% desired uterine preservation
■ 43% wanted fertility preservation if they are less than 40 years of age
Nonextirpative uterine surgery should be considered for all women who
desire pregnancy. Women of the African diaspora have the highest prevalence
and burden of fibroid-related disease.
■ Additionally, they have the greatest progressive symptomatology, younger
age of onset, greater size, and number of fibroids when compared to other
ethnic groups.
■ The etiology and genetic predisposition for this racial difference are
unknown.
■ In certain geographic regions in the United States, the incidence of
leiomyomas among women of the African diaspora is three to four times
that of Caucasian women.
Uterine fibroid embolization (UFE) is a minimally invasive outpatient
procedure performed by an interventional radiologist for the treatment of
symptomatic uterine fibroids in women who do not desire fertility yet desireuterine preservation. Treatment is performed under conscious sedation and
does not require an abdominal incision. Embolization results in ischemic
infarction of the leiomyomata and decreased vascularity. Normal
myometrium is spared.
Within 4 to 6 months the uterine fibroid diminishes in size, the fibroids
undergo hyaline degeneration, and the volume and size of the uterus
decrease. Shrinkage may continue up to 1 year after UFE. Among women
with >90% fibroid infarction, there is more symptom relief and fewer
subsequent treatments than in women with a lower infarction rate.
Magnetic resonance-guided focused ultrasound (MRgFUS) is a noninvasive
outpatient treatment option for symptomatic uterine fibroids. It was approved
by the FDA in 2004 for the treatment of uterine fibroids. Its labeling includes
use for women who desire pregnancy. MRgFUS is an outpatient procedure
that takes 2 to 4 hours and is performed under conscious sedation without an
abdominal incision.
The objective of MRgFUS is to deliver focused high-energy ultrasound
waves into the fibroid causing thermal coagulation of targeted tissue. With
the patient lying prone, the ultrasound waves are focused by lenses or
reflectors and pass through the skin and nontarget tissue and delivers
sonications (heat) to targeted fibroids. It has been compared to the principle
of focusing the sun’s rays with a magnifying glass to burn a hole in a piece of
paper.
Preprocedural magnetic resonance imaging (MRI) is required to determine
suitable candidates for MRgFUS. Fibroids most amenable to MRgFUS
treatment are those that are homogeneous and hyperintense (dark) on T2-
weighted images. They should also enhance because degenerated/infarcted
fibroids have lost their blood supply and will not respond to treatment.
Contraindications to MRgFUS include:
■ Patients with pacemakers
■ Prior UFE
■ Sensitivity to MR contrast agents
■ Severe claustrophobia
■ Patient’s body habitus exceeds the limitations of the MRI scanner
■ Pedunculated fibroids
■ Adenomyosis
■ Abdominal scarring with bowel in the pathway of the ultrasound beam
■ Intrauterine device (it would have to be removed prior to the procedure)
■ Obese patients may have too much subcutaneous fat such that the fibroid
would be out of the range of the ultrasound beam.
■ The ultrasound focus depth is limited to 12 cm for the standard protocols
or to 7 cm if enhanced sonications are performed.■ If the fibroid is out of these ranges due to obesity, then MRgFUS will not
be successful.
■ When compared to UFE there were more women excluded from MRgFUS.
In fact, in one enrollment study, only 14% of women qualified for
participation into. Limitations of the procedure include patients with
multiple abdominal scars. Numerous scars may make it difficult to
determine a safe pathway for treatment in order to avoid bowel, bladder,
or pelvic adhesions. Dominant fibroids greater than 8 to 10 cm may take
too long to sonicate in one setting.
Risks are very low but reports of skin burns to the abdomen, damage to
structures near the fibroid, nerve stimulation causing temporary back or leg
pain, and DVT.
Reported outcomes of MRgFUS include:
■ Pelvic pain and pressure resolve most quickly
■ Decrease pressure on the bladder
■ Improvements in menstrual bleeding may take 4 to 6 months
■ QOL indicators improved (heavy menstrual bleeding, nonbleeding
symptoms of fibroids and QOL impact)
■ Patients with fibroids that have the lowest signal intensity have better
symptom relief and demonstrated a higher technical success.
Tranexamic acid is an oral, nonhormonal, antifibrinolytic medical therapy
used only during menstruation in women with symptomatic fibroids–related
ovulatory heavy menstrual bleeding. Women with heavy menstrual periods
reportedly have high fibrinolytic activity due to increased endometrial levels
of plasmin and plasminogen activators. Tranexamic acid works by reversibly
blocking lysine binding sites on plasminogen, thus preventing plasmin from
interacting with lysine residues on the fibrin polymer, causing subsequent
fibrin degradation.
Tranexamic acid has been available for more than 40 years in clinical
practice and often is prescribed as an over-the-counter therapy in many
countries. In the United States, it requires a prescription. The recommended
dose is: tranexamic acid 650 mg, take two tablets by mouth every 8 hours, to
commence with the onset of menstrual bleeding for a maximum of 5 days. Its
onset of action is rapid but requires every 8 hours dosing due to short halflife. Eliminated through the kidneys, it has a half-life of 2 to 3 hours.
Tranexamic acid reduces menstrual blood loss (MBL) by 26% to 60%.
Numerous studies demonstrate that it is an effective treatment of heavy
ovulatory menstrual bleeding in women with uterine fibroids; has low sideeffect profile, favorable safety profile, and is well tolerated by patients.
