👉Definition 👉 Preoperative requisite 👉Indication and contraindications 👉 Technique 👉Result 👉Complication 👉Other methods 👉Newer minimal invasive operation

1. MYOMECTOMY AND OTHER
CONSERVATIVE SURGERY
BY
PRIYANKA SALUNKHE M
FINAL YEAR MBBS

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 .

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 .

35. NEWER MINIMAL INVASIVE PROCEDURES:
 Uterine artery embolization.
 MRI- guided laser ablation.
 Laparoscopic Myolysis.

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.

40. Thank you