What are the steps of a myomectomy procedure for a patient with uterine fibroids?

Steps of Myomectomy Procedure

Myomectomy involves surgical removal of uterine fibroids through incision, enucleation, hemostasis, and multilayer closure, with the specific approach (hysteroscopic, laparoscopic, or open) determined by fibroid location, size, and number. 1

Preoperative Preparation

• Correct anemia with iron supplementation while initiating medical therapy to control bleeding and reduce fibroid size before surgery 2
• Consider 2-3 months of preoperative medical therapy with GnRH agonists/antagonists or ulipristal acetate to shrink fibroids and facilitate minimally invasive approaches 3, 2
• Image the uterine cavity preoperatively using ultrasound or MRI to characterize fibroid location, size, and number, as medical therapy can induce fibroid migration 3, 2

Surgical Approach Selection

Hysteroscopic Myomectomy (for Submucosal Fibroids)

• Transvaginal, transcervical placement of hysteroscope with removal of submucosal fibroids using electrosurgical wire loop or other instruments 3
• Associated with shorter hospitalization and faster return to activities compared to laparoscopic or open approaches 3
• Retrospective data show pregnancy rates of 85% with live birth rates of 65% 3

Laparoscopic Myomectomy (for Intramural/Subserosal Fibroids)

• For large uteri, use Lee-Huang point (midpoint between umbilicus and xiphoid) as primary insertion and camera port to navigate when uterus obscures umbilical port 1
• Three critical technical components:
  • Incision technique to access the fibroid 1
  • Enucleation of the fibroid capsule 1
  • Hemostatic techniques and multilayer suturing 1
• Specimen removal: Place large myoma inside Endo bag, bring edges extracorporeally through port site, and incise in C-manner using scalpel to reduce size (power morcellation abandoned due to safety concerns) 1

Open Myomectomy (for Very Large or Multiple Fibroids)

• Preferred for 20-week size uteri or multiple fibroids, offering better surgical access 4
• Combined miscarriage rate of 14% comparable to general population 4

Intraoperative Steps (All Approaches)

• Incision: Make uterine incision to access fibroid while minimizing entry into uterine cavity when possible 3
• Enucleation: Dissect and remove fibroid from surrounding myometrium 1
• Hemostasis: Apply hemostatic techniques to control bleeding from fibroid bed 1
• Closure: Perform multilayer suturing to restore uterine integrity and minimize adhesion formation 1

Key Technical Considerations

• Cavity entry increases obstetric rupture risk: Entering the uterine cavity during myomectomy may increase risk of uterine rupture in subsequent pregnancy, though data are conflicting 3
• Adhesion prevention: Randomized trials demonstrate that adhesion prevention adjuvants reduce adhesion formation following myomectomy 3
• Blood loss prevention: Critical for all approaches, particularly with large or multiple fibroids 1

Postoperative Outcomes by Approach

• Laparoscopic myomectomy results in:
  • Less postoperative pain at 6 hours (2.4 points lower on 0-10 VAS scale) and 48 hours (1.9 points lower) 5
  • 50% lower risk of postoperative fever compared to open surgery 5
  • Shorter hospital stay 5
  • Similar recurrence rates to open myomectomy 5

Common Pitfalls to Avoid

• Do not perform myomectomy during pregnancy - all surgical approaches are contraindicated in pregnant women with fibroids 6
• Avoid power morcellation without containment due to risk of spreading occult malignancy 1
• Do not skip preoperative cavity imaging as medical therapy can alter fibroid position and cavity distortion 3
• Recognize that 27% cumulative 10-year recurrence rate exists, increasing with length of follow-up and number of initial fibroids 3