Laparoscopic Surgery

LAPAROSCOPY FOR MYOMA AND UTERINE SURGERIES

Myomectomy implies surgical removal of myomas – benign lesions that develop in uterus. Surgeon aims to excise myomas and smoothen intra-uterine cavity. Contrary to hysterectomy where uterus or womb is completely removed, myomectomy is based on excision of myomas and leaving uterus in body.

Benign intrauterine lumps (myomas) can be excised with laparoscopic methods, regardless of the size. Myomas are cut into small fragments that are taken out the abdominal cavity. Irrespective of patient’s age, laparoscopic surgery is a huge privilege to spare organs, if there is no risk of cancer. Patient can be discharged to home in same day after the procedure is completed.

Laparoscopic Myoma Surgery

Laparoscopic excision can be performed for a significant part of myomas. Indications of operation in myomas are as follow:

Dimension : Generally, it is recommended that myomas, measuring > 6 cm in size, with recent rapid enlargement are excised.

Bleeding: Myomas do not cause bleeding, unless they invade or compress to interior uterine layer (endometrium). If myomas invades into uterine cavity along with bleeding, surgery is recommended irrespective of bleeding. At this point, surgical intervention is hysteroscopic myomectomy, or in other words, transvaginal route is used and myoma is excised with hysteroscope.

Complaints secondary to compression: If myoma is located in the ligament (intraligamentary), they can compress ureters – canals that originates from kidneys and extend to urinary bladder. A myoma at this location should be excised, when symptoms of compression develop. Myomas on anterior wall of uterus compress urinary bladder, while posterior ones compress rectum.

Infertility: In general, myomas do not lead to infertility. However, if tests and investigations cannot clarify reason of infertility, myomas may be excised. Usually, it is recommended to excise myomas measuring >5 cm in size. If there is intrauterine myoma and couple cannot conceive, it is recommended that myomas are excised, regardless of any other complaint or size of myoma.

It is also preferred that myomas, which are eligible for laparoscopic excision, measure <8 cm, larger ones are not more than three and they are not deeply embedded into uterine wall. Couples are not allowed to conceive for 3 months after myomas are excised with laparoscopic method. Risk of adhesion is lesser than conventional myomectomies where abdominal wall is incised. Laparoscopic myoma surgery lasts 1 to 3 hours depending on size and locations of myomas. Patient usually stays 1 day at hospital and is discharged the day after.

Myomectomy is an extremely safe and effective method in the hands of an experienced surgeon.

Why is it performed?

Your doctor can recommend myomectomy, if myomas hinder daily life activities.

* If you plan pregnancy

* If myomas lead to infertility

* If you do not want to have your uterus removed

To Increase Chance of a Successful Pregnancy

How myomas lead to infertility or their relation with pregnancy is not clear yet. Many women with myoma have no difficulty in getting pregnant and they experience a pregnancy without complication. But, if you have myoma and you cannot conceive or if you experienced miscarriage multiple times, your doctor may consider a treatment for myomas, after your are carefully evaluated regarding other potential problems.

There are some evidences that submucosal myomas damage uterine cavity, lead to infertility and are indicated for excision. There is no clear consensus on what should be done for intramural myomas that develop in uterine wall and expand from there and for subserosal myomas.

Most women can conceive after myomectomy procedure. Nevertheless, fertility rate in postoperative period can largely vary. According to many studies, most women can achieve conception after myomectomy procedure.

Surgery for Myomas

Your surgeon can choose one of the following surgical approaches depending on size and type of myoma.

* Abdominal Myomectomy: Uterus is exposed with open abdominal incision and myoma are excised.

* Laparoscopic Myomectomy Several small incisions are made and myoma are excised using special equipment.

* Hysteroscopic Myomectomy: Special tools are advanced into cervix and uterine cavity through vaginal canal and myoma are excised.