Thromboembolic events have not been reported with oral treatmentregimens for the treatment of heavy menstrual bleeding. When compared to
placebo, NSAIDs, or oral cyclical luteal phase progesterone, tranexamic acid
significantly improved QOL. Levonorgestrel-releasing intrauterine system
reduced mean blood loss more than tranexamic acid in clinical trials.
Tranexamic acid should not be prescribed to women with prior history of
embolic disease, active thromboembolism, intrinsic risk for thrombosis, or
currently using hormonal therapy.
Gonadotropin-releasing (GnRH) analogs (Lupron [TAP Pharmaceutical
Products, Inc. Lake Forest, IL] may be considered for short-term use in
women with symptomatic uterine fibroids and as adjunct to surgical therapy.
GnRH agonists decrease uterine size and myoma volume by decreasing levels
of estrogen and progesterone to menopausal values. They induce myoma
degeneration, cause hyaline degeneration, decrease in the size of leiomyoma
cells, reduce extracellular matrix, and decrease blood flow to the uterus.
When used for short duration (<6 months), most women become temporally
amenorrheic, have improvement in hemoglobin, and notice a decrease in
uterine size by 40% to 60%.
GnRH analogs are often beneficial to women 50 years old or older. GnRH
therapy given for 6 months will stop menstruation with improvement in bulk
symptoms and cessation of menstruation. After 6 months of therapy, GnRH is
stopped and the patient monitored for transition into natural menopause. If
symptoms recur and patient has not entered menopause, then another 6
months of GnRH therapy instituted. Quite often these patients will enter
natural menopause and not require surgical intervention and avoid surgery if
menopause occurs shortly after completion of therapy.
Ulipristal is not currently available in this country; however, clinical trials
are underway. Promising research in Europe has demonstrated the benefits of
Ulipristal. Ulipristal is a synthetic steroid derived from 19-norprogesterone. It
is a selective progesterone receptor modulator that binds to progesterone
receptors. It exerts antiproliferative, pro-apoptotic, and antifibrotic action on
leiomyoma cells. The binding and antagonist potency with glucocorticoid
receptors is reduced compared to mifepristone.
■ Recent randomized controlled trials comparing Ulipristal to placebo and
Lupron have shown a statistically significant improvement in leiomyoma
size, QOL indicators, and decrease in fibroid and uterine volume.
■ After 13 weeks, Ulipristal controlled uterine bleeding in 91% of 96
women who received Ulipristal 5 mg/d and uterine volume decreased
21%.
■ Compared to 92% of 98 women who took 10 mg/d and uterine volume
decreased 12%.
■ Compared to 19% of 48 women who took placebo and had improvementof uterine bleeding with a 3% increase in uterine volume.
Levonorgestrel Intrauterine System
Increasingly, women with uterine fibroids, that do not distort the endometrial
cavity and with a uterine size of less than 12 to 14 gestation weeks, with
heavy bleeding have been rigorously evaluated. Improvement in primary
outcome of patient-reported scores has noted improvements in domains
(practical difficulties, social life, family life, work and daily routine,
psychological well-being, and physical health). Dysmenorrhea improved in
women using levonorgestrel intrauterine system. Menstrual blood flow
decreased and 20% to 40% of women experience amenorrhea. More women
using levonorgestrel intrauterine systems continued with therapy compared to
routine medical therapy. Low rates of surgical intervention were noted.
IMAGING AND OTHER DIAGNOSTICS
■ Several imaging modalities exist to detect uterine fibroids including
transvaginal ultrasound (TVUS), saline infusion sonography (SIS), and MRI
with gadolinium contrast. Less commonly is CAT scan employed.
■ Most patients have an initial TVUS which can differentiate a pelvic mass
from a pregnancy, adnexal mass, or uterine fibroids. However, results may
be inconclusive in some patients. Transvaginal ultrasound alone may miss
one-sixth intracavitary lesions in reproductive-aged women. This author
believes that saline infusion sonography should be performed when the
patient has complaints of heavy menstrual bleeding, intermenstrual
spotting, leukorrhea, or recurrent pregnancy loss, as it is more sensitive in
detecting intracavitary pathology.
■ Fortunately, the cost differential between TVUS and MRI is decreasing, thus
making MRI more accessible to more patients and physicians who care for
women with fibroids.
■ MRI with gadolinium contrast is the preferred imaging modality for
abdominal myomectomy. It is more definitive in determining the size,
number, and location of uterine fibroids, as well as how far from the
serosal edge the myoma is located. Additionally, the lateral and posterior
aspects of the pelvis can be better differentiated with MRI than with TVUS.
■ When intracavitary fibroids are larger than 3 to 4 cm, it may be difficult
to distend the uterine cavity with SIS. In these situations, MRI of the
pelvis is advised.
■ MRI can differentiate an adnexal mass from exophytic fibroids and is
possible with MRI of the pelvis.
■ Cervical fibroids can be better delineated with MRI.
■ MRI of the pelvis can differentiate cellular degenerative changesincluding calcification, necrosis, and possible sarcomatous changes.
PREOPERATIVE PLANNING
■ The patient should have a CBC with platelets, type, and screen available,
and a negative pregnancy test on the day of surgery.
■ If the blood loss is expected to be greater than 500 mL, consider using cell
saver intraoperatively, consider perioperative autologous blood donation,
and correct anemia.
■ Short-term use of preoperative GnRH therapy considered in women who
have symptomatic anemia and fail hormonal therapy or is contraindicated.
■ Short-term use of GnRH therapy effectively stops menstrual cycles and
improves anemia. Surgery can be scheduled once anemia has resolved.
