Myomectomy procedures

✂️ Clinical - Fertility-Sparing Fibroid Fix

• Goal: Excise leiomyomas, preserving the uterus for future fertility.

• Indications: Symptomatic fibroids (abnormal uterine bleeding, bulk symptoms, recurrent pregnancy loss) in women desiring pregnancy.

• Pre-op: GnRH agonists (e.g., leuprolide) can ↓ fibroid size and correct anemia.

• Surgical Approach Decision:

• Key Risks: Hemorrhage, adhesions.

  ⭐ Counsel on ↑ risk of uterine rupture during future labor. Cesarean delivery is strongly recommended if the uterine cavity was entered.

🗺️ Anatomy - Location, Location, Location!

A fibroid's (leiomyoma) location is the key determinant for choosing the surgical approach. The FIGO classification system provides a detailed map.

• Submucosal (FIGO 0-2): Protrude into the uterine cavity. Ideal for hysteroscopic resection.
• Intramural (FIGO 3-5): Contained within the myometrium. Often require laparoscopy or laparotomy.
• Subserosal (FIGO 6-7): Protrude from the external uterine surface. Amenable to laparoscopy or laparotomy.

⭐ Submucosal fibroids are most implicated in heavy menstrual bleeding (menorrhagia) and impaired fertility (infertility, recurrent pregnancy loss) due to endometrial cavity distortion.

🔪 Surgical Strategy Selection

• Primary Goal: Symptom relief (e.g., bleeding, bulk symptoms) while preserving the uterus for patients desiring future fertility.
• The surgical approach is tailored based on fibroid size, number, and location (FIGO classification).

• Hysteroscopic: Ideal for intracavitary lesions causing abnormal uterine bleeding. Outpatient, low morbidity.
• Laparoscopic/Robotic: Minimally invasive for subserosal/intramural types. Requires skilled suturing for multi-layer closure to ensure uterine integrity.
• Abdominal (Laparotomy): Gold standard for very large (>10 cm), numerous, or difficult-to-access fibroids. Allows for optimal uterine reconstruction but has higher morbidity (blood loss, adhesions, longer recovery).

⭐ High-Yield: Any myomectomy that breaches the uterine cavity or requires deep myometrial incision (laparoscopic or abdominal) increases the risk of uterine rupture in subsequent pregnancies. This often necessitates a planned Cesarean delivery.

⚠️ Complications - Post-Op Perils

• Intra-op & Early Post-op:

  • Hemorrhage: Most common. Requires meticulous hemostasis (e.g., vasopressin, tourniquets).
  • Organ Injury: Bladder, ureter, bowel.
  • Hysteroscopy-Specific: Fluid overload (hyponatremia), uterine perforation, gas embolism.

• Delayed & Long-term:

  • Adhesion Formation: Can cause chronic pain, infertility, small bowel obstruction. Risk varies by surgical approach.
  • Infection: Endometritis, pelvic cellulitis, abscess.
  • Uterine Rupture in Future Pregnancy: Critical risk, especially with deep intramural incisions.

  ⭐ Counsel patients on planned Cesarean delivery for subsequent pregnancies, typically at 36-37 weeks, to avoid labor and potential rupture.

  • Undiagnosed Sarcoma: Risk of morcellating an occult leiomyosarcoma (~1 in 350).

⚡ Biggest Takeaways

• Myomectomy is the uterus-sparing surgery for symptomatic fibroids in women desiring fertility preservation.
• Procedure choice depends on fibroid location: hysteroscopic (submucosal), laparoscopic (intramural/subserosal), or abdominal (large/multiple).
• The most feared long-term complication is uterine rupture during a future pregnancy.
• Patients require counseling on the high likelihood of needing a cesarean section for future deliveries.
• Major risks include intraoperative hemorrhage and postoperative fibroid recurrence.