Myomectomy is the surgical removal of uterine fibroids without the removal of the uterus. There are several techniques that may be used, and the choice of the technique depends on the location and size of the fibroids as well as the characteristics of the woman. It is sometimes impossible to remove all the fibroids, and new fibroids may grow after a myomectomy. Though myomectomy is the only accepted procedure for fibroids in a woman who wants to maintain fertility, a myomectomy may lead to scarring that can negatively affect future fertility. Following a myomectomy, cesarean delivery is frequently recommended to prevent the myomectomy scar from breaking open during labor. Types of myomectomies include:
Hysterectomy is a surgery to remove the uterus. It prevents future pregnancy and eliminates fibroid-related bleeding and pressure symptoms.
Other Surgical Procedures:
In this surgical procedure, a person is in the operating room, under general anesthesia (totally asleep). Through a small (half inch or less) incision in the belly button, carbon dioxide gas is placed inside the belly to create a space through which the surgeon can see the organs inside. This is done by putting a small “telescope” (laparoscope) through this small incision and into the bubble of gas.
The surgeon can then look around inside and get a very good view of everything there, especially all the reproductive organs, especially the womb, ovaries, and tubes. With good technique, this surgery can be done safely in women who are significantly overweight or have had prior abdominal or gynecologic surgery.
When the diagnostic part is done, and something has been found that requires surgery, additional small instruments (a quarter of an inch in diameter) are then inserted through one or more small incisions at other locations in the belly wall between the belly button and the groin areas.
Finding the cause for pain in the pelvic area can sometimes be difficult. This is especially true because all the conditions that can cause pain in some women, do not cause pain in all women. This is true for endometriosis, pelvic scar tissue, fibroids, and other problems. When laparoscopy is done with the patient totally asleep, it can sometimes be difficult to be sure that the diseased tissue seen (such as endometriosis) is really causing the pain. In some situations, pain mapping can help.
In a pain mapping procedure, a woman is brought to the operating room and given some strong medication that puts her asleep, but wears off quickly when it is stopped. After injecting local anesthetic medicine in the navel, the surgeon can put a small bubble of gas inside the belly, and then insert a very small (less than 1/8 of an inch) diameter laparoscope inside to look around. Another small instrument can then be inserted lower down on the belly and used to touch organs inside after the sleep medication is allowed to wear off. During this touching of internal organs, the surgeon can ask if a person’s pain is reproduced when an organ is touched. In most cases, for example, if the endometriosis seen is causing pain, it is tender when touched by the instrument.
Another example is when a person feels pain on the right side, but it’s hard to tell if the ovary or the appendix is responsible for the pain. Pain mapping can help figure this out, and help the surgeon pick the right procedure.
Our clinical experience tells us that better results are obtained when endometriosis is excised (cut out), rather than cauterized or lasered, whenever there is the slightest hint that the disease goes deeper than the most superficial layers of pelvic tissue. We have extensive experience with this technique, including in cases of very advanced (stage IV) disease. We perform about 200 surgeries per year on endometriosis.
Ovarians cysts up to 10 cm (3.5 inches) in diameter are routinely removed laparoscopically in our division. In some cases in which careful preoperative testing has shown that the risk of a cancer is very low, even much larger cysts have been removed laparoscopically. Once separated from the healthy ovary tissue, the cyst is put in a plastic bag which is removed through a small incision at the navel.
When careful evaluation has shown that adhesions may play a role in a person's abdominal or pelvic pain, we sometimes recommend laparoscopic surgery to try to reduce the amount of adhesions present. This type of procedure is most often helpful when adhesions are mild or moderate in degree.
When adhesions are very severe, long term results are often disappointing. We do find that even if relief is incomplete or temporary, the benefits of the surgery provide an opportunity to more effectively address other parts of the pain problem such as muscle disorders, bowel function problems, deconditioning, excess weight, and depression.
When an ovary is too involved with a disease process to salvage, it is almost always possible to remove it using laparoscopic techniques. In some cases, it is necessary to divide adhesions between the bowel and the ovary in order to remove the ovary.
Some fibroids can be removed laparoscopically. Laparoscopic surgical repair of incisions made in the uterus to remove the fibroids heal just as well as similar incisions performed through open laparotomy (large incision) surgery.
Laparoscopic myomectomy is a myomectomy performed with minimally-invasive techniques, using a narrow telescope-like instrument (laparoscope) to see inside the abdomen. The abdomen is first inflated with carbon dioxide gas to create space for operating. Four or five small (1/4 - 1/2 inch) incisions are made in the navel and lower abdomen to allow insertion of both the laparoscope and long, narrow instruments through tubes called “ports”. Using the laparoscope to see, the fibroid is shelled out of the uterus, and the uterine incision is repaired. Laparoscopic myomectomy usually requires one night of hospitalization. Recovery time is approximately 2-3 weeks.
