BASIC INFORMATION

Date & Time:

19 October 2024 | 16:30 IST

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture provides a comprehensive overview of myomectomy for postgraduate surgeons and gynecologists. It defines myomectomy as the surgical enucleation of uterine fibroids (myomas) while preserving a functional uterus for future reproduction or menstrual function. The discussion covers detailed indications for the procedure, such as persistent bleeding, significant pressure symptoms, uterine size exceeding 12 weeks gestation, and recurrent pregnancy loss. Key considerations prior to surgery are explored, including the higher risk profile of myomectomy compared to hysterectomy, the potential for recurrence (30-50%), and the possibility of persistent menorrhagia (1-5%). Contraindications, including infected fibroids and suspected malignancy, are clearly outlined. The lecture details various surgical approaches—laparotomy, laparoscopy, hysteroscopy, and vaginal myomectomy—and explains the principle of morcellation. Finally, it introduces essential surgical instruments for open myomectomy: Bonney's myomectomy screw for traction and Bonney's myomectomy clamp for hemostasis.

KEY KNOWLEDGE POINTS

Definition and goals of myomectomy.
Indications and contraindications for the procedure.
Preoperative considerations and patient counseling, including risks of recurrence, persistent symptoms, and the need for potential relaparotomy.
Surgical approaches: laparotomy, laparoscopy, hysteroscopy, and vaginal myomectomy.
The concept and application of morcellation.
Identification and function of key surgical instruments: Bonney's myomectomy screw and clamp.
Post-myomectomy pregnancy considerations, including mandatory hospital delivery.

INTRODUCTION

Uterine fibroids, or myomas, are the most common benign tumors of the female reproductive system. While many are asymptomatic, they can cause significant morbidity, including abnormal uterine bleeding, pelvic pain, pressure symptoms, and reproductive dysfunction. Management strategies range from medical therapy to definitive surgical removal of the uterus (hysterectomy). Myomectomy occupies a crucial position in this therapeutic spectrum, offering a uterine-sparing surgical option. It involves the enucleation of myomas from the uterine wall, aiming to alleviate symptoms while preserving the uterus for future childbearing or to honor a patient's desire to retain her menstrual function. This lecture focuses on the principles of myomectomy, patient selection criteria, surgical techniques, and associated risks, providing the necessary framework for sound clinical decision-making.

LEARNING OBJECTIVES

Define myomectomy and understand its primary goal of preserving a functional uterus.
Identify the clinical indications and contraindications for performing a myomectomy.
Evaluate the preoperative considerations and risks associated with myomectomy, including recurrence and persistent symptoms.
Differentiate between the various surgical approaches to myomectomy (laparotomy, laparoscopy, hysteroscopy, vaginal).
Recognize and describe the function of specialized instruments used in open myomectomy.

CORE CONTENT

1. Definition and Rationale

Definition

Myomectomy is the surgical procedure involving the enucleation of myomata (fibroids) from the uterus, leaving behind a potentially functional organ capable of future reproduction and normal menstrual function.

Enucleation

The term "enucleation" is used because fibroids possess a pseudocapsule, a layer of compressed myometrial tissue that separates the tumor from the surrounding healthy uterine wall. The surgical technique involves incising this pseudocapsule and dissecting the fibroid out, analogous to removing a nucleus from its covering. The goal is to leave a healthy, viable uterine remnant that can be repaired.

2. Indications for Myomectomy

Myomectomy is selected over hysterectomy in specific clinical scenarios, primarily when uterine preservation is desired.