Abdominal Myomectomy (Laparotomy)

Abdominal myomectomy is performed under general anesthesia. Uterine cavity is exposed with one or two incision(s).

* Vertical Incision: This incision is made on median line on abdominal wall and extended down the symphisis pubis. Vertical incision enables the surgeon to expose uterus easily and it decreases bleeding. Some surgeons recommend vertical incision, if uterus enlarges to a size similar to 16 weeks’ pregnancy. This incision is also useful, if myoma is located at connective tissue between uterus and pelvic wall.

* Horizontal Incision: This incision is made over symphisis pubis. Since this incision is made over native skin folds, it will cause a thinner scar and lesser pain. However, accessibility of pelvis is also lesser, resulting with a significant problem if uterus is enlarged or deteriorated.

Surgeon inspects uterus and palpates myoma during operation. Several incisions are made in uterus down the myoma that is grasped with special tools and extirpated. Next, uterus is repaired.

Medical staff will postoperatively monitor you at patient room. After you recover from anesthesia, you will be referred to your room for observation.

You will receive morphine or similar drugs to manage pain. Nowadays, you can manage your pain by pushing a button on a sophisticated pain control device that is nowadays available in many hospital.

In general, you are switched from intravenous medications to oral forms next day. You may be infused isotonic saline solution until you can take fluids by mouth, and you will not be immediately allowed to eat solid foods. Medical staff encourages you to walk as soon as possible in order to minimize risk of postoperative complication(s).

When you are discharged, your doctor will prescribe a painkiller and you are informed about surgical wound care, diet list and activities. You should avoid driving, lifting heavy subjects and climbing up stairs etc… You should avoid sexual intercourse and using tampon for 6 weeks. Vaginal discharge can also be observed in this period.

After abdominal myomectomy, you should be hospitalized for 2 to 3 days. Recovery can take 4 to 6 weeks.

Laparoscopic Myomectomy

In this method, a tiny incision is made in the close proximity with the umbilicus and abdominal cavity is insufflated with carbon dioxide. The device, called laparoscope, is inserted to pelvic cavity and images of uterus, ovaries and neighboring pelvic organs are obtained. Next, procedure is maintained with other small incisions that are made on abdominal wall. Extra small incisions are made on abdominal wall and myoma is taken out through a small incision made on the vagina. (Colpotomy)

Smaller incisions are made in laparoscopy when compared with laparotomy, and thus, postoperative healing period shortens. Many surgeons adopt some laparoscopic surgery criteria to decide when laparoscopy will be performed depending on size and number of myoma. However, there is no consensus on such criteria. A surgeon can use this method only for intramural myoma or myoma that are hardly accessible. An experienced surgeon can use laparoscopic method to excise even huge myoma.

Hospitalization is not usually required in laparoscopic myomectomy and recovery lasts several days to 2 weeks. It has very clear advantages when compared with open surgery.

Hysteroscopic Myomectomy

Hysteroscopic myomectomy can be recommended to treat the submucosal myomas that cause lumps protruding into intrauterine cavity.

General or spinal anesthesia is induced for hysteroscopic myomectomy. A small light device, called resectoscope that can extirpate myomatous tissues, is inserted into vaginal canal. A tube is mounted on this device. Clear fluid is instilled into intrauterine cavity in order to expand the cavity. Thus, wall of uterus can be evaluated.

Next, myoma is extirpated with resectoscope until surface of intrauterine cavity appears smooth. The tissue extirpated is irrigated and cleansed with fluid that expands the cavity.

Usually, hospitalization is not required in myomectomy and recovery lasts shorter than one week.

Outcome

After myomectomy procedure, 80% of women get rid of annoying symptoms, such as heavy vaginal bleeding, pelvic pain and pressure etc… However, myomectomy is not a radical solution for myoma. New myoma can develop and treatment can be required.

Women who plan conception may become pregnant approximately within 1 year after myomectomy. However, contraception is a necessity for minimum 3 months after operation.

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