What are the possible intra‑ and postoperative complications after myomectomy in a 39‑year‑old woman with no comorbidities and normal pre‑operative labs?

Complications of Myomectomy in a 39-Year-Old Woman with No Comorbidities

Myomectomy carries a moderate risk of complications, with intraoperative hemorrhage requiring transfusion (occurring in approximately 20% of cases) being the most significant concern, followed by postoperative adhesion formation, febrile morbidity, and rare but serious complications including organ injury and conversion to hysterectomy. 1, 2

Intraoperative Complications

Hemorrhage and Blood Loss

• Significant intraoperative blood loss is the most common complication due to the uterus's rich vascular supply, with mean blood loss ranging from 342 mL in abdominal myomectomy 2
• Approximately 20% of patients require blood transfusion (70% receiving autologous blood only), though this rate can be reduced with proper hemostatic techniques 2
• Conversion to hysterectomy occurs in approximately 1% of cases due to uncontrollable bleeding 2
• Posterior uterine fibroid location significantly increases the risk of major intraoperative hemorrhage and requires careful pre-operative evaluation 1
• Uterine size equivalent to ≥16 weeks' gestation markedly increases transfusion risk 1, 3

Direct Organ Injury

• Uterine perforation can occur, particularly during hysteroscopic myomectomy 1
• Bowel and bladder injury are possible, especially when incisions are not confined to the anterior uterine surface 4
• Rectal injury occurs in approximately 0.9% of vaginal myomectomy cases 5

Conversion to More Extensive Surgery

• Conversion from laparoscopic to open myomectomy occurs in 0.8-15.7% of cases, depending on surgical approach and fibroid characteristics 6, 5
• Larger fibroid weight (mean 270g vs 181g) significantly increases conversion risk 5

Postoperative Complications

Adhesion Formation

• Postoperative adhesions represent a major risk, occurring at incision sites and as de novo adhesions from peritoneal trauma 4
• These adhesions can result in reduced subsequent fertility or bowel obstruction 4
• Open abdominal myomectomy carries a higher incidence of adhesion formation compared to laparoscopic approaches 3, 7
• Laparoscopic surgery does not reduce adhesions at the operative site but does decrease de novo adhesion formation elsewhere in the pelvis 4

Infectious Complications

• Febrile morbidity occurs in approximately 12-15% of abdominal myomectomy patients 2, 8
• Wound infection occurs in approximately 3% of cases, with higher rates in open versus laparoscopic approaches 3, 6
• Pelvic abscess formation occurs in 4.7% of vaginal myomectomy cases 5
• Endomyometritis is a recognized complication of hysteroscopic myomectomy 1

Hematologic Complications

• Mean hemoglobin decrease ranges from 1.38-1.7 g/dL postoperatively 6, 8
• Postoperative hemorrhage requiring transfusion occurs in approximately 3% of cases 8
• Pelvic hematoma can develop, detected in 3.4% of patients on 30-day ultrasound follow-up 8

Thromboembolic Events

• Deep venous thrombosis occurs in approximately 2% of abdominal myomectomy cases 2

Gastrointestinal Complications

• Paralytic ileus occurs in approximately 2% of cases 2

Fluid and Electrolyte Disturbances

• Fluid overload is a specific risk during hysteroscopic myomectomy 1

Approach-Specific Complication Profiles

Hysteroscopic Myomectomy

• Shortest hospital stay and fastest recovery but carries risks of uterine perforation, fluid overload, and need for re-intervention 1

Laparoscopic Myomectomy

• Overall complication rate of 7.7%, with significantly lower hemoglobin drop (WMD = -0.48), less postoperative fever (RR = 0.43), and reduced pain at 48 hours compared to open surgery 7, 6
• Intraoperative complications occur in 3.34% of cases 8
• Mean operation time of 100-113 minutes with hospital stay of 2.2-2.9 days 6, 8

Open Abdominal Myomectomy

• Higher rates of wound infection, longer recovery time, and increased adhesion formation compared to minimally invasive approaches 1, 3
• Average estimated blood loss of 342 mL, with 4% experiencing blood loss >1000 mL 2

Long-Term Complications

Pregnancy-Related Risks

• Both laparoscopic and open myomectomy carry a measurable risk of uterine rupture in subsequent pregnancies 1, 3
• Patients should wait 2-3 months before attempting conception to allow adequate uterine healing 1, 9, 3

Fibroid Recurrence

• Approximately 50% of patients experience fibroid recurrence following surgical removal 1

Critical Pitfalls to Avoid

• Performing myomectomy during operative delivery is especially hazardous due to heightened uterine vascularity in pregnancy 4
• When vasopressin is used intramyometrially, surgeons must verify that postoperative myometrial incisional bleeding does not occur after the vasopressin effect dissipates 4
• Posterior uterine incisions should be avoided when possible due to higher risk of severe bleeding 1
• Pre-operative anemia correction and autologous blood storage should be implemented for high-risk patients 1, 3