Home Myoma surgery (myomectomy)

Myoma surgery (myomectomy)

Myomas are benign tumors of the muscular layer of the uterus (myometrium) of unknown origin. It is known that it is estrogen-dependent, so in menopause it generally stops growing and decreases.

Myomas are operated upon in case they give symptoms such as pain, a feeling of pressure in the abdomen and pressure on the urinary bladder, irregular and heavy bleeding, as well as when it is estimated that myomas are the cause of infertility or spontaneous abortions.

In most patients, the aim is to preserve the uterus through myomectomy, which leaves the possibility for further pregnancy.

In women who no longer want to give birth, the entire uterus is usually removed.

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Options for fibroid surgery

Fibroids can be removed laparoscopically (by inserting a camera and instruments through small incisions in the abdomen), through an open incision in the abdomen, or hysteroscopically (when a camera and instruments are inserted through the cervix, without an incision in the abdomen) depending on the size and location of the fibroids.

Hysteroscopic myomectomy

Laparoscopic myomectomy

Laparotomy for a myoma

The hysteroscopic method is used to operate on submucosal myomas, as well as myomas that are partly intramural and partly submucosal.

A hysteroscope, that is, an instrument with a camera, is inserted through the vagina into the canal of the cervix and then into the uterine cavity.

Fluid is injected into the uterus to separate the front from the back wall so that the entire uterine cavity of the uterus lining (endometrium) can be analyzed.

The camera is connected to a monitor, which shows the inside of the uterus.

Subserosal and intramural myomas are operated on laparoscopically. Miomas that cause symptoms are operated on.

We perform classic laparotomy with a special focus on mini-laparotomy, which is characterized by a discreet, low incision of 4-6 cm that provides faster recovery and minimal scarring.

When fibroids are very large or located on the posterior wall, a longitudinal incision is used for optimal access and safety. This technique is ideal for the effective removal of subserous and intramural myomas, especially when they are larger than 10 cm or there are more of them.

Hospital stay lasts for one day after laparoscopic myomectomy, 2-4 days after open incision surgery and several hours after hysteroscopic surgery.

The patient returns to normal activities very quickly after laparoscopic and hysteroscopic surgery.

Hysteroscopic myomectomy in Gyn-Fertility Clinic Milenković

The decision on hysteroscopic myomectomy is made after a gynecological and ultrasound examination and a consultation with a gynecologist.

The intervention is performed in the period between 5 and 12 days of the cycle for women in the reproductive period, while for women in menopause it can be performed at any time.

The operation can be done at any stage of the cycle when the woman is taking birth control pills.

Preparation

Hysteroscopy procedure

After hysteroscopy

The patient fills out a detailed questionnaire about her health condition.
Hysteroscopic myomectomy is performed under short-term general anesthesia.
Before the operation, a consultation is held with a doctor specializing in anesthesia and blood tests are performed.
When there is a disease, it is necessary to do additional analyses and an examination by a doctor of another specialty, most often an internist.
The patient receives an antiseptic shampoo in the Clinic, with which she will take a shower the night before and the morning before the surgery, as well as a prostaglandin tablet that is placed in the vagina 6 hours before the hysteroscopy.
Hysteroscopic myomectomy is performed as day surgery.
The patient leaves the office no later than 2 hours after the surgery.
6-8 hours before the surgery, the patient stops taking food and liquids.

Upon arrival at the Clinic, the patient is placed in the patient room where she is prepared for the surgery. A cannula is inserted into the vein so that the patient can receive the necessary drugs.
The vagina is treated with a saline solution or an antiseptic agent containing iodine or chlorine.
After receiving anesthesia, the hysteroscope is "inserted" into the cervix. Considering that the hysteroscope is 5-9 mm in diameter, it is most often necessary to perform dilatation, that is, to widen the cervix canal with instruments so that the hysteroscope can reach the uterine cavity.
First, the cervical canal is examined, and then the uterine cavity itself, where the myoma is identified.
Resectoscopic removal of myomas is done by inserting a looped instrument into the hysteroscope connected to a bipolar energy generator. With the loop, the myoma is removed part by part until it reaches the level of the uterine wall, that is, the myometrium.
When resectoscopy is combined with a mechanical instrument, the part located in the wall of the uterus (intramural part) is removed with the help of a mechanical hook and then the operation continues with the resectoscope. "
“Shaver" is an instrument with rotating blades that remove the myoma and then parts of the myoma are aspirated from the uterine cavity. The fluid that is always in the uterus is saline solution.

Sometimes it is necessary to repeat the hysteroscopy if the myoma is larger than 3 cm.

The tissue that is removed is sent to a pathologist for analysis.

