How is a myomectomy performed and what is the postoperative recovery?

How Myomectomy is Performed and Postoperative Recovery

Myomectomy is performed through three distinct surgical approaches—hysteroscopic, laparoscopic, or open abdominal—with technique selection determined by fibroid location, size, and number; recovery is fastest after hysteroscopic resection (1–2 weeks to usual activities), intermediate after laparoscopy (2–3 weeks), and longest after open surgery (3–4 weeks), though all approaches achieve equivalent quality-of-life improvements by 2–3 months postoperatively. 1, 2

Surgical Techniques by Fibroid Location

Hysteroscopic Myomectomy

• Indicated specifically for submucosal fibroids (those projecting into the uterine cavity), particularly pedunculated lesions ≤5 cm in diameter 1, 2, 3
• Technique: The surgeon inserts a hysteroscope through the cervix and uses an electrosurgical wire loop or other instruments to resect the fibroid under direct visualization 1
• No abdominal incisions are required, making this the least invasive approach 3
• Recovery advantage: Shortest hospitalization and fastest return to usual activities compared to all other approaches 1, 2
• Complications include: uterine perforation, fluid overload, need for blood transfusion, bowel or bladder injury, endomyometritis, and potential need for repeat intervention 1, 3
• Important limitation: Patients with substantial intramural or subserosal fibroid burden or coexisting adenomyosis are unlikely to achieve symptom relief from hysteroscopic myomectomy alone 1, 3

Laparoscopic Myomectomy

• Indicated for subserosal or intramural fibroids when the overall fibroid burden is limited 1, 2
• Technique: Multiple small abdominal incisions (typically 5–10 mm) allow insertion of a laparoscope and surgical instruments to enucleate fibroids from the uterine wall 2
• The myometrium is then sutured closed laparoscopically, which is technically demanding and requires advanced surgical skill 2
• Robotic-assisted laparoscopy is increasingly utilized with similar outcomes to traditional laparoscopy in terms of operative time, hospital stay, and complications 1
• Recovery advantage: Shorter hospital stays, faster return to daily activities, and lower wound infection rates compared to open surgery 1, 2
• Does not reduce adhesions at the operative site but does decrease new adhesion formation elsewhere in the pelvis 2

Open (Abdominal) Myomectomy

• Preferred for multiple fibroids or very large uteri where minimally invasive techniques are not feasible 1, 2
• Technique: A horizontal or vertical abdominal incision (typically Pfannenstiel or midline) provides direct access to the uterus 2
• Fibroids are enucleated through uterine incisions, which are then closed in multiple layers 2
• Incisions should be confined to the anterior uterine surface to avoid injury to bowel and adnexal structures; posterior incisions carry higher risk of severe bleeding 2
• Recovery disadvantage: Higher incidence of postoperative adhesions, longer recovery time, and increased wound infection rates 2
• Long-term benefit: Provides durable quality-of-life improvement maintained for up to 10 years 1, 2

Intraoperative Hemostatic Techniques

• Intramyometrial vasopressin injection is recommended to diminish hemorrhage during fibroid enucleation, though surgeons must verify that bleeding does not recur after the vasopressin effect dissipates 2
• Tourniquet application to vascular pedicles effectively reduces intraoperative blood loss 2
• Blood-scavenging systems can decrease net surgical blood loss 2
• Significant intraoperative hemorrhage is common due to the uterus's rich vascular supply, particularly with posterior fibroid locations 2

Postoperative Recovery Timeline

Hysteroscopic Approach

• Hospital stay: Typically same-day discharge or overnight observation 1
• Return to usual activities: 1–2 weeks for most patients 2
• Physical therapy clearance: May begin gentle activity within 1–2 weeks if patient is pain-free, afebrile, and has no bleeding 2
• Formal physical therapy often unnecessary as patients return to baseline function rapidly 2

Laparoscopic Approach

• Hospital stay: 1–2 days on average 1, 2
• Return to usual activities: 2–3 weeks 2
• Recovery is faster than open surgery with less postoperative pain and reduced febrile morbidity 4

Open Abdominal Approach

• Hospital stay: 2–4 days typically 2
• Return to usual activities: 3–4 weeks or longer 2
• Higher complication rates including increased adhesion formation and wound infections 2

Quality-of-Life Outcomes Across All Approaches

• Symptom improvement and quality-of-life scores become equivalent across all surgical techniques by 2–3 months postoperatively 1, 2, 3
• Quality-of-life improvements persist for up to 10 years regardless of surgical approach used 1, 2
• In a randomized trial comparing myomectomy to uterine artery embolization, myomectomy showed superior quality-of-life scores at 2 years, though this difference was no longer significant at 4 years 1

Critical Postoperative Considerations

Pregnancy Timing

• Patients should wait 2–3 months after myomectomy before attempting conception to allow adequate uterine incision healing and lower the risk of uterine rupture in subsequent pregnancy 2
• Both laparoscopic and open myomectomy carry measurable risk of uterine rupture in later pregnancies 1, 2
• Pregnancy is possible after all myomectomy approaches, and patients should receive appropriate contraceptive counseling regardless of their stated fertility desires 1, 2

Fertility Outcomes

• Large prospective registries show no significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy 1, 2, 3
• Among women attempting conception after myomectomy, fewer than 50% achieve pregnancy within 3 years, and fewer than half of those pregnancies result in live birth 1, 2
• High-quality evidence demonstrating increased live-birth rates is lacking, with retrospective data suggesting pregnancy rates of 85% and live birth rates of 65% after hysteroscopic myomectomy 1, 3

Preoperative Optimization

• Correcting preoperative anemia reduces the likelihood of perioperative blood transfusion 2
• Autologous blood storage should be considered for patients identified as high-risk for bleeding 2
• Women with uterine size equivalent to ≥16 weeks' gestation have markedly higher risk of intraoperative transfusion and require enhanced preparation 2

Common Pitfalls to Avoid

• Never perform myomectomy during operative delivery as it is especially hazardous due to heightened uterine vascularity in pregnancy 2
• Do not recommend hysterectomy as initial treatment for patients who wish to preserve fertility 2, 3
• Endometrial ablation should never be performed in women desiring future fertility, as it markedly increases pregnancy complication risk 2
• Do not assume myomectomy will automatically improve fertility—clinicians must counsel patients that high-quality evidence for improved live-birth rates is lacking 2, 3
• Approximately 50% of patients experience fibroid recurrence following surgical removal 2