Intramural and subserous fibroids can be removed through an incision in the abdomen, similar to a cesarean section. There is no limit to the size or number of fibroids that can be removed this way. This is done in a hospital and usually requires a one or two night stay.
Blood loss and Myomectomy
Typically there is little blood loss when a myomectomy is done by an expert surgeon. There are a number of ways to decrease blood loss, including medications to constrict blood vessels and the use of a laser or other instruments to seal blood vessels. In doing a myomectomy extensive experience will help the surgeon find the plane between the fibroid and the myometrium (the wall of the uterus) to avoid shredding the wall. Although the need for blood transfusions is low, women with very large fibroids may bank some of their own blood ahead of time.
What is the risk of waking up and finding I had a hysterectomy?
So far I have never gone into surgery with the intent of doing a myomectomy in a women of childbearing age and found it necessary to do a hysterectomy. In the rare situation where an obvious cancer is found, a hysterectomy would be necessary, but the risk of this is probably under 1 in 1000. On the other hand, I have had women ask me next next day if I thought that they should have had a hysterectomy because of severe endometriosis or other disease. It is important to have a clear understanding with your physician before surgery about what, if any conditions you would elect to have a hysterectomy. Fortunately many of these conditions, such as adenomyosis, can be diagnosed by MRI so they can be discussed before surgery to avoid any surprises.
Can any gynecologist do a myomectomy?
Yes and no. Most OB-GYN’s spend most of their time doing obstetrics, and don’t do this type of surgery on a regular basis. Many residencies provide little training and experience in doing myomectomy. I’ve seen number of women who have had surgery (several at major university hospitals) with the intent of having a myomectomy only to be told the fibroid was too close to big blood vessels to be removed. In all of these cases did I was able to do myomectomy, but it is unfortunate that the women had to have an additional surgery. I would be very nervous if a doctor tells you he or she will try to do a myomectomy. The risk of needing a hysterectomy in experienced hands should be less than 1 in 100.
What is the recovery time for an abdominal myomectomy?
Having been involved in laparoscopic as well as conventional surgery for over 30 years, I have been amazed in how much more important the attitude of the patient is than the size of the incision in determining recovery time. I did an abdominal myomectomy on one of the busiest doctors in town, and she was back to full time practice in two weeks. Most women will take a month off work that doesn’t involve strenuous physical activity, but it will take longer to feel 100% recovered.
What are the advantages and disadvantages of an abdominal myomectomy
The biggest advantage of the abdominal approach is that the surgeon can actually feel the uterus. This helps with locating deep fibroids, and when there are many smaller fibroids makes it less likely that they will be left behind. It is also possible to do a more precise repair of the uterus, especially when large or deep fibroids have been removed. On the other hand, when fibroids are on the surface (subserous or pedunculated) and not too large, a laparoscopic or robotic approach may be worthwhile. In general I will approach large, deep, or a large number of fibroids abdominally. If there are a small number or the fibroids are not to large, I will consider a laparoscopic or robotic myomectomy if they need to be removed at all. Fibroids that are mostly inside the cavity can often be removed by hysteroscopic resection. The most important consideration is what technique will give the best result in the long run. For a woman who wants to have a baby, whether or not she is able to have a child is far more important than an extra few weeks of recovery time. It is important to consult a gynecologist with experience in all methods of myomectomy to help you decide on the best approach.
Below are photographs of an actual myomectomy
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Abdomen is distended by her uterus which is the size of a 20 week pregnancy. The uterus is up to her belly button. |
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The uterus, which is enlarge by the fibroid, is lifted through the incision. (It is still attached). A laser is being used to make an incision through the myometrium down to the fibroid. |
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The fibroid is being separated from the wall of the uterus (myometrium). It is very important to do this in the exact location between the fibroid and the myometrium in order to prevent excess bleeding. |
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The fibroid is almost complete free from the uterus. An electrosurgical device is being used to seal blood vessels. |
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The uterus is being reconstructed by suturing the walls together with dissolving suture. This is being done in multiple layers to ensure a precise repair. |
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The last layer of sutures is placed, and the uterus is completely restored. A barrier to prevent adhesions will be placed before the uterus is replaced into the abdomen and the abdomen closed. |
I’ll be posting many more photos of abdominal, laparoscopic, robotic, vaginal, and hysteroscopic myomectomy. Sign up for email updates and you will be notified any time the site is updated!