The surgery lasts 15-45 minutes.

The patient moves to the patient room where she stays for up to 2 hours after the fibroid surgery.
First she gets water and then a light meal.
Antibiotics are usually prescribed after hysteroscopy.
Pain in the form of cramps or menstrual pain is treated with painkillers, most often paracetamol, ibuprofen and diclofenac.
Sometimes there is a feeling of nausea and a feeling of fatigue.
The patient is not advised to drive a car on the day of surgery.
Vaginal bleeding usually stops 2-3 days after surgery.
The patient can return to normal activities the day after the surgery.
The use of vaginal tampons, bathing in the bathtub, swimming, as well as sexual intercourse is not recommended as long as the bleeding lasts.
The next period will come at the expected time.

The patient will be informed about the result of the histopathological findings 7-10 days after the surgery.

Hysteroscopic techniques used

Resectoscopic technique - TCRM transcervical resection of myoma - bipolar energy is used;
by a combination of a resectoscope and mechanical instruments - when there is an intramural part of the myoma;
"shaver" - a mechanical instrument without the use of energy.

When can't hysteroscopic myomectomy be performed?

Hysteroscopic myomectomy is not performed:

during menstrual bleeding;
infections of the genital organs.

Complications during and after hysteroscopic myomectomy

Complications during and after hysteroscopic myomectomy occur in less than 1% of cases and can be:

passage of the instrument through the wall of the uterus (perforation) when there may be injury to the intestines, bladder and wall of the uterus;
bleeding;
infection of the uterus;
a scar that remains inside the uterus after surgery;
complications related to the use of liquid that is inserted into the uterine cavity (extremely rare if saline solution is used).

Removal of myomas larger than 3 cm is sometimes done in two sessions.

Laparoscopic myoma surgery in Gyn-Fertility Clinic Milenković

Laparoscopic surgeries are performed in hospitals in Novi Sad and Belgrade. The staff from the Clinic contacts the hospital and arranges admission.

Before the operation

Laparoscopic surgery

After the surgery

The patient fills out a detailed questionnaire about her health condition and receives an antiseptic shampoo with which she will take a shower the night before admission and on the day of the surgery itself.
A blood count and blood type are done.
Before the surgery, a consultation is held with an anesthesiologist and an internal medicine specialist if there is an additional risk factor.
The patient signs the consent that she agrees to the surgery.
The intake of food and water is not allowed 8 hours before the surgery.

A catheter is inserted into the patient's bladder.
If it is determined on the ultrasound examination that the myoma is very close to or touching the uterine cavity, a catheter is inserted into the uterus into which a sterile blue liquid is injected for easier orientation during the surgery.
After preparing the operating field and receiving general anesthesia, a small incision is made on the navel and carbon dioxide is injected into the abdominal cavity with a special needle to "separate" the organs from the front abdominal wall.
An instrument with a camera is inserted into the abdominal cavity through the same incision, and then two or three small 5 mm incisions are made to insert additional instruments.
Then the myoma is separated from the uterine wall with adequate stopping of bleeding.
The wall of the uterus is sutured with sutures that dissolve spontaneously a certain time.
Myomas are removed from the abdominal cavity by widening an incision in the skin or using a special instrument with rotating blades that itself pulls out the myoma itself in small pieces.
Myomas can be removed laparoscopically using radiofrequency energy, which causes the myomas to die.
The tissue that is removed is sent for histo-pathological examination.
Instruments are removed from the abdomen and carbon dioxide is "blown" out of the abdominal cavity.
The skin incisions are sutured with a suture that does not need to be removed. A protective patch is placed on the incisions and removed after 3-4 days.

The patient returns to the patient room and receives medication for pain and nausea.
3-4 hours after the surgery, the patient starts to drink liquid, and then she is given light food.
The catheter from the urinary bladder is removed a few hours after the surgery and the catheter from the uterine cavity immediately after the surgery.
It is desirable that the patient gets out of bed with the help of the staff 2-3 hours after the surgery and can go to the toilet on her own.
Sometimes a blood transfusion is needed.
The patient can take a shower on the same day with the help of the staff and is usually discharged from the hospital the day after the surgery.
It is recommended to avoid work for up to 7-10 days, possibly longer if the patient is not feeling well.
The protective patches are removed after 3-4 days, while the suture threads do not need to be removed.
If there is scanty bleeding or secretion from the incisions, it is recommended to wash it exclusively with saline solution.
In case of temperature, pain or conditions that deviate from normal, the patient contacts the Clinic or the Hospital.
The patient is informed about the result of the histopathological analysis 7-10 days after the surgery.
Check-up is usually 3-4 weeks after surgery.
The patient returns to her usual activities 7-10 days after the surgery.
She can start training 10-14 days and have sexual intercourse 3-4 weeks after the surgery.

