Is an abdominal myomectomy considered high-risk surgery?

Abdominal Myomectomy: Risk Assessment

Abdominal myomectomy is considered a moderate-risk surgical procedure with significant potential for complications, particularly intraoperative hemorrhage requiring blood transfusion, but it is not classified as high-risk surgery when performed by experienced surgeons. 1

Complication Rates and Risk Profile

• Major complications occur in approximately 43.6% of abdominal myomectomy procedures, with minor complications in 32.9% 2
• The most common significant complication is intraoperative hemorrhage requiring blood transfusion, with mean estimated blood loss of 630.88 ± 392.42 mL 2
• Blood transfusion rates range from 20% in some studies to lower rates when autologous blood donation is utilized 3, 2
• Febrile morbidity occurs in approximately 12% of patients 3
• Serious postoperative complications such as paralytic ileus, wound infection, and deep venous thrombosis occur in about 2% of cases 3

Risk Factors for Complications

• Uterine size equivalent to 16 weeks' gestation or larger significantly increases risk of:
  • Heavier blood loss
  • Need for blood transfusion
  • Postoperative fever 2
• Other significant risk factors for major intraoperative hemorrhage include:
  • Menstrual flow of 6 days or more
  • Preoperative anemia
  • Previous abdominal surgery
  • Posterior uterine incision
  • Surgery duration longer than 4 hours 2
• Risk of unplanned conversion to hysterectomy during myomectomy is approximately 3.0%, with higher rates (7.1%) during laparoscopic approaches 4

Comparison to Other Surgical Approaches

• Open abdominal myomectomy is associated with:
  • Longer hospital stays compared to laparoscopic approaches
  • Longer recovery time compared to minimally invasive techniques
  • Greater risk of adhesion formation 1, 5
• Laparoscopic myomectomy offers:
  • Shorter hospital stays
  • Faster return to usual activities
  • Lower rates of wound infection compared to abdominal approach 1, 5
• Hysteroscopic myomectomy (for submucosal fibroids) has:
  • Shorter hospitalization
  • Faster recovery than abdominal approaches
  • Equivalent improvement in symptom scores at 2-3 months 1

Hemostatic Techniques to Reduce Risk

• Various hemostatic techniques have been developed to minimize blood loss during myomectomy:
  • Application of tourniquets on vascular pedicles
  • Myometrial injection of vasospastic agents such as vasopressin
  • Intraoperative blood scavenger systems 1, 6
• Preoperative measures to reduce risk include:
  • Correction of anemia
  • Storage of autologous blood
  • Careful surgical planning 1, 3

Long-term Outcomes

• Both laparoscopic and open myomectomy are associated with improved quality of life for up to 10 years 1
• Pregnancy is possible after myomectomy, though patients should wait 2-3 months before attempting pregnancy to allow uterine incisions to heal 1
• Case reports have associated laparoscopic and open myomectomy with rare instances of uterine rupture during subsequent pregnancy 1

Conclusion

While abdominal myomectomy carries significant risks, particularly of hemorrhage requiring transfusion, it has an acceptably low rate of severe complications and mortality when performed by experienced surgeons. The procedure should be considered moderate-risk rather than high-risk surgery, with appropriate preoperative planning and intraoperative techniques to minimize complications 1, 3, 2.