2. DEFINITION OF MYOMECTOMY:
• MYOMECTOMY refers to the removal of fibroids, leaving the uterus behind.
• It is indicated in infertile women or a women desirous of childbearing and wishing to retain
the uterus.
• It is done by open surgery, laparoscopically, vaginal or through hysteroscopic route.
3. Preoperative requisites:
• Hemoglobin should be restored.
• Auto transfusion arranged a few days before the surgery Is preferred Is preferred to donor transfusion
to Avoid transmission risk of HIV, Malaria And hepatitis B.
• In infertility, other causes of infertility should be excluded .
• Signature for hysterectomy is required in difficult unforeseen circumstances.
• Myomectomy should be performed in pre ovulatory menstrual cycle to reduce blood loss during surgery.
• Endometrial cancer to be ruled out by D&C.
• Bowel preparation avoids bowel injury .
4. INDICATIONS AND CONTRAINDICATIONS:
INDICATIONS :
Persistent Uterine bleeding despite the
medical management.
Excessive pain or pressure symptoms.
Size >2 weeks, women desirous to have a
baby.
Unexplained infertility.
Recurrent pregnancy wastage due to fibroid .
Rapidly growing myoma during follow up.
Subserous pedunculated fibroid
CONTRAINDICATIONS :
Infected fibroid
Growth of myoma after menopause
Parous women where hysterectomy is safer .
Function less fallopian tube .
Pelvic or endometrial tuberculosis.
During pregnancy or cesarean section.
5. TECHNIQUE :
Opening the abdominal cavity by Pfannenstiel incision. ( Uterus 16-20
weeks size and mobile).
Vertical paramedian incision ( large uterus, fixed uterus with adhesions
, associated PID, and endometriosis).
Care should be taken not to injure the bladder .
The pelvic organs should be carefully inspected .
Incision over the anterior uterine wall is preferred.
6. Hemorrhage should be controlled with Myomectomy clamp.
( Bonney’s Myomectomy clamp used ) From the pubic end of the abdominal
wound and the round ligaments which will include the uterine vessels should be
gripped . Ovarian vessels are occluded by sponge forceps.
Local injection of dilute vasopressin used – help to reduce blood loss .
The capsule should be incised and the fibroid is enucleated by Myomectomy
screw .
Haemostasis is attained and the cavity is closed by several catgut suture .
Clamp should be released and hemostatis confirmed. Hydroflotation also
reduce adhesions .
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32. RESULTS:
40-50% pregnancy rate has been reported.
10-15% continue to suffer from menorrhagia .
5-10% has recurrence of fibroids.
33. COMPLICATION:
Primary , reactionary and secondary hemorrhage.
Trauma to the bladder , ureter and bowel during surgery.
Infection.
Adhesions and intestinal obstruction.
Recurrence of fibroids.
Persistent of menorrhagia.
34. OTHER MYOMECTOMY :
Vaginal Myomectomy – Indicated in submucous fibroid polyp , cervical fibroids and pedunculated fibroid
polyp.
Hysteroscopic Myomectomy – Indicated in submucous fibroid but not removable easily by vaginal route .
Excised through cautery, laser , resectoscope . Best done under laparoscopy .
Laparoscopic Myomectomy – A pedunculated fibroid , subserous fibroid , Laparoscopic-assisted vaginal
hysterectomy (LAVH).
Disadvantages:
Bleeding occur more due to nonappilicability of hemostatic clamp.
Postoperative adhesions causes infertility rate high.
Scar rupture in late pregnancy and during labour .
36. Uterine artery embolization:
Aim : To reduce vascularity and the size of fibroid.
Procedure: Under local sedation , bilateral UAE is approached
through percutaneous femoral catheterization.
Done under polyvinyl alcohol, gel foam particles or metal coils .
Result : Embolization reduces vascularity and size of fibroid in 3 - 4
months.
Pregnancy should be postponed for at least 6 months.
Follow up with ultrasound 6 months later .
37. ADVANTAGES:
No major surgery.
No intraoperative bleeding .
Short hospital stay
Less abdominal adhesions.
Menorrhagia relived (80-90%).
Pressure symptoms relived (40-70%).
75-80% women are satisfied.
CONTRAINDICATIONS:
q Subserous and pedunculated fibroids.
q Submucous fibroid is not cured .
q Calcified fibroid cannot shrink.
38. MRI – GUIDED FOCUSED ULTRASOUND :
This is a non-invasive technique and uses high-intensity focused ultrasound beam that
heats and destroy tissues .
A large fibro myoma can be treated in 2 sessions .
Side effects: skin Burn, pain , nerve damage.
Advantages: Non-invasive technique, no hospitalization , no scar , quick recovery.
CONTRAINDICATIONS: Calcified fibroid, degenerated fibroid.
39. LAPROSCOPIC MYOLYSIS:
MYOLYSIS – a technique of destruction of myoma tissue by laser or
cautery.
Done using – Nd-YAG laser , cryoprobe to coagulate a subserous
fibroid .
Used in multiparous women.