Classical myoma surgery (laparotomy, mini laparotomy)

Laparotomy is a surgery where a classic open incision is made on the abdomen.

In the Gyn-Fertility Clinic Milenković, the first choice is a mini-laparotomy, that is, a low transverse incision on the abdomen, usually 4-6 cm, which can be expanded as needed.

In case of extremely large myomas, especially on the back wall, a longitudinal incision is made on the abdomen.

Classical surgery is performed for subserosal and intramural myomas, especially when there are multiple myomas or the size of one myoma exceeds 10 cm.

Before the surgery

Laparotomy

After laparotomy

The patient fills out a detailed questionnaire about her health condition and receives an antiseptic shampoo with which she will take a shower the night before admission and on the day of the surgery itself.
A blood count and blood type are done.
Before the surgery, a consultation is held with an anesthesiologist and an internal medicine specialist if there is an additional risk factor.
The patient signs the consent that she agrees to the surgery.
The intake of food and water is not allowed 8 hours before the surgery.

A catheter is inserted into the patient's bladder.
After preparing the operative field and obtaining general anesthesia, a low transverse incision is made 2-3 cm above the pubic bone in a length of about 4-6 cm, but it can be extended if necessary. If the patient has an incision from a previous surgery, the abdominal cavity is opened according to the old incision.
In the case of large myomas, a longitudinal incision is sometimes made from the pubic bone to the navel.
The myoma is separated from the surrounding healthy tissue.
After removal of myoma, with adequate control of bleeding, the wall of the uterus is sutured.
The entire uterus is carefully examined to identify small myomas.
Sometimes a drain is placed in the abdominal cavity, which is removed after 24 hours at the latest.
The abdominal wall is sutured in layers.
The skin is stitched with absorbable sutures and a protective patch is placed on the wound.

The preparation, that is, the tissue removed from the organism, is sent for histo-pathological examination

The patient returns to the patient room and receives medication for pain and nausea.
3-4 hours after the surgery, the patient starts to drink liquid, and then she gets light food.
The catheter from the urinary bladder is removed a few hours after the surgery and the catheter from the uterine cavity immediately after the surgery.
It is desirable that the patient gets out of bed with the help of the staff 2-3 hours after the surgery and can go to the toilet on her own.
Sometimes a blood transfusion is needed.
The patient can take a shower on the same day or the day after the surgery with the help of the staff and is usually discharged from the hospital a day or two after the surgery.
It is advised to avoid the work for up to 3-4 weeks, possibly longer if the patient is not feeling well.
The protective patches are removed after 5-6 days, while the absorbable sutures do not need to be removed.
If there is scanty bleeding or secretion from the incision, it is recommended to wash it exclusively with saline solution.
In case of temperature, pain or conditions that deviate from normal, the patient contacts the Clinic or the Hospital.
The patient is informed about the result of the histopathological analysis. Check-up is usually 3-4 weeks after surgery.

The patient returns to her usual activities 3-4 weeks after the surgery. She can start training and having sexual intercourse 3-4 weeks after the surgery, depending on how he subjectively feels.

Myoma surgery and pregnancy

Pregnancy, either spontaneous or insemination and in vitro fertilization (IVF) can be attempted two months after hysteroscopic surgery and three months after myoma surgery by laparoscopic and classical surgery.

Myomas can be operated on during pregnancy in exceptional cases when the symptoms are pronounced, as well as during a caesarean section if necessary.

A woman can give birth vaginally after myoma surgery, but in daily clinical practice, cesarean section is performed after classic and laparoscopic surgery.

Complications during and after myoma surgery

Complications after hysteroscopic myoma surgery are very rare.

Bleeding during and after laparoscopic and classical surgery occurs in 4-5% of cases, since myomas and the tissue around them are rich in blood vessels.

Sometimes a blood transfusion is needed after surgery.

Infection and leakage of the wound occurs in about 5% of cases.

Case presentation

Case 1

Case 2

Case 3

32-year-old female patient, primary infertility for 18 months. Regular and abundant menstruation. Normal sperm analysis.
Had hysteroscopic myoma surgery six months earlier.
On ultrasound examination, submucosal/intramural myoma 3 cm, mostly submucosal part.
Hysteroscopic myoma surgery was performed, a combination of resectoscopy and mechanical enucleation of the intramural part (cold loop myomectomy).

At the check-up examination after four weeks, there were no myomas. The patient conceived spontaneously five months after the surgery and gave birth vaginally at term.

