Laparoscopic Myomectomy – Simplified
Dr. Neena Singh Kumar
Gynecologic Endoscopic Surgeon
Uterine fibroids are the most frequently encountered pelvic tumours. Between 20 to 25% of women of childbearing age have fibroids. The fibroid may be as small as a pea or grow as large as a grape fruit. Fibroid can occur as a single growth or multiple growths inside the uterus (sub mucosal), within the walls (intramural) or on its surface (sub serous). However the diagnosis of uterine fibroids is by no means synonymous with the indication to operate. Only fibroids which give rise to symptoms and/or complicated myomas require surgical treatment.
Laparoscopic Myomectomy has provided a minimally invasive alternative to laparotomy for symptomatic fibroids. Laparoscopic Myomectomy is associated with faster post-operative recovery and potentially reduces the risk of post-operative adhesions compared to laparotomy. In fact, in good hands, the rate of peri-operative complications is less as compared to laparotomy.
Symptoms of Fibroids
- Abnormal bleeding (heavy bleeding, longer periods or more frequent periods)
- Pressure symptoms (frequency of urine or retention of urine because of pressure on bladder/pressure on bowel)
- Pain (abdominal discomfort, heaviness, dyspareunia occur in one-third of patients)
- Abdominal mass (in big sized fibroids)
- Inability to conceive
- Anemia due to chronic excessive bleeding
If fibroids are thought to be unrelated to reproductive dysfunction or if they are asymptomatic, no treatment is indicated. Indications for removal of fibroid are shown in the table below:
- Infertile patients, after excluding all other causes of infertility ad in the presence of markedly distorted cavity.
- Patients with recurrent miscarriages or pregnancy complications after evaluation of other potential causes
- Symptomatic patients:
- Abnormal bleeding patterns
- Pelvic pain
- Pressure symptoms
- Very large fibroid
Procedure of Laparoscopic Myomectomy
Laparoscopic Myomectomy is reserved for removing sub-serosal or intra mural fibroid.
- Vasopressin solution on the pedicle or in the body of the myoma is injected.
- Incision is given in the superficial peritoneum either with scissors or monopolar electrode to identify the cleavage line between uterine wall and fibroid. The incision should be large enough to deliver the myoma.
- Once the dissection plane for enucleating the myoma is identified, traction may be applied to the myoma with 5 mm myoma spiral or tenaculum depending on the situation. In order to free the myoma completely, use scissors and coagulate the bleeding vessels intermittently with bipolar forceps.
- Parking the fibroid: After removal, the fibroid is parked either in pouch of Douglas or in appendicular area.
- Excessive capsular area needs to be refashioned
- Suturing of the uterine wall: The hysterotomy is closed with interrupted intra corporeal sutures with no. 1-0 vicryl in one or two layers depending on the depth of the myoma in the uterine wall. If the uterine cavity is opened, we close the uterine wall in 2-3 layers excluding endometrium.
- Removal of myoma: The advent of electromechanical morcellators has simplified the removal of myomas making it possible to tackle big myomas and cut short the time taken to complete Myomectomy without any additional incisions.
- Irrigation of peritoneal cavity: Copious lavage of peritoneal cavity is performed with Ringer lactate solution; approximately 500-1000 ml. Hydro floatation leaving at least 250 ml of lactated Ringer’s solution is done.
- Tracing the ureters: The ureters are traced again especially in case of broad ligament myoma. Haemostasis checked, especially at the hysterotomy stitch line.
- 15 mm accessory port is closed using a port closure needle.
Post - operative care
- Antibiotics are administered peri-operatively and post-operatively.
- According to difficulties in surgery (bleeding, trauma, suture, vaginal incision) patient can be discharged 24-48 hours after surgery.
- Mild analgesics are usually sufficient to control post-surgical pain
We have done 20 cases of Myomectomy in our hospital. Mostly patients were between the ages of 18-39 years of age, the size of fibroids was 2cms to 12cms in size. All were done laparoscopic. The smaller fibroids were delivered through the pouch of Douglas but the bigger fibroids were morcellated using electronic morcellators, Intra-Corporeal suturing was done of the hysterotomy incision. 2 patients required 2 units of blood because of anemic status pre-operatively. They all were on full diet in 48 hours and discharged from the hospital in 72 hours.