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Myomectomy

A myomectomy is a procedure for removing uterine fibroids while leaving the uterus intact. The procedure can be completed abdominally, laparoscopically or hysteroscopically. Using a power morcellator is one option, but there are associated risks.

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Female Reproductive System

Myomectomy is a surgical procedure that is performed when uterine fibroids need to be removed. Unlike hysterectomy, which removes the entire uterus, the goal during myomectomy is to take out the symptom-causing fibroids and reconstruct the uterus, leaving the uterus intact.

Removing the fibroids usually reduces or eliminates symptoms, including heavy bleeding and pressure in the pelvis. According to data from the National Uterine Fibroids Foundation, fewer than approximately 40,000 myomectomies are performed in the United States each year.

Symptoms of Fibroid Problems

When symptoms become problematic such that they interfere with a woman’s lifestyle, a myomectomy may be recommended for fibroids causing these symptoms. If surgical removal of the fibroids is necessary, a myomectomy instead of hysterectomy may be chosen for the following reasons:

  • A woman plans to get pregnant
  • Fertility might be affected by fibroids
  • A woman does not want to lose her uterus

A power morcellator is sometimes used during minimally invasive myomectomy.

Abdominal Myomectomy

In abdominal myomectomy (laparotomy), the surgeon makes an open abdominal incision to access the uterus and remove fibroids. One of two incisions is made into the pelvic cavity:

  • A horizontal bikini-line incision that runs about an inch (about 2.5 cm) above the pubic bone. This incision follows natural skin lines, so it usually results in a thinner scar and causes less pain than a vertical incision does. It may be only 3 to 4 inches (8 to 10 cm), but may be much longer. Because it limits the surgeon’s access to your pelvic cavity, a bikini-line incision may not be appropriate if you have a large fibroid.
  • A vertical incision that starts in the middle of the abdomen and extends from just below the navel to just above the pubic bone. This gives the surgeon greater access to the uterus than a horizontal incision does and reduces bleeding. It’s rarely used, unless the uterus is so large that it extends up past the navel.

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Laparoscopic or Robotic Myomectomy

In laparoscopic or robotic myomectomy, minimally invasive procedures, the surgeon accesses and removes fibroids through several small abdominal incisions.

During laparoscopic myomectomy, a small incision is made in or near the belly button. Then the doctor inserts a laparoscope — a narrow tube fitted with a camera — into the abdomen. The surgeon performs the procedure with instruments inserted through other small incisions in the abdominal wall. During robotic myomectomy, instruments are inserted through similar small incisions, and the surgeon controls movement of instruments from a separate console.

The fibroid is cut into smaller pieces and removed through these small incisions in the abdominal wall or, rarely, through an incision in the vagina (colpotomy).

Laparoscopic and robotic surgery use smaller incisions than a laparotomy does. This can cause less pain and blood loss so the patient can return to normal activities more quickly and easily than with a laparotomy. Uterine size and fibroid number and location are factors in determining when laparoscopic surgery is appropriate.

In certain cases, a surgeon might also use a laparoscope inserted through a small incision in the abdomen so that the pelvic organs may be viewed and monitored outside of the uterus during a complicated hysteroscopic myomectomy.

Hysteroscopic Myomectomy

To treat fibroids that bulge significantly into your uterine cavity (submucosal fibroids), the surgeon may opt to perform a hysteroscopic myomectomy. The fibroids are accessed and removed by inserting the instruments through the vagina and cervix into the uterus.

A small, lighted instrument called a resectoscope is inserted. The resectoscope cuts (resects) fibroid tissue using electricity or a laser beam. A clear liquid, usually a sterile salt solution, is injected into the uterine cavity to expand it and allow for easier examination of the uterine walls. Fibroid pieces are then shaved off with the resectoscope until the fibroid aligns with the inner surface of the uterus. The removed tissue fragments are then removed in the clear liquid that was initially inserted to expand the uterus during the procedure.

In certain cases, a surgeon might also use a laparoscope inserted through a small incision in the abdomen so that the pelvic organs may be viewed and monitored outside of the uterus during a complicated hysteroscopic myomectomy.

Risks of Fibroid Removal Procedure

Although there is a low rate of complications with myomectomy, there are still potential risks associated with this procedure. These include:

Risks of Myomectomy
Excessive Blood Loss Because of heavy bleeding with menstruation, some women may already be anemic, or have low blood counts. These patients are at higher risk so their physician might try to increase these numbers prior to the surgery. In addition, the surgeon will also take extra precautions to avoid excessive bleeding by blocking certain arteries and constricting the blood vessels with medication.
Scar Tissue When an incision, or cut, is made into the uterus to remove the fibroid, scar tissue is formed along this site as the uterus heals. These bands of scar tissue, or adhesions, can attach to and get entangled with other pelvic or abdominal organs, leading to further complications and pain. Rarely, adhesions may form within the uterus and lead to light menstrual periods and difficulties with fertility (Asherman’s syndrome). A laparoscopic myomectomy may result in fewer adhesions than abdominal myomectomy (laparotomy).
Childbirth Complications If the surgeon had to make a deep incision in the uterine wall during a myomectomy, the physician who manages the subsequent pregnancy(s) may recommend cesarean delivery (C-section) to avoid rupture of the uterus during labor, a very rare complication of pregnancy.
Hysterectomy In rare cases, bleeding may become excessive and uncontrollable during a myomectomy. If this occurs, the surgeon may need to remove the uterus. As well, the uterus may need to be completely removed if there are other abnormalities found in addition to the fibroids.

Power Morcellation and Myomectomy

Power morcellation may be used during minimally invasive myomectomy to facilitate removal of leiomyomas (fibroids) that might otherwise require a larger incision. However, the technique has come under recent scrutiny due to concern about the risk of intraperitoneal dissemination of malignant and benign tissue to the abdominal cavity, particularly uterine sarcomas.

The U.S. Food and Drug Administration (FDA)
released a safety communication in early 2014 recommending against the use of uterine power morcellation in hysterectomy and myomectomy. Ethicon, the division of Johnson & Johnson that manufactures several power morcellators, suspended sales worldwide pending more research. It is important to note, however, that this suspension of sales is not technically a recall.

  1. The Mayo Clinic. Tests and Procedures: Myomectomy. Last Updated: June 4, 2013. Available at: http://www.mayoclinic.org/tests-procedures/myomectomy/basics/definition/prc-20012919. Accessed on: June 10, 2014.
  2. National Uterine Fibroids Foundation. Statistics. Last Updated November 21, 2010. Available at: http://www.nuff.org/health_statistics.htm. Accessed on: June 11, 2014.
  3. The American College of Obstetricians and Gynecologists: Women’s Health Care Physicians. Power Morcellation and Occult Malignancy in Gynecologic Surgery: A Special Report. May 2014. Available at: http://m.acog.org/Resources_And_Publications/Task_Force_and_Work_Group_Reports/Power_Morcellation_and_Occult_Malignancy_in_Gynecologic_Surgery. Accessed on June 10, 2014.
  4. US Food and Drug Administration: FDA News Release. FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids. Last Updated April 17, 2014. Available at: http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm393689.htm. Accessed on: June 11, 2014.