Persistent Uterine Bleeding: Abnormal uterine bleeding that is refractory to medical therapy in a patient desiring uterine preservation.
Excessive Pain or Pressure Symptoms: Significant pelvic pain, heaviness, or pressure on adjacent organs (e.g., bladder or rectum) causing urinary frequency, retention, or constipation. This is a common indication for subserosal fibroids.
Uterine Size: A uterus enlarged by fibroids to a size greater than 12 weeks of gestation, particularly when fertility is a concern.
Distortion of the Uterine Cavity: Significant distortion of the endometrial cavity by submucosal or intramural fibroids, which can impair fertility.
Reproductive Issues: Infertility or recurrent pregnancy loss attributed to the presence of a fibroid.
Rapidly Growing Myomas: A noticeable increase in fibroid size observed during follow-up, raising concerns even in the absence of malignancy.
Subserosal Pedunculated Fibroid: These fibroids should be removed to prevent potential complications such as torsion or secondary degenerative changes.

3. Preoperative Considerations and Patient Counseling

A thorough discussion with the patient is essential before proceeding with myomectomy.

Reproductive and Menstrual Function: The primary goals are the preservation of reproductive potential and menstrual function. For parous women who have completed their families but wish to avoid hysterectomy, a judicious discussion of risks and benefits is mandatory.
Surgical Risk: Myomectomy, particularly for large or multiple fibroids, is often a more complex and riskier operation than hysterectomy. Blood loss can be substantial due to the rich vascular supply of the myometrium.
Risk of Recurrence: Patients must be counseled that myomectomy is not a definitive cure. New fibroids can develop from other myocytes. The risk of recurrence is estimated to be 30-50%.
Risk of Persistent Menorrhagia: Approximately 1-5% of patients may experience persistent heavy menstrual bleeding post-myomectomy, potentially due to coexisting pathology like adenomyosis or endometrial dysfunction.
Risk of Relaparotomy: Secondary hemorrhage into the myomectomy bed or from another site may necessitate an emergency relaparotomy to control bleeding and save the patient's life. The risk is cited as 20-25% in complex cases.
Post-Myomectomy Pregnancy: Pregnancy rates following myomectomy range from 40-60%, highly dependent on patient selection and the type/location of the fibroid removed. Patients who conceive after myomectomy should have a mandatory hospital delivery due to the risk of uterine scar rupture during labor, although this complication is rare.

4. Contraindications to Myomectomy

Infected Fibroid: Attempting myomectomy on an infected fibroid (e.g., a degenerating submucous fibroid post-abortal) is contraindicated as it can disseminate infection and lead to sepsis.
Growth After Menopause: Any growth of a myoma after menopause is highly suspicious for sarcomatous transformation. In such cases, a conservative surgery like myomectomy is inappropriate; hysterectomy is indicated.
Suspected Malignancy: If there is any suspicion of a leiomyosarcoma based on clinical or imaging findings (e.g., rapid growth), myomectomy should be avoided.
Parous Woman with Completed Family: For a parous woman with no desire for future childbearing, hysterectomy is a safer and more definitive treatment, as it eliminates the risk of recurrence.

5. Surgical Approaches

The choice of approach depends on the size, number, and location of the fibroids (fibroid mapping).

Laparotomy (Open Myomectomy): The traditional approach involving an abdominal incision. It is suitable for very large, numerous, or awkwardly located fibroids.
Laparoscopy: A minimally invasive approach using small incisions (ports) for a camera and instruments. It offers benefits like reduced pain and faster recovery but requires advanced surgical skills.
Hysteroscopy: The preferred approach for submucous myomas. A hysteroscope is inserted through the cervix into the uterine cavity to resect the fibroid.
Robotic-Assisted Myomectomy: A variation of laparoscopy where the surgeon controls robotic arms to perform the dissection and suturing, offering enhanced precision and dexterity.
Vaginal Myomectomy: Suitable for a prolapsed, pedunculated submucous fibroid that is visible or palpable at the cervix. The fibroid can be twisted off (polypectomy) or morcellated and removed vaginally.

6. Surgical Instruments for Open Myomectomy

Knowledge of key instruments is essential for trainees.