■ Short-term use of GnRH therapy considered in patients with anemia and
who refuse blood products. Surgery is scheduled once anemia resolves.
■ Moderate anemia can be improved with oral, IV iron therapy, iron rich
foods, and supplementation with Vitamin C.
■ A consult with blood management is helpful in patients who do not
tolerate oral iron therapy.
■ Iron stores can be repleted promptly with IV iron.
■ Preoperative informed consent is critical. When possible the patient’s
partner or family member should be available for the consultation, with
patient permission. Several components of informed consent must be
discussed and documented:
■ Risk of conversion to hysterectomy:
■ Risk of intraoperative conversion to hysterectomy when diffuse
leiomyomatosis is encountered.
■ Massive intraoperative or postoperative blood loss.
■ Inability to reconstruct the myometrial cavity.
■ Risk of conversion to hysterectomy if a large cervical leiomyoma is
encountered. Removal of broad lower uterine segment fibroids may
detach the cervix or amputate the cervix from the body of the uterus.
■ Intraoperative frozen section reveals leiomyosarcoma.
■ Need for intraoperative or post-operative blood or blood product
transfusion.
■ Risk of postoperative infection and prolonged hospitalization.
■ Risk of ureter injury when a leiomyoma involves the broad ligament or
cervical leiomyoma with distortion of the anatomic pathway of the ureter.
■ Informed consent should also document risk of recurrence, subsequent
infertility, need for C/section, uterine dehiscence/uterine rupture in
pregnancy, postoperative adhesion formation, bowel obstruction, and moredifficult abdominal surgery in the future as a result of postoperative
adhesions.
■ Additional preoperative planning essentials:
■ If the fibroid distorts and abuts or enters the endometrial cavity, removal
must be judicious. Care taken to avoid removal of endometrium
immediately adjacent to the fibroid. Removal of the endometrium may
lead to hypomenorrhea, secondary amenorrhea, and intrauterine
synechiae and infertility.
■ Placement of an intrauterine Foley catheter filled with methylene blue
dye or intrauterine manipulator helps to identify entrance into the
endometrial cavity.
■ If the endometrium is entered, it must be closed separately from the
myometrium.
■ Consider postoperative hysteroscopy to evaluate the endometrium and
exclude intrauterine adhesions.
■ It is imperative to determine if there are intracavitary fibroids present
prior to abdominal myomectomy, especially in women with large
intramural or subserosal fibroids.
■ If the endometrium is ill-defined, nonvisualized, or incompletely seen
with preoperative imaging, diagnostic office hysteroscopy
preoperatively should be performed to exclude intracavitary
leiomyoma.
■ If office hysteroscopy is not available, then intraoperative diagnostic
hysteroscopy should be performed prior to performing the abdominal
myomectomy (same day of surgery).
■ Detection of tubal patency with preoperative hysterosalpingogram (HSG)
is of equivocal use. There have been cases of tubal obstruction noted
perioperatively but resolved when HSG was performed after abdominal
myomectomy.
■ It is the opinion of this author that preoperative HSG is not useful and
would not change recommendation for abdominal myomectomy.
■ Assisted reproductive technology may be indicated for tubal occlusion.
■ Endometrial biopsy should be performed prior to abdominal myomectomy:
■ To exclude leiomyosarcoma
■ There is an increased risk of endometrial hyperplasia in women with
uterine fibroids.
■ Higher concentration of estrone and estradiol sulfatase activity has
been observed in the endometrium overlying a leiomyoma.
■ Cystic, simple, and complex endometrial hyperplasia has been reported
in women with uterine fibroids.
■ While office endometrial biopsy is helpful, remember that the sensitivity ofdetecting endometrial pathology is less in women with increased
endometrial circumference, uterine size, or uterine sounding length. This is
especially true in women with a uterine sounding length of greater than 12
cm.
SURGICAL MANAGEMENT
■ Abdominal myomectomy is indicated in women with symptomatic uterine
fibroids. Generally intramural and subserosal fibroids that cannot be treated
with the laparoscopic or robotic approach are selected for open
myomectomy.
■ Some patients with submucosal and intramural fibroids that protrude into
the endometrial cavity are treated with abdominal myomectomy.
■ Patients with an intracavitary leiomyoma that cannot be removed with a
one-staged hysteroscopic procedure (usually size >5 cm) may be treated
with an abdominal myomectomy approach.
■ Surgical management of uterine fibroids is dictated by fibroid size, number,
direction of growth, location, patient’s desire for definitive treatment and
invasiveness of treatment, and surgeon’s clinical expertise.
■ Recent concerns have been raised about the potential of
leiomyosarcomatous changes within uterine fibroids.
■ There is no set of testing that has high sensitivity in detecting sarcoma
preoperatively, except for preoperative endometrial biopsy that
demonstrates malignancy. However, MRI of the pelvis with and without
contrast, LDH isoenzymes, and gross pathology can increase the suspicion
of malignant degeneration.
■ Leiomyoma sarcomatous changes are defined by mitotic index (>10
mitotic figures per 10 high-power fields, presence of nuclear
hyperchromatism, nuclear pleomorphism, giant cells, and other bizarre
cell form changes).
■ There are no national consensus guidelines for recommending abdominal
myomectomy. However, the following clinical scenarios provide a practical
clinical guide to recommend abdominal myomectomy to women:
■ Symptomatic patients with bulk symptoms, abnormal bleeding, and
cosmetic concerns from increased uterine size.
