Laparoscopic Myomectomy

What is laparoscopic myomectomy?

Laparoscopic myomectomy is a minimally invasive surgical procedure performed to excise uterine fibroids.

CONDITION

What are uterine fibroids?

Uterine fibroids are common noncancerous tumours that form in the uterus. They can form at any age, but usually occur during a woman’s childbearing years. Fibroids can appear on the inside or outside lining of your uterus, or within its muscular wall. They usually develop from a single smooth muscle cell that continues to grow.

Fibroids

Fibroids

What are the common names for uterine fibroids?

Uterine fibroids are also called leiomyomas, myomas or fibromyomas.

What is the percentage of population affected by uterine fibroids?

Uterine fibroids are the most common type of benign growth that affects the uterus. It affects about 70% of white women and more than 80% of black women.

Which part of the body is affected?

The female reproductive system is made up of the following parts:

  • Vagina: opening of the reproductive system, which allows the entry of sperm
  • Cervix: narrow region that connects the vagina to the uterus
  • Uterus: womb, where a fertilised egg implants and grows to develop into a baby
  • Ovaries: organs on either side of the uterus, which release an egg each month in the prospect of a pregnancy
  • Fallopian tubes: narrow tubes that open out at the ovaries to pick up the released egg for fertilisation

The uterus is made up of three layers – The innermost layer is called the endometrium, the second layer, myometrium and the third layer, the serosa. Every month, the endometrial layer is built, and thickens in preparation to accept the fertilised egg for implantation and provide nourishment to the growing embryo, until birth. If the egg does not get fertilised, the layer of tissue that is formed slogs off and passes out in the form of your monthly period.

How do uterine fibroids affect you?

Uterine fibroids usually cause problems during your periods. They can be very painful, affect your fertility and cause complications during your pregnancy.

What are the different types of fibroids?

Fibroids are categorised by their location, which include:

  • Intramural: most common variety that grows in the uterine wall
  • Submucosal: grows in the uterine lining (endometrium), causing excessive menstrual bleeding and period pain
  • Subserosal: grows on the exterior wall of the uterus and sometimes appears as long stalks

What are the causes of uterine fibroids?

Uterine fibroids may be caused by:

  • Genetic changes
  • Presence of high levels of oestrogen and progesterone hormones
  • Growth factors

Who is at risk of developing uterine fibroids?

The risk factors for uterine fibroids are:

  • Increasing age
  • High BMI
  • High alcohol consumption
  • History of infertility

What are the signs and symptoms of uterine fibroids?

In many cases, fibroids are asymptomatic. Symptoms may include:

  • Heavy periods
  • Lengthy periods that last more than a week
  • Painful periods
  • Spotting between periods
  • Painful intercourse
  • A sense of heaviness or pressure in the back, bowel and bladder
  • Frequent urination
  • A lump or swelling in the lower abdomen

What are the related disorders that can occur with uterine fibroids?

Uterine fibroids can be associated with anaemia, urinary problems, miscarriage, premature labour and infertility. Fibroids can prompt the growth of polyps in the uterine lining (endometrium). A polyp is a small protrusion that looks like a tiny ball on the end of a slim stalk. Endometrial polyps can also contribute to menstrual problems, such as excessive bleeding and pain.

How are uterine fibroids diagnosed?

Fibroids can be detected using an ultrasound, where sound waves create a two-dimensional picture. The inside of the uterus can be examined with a hysteroscope, which is a thin tube passed through the cervix. A small camera may be placed at the tip of the hysteroscope, so that the interior of the uterus can be viewed on a monitor.

TREATMENT

What are the consequences of not treating uterine fibroids?

Most uterine fibroids that do not cause any problem can be left untreated. They are benign, and may remain the same size or grow very slowly, causing no symptoms to mild signs and symptoms. As the levels of reproductive hormones drop with menopause, the fibroids usually shrink in size.

When should I consider watchful waiting of uterine fibroids?

Close monitoring is required when your fibroids are not causing any problems and treatment is stalled for further development. In rare cases, it can rapidly grow into a tumour or to sizes that can cause significant problems, and make surgical removal difficult and risky.

What are the treatment options for uterine fibroids?

Treatment depends on the location, size and number of fibroids, but may include:

Non-surgical treatments

  • Medication: such as hormones, are used in combination to shrink the fibroids prior to surgery
  • Uterine artery embolisation (UAE): blocking the blood supply to the fibroids and in turn causing them to shrink
  • Endometrial ablation: removing the uterine lining containing the fibroid with the help of a laser, heated wire loop or hot liquid in a balloon
  • MRI-guided procedures: ultrasound or laser energy passed through small needles that are inserted under the guidance of MRI

Symptoms caused by uterine fibroids usually resolve by the time you reach menopause. Hence, if you are nearing menopause you can consider controlling symptoms with home treatment and medicine.

Surgeries

  • Open surgery: required for the removal of larger fibroids
  • Laparoscopy: keyhole surgery is performed where a thin tube is inserted through the abdomen to remove the fibroids
  • Myomectomy: uterine fibroids are excised, retaining the ovaries
  • Hysterectomy: a part or all of the uterus is removed
  • Hysteroscopy: fibroids are removed via the cervix, using a hysteroscope

Am I candidate for laparoscopic myomectomy?

Fibroids may require treatment in the following circumstances:

  • Grow large enough to cause pressure on other organs, such as the bladder
  • Grow rapidly
  • Profuse bleeding that can lead to anaemia and lifestyle problems
  • Chronic abdominal pain, or pelvic or lower back pressure
  • Cause problems with regard to fertility

Laparoscopic myomectomy is indicated if you wish to bear children and do not want to undergo hysterectomy, where your uterus is removed.

How do I prepare for laparoscopic myomectomy?

Before laparoscopic myomectomy, you will be advised to stop eating or drinking anything at least 6 hours before the procedure. Discuss all the medications that you are taking on a regular basis so that your doctor can advise you on the ones that you can safely continue and those that may need to be stopped during the time of surgery.

How is laparoscopic myomectomy performed?

Laparoscopic myomectomy may be performed under spinal or general anaesthesia. It is a minimally invasive procedure where a narrow lighted tube called a laparoscope is inserted into an incision made at your belly button. A camera attached to the laparoscope relays images of the operative site on a large monitor that guides your surgeon during the procedure. Other surgical instruments are inserted through small incisions made on your abdomen. With the help of these instruments, your surgeon cuts the fibroid into pieces using a laser, cryotherapy (extreme cold) or cautery (extreme heat), and removes them through a small incision made in the abdominal wall.

A larger incision is required if the fibroid is removed without being cut into pieces. In some cases, the fibroid is removed through the vagina by a process called colpotomy.

Following the excision, the defects are irrigated to control bleeding and sutured. The entire procedure may take 50 to 160 minutes.

What can I expect after laparoscopic myomectomy?

After laparoscopic myomectomy, you may be required to stay in the hospital for 7 to 48 hours.

What are the advantages of laparoscopic myomectomy?

The advantages of laparoscopic myomectomy are:

  • Less blood loss
  • Lower postoperative pain
  • Fewer complications
  • Faster recovery
  • Minimal scar formation

However, laparoscopic myomectomy may be associated with challenges in suturing the defect left after the removal of the fibroid as well as the detection and removal of small uterine fibroids, and large fibroids from difficult locations such as the lower region of the uterus or junction of the cervix.

Describe the stages of recovery and care plan?

You may have to stay overnight in the hospital after laparoscopic myomectomy. You will be prescribed medication to relieve pain, and advised on your diet and the activities you should avoid during your recovery. You may experience vaginal spotting or staining for a couple of days to six weeks.

You should wait at least three months for your uterus to heal before attempting to get pregnant.

What are the outcomes of laparoscopic myomectomy?

Following laparoscopic myomectomy, you can expect improvements in symptoms such as pelvic pain and pressure, and extensive bleeding. It can also enhance your chances of fertility and pregnancy.

What are the potential complications of laparoscopic myomectomy?

As with most surgical procedures, laparoscopic myomectomy may be associated with certain complications such as:

  • Injury to ureters, bladder, bowel or blood vessels
  • Need to change to an open surgery or laparotomy
  • Chances of uterine rupture during labour
  • Recurrence

What is the downtime of laparoscopic myomectomy?

It may take you about 3 months for your uterus to heal from the fibroids.

What is the cost of laparoscopic myomectomy?

Any costs involved will be discussed with you prior to your surgery.

What is the likelihood of uterine fibroids recurrence? How can it be managed?

There are chances of fibroid recurrence after laparoscopic myomectomy. This requires repeat surgery.

What are the current research regarding laparoscopic myomectomy?

Extensive research is being done to better treatment outcomes with laparoscopic myomectomy. Some of the recent studies are listed below:

  • Ghezzi F, Casarin J, De Francesco G, et al. Transvaginal contained tissue extraction after laparoscopic myomectomy: A cohort study. BJOG. 2017 May 3. doi: 10.1111/1471-0528.14720. [Epub ahead of print]
  • Shin DG, Yoo HJ, Lee YA, Kwon IS, Lee KH. Recurrence factors and reproductive outcomes of laparoscopic myomectomy and minilaparotomic myomectomy for uterine leiomyomas. Obstet Gynecol Sci. 2017 Mar;60(2):193-199.