Myomectomy is the surgical removal of fibroid from the uterus. It is recommended when the fibroid is causing significant symptoms such as heavy menstrual bleeding, reduced fertility or pressure symptoms such as bladder pressure, urinary frequency, bowel pressure, and bloating.
Myomectomy can be done in different ways depending on the size and location of the fibroid.
Pedunculated fibroids (that grow on stalks), subserosal fibroids (that grow from the outer wall of the uterus) and intramural fibroids (that grow deep within the muscle of the uterus) may be removed laparoscopically (key-hole surgery). Morcellation (cutting the fibroid into smaller pieces in a bag) may then be performed to allow its removal from the key-hole incisions.
Open surgery may be required if the fibroids are large, numerous or deep within the uterus or pelvis.
Submucosal fibroids (that grow from the inside wall of the uterus and protrude into the uterine cavity may be removed hysteroscopically (from the inside of the uterus without any skin incisions). Our blog on surgical removal of submucosal fibroids explains how this is done.
Size is not the only determinant whether a fibroid can be removed laparoscopically or hysteroscopically. It depends also on location, number, together with preference and experience of your gynaecologist.
The size of a normal uterine cavity in women of reproductive age is approximately 4cm. While a 2-3cm submucosal fibroid can be resected through a hysteroscope, a larger submucosal fibroid may require repeated procedures to achieve complete resection and symptom relief. Hysteroscopic resection may not be suitable if the submucosal fibroid is larger than the size of a normal cavity (4cm).
The location of a subserosal or intramural fibroid also determines its suitability for laparoscopic myomectomy. A larger fibroid (such as 10cm) may be more likely to be removed laparoscopically if it is more superficial (rather than deep into the muscle of the uterus) and closer to the top of the uterus (fundus) rather than the bottom (cervix). Laparoscopic myomectomy is also more achievable when there is a single or fewer fibroids compared to numerous large fibroids.
While it is always preferable to perform the myomectomy in minimally invasive way to minimise risks associated with open surgery and allow quicker recovery, it is also important to do so safely, based on your gynaecologist’s assessment.
Laparoscopic myomectomy should be performed by specialist gynaecologists who have completed additional training either in minimally invasive gynaecology surgery, or in surgical gynaecological oncology in order to learn techniques and procedures to complete the most complex surgeries with lower complication rates and quicker recovery period. They also perform higher volume of more complex cases. Kent is available to see his private patients in Epworth Freemasons in East Melbourne. He also consults in Box Hill and Werribee.
Morcellation is the process to cutting the large fibroid into smaller pieces within the abdomen to allow its extraction through the small (usually only 1-2cm) ‘key-hole’ incision. This allows the procedure to be performed in a minimally invasive way by an experienced gynaecologist, reducing the risks of an open surgery.
A potential issue with morcellation is the unexpected finding of malignant cells within the fibroid (the risk of this is between 1 in 600 to 1 in 1000). Morcellating the fibroids into smaller pieces within the abdomen can spread the malignant cells all over the abdomen.
Fibroids are now placed into a special bag (that fits into the ‘key-hole’ incision) within the abdomen, before being morcellated within the contained bag. This will ensure that no abnormal cells spread anywhere outside the bag even if there were unexpected malignant cells within it.
This is the same process of removing a large fibroid uterus in a laparoscopic hysterectomy, when the uterus cannot fit for removal through the vagina (this is the usual way).
There is potential risk of complications with any surgery including myomectomy. This includes: