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What is myomectomy?
Myomectomy is a surgical procedure to remove the fibroids without removing the womb (uterus).
| Symptoms relieved by myomectomy |
Abnormal menstrual periods leading to anaemia (>80% improvement in abnormal uterine bleeding).
Pelvic pain.
Back pain.
Pressure on the bladder such as leakage, dribbling, frequent passing of urine.
Fertility problem (infertility, premature labour, miscarriages) caused by fibroids.
Discomfort during sexual intercourse.
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There are 2 different types of myomectomy:
| Types of myomectomy |
| Type of operation |
What is? |
Type of anaesthesia |
Hospital Stay |
Recovery time |
| Laparoscopy (keyhole) |
Through a keyhole cut, uses a surgical instrument to remove the fibroids. |
General by injection and inhalation and local. |
1 day or overnight stay. |
1 to 2 weeks |
| Laparotomy (Open) |
A cut is made in the abdomen to remove the fibroids. |
General: injection and inhalation. |
3 to 5 days (in some cases, 7 days) |
4 to 6 weeks |
Not all fibroids are suitable for laparoscopic myomectomy. Only women with one or two fibroids no larger than 7 cm in size are suitable for laparoscopic myomectomy. The location of the fibroids is also important consideration and it is feasible to remove a pedunculated subserous fibroid larger than 7 cm in size laparoscopically.
Like all operations, myomectomy carries risks and complications, which are listed in the table below.
| Possible Risks/Complications of myomectomy |
- Excessive bleeding during the operation requiring blood transfusions.
- Anaemia due to blood loss during the operation and post-operation.
- Adverse reactions due to anaesthetics.
- Puncture of bowel or bladder during surgery.
- Opening of the womb or bowel during operation.
- If a large fibroid is removed, the wall of the womb may be weakened leaving a deep wound.
- Blood clot in legs (deep vein thrombosis) or sometimes, part of this clot can break off and travel to the lungs (known as PE). This can cause shortness of breath or even occasionally be fatal.
- Wound infection.
- Pelvic adhesion that can cause pain and/or bowel blockage.
- Risk of conversion to hysterectomy (very low).
- A keyhole (laparoscopic) myomectomy may be converted into an open abdominal procedure for effectiveness and safety reasons.
- Eventual re-growth of fibroids. Re-treatment rates for over 5-10 years are 10% for single myomectomy and 25% for multiple myomectomy. For laparoscopic myomectomy, symptoms can recur in up to 2 in 5 cases within 5 years.
- Special precautions in pregnancy: consideration for the need for caesarean section delivery.
- Possible heart attack due to strain on the heart.
- Death due to severe complications during or after the operation.
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It is important that you know the nature of the procedure, why it is done and what you can expect from having it.
In the next sections, we offer a step by step guide "how you prepare yourself for the operation".
What happens to you BEFORE the operation?
Your surgeon will have to carry certain tests to make sure that you are fit for the procedure (see Table).
| List of possible things may be carried out by the hospital (pre-op) |
Physical examination
Pregnancy test.
Check what medications you are taking regularly.
Check your blood levels to see if you are fit enough to go through.
Check blood pressure and heart rate.
Check for ECG to see if the heart is fit.
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You should compile a list of questions you may want to ask to put your mind at ease (see Table).
| Points you may want to discuss with your surgeon |
The possibility that he/she finds signs of malignant cancer in the womb during the operation.
Think what action you would like him/her to do.
Would you give consent to remove the womb?
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Would it be beneficial for you to receive hormone treatment such as GnRH agonist for 2 to 4 months before the operation.
This may shrink the fibroids and makes removal of fibroids easier and can minimise blood loss during the operation.
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Should you consider banking your own blood before surgery in case you need it for religion or some other reasons that
prevent you from receiving donor blood from the blood bank.
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If you are on warfarin or blood thinning agents (e.g. Aspirin 75 mg), ask whether you should stop it.
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What happens to you ON THE DAY of the operation?
- On the day of the operation, you will be taken to a waiting room where a nurse will check you in.
- Some surgeons may request you have an enema and a portion of your pubic hair shaved before the operation.
- You will then be seen by the anaesthetist.
He/she will go though the type of anaesthesia applicable for your case with you and ask questions on history of previous operation(s) if you had any and your family's.
Also, he/she will give you warnings on possible side-effects (see Table). The risk of anaesthetic depends very much on your general health. A fit, healthy 20 year old person would be at far less risk than an 80 year old person would with some serious disease.
Don't forget to mention any previous operation(s) you had and any side-effects. If you never had an operation under general anaesthesia, tell him/her about your family's operation(s).
| Possible risks of anaesthetic |
| Nausea and Vomiting |
Not always occur. May also be caused by the surgical procedure or pain relief medication. Medications and fluids may be required.
This may be from a tube in the mouth or throat during anaesthetic. Cough lozenges, gargle, simple pain killer may help. |
| Muscle weakness |
Muscle pain may be from spasm around the wound or the use of certain anaesthetics. Pain killers and rest usually settle it. |
| Blurred or Double vision |
Usually settles down with rest. |
| Post operative pain |
This is due to cuts in your skin and tissues. Resolve with painkillers and anti-inflammatory. |
| Allergic reactions |
Your anaesthetist will avoid any known drugs that you know you are allergic to. In case of unexpected reaction, the team is well trained and qualified to deal with it. |
| Damage to teeth |
Once you are deeply asleep, tubes may be placed inside your mouth and throat. The shape of your mouth varies and different types of dental diseases, loose teeth, bridge and crowns may be present.
The anaesthetist talks about the possible damage to you before the operation. If damage occurs, you will be told about it afterwards and repair is arranged. |
- In the pre-op room, an intravenous line is inserted for drugs to be given.
- You will be moved to the operating theatre where various monitors will be connected to help to care for you while you are anaesthetised.
- The anaesthetist will put you to sleep. Tube may be put into your mouth to help you to breathe and taken out at the end of the operation.
- The anaesthetist will stay with you throughout to make sure that you remain safe.
What happens DURING the operation?
What the surgeon does during the operation depend on the type of myomectomy, whether open abdominal or laparoscopic (keyhole) surgery.
Laparoscopic surgery
Generally speaking, the surgeon performs the followings:
- Insert a catheter into the womb (uterus). Carbon dioxide gas is used to inflate the abdomen to create the space for the surgeon to work
- Inject a blue dye to stain the womb cavity which makes it easier to locate the fibroids.
- Make a small incision (cut) in the navel.
- Insert the laparoscope (a specialised endoscope with fibre optic tube attached to a viewing device) into the womb to examine the abdomen.
- Make two or 3 additional incisions in the abdomen.
- Insert special laparoscope through these incisions to find each fibroid and remove it surgically.
In some cases, the surgeon first injects a drug called Pitressin into the fibroid to stop its blood supply for 20 mins in order to reduce bleeding when removing the fibroids. Or the tourniquet is used for the same purpose.
- After removing the fibroids, they are cut into pieces by special instruments and removed, and if necessary, the wall of the womb is repaired.
- At the end of the operation, as much gas as possible is removed.
- Close up all incisions with either stitches or clamps/staples.
Open abdominal surgery
Generally speaking, the surgeon performs the followings:
- Insert a catheter into the womb (uterus).
- Inject a blue dye to stain the womb cavity which makes it easier to locate the fibroids.
- An opening is made in the abdomen. In some cases, more than one incision is required. Generally, your scar will look like a hair line bikini (a) or vertical (b) as shown below.
- Muscles are separated and connective tissue is cut to expose the womb.
- Remove the fibroids surgically.
In some cases, the surgeon first injects a drug called Pitressin into the fibroid to stop its blood supply for 20 mins in order to reduce bleeding when removing the fibroids. Or a tourniquet is used for the same purpose.
- After removal of the fibroids, each layer of tissue in the womb is carefully stitched together.
- Close up all incisions with either stitches or staples.
When the operation is over, the anaesthetist will bring you back to consciousness. You will then be moved to the recovery room where you are being watched by the anaesthetist and given oxygen.
You will continue to wake up, feel drowsy and weak for a little while. Specially trained nurses will care for you in the recovery room until you are fine to move to the ward.
What happens AFTER operation?
When you wake up from the operation, you will notice that you have the followings:
- An oxygen mask to help you breathe.
- A drip in the arm to give fluids, blood, plasma.
- A temporally bladder catheter.
- A drain from the wound if you have open surgery.
- A pain relieve pump:
Either a PCA (patient controlled analgesia). You have a handheld device where you can press every time you want to give yourself a dose of the pain killer.
Or an epidural pump which delivers the pain killer via your back.
Generally:
- You will feel extremely tired and sleepy.
- If you have a keyhole (laparoscopic) myomectomy, it is likely that you feel some shoulder-tip pain and/or abdominal bloating or pain due to the carbon dioxide gas used in the operation.
- For the next few days, you may be given anticoagulant injection to prevent DVT such as Clexane.
- The PCA for pain relief will be discontinued within 48 hours and you will be given oral pain killers (paracetamol, diclofenac, dihydrocodeine or morphine).
- Tell your nurses as soon as you pass wind or a bowel motion because this shows that your digestive system is getting back to normal. If you do not open your bowel after 3 days, you will be given suppositories to help.
- The urinary catheter will be removed once you are able to make yourself to the toilet. The drain bottle from to wound is usually disconnected within 2 -3 days.
For self-care in the hospital, you can follow the following guide.
| Self-care guide |
| Time post-operation |
What to do |
| First day post-op |
Start drinking small sips of water to kick starts your gut into working. |
| Sit up right, especially out of bed. This helps to prevent chest infection. |
| Start moving round. Wear your TED socks to help to prevent DVT. |
| From second day to discharge time (5 to 6 days) |
Try to move around more and become independent. Drink plenty of fluid & walk around to help your bowel working again. |
| Do pelvic floor exercise per instructions from the physiotherapist. |
Care At Home Guide
- The pinkish/brown vaginal discharge continues for 10-14 days post-op. This is normal as part of the healing process.
- Carry on with pelvic floor exercise per instructions from the physiotherapist.
- Most importantly, keep the wound (incision site) clean and dry. There is no need to put any dressing over it. Apply daily dry antiseptic spray such as
Savlon Dry Antiseptic or Betadine Dry Spray (you can buy from pharmacy). The key objective here is to avoid infection for healing to take place.
- A DO and DON'T list is compiled for you as a guide, as always, use your common sense as well.
| DO and DON'T List |
| Time post-op |
DO |
DON'T |
| Week 1 to 2 |
- Use sanitary towels instead of tampons.
- When you have a bath or shower, use only unscented bath/shower gel or soap around the wound area.
- Pat dry your wound afterwards.
- Avoid vaginal lubricant, gel or cream.
- Start gentle walking around the house in week 1.
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- DON'T lift anything heavier than a full kettle.
- DON'T drive.
- DON'T have sexual intercourse.
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| Week 3 to 5 |
- Gently increase your physical activities.
- Allow rest time throughout the day.
- Start short walk in week 2.
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- DON'T put anything inside your vagina.
- DON'T drive.
- DON'T have sexual intercourse.
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| Week 6 Onwards |
- Resume light work.
- If you have no pain, you can start driving. If in doubt, see your GP.
- You can start sexual intercourse if you have no pain or vaginal bleeding. If you experience pain or bleeding after sex, contact your GP for advice.
- Start driving if you are confident to handle the car.
- Return to heavier work and all activities without restrictions in week 10.
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What symptoms to call for emergency medical attention?
While it is unusual to have problem once you are at home, contact your Gynaecology Emergency Unit if you discover any of the following symptoms below:
| Symptoms to call for emergency medical attention |
Fever with temperature above 38 degree C.
- Nausea and vomiting.
- Severe and increasing pain.
- Increased red blood/clots bleeding from the vagina.
- Foul-smelling vaginal discharge (yellow/green colour).
- Discharge from wound or wound opening.
- Burning pain when passing urine.
- Difficulty or unable to pass urine.
- Sudden chest pain or shortness of breath.
- Pain, swelling or redness in the calf.
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