■ Patients who do not meet inclusion criteria for minimally invasive
options including laparoscopic or robotic myomectomy approach.
■ Patients who do not have access to physicians who perform minimally
invasive myomectomy.
■ More than five uterine fibroids with variable individual size
■ Potential difficulty in reconstruction of the uterus with a laparoscopic or
robotic approach in patients desirous of pregnancy■ Large fibroids in the broad ligament that distorts the ureter
■ MRI pelvic imaging that is highly suggestive of hyaline degeneration
with extensive liquefaction or gelatinous material that would be difficult
to extract with minimally invasive techniques.
■ Extensively calcified leiomyoma that coexist more frequently with
pedunculated subserous leiomyoma. Extensive degeneration of intramural
fibroids may create a “womb stone” more often predisposed to older
women and women from the African diaspora.
Figure 7.1.1. Satinsky clamp on ovarian vessels.
■ Abdominal myomectomy is contraindicated:
■ with coexisting endometrial cancer, cervical cancer, or known
leiomyosarcoma.
■ with fibroids that enlarge and become symptomatic in menopause.
■ Controlling intraoperative blood loss is essential during abdominal
myomectomy. The uterine anatomy and access to the uterine arteries may
dictate choice of technique.
■ Average blood loss for abdominal myomectomy varies between 200 and
800 mL. The risk of blood transfusion is 2% to 28%. Options to decrease
intraoperative bleeding include:
■ Perioperative and intraoperative administration of intravenous
tranexamic acid
■ Intramyometrial injection of a dilute solution of vasopressin
■ Temporary occlusion of the infundibular pelvic ligament blood vessels
with Satinsky clamps (Figs. 7.1.1 and 7.1.2)
■ Tourniquets placed around the uterine arteries when feasible (Figs. 7.1.3
and 7.1.4)
■ Preoperative use of GnRH agonist for women with anemia. Some authorsbelieve that routine use should be avoided as it may distort the cleavage
planes and make enucleation of fibroids more difficult.
■ Perioperative uterine artery embolization
Figure 7.1.2. Satinsky clamps occlude infundibular ligaments.
Figure 7.1.3. Red rubber catheter. Tourniquet around the lower segment.
Positioning
■ The patient should be placed in the dorsal lithotomy position with the legs
appropriately positioned and padded in Allen stirrups.
■ Foam padding should be placed next to the patients’ knees.
■ PAS stocking should be placed prior to the induction of anesthesia.
■ The arms should be placed horizontally on arm boards.
Approach
■ There are no universal guidelines or high-quality data for the use ofprophylactic antibiotics for abdominal myomectomy. Despite the lack of
guidelines, this author utilizes preoperative and additional dosing if surgical
case is greater than 4 hours of blood loss >1.5 L in order to avoid pelvic
infection. This is important for women who desire pregnancy as pelvic
infection may compromise future pregnancy.
■ The team huddle is performed with the patient, nursing, entire surgical
team, and anesthesia to discuss the proposed surgery.
■ This team huddle should outline anticipated length of surgery,
anticipated blood loss, need for antibiotic prophylaxis, and answer
patient-centered concerns.
Figure 7.1.4. Red rubber catheter. Close-up of tourniquet.
■ Confirm that all needed instrumentation is available.
■ If cell saver will be used, then the blood bank team is also included in the
discussion.
■ After induction of anesthesia and legs appropriately placed, an abdominal
bimanual and rectal examination performed.
■ Uterine mobility should be accessed and will aid in the determination of the
abdominal incision.
■ This author advocate’s placement of an intrauterine Foley catheter (10- to
30-cc balloon) filled with a dilute solution of methylene blue dye. If the
endometrial cavity is entered, the blue color of the Foley can be seen and
palpated confirming entrance into the endometrium.
■ Alternatively, a uterine manipulator be placed and methylene blue dye
can be administered through the cannula to determine if the endometrial
cavity has been entered.
■ Occasionally it is difficult to determine the boundaries of the endometrial
cavity once extensive myomectomy has been performed.■ The ability to palpate the intrauterine Foley catheter confirms that the
endometrium has not been entered.
■ Or if the Foley catheter is seen, it can be deflated slightly to close the
endometrial cavity, taking care not to incorporate the Foley catheter
into the suture. As long as the Foley catheter fluid contact remains
intact, the surgeon can be confident that the endometrium is not
compromised.
■ It is important that the endometrial cavity not be incorporated into the
myometrial closure; otherwise, menstrual aberrations including
secondary amenorrhea, hematometria, or secondary infertility may occur.
■ Exploration of the upper and lower abdominal cavity performed to
determine the mobility of the uterus exclude parasitic fibroids, presence
of adhesions, endometriosis, adnexal masses, or unanticipated pathology.
■ When possible the uterus is exteriorized from the peritoneal cavity and
an assessment of the number of fibroids and locations of the fibroids
ascertained.
■ Self-retaining retractors are not routinely used as exteriorization of the
uterus provides ample anatomic exposure.
■ The use of uterine artery tourniquets, placement of Satinsky clamps, or
the use of myometrial vasopressin injection is individualized.
■ Minimal use of peritoneal packing decreases the risk of postoperative
adhesions.
■ Traumatic instruments such as Kocher clamps and forceps with teeth on
the serosa should be avoided. Rather, smooth pick-ups utilized on the
serosa to minimize serosal trauma.
■ Meticulous hemostasis should be evident at the end of surgery.