Bonney's Myomectomy Screw: A screw-tipped instrument designed to be inserted into the fibroid. It serves as an excellent traction device, allowing the surgeon to pull the fibroid upwards and outwards during enucleation. This facilitates dissection and provides control over the tumor.
Bonney's Myomectomy Clamp: A clamp designed to be placed across the uterine isthmus or infundibulopelvic ligaments to temporarily occlude the uterine arteries. This reduces blood flow to the uterus, minimizing intraoperative blood loss during the enucleation and repair phases of the surgery.

7. Morcellation

Morcellation is the process of cutting a large tissue mass (like a fibroid) into smaller pieces to facilitate its removal through a small incision. This technique is commonly used in laparoscopic and robotic myomectomy to extract the specimen from the abdominal cavity. Vaginal morcellation can also be performed for large, prolapsed submucous fibroids.

SURGICAL PEARLS

Proper patient selection is paramount for achieving successful outcomes, especially regarding future fertility. Removing a subserosal fibroid may not improve fertility unless it is causing tubal obstruction.
The key to a successful myomectomy is meticulous hemostasis and careful, layered closure of the uterine defect to obliterate dead space and prevent hematoma formation.
Always be prepared for significant blood loss. Ensure adequate intravenous access and cross-matched blood availability, especially for large or multiple myomas.
When counseling a parous woman desiring myomectomy, emphasize that while it preserves the uterus, it carries a higher immediate surgical risk and a long-term risk of recurrence compared to hysterectomy.

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative:
- Hemorrhage: The most common and significant complication. Managed with uterine artery clamps (e.g., Bonney's clamp), vasopressin injection, and meticulous surgical technique. In uncontrollable cases, conversion to hysterectomy may be life-saving.
Early Postoperative:
- Secondary Hemorrhage: Bleeding into the myomectomy cavity or abdomen. May require re-exploration (relaparotomy) for hemostasis.
- Infection/Sepsis: Risk increases with prolonged surgery, large hematomas, or pre-existing infection.
Late Postoperative:
- Uterine Scar Rupture: A rare but catastrophic risk during a subsequent pregnancy, mandating hospital delivery.
- Adhesion Formation: Can lead to chronic pain or secondary infertility.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

Informed consent must explicitly detail the risks of hemorrhage, infection, recurrence (30-50%), potential for conversion to hysterectomy, and the need for relaparotomy (risk cited up to 20-25%).
The possibility that myomectomy may not resolve menorrhagia (1-5% persistence) should be clearly communicated.
For women desiring fertility, it is critical to explain that myomectomy improves pregnancy rates only in select cases (40-60%) and does not guarantee conception.
Document the discussion of hysterectomy as an alternative, safer, and definitive procedure, especially for women who have completed their families.

SUMMARY AND TAKE-HOME MESSAGES

Myomectomy is a uterine-sparing surgery for symptomatic fibroids, primarily indicated for women desiring future fertility or uterine preservation.
It is a technically demanding procedure with higher risks of hemorrhage and recurrence compared to hysterectomy; comprehensive patient counseling is essential.
The surgical approach (laparotomy, laparoscopy, hysteroscopy) is tailored to the fibroid's size, number, and location.
Pregnancy after myomectomy requires mandatory hospital delivery due to the risk of uterine rupture.

MULTIPLE CHOICE QUESTIONS (MCQs)

What is the primary goal of myomectomy?

a) To definitively cure fibroids

b) To remove the uterus

c) To preserve a functional uterus

d) To perform a biopsy of the myoma
The term "enucleation" in myomectomy refers to removing the fibroid from its:

a) Vascular pedicle

b) Endometrial lining

c) Pseudocapsule

d) Ovarian attachment
Which of the following is a primary indication for myomectomy?

a) A 2 cm asymptomatic intramural fibroid

b) Recurrent pregnancy loss attributed to a uterine-distorting fibroid

c) Asymptomatic fibroids in a postmenopausal woman

d) A desire for permanent sterilization
What is the approximate risk of fibroid recurrence after myomectomy?

