Myomectomy: 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: Hysterectomy is a surgery to remove the uterus. It prevents future pregnancy and eliminates fibroid-related bleeding and pressure symptoms.
There are two categories of hysterectomy: Other Surgical Procedures: Diagnostic laparoscopy – What is laparoscopy? 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. Back to top 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. Back to top 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. Back to top 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. Back to top 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. Back to top 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. We have extensive experience in performing this difficult level of laparoscopic surgery. In performing this type of procedure over the past 22 years, we have had only one case in which significant bowel injury took place. Back to top 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. The introduction of a new suture, the Quill™ suture, allows suturing using regular laparoscopic instruments. 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.
Robot-assisted laparoscopic myomectomy is a type of laparoscopic myomectomy performed using robotic surgery techniques and the Da Vinci® Surgical System. 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. This system provides more flexibility of hand movements than is possible with traditional laparoscopic surgery. Robot-assisted laparoscopy also provides a better camera view than traditional laparoscopy. These advantages allow laparoscopic removal of bigger fibroids than previously possible.
As in any surgery, complications from myomectomy, such as bleeding, infection, or injury to nearby organs, may occur. There is a 1-8% chance of having to convert from a laparoscopic myomectomy to an abdominal myomectomy. During myomectomy, rarely (in less than 1%) an unplanned hysterectomy may be required, for instance, if the uterus bleeds excessively. Recurrent fibroids may follow up to one third of myomectomies. Pregnancy is not recommended during the first 3-6 months after surgery. Back to top
Laparoscopic hysterectomy involves removing fibroids 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.) Using the laparoscope to see, the fibroids are shelled out of the uterus, and the uterine incision is repaired. Laparoscopic myomectomy usually requires one night of hospitalization, and recovery time is about 2-3 weeks. Most fibroids can be removed laparoscopically. The introduction of a new suture, the “Quill” suture, in January, 2009, allows suturing with regular laparoscopic instruments, similar to what is achieved with robotic assistance. Although we have also had extensive experience with doing these procedures using the assistance of the robot, more recently we have found success with the traditional laparoscopic approach. We credit our extensive laparoscopic experience over the years for this achievement. Back to top In the last 5 or 6 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 suggest that leaving the cervix in place may help prevent problems with pelvic support (bladder dropping, bladder leakage, etc.) in later years, while others suggest that the cervix contributes importantly to sexual satisfaction, and should therefore not be removed unless absolutely necessary. Unfortunately, we do not have good, reliable scientific information on either of these points. In fact, there are now three very good studies that show that leaving the cervix in place does not make any difference in sexual pleasure. Our feeling in general is that if there is not a good medical reason to remove the cervix, then a woman should have the option of keeping it if she wishes. We and others have noted that, despite the best of surgical technique, about 5% of women have some continued regular cyclic bleeding (a "mini-period") after hysterectomy if the cervix is not removed. In the course of performing this procedure since 1998, we have had to return to remove the cervix for bleeding in about 1% of case. Back to top 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 about 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 us, 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. Back to top 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. Back to top 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. Back to top 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, predominantly use the NovaSure® endometrial ablation system. In long-term followup 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 years later for the bleeding problem. Back to top 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 stand-by 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. In most circumstances, if a woman has not delivered a full-term baby vaginally, the hysterectomy is more easily accomplished by the laparoscopic route. Vaginal hysterectomy is the removal of the uterus performed through an incision in the vagina. Special surgical techniques are used to separate the uterus from its attachment to surrounding structures, such as the bladder, ovaries, blood supply and ligaments. Women who have had at least one vaginal delivery are better candidates for vaginal hysterectomy. Hospital stay is usually 1-2 nights and recovery time is approximately 2-3 weeks. The presence of any of the following may prevent a vaginal hysterectomy: obesity, a large uterus, and pelvic scarring, (such as from previous surgery, cesarean delivery, or endometriosis). Following any hysterectomy, intercourse should be avoided for 6 weeks. Compared to abdominal hysterectomy, vaginal hysterectomy has a shorter hospital stay and recovery time, and may be associated with less pain following surgery. Back to top
Robot-assisted laparoscopic myomectomy is performed using robotic surgery techniques and the DaVinci Surgical System. 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 surgical movements inside the abdomen. For the myomectomy procedure, the major advantage the robot offers is to make suturing easier for some surgeons. However, as mentioned, the new “Quill” suture readily allows excellent suturing to be done quickly using routine laparoscopic techniques, without the robot. (link to paragraph on robotic surgery in general) Just how useful is the surgical robot for gynecologic surgery? In recent years, the Da Vinci surgical robot has gotten a great deal of attention as an advance in laparoscopic surgery. Using this device, laparoscopic instruments are attached to 3 or 4 arms of the robot. The instruments are controlled by a surgeon sitting at a console placed 8-10 feet away from the operating table.Some surgeons find that the robot helps greatly with their surgeries, while others feel comfortable doing most, if not all, their laparoscopic gyn surgeries without the robot. The advantages of the robot include 3D vision and a steadying effect on the surgeon’s hands. Many experienced surgeons feel that the 3D vision is not necessary. In the area of benign (non-cancer) gynecology, traditional laparoscopic techniques, in experienced hands, can be used with equal success to complete most surgeries. At present, it appears that recovery times and comfort after benign gynecologic surgery done laparoscopically are the same, whether or not the robot is used. Further studies are needed to better define the appropriate niche for robotic surgery in gynecology. Back to top 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 by weeks. Mini-laparotomy 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. Back to top 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. Back to top 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. Back to top 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 precise surgical movements inside the abdomen. This system provides more flexibility of hand movements than is possible with traditional laparoscopic surgery. Hospital stay is usually overnight and recovery time is approximately 2-3 weeks. Back to top | 
