Can Large Fibroid Removal Cause Hernia?
Large fibroid removal through open abdominal myomectomy can theoretically increase hernia risk due to the abdominal wall incision, but this is not a commonly reported complication in the fibroid surgery literature, and current guidelines do not list incisional hernia as a standard risk of myomectomy.
Understanding the Surgical Approaches and Their Hernia Risk
The risk of hernia development depends entirely on the surgical approach used for fibroid removal:
Laparoscopic and Hysteroscopic Approaches (Minimal Hernia Risk)
- Laparoscopic myomectomy uses small port-site incisions (typically 5-12mm) and is associated with shorter hospital stays and faster return to usual activities compared to open surgery 1.
- Hysteroscopic myomectomy is performed transvaginally through the cervix with no abdominal incisions, eliminating any abdominal wall hernia risk 1.
- Port-site hernias after laparoscopy are rare and typically occur only at trocar sites ≥10mm, representing a minimal risk 1.
Open Abdominal Myomectomy (Theoretical Hernia Risk)
- Open myomectomy requires a laparotomy incision and is preferred for multiple fibroids or very large uteri 1.
- While the guidelines extensively document risks including uterine perforation, bleeding requiring transfusion, and bowel or bladder injury 1, 2, incisional hernia is notably absent from the listed complications of myomectomy in current ACR guidelines 1.
- This contrasts sharply with abdominal wall hernia literature, where hernias are well-documented complications of other abdominal surgeries 1.
Clinical Evidence Linking Fibroids to Hernias
The relationship between fibroids and hernias appears to be incidental rather than causative:
- Case reports document fibroids herniating through pre-existing hernias rather than fibroid surgery causing hernias 3, 4, 5.
- One case described a Foramen of Winslow hernia secondary to large uterine fibroids due to increased intra-abdominal pressure, which resolved after laparoscopic treatment 3.
- A Spigelian hernia containing part of a fibroid uterus was reported, but the fibroid herniated into an existing defect 4.
- An incarcerated uterine fibroid in an epigastric hernia during pregnancy was documented, again representing herniation through a pre-existing defect 5.
Risk Factors for Incisional Hernia (If Open Surgery Required)
While not specific to myomectomy, general risk factors for incisional hernia after abdominal surgery include:
- Body mass index >30 kg/m² is associated with higher hernia recurrence rates 6.
- Hernia defect size >2 cm increases recurrence risk 6.
- History of abdominal wound infections significantly increases hernia risk (OR 3.4) 7.
- Diabetes mellitus is associated with surgical complications and poor wound healing 7.
Practical Clinical Recommendations
To minimize any theoretical hernia risk when fibroid removal is necessary:
- Prioritize minimally invasive approaches (laparoscopic or hysteroscopic) whenever technically feasible, as these have documented lower morbidity and essentially eliminate incisional hernia risk 1.
- Reserve open myomectomy only for cases with multiple fibroids or very large uteri where laparoscopy is not feasible 1.
- Optimize modifiable risk factors before elective surgery, including glycemic control in diabetics and weight management in obese patients 6, 7.
- Use proper surgical technique with adequate fascial closure if open surgery is performed 1.
Important Caveats
- The absence of incisional hernia in guideline-listed complications suggests it is either extremely rare or not systematically tracked in fibroid surgery outcomes 1.
- Abdominal hysterectomy (not myomectomy) carries documented risks of longer hospital stay, greater pain, and higher infection risk, which could theoretically increase hernia risk, though this is not explicitly stated 1.
- Patients should be counseled about the documented complications of myomectomy (perforation, bleeding, organ injury) rather than focusing on the theoretical but undocumented risk of hernia 1, 2.