a) 1-5%

b) 5-10%

c) 10-20%

d) 30-50%
Which of the following is a strict contraindication for myomectomy?

a) A 14-week size uterus with fibroids

b) Multiple fibroids

c) A rapidly growing myoma after menopause

d) A subserosal pedunculated fibroid
Compared to hysterectomy for fibroids, myomectomy is generally considered:

a) A less risky operation with less blood loss

b) A more risky operation with greater potential for blood loss

c) An equally safe procedure

d) The definitive treatment with no risk of recurrence
What is the estimated pregnancy rate following myomectomy?

a) 10-20%

b) 20-30%

c) 40-60%

d) 80-90%
Why is mandatory hospital delivery recommended for pregnancies following myomectomy?

a) Due to high risk of preterm labor

b) Due to risk of uterine scar rupture during labor

c) To monitor for fibroid recurrence

d) Because all post-surgical pregnancies are high-risk
What is the function of the Bonney's myomectomy screw?

a) To suture the uterine wall

b) To clamp the uterine arteries

c) To provide traction on the fibroid for enucleation

d) To morcellate the fibroid
What is the purpose of the Bonney's myomectomy clamp?

a) To hold the fibroid

b) To temporarily reduce blood supply from the uterine arteries

c) To grasp the fallopian tubes

d) To close the abdominal wall
Which surgical approach is most appropriate for a small, purely submucous fibroid?

a) Laparotomy

b) Laparoscopy

c) Hysteroscopy

d) Vaginal myomectomy
The term "morcellation" refers to:

a) Suturing the uterine defect

b) Cutting a large tumor into smaller pieces for removal

c) Clamping the blood supply

d) Twisting a pedunculated fibroid off its stalk
Persistent menorrhagia after myomectomy can occur in what percentage of patients?

a) <1%

b) 1-5%

c) 10-15%

d) 20-25%
For which type of fibroid would a vaginal myomectomy be most suitable?

a) A large intramural fibroid

b) A subserosal fibroid on the uterine fundus

c) A prolapsed, pedunculated submucous myoma

d) Multiple small fibroids throughout the myometrium
What is the most significant intraoperative risk during a myomectomy for large fibroids?

a) Injury to the ureter

b) Bowel injury

c) Hemorrhage

d) Nerve damage
A patient who has completed her family presents with symptomatic fibroids. The safest and most definitive treatment is:

a) Myomectomy

b) Hysterectomy

c) Medical management

d) Uterine artery embolization
The risk of requiring a relaparotomy after a complex myomectomy is cited as:

a) <1%

b) 1-5%

c) 5-10%

d) 20-25%
What is the main reason myomectomy is not performed for fibroid growth after menopause?

a) The surgery is technically more difficult

b) The risk of sarcomatous change is high

c) Patients are poor anesthetic candidates

d) Medical therapy is more effective in this age group
Which factor most heavily influences the improvement in pregnancy rates after myomectomy?

a) The surgeon's experience

b) The use of robotic assistance

c) Proper patient selection based on fibroid location

d) The size of the abdominal incision
A patient is counseled for a laparoscopic myomectomy. How will the large, enucleated fibroid be removed from the abdomen?

a) Through a large abdominal incision

b) It will be left inside to dissolve

c) Through the vagina

d) It will be morcellated and removed through a small port site

MCQ Answers: 1-c, 2-c, 3-b, 4-d, 5-c, 6-b, 7-c, 8-b, 9-c, 10-b, 11-c, 12-b, 13-b, 14-c, 15-c, 16-b, 17-d, 18-b, 19-c, 20-d

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The scalpel is an extension of your knowledge, not just your hand. Master the 'why' before you perfect the 'how,' for true surgical excellence lies in the wisdom of your decisions, not merely the dexterity of your fingers.

May your pursuit of surgical mastery be guided by discipline, compassion, and an unwavering commitment to your patients.