Laparoscopic hysterectomy involves removing the entire uterus with minimally-invasive techniques, using a narrow telescope-like instrument (laparoscope) to see the inside of the abdomen. Under complete general anesthesia, the abdomen is first inflated with carbon dioxide gas to create space for operating. Four or five incisions (1/4 to ½ inch each) are made in the navel and lower abdomen to allow insertion of both the laparoscope and long, narrow instruments through tubes called “ports.” (When using the robot, the incisions are higher up, at the level of the belly button and higher up towards the head.) A normal sized uterus, once it is detached from its supports, can be removed through the vagina. A large uterus can be reduced to smaller pieces using a laparoscopic morcellator. With our long experience and high volume, we are comfortable removing a uterus as large as a 30 week pregnancy.
Once the uterus is removed, the inside edges of the vagina are brought together using suture, which is readily done laparoscopically. We credit our extensive laparoscopic experience over the years for this achievement.
In the last 10 years in the United States, more and more gynecologists have been offering their patients the option of leaving the cervix in place when performing a hysterectomy. The only medical reason for removing the cervix is to prevent cancer of the cervix. If a woman is at low risk for this problem, then the cervix may be left in place, as long as she agrees to continue having regular Pap smears performed.
Some physicians have suggested that leaving the cervix could help preserve sexual function or avoid problems with pelvic support (bladder dropping, bladder leakage). Several good studies, however, have demonstrated these hypotheses don’t seem to be the case. If there is not a good medical reason to remove the cervix, a woman certainly has the option of keep it if she wishes, but, without good evidence to suggest it makes a clinical difference, most women in our practice elect to have the cervix removed. If the cervix is not removed, there is a small chance (the published literature reports rates of 5-10%; our experience has been about 1%) of needing to remove the cervix because of persistent cyclic bleeding after supracervical hysterectomy. If a woman has a history of abnormal pap tests or endometriosis, it is generally not a good idea to leave the cervix.
In about 15-20% of women, the top end of the uterus leans back toward the backbone, instead of leaning forward, toward the bladder. This is called a retroverted, or "tipped" uterus. In some women, this position of the uterus can be associated with pain, especially pain during sexual intercourse. A laparoscopic uterine suspension can fix this problem with a very high degree of success (over 90%).
Many years ago, this variation of normal anatomy was thought to produce infertility, and several different surgical procedures were developed to correct the problem. Unfortunately, all the techniques involved shortening ligaments that were known to be weak in the first place. As one might expect, the repair frequently failed after 1-2 years, and the uterus returned to the "tipped" position. As a result of these failures, the procedure fell out of favor.
A technique developed in 1998 has proven to be more effective and long lasting than those previously used. It involves placing a long suture through the entire length of the ligaments that hold the uterus up, and tightening the suture until the desired position of the uterus is produced. The repair depends on the strength of the suture, not the strength of the ligaments. The suture stays in place, and does not dissolve, but we use a type of suture (Gore-Tex®) that the body tolerates very well. This suspension procedure can be performed as outpatient surgery, with a few days to a week of recovery needed before returning to normal activities.
When abnormalities such as polyps or small fibroids grow inside the uterus, irregular and heavy bleeding can result. In many cases, they can be removed by placing an instrument called a hysteroscope through the cervix to examine the inside of the uterus and then using various instruments to remove or vaporize the fibroid or polyp a little at a time. It takes between 30 and 90 minutes to accomplish, and usually the patient can go home the same day.
Many different surgeries have been developed to treat "stress incontinence," or loss of urine during coughing, laughing, or any other physical activity. This problem most typically develops after childbearing, and is aggravated by age, smoking, obesity, and other factors. The surgeries are done to improve support for the bladder itself and for the valve mechanism at the bladder neck.
In some circumstances, it make sense to repair the bladder supports laparoscopically, usually when other surgical tasks need to be accomplished as well, such as removal of the uterus and/or ovaries. When bladder repair is all that is needed, then open surgical procedures that usually require a small incision, are almost the same in terms of the discomforts of post-operative recovery.
There are now about 8 different approved methods for applying some form of energy to the lining of the uterus (the endometrium) in order to reduce the amount of menstrual flow for a person who has regular, but quite heavy, periods. If irregular bleeding is the more troublesome part of the problem, then endometrial ablation techniques are less satisfactory. All of the techniques can be performed as outpatient surgery, and a few can be done in a clinic setting.
At UNC, we predominantly use the NovaSure® endometrial ablation system. In long-term follow-up studies, about 90% of women having this procedure are happy with the results after three years. However, in one study that randomly assigned women to endometrial ablation vs hysterectomy, those having hysterectomy were more satisfied when evaluated four years later. The reason is that a certain number of women having an ablation procedure will end up having further surgery for the bleeding problem. There are also some concerns that we may not be able to assess endometrial (uterus) cancer risk accurately in women who have had an ablation, and some women develop new pelvic pain as a result of this procedure, particularly when a tubal ligation has also been performed.