■ Adhesion barriers should be considered at the conclusion of the surgery
to decrease risk of postoperative adhesions.Procedures and Techniques (Video 7.1)
Perform time out and place mechanical PAS stocking for
thromboprophylaxis
Administer IV tranexamic acid for cases with anticipated blood loss of >500
mL
■ Tranexamic acid 10 mg/kg/dose, in NaCl 0.9% in 100 mL (Cyklokapron)
■ Loading dose given intravenously 15 minutes prior to incision in the operating
room. Maximum infusion rate of 100 mg/min.
■ Intraoperative maintenance dose, tranexamic acid 1,000 mg in NaCl 0.9% 100
mL (Cyklokapron), 1 mg/kg/hr, with maximum total dose 1 g. Use
intraoperatively only and stop infusion at the end of surgery.
■ Tranexamic cannot be used in patients with prior embolic phenomena or who
currently are receiving anticoagulation.
■ Misoprostol (400 mcg) intravaginally or rectally 1 hour prior to surgery.
Administer antibiotics at the induction of anesthesia
Place patient in Allen stirrups
Perform examination under anesthesia
Surgical prep
■ The patient’s mons pubis hair should be clipped in the operating room prior to
the abdominal prep.
■ A wide surgical prep including the abdomen, mons pubis, vulva, vagina, cervix,
mid-thigh, and buttock. The extent of the prep will be dependent upon whether a
low-transverse abdominal incision, vertical incision, or incision that extends above
the umbilicus is utilized.
Sterile draping and additional considerations
■ Sterile drapes placed to cover the abdomen and perineum.
Foley bladder catheter placement
■ Insert a continuous indwelling bladder Foley catheter for continuous
measurement of urine output.
Diagnostic hysteroscopy (if applicable)
■ Ideally the endometrium should be evaluated prior to abdominal myomectomy.However, if preoperative evaluation demonstrated an ill-defined endometrium,
poorly visualized endometrium, or inconclusive imaging of the endometrium, then
diagnostic hysteroscopy should be performed in the OR if it was not performed
in the office.
■ Diagnostic hysteroscopy excludes coexisting intracavitary fibroids or polyps
and should be removed during surgery.
■ Occasionally uterine enlargement and cervical distortion prevent office
hysteroscopic evaluation of the endometrium.
■ In the OR, a small rigid or flexible diagnostic hysteroscope can be used to
evaluate the endometrium. Attach sterile IV tubing to the hysteroscope and
manually infuse saline via 60-mL syringes for uterine distension.
■ If an intracavitary fibroid is identified, this author recommends its removal at
the time of the abdominal myomectomy by opening the endometrial cavity,
rather than performing hysteroscopic myomectomy with the abdominal
myomectomy. The endometrium is reapproximated by repairing the
myometrium at the interface of the uterine cavity and endometrial cavity with a
running or interrupted suture of 3-0 polydioxanone (PDSTM) avoiding
placement of suture in the endometrial cavity.
■ If an endometrial polyp is detected, then the endometrial cavity can be opened
and polyp removed concomitantly at the time of myomectomy, and cavity
closed (as previously discussed).
■ This step can be avoided if office or outpatient endometrial evaluation is negative
for intracavitary pathology. Otherwise proceed to the placement of the intrauterine
Foley catheter as described below.
Intrauterine Foley catheter placement
■ Place a heavy-weighted speculum or open-sided speculum in the vagina to
visualize the cervix.
■ Grasp the cervix with a single-toothed tenaculum, dilate the cervix with Hegar
dilators of size 4 to 6, enough to accommodate a 12- to 16-French intrauterine
Foley catheter.
■ Use a Foley with a balloon that can expand to 10 to 30 mL. If the uterine cavity
is greater than 12 cm, it is helpful to employ a Foley catheter guidewire to
atraumatically guide and place the Foley in the uterine cavity until the fundus is
reached.
■ Mix one ampule of methylene blue diluted with 50 cc of saline. After the
intrauterine Foley catheter is placed, distend the balloon with the methylene
blue solution until resistance is met.
■ With extensive myometrial dissection and multiple myometrial defects,
sometimes it is difficult to discern if the endometrium is entered. Placement of
a distended intrauterine Foley balloon helps identify endometrial landmarks.The author recommends this technique because it confirms entrance into the
endometrial cavity if it occurs.
■ The distended balloon can be palpated during the myomectomy alerting the
surgeon when in close proximity to the endometrium. If the surgeon is not
sure of landmarks, the balloon can be further distended or deflated providing
a tactile guide to determine the proximity of the endometrium.
■ If the pigmented blue tinged balloon is seen, it confirms that the endometrial
cavity has been entered during the procedure.
■ Additionally, if suture is inadvertently placed during myometrial closure in the
endometrial cavity, the punctured balloon will rupture and dissipate the darkly
pigmented methylene blue in the surgical site, providing visual feedback that
the endometrial cavity has been breached and corrective measures taken to
ensure that the endometrial cavity is not obliterated during myometrial
closure.
■ At the conclusion of the procedure, gently retract or pull the intrauterine
Foley. If it is still intact, it will not slip out of the cervix and confirms that the
endometrial cavity has not been entered or compromised.
■ If the intrauterine Foley ruptures, consider diagnostic hysteroscopy after
myometrial closure to exclude suture within the endometrium.
Surgical incision
■ Depending upon the size of the uterine fibroid, the mobility of the uterus, or prior
abdominal surgical incisions, a Pfannenstiel incision, Maylard incision, or vertical
abdominal incision is made. This author prefers the Maylard incision when the
uterine size is greater than 15-week gestational weeks and limited uterine mobility
noted under anesthesia. This muscle splitting incision provides excellent lateral
visualization.