A 30-year-old female patient with 15 intramural and subserous fibroids from two to eight centimeters.
Regular, heavy menstruation.
A mini-laparotomy was performed and all myomas were removed.
The surgery went smoothly and the patient was discharged home on the second day after the surgery.

At the check-up six months after the surgery, there were no myomas. Menstruation has returned to normal, but she is still not planning a pregnancy.

35-year-old female patient. One cesarean delivery.
The patient had a 10 cm subserous myoma during pregnancy. Three years after delivery, the myoma was 20 x 20 cm in size and the enlarged abdomen was clearly visible.
The patient became pregnant spontaneously and an early vital pregnancy was confirmed by ultrasound examination.
Considering the size of the myoma, it was estimated that the risk of pregnancy complications would be high.
Termination of pregnancy was performed and then myoma was removed by classic surgery where a low transverse incision was used after caesarean section with a length of 10 cm.
The patient received a postoperative blood transfusion and was discharged from the hospital on the fourth postoperative day.
3 months after surgery, patient achieved spontaneous pregnancy. Pregnancy was uneventful and she delivered healthy baby by cesarean section.

Expert advice: frequently asked questions

Answers by: Milan Milenković. MD, PhD

When can spontaneous pregnancy be attempted or insemination or IVF performed after myoma surgery?

Pregnancy, either spontaneous or insemination and in vitro fertilization (IVF) can be attempted two months after hysteroscopic surgery and three months after laparoscopic and conventional surgery.

When can I take a shower after myoma surgery?

You can shower immediately after hysteroscopic fibroid surgery, or a few hours or the next day after laparoscopic and classical surgery. In the Gyn-Fertility Clinic Milenković, patches are used, with which you can take a shower. It is not recommended to take a bath and swim while bleeding continues after hysteroscopy and one month after classical and laparoscopic surgery.

When can I train after fibroid surgery?

You can start training two or three days after hysteroscopic myoma surgery. You can start light training 3-4 weeks after classic and laparoscopic surgery. Contraception is recommended for two months after hysteroscopic surgery and for 3 months after classical and laparoscopic surgery.

When can I have sex after fibroid surgery?

Sexual intercourse after hysteroscopic surgery is not advised as long as the bleeding lasts and for 3-4 weeks after laparoscopic and classic surgery. Pregnancy, either spontaneous or insemination and IVF can be attempted 2 months after hysteroscopic surgery and 3 months after laparoscopic and classic fibroid surgery.

When is the first check-up after myoma surgery?

Check-up after myoma surgery is usually done 3-4 weeks after surgery.

In which acute situations should the Clinic be contacted?

In case of pain, high body temperature and heavy bleeding, you should call 069 50 22222, send a message to info@drmilenkovic.com or contact the nearest emergency department.

How long does the recovery take after fibroid surgery?

The patient can return to normal activities the next day after hysteroscopic myoma surgery, 10-14 days after laparoscopic surgery and 2-4 weeks after classical surgery.

When can I expect my first period after fibroid surgery?

The first period after fibroid surgery will come at the expected time. If the submucosal myoma has been operated on, it is expected that menstruation will be less abundant and painful.

What is a myomectomy and how is it different from other fibroid surgeries?

Myomectomy or myoma enucleation is the removal of fibroids located in the uterus while preserving healthy uterine tissue and reproductive function. Hysterectomy, that is, removal of the uterus, is a method used when a woman no longer wants to give birth, when it is not possible to perform a myomectomy, at the request of the patient and when there is some additional indication.

10.

Will there be pain after fibroid surgery?

After hysteroscopic surgery, pain similar as menstrual cramps occur most often, which can be alleviated with appropriate analgesics. The usual therapy includes the use of tablets based on paracetamol, in doses adapted to individual needs, up to several times a day. If necessary, they can be combined with non-steroidal anti-inflammatory drugs, which contribute to the reduction of pain and inflammation.

Pain after laparoscopic and classical surgery is most often localized in the front abdominal wall at the place where the incisions are made. Pain in the lower abdomen occurs in the first days after surgery. The same therapy as after hysteroscopic surgery is recommended, namely, taking medication regularly for six to eight hours during the first days.

11.

When is myomectomy performed by mini-laparotomy?

Mini-laparotomy is a minimally invasive approach to fibroid surgery. In this way, large fibroids can be removed through a small incision, which significantly speeds up recovery and reduces pain after surgery. Mini-laparotomy is the first choice in the Gyn-Fertility Clinic Milenković. The patient stays in the hospital for a day or two and the recovery is much faster than after a classic incision, and fibroids that cannot be removed laparoscopically can be operated on.

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