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Laparoscopic surgery for fibroids (Myomectomy)

A fibroid or myoma is a benign tumor of the uterine muscle , it can be single or multiple, and may vary in size from very small to very large causing abdominal swelling.

Fibroids can be totally asymptomic and only discvered on ultrasound examination or can be symptomatic causing heavy menstrual bleeding, pelvic pain , and severe dysmenorrhea. The larger fibroid can cause abdominal swelling , urinary and gastrointestinal symptoms due to pressure on bladder , ureters and rectum. During pregnancy, fibroids tend to grow and can lead to complications such as spontaneous abortion , preterm labor and acute abdominal pain.

Management of fibroids varies depending on many factors, if small and asymptomaticthey may be observed avoiding surgical intervention unless they enlarge and cause symptoms or they can be surgically removed as a preemptive measure. Such decision will need a thorough discussion between the patient and her doctor including the pros and cons of either approach . Hormonal therapy may control the bleeding and dysmenorrhea in some women but at the same time long term hormonal treatment may facilitate further fibroid growth.

Fibroids can be surgically removed by a procedure called myomectomy in which the fibroid is shelled out of the uterine wall. Repair of the uterine muscle is then accomplished with sutures  unless the fibroid is completely protruding to the outside of the uterine wall (subserosal) or completely protruding to the uterine cavity (submucosal) in which case repair is not needed.

The decision on how to perform the myomectomy depends on the size, number, and location of the fibroids.A fibroid protruding into the uterine cavity can be removed by hysteroscopic resection ,  a procedure in which a hysteroscope is introduced into the uterine cavity via the vagina and cervical canal allowing the surgeon to see the fibroid inside the cavity on a monitor and then remove it under visual control with special instruments designed to pass through the hysteroscope.

On the other hand if the fibroid is within the uterine muscle (intramural) or protruding to the outside (subserosal) then either laparoscopy or laparotomy will be needed for removl.

With the current advances in laparoscopic surgery, the vast majority of fibroid surgery can be accomplished via the laparoscope avoiding the large laparotomy incision.

The procedure is performed usually under general anesthesia and requires 3-4 small incisions in the skin of the abdominal wall , each incision is 0.5 cm to 1.2 cm through which the camera and surgical instruments are introduced and through which the fibroid tissue is removed after morcellation which is done using a device that cuts the fibroid tissue into strips and then be removed through one of the small incisions. The laparoscopic myomectomy is usually performed as an outpatient procedure with discharge from hospital within less than 24 hours.

Another option for management of fibroids is uterine artery embolisation which reduces blood flow to the fibroid by occluding the supplying vessels with particles injected via a vascular catheter inserted through the thigh vessels. The procedure is helpful to those with large symptomatic fibroids who do not desire having surgical removal. The fibroids shrink and their symptoms are reduced. Because of concern of the procedure effect on the integrity on the uterine wall,the embolisation procedure is considered relatively contraindicated for women who desire childbirth inspite of the fact that pregnancies after embolisation have been documented.

Our final thoughts is that women with fibroids have several minimally invasive management options that can be tailored to the specifics of each patient’s condition with quick recovery and resumption of normal physical activities.

The following are video clips of  laparoscopic myomectomy procedures:

  • Laparoscopic myomectomy of an 8 cm low  posterior fibroid with audio

  • Laparoscopic myomectomy of a7cm intramural fibroid

  • Laparoscopic myomectomy of a 15 cm  cervical fibroid