■ If the patient has had a prior vertical incision, then that incision may be used.
■ Traditional entrance and safeguards are taken to enter the peritoneal cavity.
Exploration of the abdominal cavity
■ Once the peritoneal cavity has been entered, the surgeon should determine, if
the uterus is mobile, the presence of adhesive peritoneal disease, determine if
there are adnexal masses, endometriosis, or unanticipated surgical findings.
■ If the uterus is mobile, it should be elevated out of the peritoneal cavity.
■ Advise the anesthesiologist that the uterus is being elevated out of the uterine
cavity, especially if it is over 20 weeks gestational size, because changes in the
hemodynamic state can occasionally occur when pressure is taken off of the
great vessels.
■ If uterine mobility limits extirpation of the uterus, then leave the uterus in the
pelvis and extracts as many fibroids until uterine mobility permits exteriorization ofthe uterus and removal of remaining fibroids.
Evaluate and palpate location of all fibroids
■ Choose an incision in which most fibroids can be removed with a single incision.
Sometimes this is not practical as multiple incisions may be needed for safe
removal.
■ A transverse or vertical serosal incision can be utilized.
■ Avoid incisions that will extend into the tubes, cornua, and uterine arteries.
■ Palpate the myometrium throughout the procedure as additional smaller fibroids
may be encountered after enucleation of larger myomas.
■ Anterior incisions are associated with less risk of postoperative adhesions.
However, if a fibroid is posterior it is recommended to make an incision
posteriorly rather than tunnel through anteriorly.
Slowly inject a dilute solution of vasopressin
■ Confirm with the anesthesiologist that vital signs are normal prior to proceeding
with the slow injection of a dilute solution of vasopressin into the leiomyomas
(Tech Fig. 7.1.1).
■ Vasopressin constricts smooth muscle in vascular capillaries, arterioles, and
venules which helps decrease blood loss.
■ A dilute solution of vasopressin ([20 units = 1 ampule] mixed in 200 mL saline)
is slowly injected into multiple uterine sites including the uterine serosa,
intramyometrial or stalk of pedunculated leiomyomas until blanching occurs.
■ A 10-mL control-top syringe and 20- to 22-gauge needle is recommended for
injection.
■ For every 10 mL injected with this ratio, one unit of vasopressin is
administered.
■ Inform the anesthesiologist of the total amount used.
■ Vasopressin can be slowly injected into the planned serosal uterine incision
and myometrium until blanching occurs. Multiple injection sites are made
circumferentially in the myometrium. Always aspirate before injecting additional
vasopressin. Wait 3 to 5 minutes for vasoconstriction before making the
uterine incision.
■ This author injects one fibroid at a time.
■ Record the time of the injection. The half-life of vasopressin is 10 to 30
minutes and the duration of action is 2 to 8 hours. Vasopressin may be
injected intermittently during surgery.
■ Avoid vasopressin in patients with coronary artery, vascular or renal disease
as hypotension, bradycardia, arrhythmias, and death have been reported.
Tech Figure 7.1.1. Slowly inject dilute vasopressin solution.
Additional methods for hemostasis: tourniquets and clamps
■ Factors that increase blood loss include size, number, and location of
leiomyomas. Tourniquets may be used to decrease bleeding in patients who will
have multiple leiomyomas removed.
■ Dissect the bladder peritoneum.
■ Identify a free space in the broad ligament by palpating the broad ligament
above the internal os. Identify the ureter and uterine artery. Make a 1-cm
incision with an electrosurgical instrument into this free space.
■ Pass a Penrose or red rubber catheter drain in this space and secure tightly
posteriorly and secure with a Kelly clamp.
■ Tourniquets are removed at the completion of the myomectomy.
■ The infundibular ligament with the ovarian artery and vein can be temporarily
compressed with Satinsky clamps. They are removed after completion of the
myomectomy.
Removal of myomas
■ The easiest fibroids to treat are those that are pedunculated. The base of the
pedunculated area should be injected with a dilute solution of vasopressin. The
incision is made into the serosa over the leiomyoma until the pseudocapsule is
reached. Using a towel clamp or single tooth tenaculum, the myoma can be
bluntly dissected away from the stalk. Avoid transection of the fibroid from its
stalk as brisk bleeding might occur and require many sutures for hemostasis.
■ A monopolar instrument set on 30 to 40 W cutting current is used to make a
vertical or horizontal serosal incision. The incision is extended until the
pseudocapsule is reached (Tech Figs. 7.1.2 and 7.1.3). The length of the incisionshould incorporate the majority of the area involved with the fibroid.
■ Grasp the myoma with towel clamps and apply traction to fibroid. Separate the
pseudocapsule from the myoma bluntly with an open 4 × 4 sponge or back of
an empty knife handle (Tech Figs. 7.1.4 to 7.1.6). When the surgeon is in the
appropriate plane the myoma literally peels away from the pseudocapsule and
myometrium.
Tech Figure 7.1.2. Manual compression of fibroid facilitates incision with monopolar
device.
Tech Figure 7.1.3. Incision of pseudocapsule.
Tech Figure 7.1.4. Apply towel clamp to myoma to facilitate myoma enucleation. Grasp
with towel clamp.
Tech Figure 7.1.5. Apply towel clamp to myoma to facilitate myoma enucleation.
Dissection of myoma.
Tech Figure 7.1.6. Dissection with 4 × 4 sponge to develop surgical plane.