When the cervix and the uterus are surgically removed by operating through the vagina, this is called a vaginal hysterectomy. This procedure has been a standard in gynecology for over 50 years. In the 1970's it was commonly performed as a sterilization procedure, hence many gynecologists trained during that time gained a great deal of experience in performing the procedure. As the rate of hysterectomy has declined, and as other methods have been developed, more recently trained gynecologists have had less experience performing this procedure.
When it is surgically possible to perform vaginal hysterectomy, then the laparoscopic approach has few advantages when the surgeon is equally skilled at both. There are some situations which increase the risk of vaginal hysterectomy, however: multiple prior Cesarean sections, other major abdominal surgery, past pelvic infections, endometriosis, obesity, small pelvic bony canal, etc. Hospital stay is usually 1 night and recovery time is approximately 2-3 weeks.
As with traditional laparoscopic myomectomy, 4-5 small incisions are made and instruments are placed in the lower abdomen through “ports”. The robotic system translates the surgeon’s hand movements outside the woman’s body into precise surgical movements inside the abdomen. Some feel these instrument capabilities are advantageous for laparoscopic myomectomy and we do sometimes use robotics in this setting. It is important to note, however, that while there is a difference between laparoscopy and laparotomy in terms of patient outcomes, both traditional and robotic laparoscopy offer similar benefits. The experience and skill of the surgeon is much more important than whether the robot is employed as a tool.
Aggressive marketing by the manufacturer of the robot, as well as by enthusiastic gynecologic surgeons who use it, has led in some cases to a general perception that surgery done using robotic assistance (compared to standard “straight sticks” laparoscopy) produced better results in less time and with greater safety. The literature of over 300 articles, published since the FDA approved the robot for use in gynecologic surgery in April of 2005, does not contain a single article that supports any of these claims. Although we sometimes use the robot, our position is that the experience and skill of the surgeon are far more important in producing good outcomes.
Abdominal myomectomy is performed using a horizontal (“bikini”) or vertical incision in the abdominal wall. This type of operation is called a laparotomy and allows the surgeon to have direct access to the uterus. Traditional surgical instruments and techniques are used. Most patients have general anesthesia (go to sleep), and are usually hospitalized for two nights. Full recovery is expected by 4-6 weeks. Mini-laparotomy (an incision about 2 inches long) is sometimes possible in thin patients without significant scarring. Mini-laparotomy involves a smaller horizontal incision with advantages of less pain, a shorter hospital stay, and faster recovery.
Hysteroscopic myomectomy is a different type of myomectomy which involves removing a submucosal fibroid from the inside wall of the uterus. To allow surgery inside the uterus, a narrow telescope-like instrument (hysteroscope) is passed through the cervix to visualize the uterine cavity. Hysteroscopic myomectomy is possible only for smaller fibroids (less than 5cm) and only if at least one half of the fibroid bulges into the uterine cavity. Often a laparoscopy is done during the hysteroscopy to make sure neither the fibroid nor the surgery extends through the uterine wall. This type of myomectomy is performed in the operating room under anesthesia and is usually an outpatient procedure. Most patients return to normal activities within 48 hours. Possible complications of hysteroscopy include: uterine perforation (puncture of the uterus), fluid overload (from absorption through the uterus), bleeding, and the formation of scarring inside the uterus. Attempts at pregnancy are best postponed for 60-90 days.
Abdominal hysterectomy is the removal of the uterus performed through a horizontal (“bikini”) or vertical incision in the abdominal wall, using traditional instruments and surgical techniques. Most patients have general anesthesia (go to sleep) and are hospitalized for 1-2 nights. Full recovery generally takes 4-6 weeks during which time heavy lifting must be avoided. Driving should be avoided for 1-2 weeks, and sexual intercourse should be avoided for 6 weeks.
Robot-assisted laparoscopic hysterectomy is the removal of the uterus using the Da Vinci® Surgical System (robot) to perform a laparoscopic hysterectomy. As with traditional laparoscopic hysterectomy, 4-5 small incisions are made and instruments are placed in the lower abdomen through “ports”. The robotic system translates the surgeon’s hand movements outside the woman’s body into surgical movements inside the abdomen. Hospital stay is usually overnight and recovery time is approximately 2-3 weeks.
Aggressive marketing by the manufacturer of the robot, as well as by enthusiastic gynecologic surgeons who use it, has led in some cases to a general perception that surgery done using robotic assistance (compared to standard “straight sticks” laparoscopy) produced better results in less time and with greater safety. The literature of over 300 articles, published since the FDA approved the robot for use in gynecologic surgery in April of 2005, does not contain a single article that supports any of these claims. Although we do use the robot in some cases, our position is that the experience and skill of the surgeon are far more important in producing good outcomes.