What is a laparoscopic myomectomy?

Laparoscopic myomectomy for uterine fibroidsFibroids that are attached to the outside of the uterus by a stalk (pedunculated myomas)  are the easiest to remove laparoscopically.  Many subserous myomas (close to the outer surface) can also be removed through the laparoscope.   
Fibroids that are deep in the wall of the uterus, or submucous are most difficult to remove laparoscopically.  Although there have been successful pregnancies after laparoscopic removal of deep or multiple myomas, the real question is whether or not the uterus can be repaired as well through the laparoscope as can be done through an abdominal myomectomy.   


What are the advantages and disadvantages of laparoscopic myomectomy?   
The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions are used rather than one larger incision.  It is important to understand that even a laparoscopic myomectomy is real surgery, and often requires several weeks of recovery.  Another major factor in recovery time is motivation; I have found motivation can be just as important in recovery as the type of surgery.  
One concern when there are multiple fibroids is of leaving smaller myomas behind.  Often it is necessary to feel the uterus to find the smaller myomas; these likely would be left behind during a laparoscopic myomectomy.  To summarize, I think laparoscopic myomectomy is best for pedunculated and superficial myomas.  When there are deep myomas and a large number of myomas, I think that it is possible to repair the uterus better by doing an abdominal myomectomy.

A bit of editorializing...
One of my colleagues assisting me in a difficult laparoscopic surgery asked me when would I do a laparotomy (make a regular incision.)  My answer was that  I do the type of surgery that will obtain the best results.  If I can obtain just as good results through the laparoscope I will do the procedure that way.  But if I feel I can do a better job through a regular incision, then I will recommend that approach.  When someone looks back years after surgery, the quality of surgery inside will be far more important than recovering 1 or 2 weeks earlier.  Sometimes I will take a look through the laparoscope, and decide which way to approach the myomectomy at that time.  What is an "abdominal myomectomy?

An abdominal myomectomy is the removal of fibroids through an incision in the abdomen.  I usually can do this through a horizontal ("bikini") incision, even for large fibroids.  There is no limit to the size or  number of fibroids that can be removed.  Abdominal myomectomy is done in a hospital, and women usually can go home within 48 hours of surgery.  Photos below show an actual abdominal myomectomy.

Is there much blood loss with myomectomy?..
Usually there is little loss of blood when a myomectomy is done by a surgeon with extensive experience in the procedure.  There are a number of ways to reduce blood loss.  I use a laser to make the incision into the uterus, which seals blood vessels and reduces bleeding.  Before the incision, medicines are injected into the uterus to shrink blood vessels.  As a result, I find it unusual to lose an excess amount of blood during a myomectomy, even with large fibroids.There are a number of surgical techniques to reduce blood loss, so it is important to find a surgeon who is experienced in myomectomy.

What are the advantages and disadvantages of an abdominal myomectomy?
The ability to actually feel the uterus allows me to find fibroids deep inside the uterus that may not be visible just by looking.  As you can see from the photos, being able to hold the uterus allows me to accurately repair the area from which large fibroids have been removed.
The disadvantage of an abdominal myomectomy is that it requires an incision, so recovery is somewhat longer than required if an incision is avoided.  Fibroids that are on the inside of the uterus (submucous) can usually be removed with a resectoscope, without requiring any incision.  Fibroids on the outside of the uterus (subserous) can sometimes be removed through a laparoscope, through several small incisions.  I feel that this is often the method of choice for subserous or pedunculated (on a stalk) fibroids.  If there are many fibroids or fibroids that are deep I can do a better job by doing an abdominal myomectomy.  Most women feel that in the long run doing the best possible procedure to restore the health of the uterus is more important than recovering several weeks sooner.

How is an abdominal myomectomy done?

Here are photographs of an actual abdominal myomectomy. 

Uterine myomectomy - before surgery

Here is the abdomen before surgery.  The uterus is the size of a 5 month pregnancy.  It can be seen to protrude up to the belly button.


Uterine myomectomy - beginning of incision with laser

The uterus, which, is greatly enlarged by the fibroid, is lifted through the incision.  A laser is being used to make an incision into the uterus so the fibroid can be removed.


Uterine myomectomy - fibroid beeing freed from uterus

The fibroid is being separated from the wall of the uterus (myometrium).  It is very important to do this in the exact location between the fibroid and the myometrium in order to prevent excess bleeding.


Uterine myomectomy - fibroid being freed from uterus

This shows the fibroid almost completely free from the uterus.  It is attached only at the base.  The blood vessels at the base are being sealed with an electrosurgical device.


Uterine myomectomy - reconstruction of uterus

The uterus is being reconstructed by suturing the walls together with dissolving suture.  This is being done in multiple layers to ensure a precise repair.


Uterine myomectomy - reconstruction of uterus complete

The last layer of sutures is placed, and the uterus is completely restored.  A barrier to prevent adhesions will be placed before the uterus is replaced into the abdomen and the abdomen closed.


What is the recovery time for an abdominal myomectomy?

Recovery varies tremendously from person to person.  Most women can return to work that does not require heavy lifting in 4 weeks.  Many women can return in 2 weeks, and some women take 6 weeks. 




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