■ Avoiding use of fingers to bluntly shell out the fibroids as more bleeding is
encountered because the blood vessels are torn in the periphery and base of
the leiomyoma.
■ Push the surrounding tissue planes away from the fibroid. The towel clamps or
Lahey clamps should be advanced as the fibroid begins to separate from the
myometrium.
■ The surgeon can squeeze the leiomyoma. This will help it bulge out further
from the myometrial bed.
■ With a large fibroid greater than 6 to 8 cm, a myoma cork screw may be used
to apply traction to the myoma helping to enucleate the fibroid. Visible
pseudocapsule that envelops the myoma may be cut in order to extricate the
myoma.
■ Small-surface blood vessels are coagulated with Bovie tip cautery. Hemostasis
should be prioritized throughout the surgical procedure.
■ If the leiomyoma protrudes into the endometrial cavity, identify the
endometrium and separate it from the fibroid. The goal is to not have any
endometrium removed with the leiomyoma.
■ If the endometrial cavity is entered, it must be closed separately from the
myometrium (Tech Fig. 7.1.7). Then the myometrium is reapproximated over the
endometrium, avoiding closure of the endometrial cavity (Tech Figs. 7.1.8 and
7.1.9).
■ Carefully palpate the myometrium after the dominant fibroid is removed in order
to detect other lesions. The decision to close the defects immediately or after
total enucleation of fibroids will depend upon the amount of bleeding that is
encountered.
Tech Figure 7.1.7. Endometrium is opened and identified with a white probe.
Tech Figure 7.1.8. Closure of the endometrial cavity taking care to avoid suture
placement within the cavity. Reapproximate only endometrial edges.
Tech Figure 7.1.9. Final closure of endometrial cavity.
Closure of the myometrial defects
If there are small residual areas of dead space, apply AristaTM (Bard), Floseal
(Baxter International Inc., Hayward, CA), or Surgiflo (Ethicon, San Angelo, TX).
They are thrombin-infused gelatin products and can be placed in the myometrial
bed and dead spaces for additional hemostasis (Tech Fig. 7.1.10).
■ Deeper intramural fibroids should be closed when possible with a three-layer
closure, with zero-delayed reabsorbable suture beginning at the base and
obliterating the space with a continuous-running suture or interrupted figure of
eight sutures (Tech Figs. 7.1.11 and 7.1.12). During suturing, the assistant should
squeeze the uterine walls together to help the surgeon close the myometrium
effectively. Continue this deep-layer closure approximating the myometrium until
the serosal edge is reached.
Tech Figure 7.1.10. Hemostatic agent is applied. In this case, Arista was used between
the myometrial layers.
■ The edges of the serosa are closed with an imbricating continuous, “baseball”
stitch on the serosa. Synthetic absorbable 3-0 sutures are used including
Vicryl, PDS, or Maxon suture, which are associated with delayed absorption
and limited inflammatory response (Tech Fig. 7.1.13).
■ Attempt to bury all surgical knots to a decrease adhesion formation.
■ Place adhesion barriers such as InterceedTM (oxidized cellulose) over the
suture lines, after irrigating the peritoneal cavity and ensuring hemostasis, if
conditions ideal.
Tech Figure 7.1.11. First layer closure of the myometrium with delayed absorbable
suture.
Tech Figure 7.1.12. Final multilayered closure of myometrium.
Tech Figure 7.1.13. Serosal closure.
■ Send all leiomyomas for histological evaluation. Tabulate the number, size, and
aggregate weight of all fibroids.
■ The myometrium should be closed meticulously in a layered fashion. Surgeons
must avoid placement of just a few two or three large through-and-through
closures if the patient is interested in future pregnancy. A limited follow-up of
patients who had abdominal myomectomy with meticulous closure and
subsequent pregnancy observed that the majority of scars were symmetric and
with uniform thickness compared with surrounding myometrium.
■ Maintain awareness of the location of the fallopian tubes and avoid ligation of the
fallopian tubes during myometrial closure.■ Copiously lavage the peritoneal cavity with saline or Ringer lactate solution after
completion of the surgery.
■ Once hemostasis is confirmed, application of an adhesion barrier is advised.
Two current adhesion barriers are currently available for abdominal myomectomy.
Seprafilm, a bioresorbable membrane (Genzyme Corporation, Cambridge, MA),
and Interceed (oxidized regenerated cellulose) have been associated with
decreased postoperative adhesion formation.
Abdominal closure
■ Once completed, the nurses should perform the final instrument, needle,
sponge, and ancillary equipment counts.
■ The fascia and skin closure is performed per physician preference.
Perform vaginal sweep
■ At the completion of surgery, remove the intrauterine Foley catheter.
■ Perform a “vaginal sweep” to make sure that no foreign bodies are left in the
vagina.PEARLS AND PITFALLS
Confirm that abdominal myomectomy is indicated
Recommending surgery for minimal clinical symptoms or for symptoms that will not be
alleviated with surgery increases the risk of unnecessary operative complications
Exclude intracavitary fibroids even if the patient has multiple intramural and serosal
fibroids
Failure to remove intracavitary fibroids may cause menstrual dysfunction, infertility, or
may leiomyoma prolapse after surgery
Identify ureter if fibroids distort the broad ligament and cervix
Injury or transection of ureter
Meticulous myometrial and serosal closure
Increased intraoperative and postoperative blood loss. Increased risk for
postoperative adhesions
Place intrauterine Foley catheter in order to identify entrance into the endometrium
Inadvertent closure of the endometrial cavity can be associated with secondary
infertility, Asherman syndrome, and intracavitary distortion
POSTOPERATIVE CARE
■ Postoperatively the patient is admitted to the hospital for 1 to 3 days until
standard postoperative milestones are met.
■ Patient is ambulatory
■ Taking fluids
■ Pain is controlled
■ Afebrile and stable vital signs
■ Serial CBC and platelet count until labs are stable. Additional postoperative
labs followed if the patient has other comorbidities including renal, liver
disease, or diabetes.
■ Evaluate this patient for coagulopathy if large blood loss occurs.
■ Early ambulation and early feeding are advisable. Both of these help to
decrease atelectasis pneumonia, postsurgical embolism (DVT or pulmonary
emboli), and decrease postoperative ileus.
■ Utilize postoperative incentive spirometry.
■ Approximately 12% to 67% of women have a nonlocalizing fever 48 hours
after myomectomy. Generally, no focal findings are limited. However,
standard fever works up and clinical examination is recommended.
■ Consider withholding nonsteroidal pain medications if moderate or
significant intraoperative bleeding.■ Follow serial CBC and coagulation panel if large intraoperative blood loss
occurs. Evaluate the patient for disseminated intravascular coagulation if
the patient continues to bleed postoperatively.
■ Use of the patient-controlled analgesia (PCA) is often favored by patients
and nursing staff for management of postoperative pain. Generally, after
the first 24 hours, the PCA pump is discontinued and oral narcotic therapy
and NSAIDs begin.
■ When stable, the indwelling Foley catheter is removed the morning after
surgery.
■ The patient can be discharged home when afebrile, vital signs, and labs are
stable, tolerates liquids, and able to ambulate.
■ Homegoing discharge instructions should be reviewed with the surgeon.
Additionally, homegoing written discharge instructions are given.
■ Special emphasis must communicated with the patient prior to discharge:
■ Patient instructed to call if she has a persistent temperature of greater
than 100 degrees.
■ Nausea, vomiting, leg pain, new onset anxiety, or shortness of breath.
■ Reminder to keep the incision dry. Call if redness, discharge, wound
separation, foul smell, change in color (dusky or black color), or increasing
tenderness occurs.
■ Avoid vaginal intercourse for four weeks.
■ May shower immediately and cover the wound.
■ No heavy lifting of more than 10 pounds.
■ Resume hormonal contraception four weeks after surgery.
■ Arrange for postoperative follow-up four weeks after surgery.
■ Review pathology.
■ Discuss route of delivery based on complexity of the abdominal
myomectomy.
■ Most patients return to work and full activities 4 to 6 weeks after surgery.
■ Wait 3 to 6 months before attempting pregnancy.
OUTCOMES
■ Morbidity and mortality are similar to an abdominal hysterectomy.
However, complications such as vaginal vault prolapse and injury to the
bladder and ureters are lower in patients undergoing abdominal
myomectomy compared to abdominal hysterectomy.
■ Bulk symptoms and heavy menstrual bleeding are greatly improved in 80%
of women undergoing abdominal myomectomy when fibroids are
completely removed.
■ Approximately 36% of women develop postoperative adhesions.■ While generally improved, pelvic pain and dysmenorrhea may not be
completely alleviated if coexisting adenomyosis or endometriosis exists.
■ Prospective, randomized controlled studies are lacking regarding the
impact of abdominal myomectomy on fertility. Fibroids can distort tubal
anatomy and the uterine cavity. Male factors also impact fertility outcomes.
Small series document a 57% conception rate following abdominal
myomectomy.
■ The number of women who wish to conceive after abdominal myomectomy
is unknown, thus making fertility outcomes difficult to calculate.
■ Among women with recurrent pregnancy, loss or prior infertility successful
pregnancies have been associated with abdominal myomectomy.
■ The rate of recurrence of uterine fibroids is variable depending upon the
length of time of follow-up after surgery.
■ Among patients followed for 7 to 10 years after surgery, 21% to 34%
required subsequent surgery for fibroid-related symptoms.
■ Additional factor affecting recurrence of fibroids includes age of initial
surgery, interval pregnancy after myomectomy, age of patient, race, and
the number of fibroids removed.
■ Despite these limitations, uterine sparing surgical options should be
available to women who have this preference even if there are no plans for
childbearing.
COMPLICATIONS
■ Complications from abdominal myomectomy include:
■ Infectious morbidity
■ Respiratory
■ Atelectasis
■ Pneumonia
■ Urinary tract infection
■ Wound infection
■ Microscopic abscesses within the myometrium
■ Endometritis
■ Embolic
■ Deep venous vein thrombosis
■ Pulmonary embolism
■ Intraoperative and postoperative bleeding
■ Acute
■ Delayed
■ Coagulopathy
■ Infertility■ Obstruction of the fallopian tube
■ Iatrogenic closure of the endometrium leading to secondary
amenorrhea
■ Asherman syndrome due to complete or incomplete removal of the
endometrium when performing myomectomy that involves myomas
that abut the endometrium. Endometrium overlying the leiomyoma
may be inadvertently removed.
■ Postoperative bowel adhesions
■ Uterine rupture during pregnancy or partial uterine dehiscence
■ If the patient becomes pregnant following the procedure, she should be
informed to contact her obstetrician promptly if abdominal pain occurs
during pregnancy.
■ Fetal loss
■ Postpartum hemorrhage
■ Hysterectomy
■ Death
Nhận xét
Đăng nhận xét