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Should I remove the fibroids or the womb?

When your fibroids are large and give you significant symptoms, and that medical therapies failed to resolve the problems, it is time to consider definitive surgical management. At this point, the first decision that has to be made is to perform a myomectomy or a hysterectomy.

Advantages of Myomectomy

In myomectomy, we remove the fibroids and leave behind the womb. By conserving the womb, the woman retains her ability to bear children. Fertility may also be preserve when she undergoes the procedure of uterine artery embolization, but the safety and outcome of future pregnancy have not been established. Besides, with uterine artery embolization (which essentially starved the fibroids of blood, thereby shrinking the fibroids), the average fibroid volume reduction is 50%. With myomectomy, all palpable fibroids will be removed by the abdominal approach or all visible fibroids will be removed by the laparoscopic approach. Removal of fibroids will restore the uterine architecture and function, thereby relieving symptoms such as abnormally heavy uterine bleeding and pain or pressure symptom.

Disadvantages of Myomectomy

When only fibroids are remove, there is the risk of recurrence. Whether the risk is high depends on several factors, such as – woman’s age, presence and number of tiny fibroids that were not removed or removable and the concomitant use of hormonal treatment. In some woman, the removal of the fibroids may not entirely resolve their symptoms of heavy menstrual periods, because there is another underlying pathology such as uterine adenomyosis.

The Option of Hysterectomy

Removal the entire womb not only rid the woman of her fibroids and cure her fibroid related symptoms, it also obviate the chance of any recurrence. Hysterectomy is only performed when the woman has completed her family or has given up her desire to bear a child. The womb has no other role besides child-bearing. It has no hormonal function and its removal will not generally affect the woman’s quality of life. Some women mistakenly believe that a hysterectomy procedure will hasten their aging, loss of vital energy and femininity.

Myomectomy And Uterine Fibroids

Myomectomy is the surgical removal of fibroids in the womb. We have developed several surgical approaches to this procedure:
    Abdominal myomectomy
    Transvaginal myomectomy
    Laparoscopic myomectomy
    Hysteroscopic myomectomy
    Robot assisted myomectomy

What is Abdominal Myomectomy?

In this approach, the fibroids are removed through an abdominal incision. The cut may be midline vertical, or made horizontally across the lower abdomen. The horizontal cut is usually favoured for cosmetic reason. Most fibroids can be excised through the horizontal incision. Myomectomy and blood loss In fibroid removal, especially when there are multiple of them, blood loss from the womb muscle has always been a challenge. Various techniques have been developed to minimize this loss. Use of adjunctive measures and good surgical skill ensure good outcome.

Advantages & Disadvantages of Abdominal Myomectomy

Abdominal myomectomy is the only way to remove large fibroids, and when the uterus is larger than 16 weeks. The ability to handle the womb and fibroid manually in abdominal myomectomy enables swift extrication of the fibroids and accurate repair of the operated areas. The integrity of the scar from adequate suturing of the uterine incision is far better than that achieved by minimal access techniques. Incising the abdomen results in more surgical pain and the patient has a slower recovery to full physical mobility. Studies have also shown that more pain killers are necessary and the hospital stay is longer, in comparison to key-hole surgery. Base on the size and location, certain fibroids are amenable to removal via minimal access. If there are many fibroids and they are deep seated, where access is limited, minimal access may prolong the operating duration and compromise adequate repair. It may be more appropriate to restore the integrity of the uterus than to recover from the operation several weeks sooner. Patient varies in the time to recover from an abdominal surgery. It largely depends on the extent of the procedure, the way the incision was made and the women’s healing ability. Most women can return to pre-operative functioning status in four to six weeks.

Laparoscopic Myomectomy
- The New Standard?

Fibroids may be removed using long instruments inserted into the abdominal cavity through small cuts. The operative field is visualized via an endoscope inserted through the belly button, with the images transmitted onto a monitor using fibre-optics. This approach is suitable if the fibroids are small, and arise near the outer surface of the womb or are attached to the uterus by a stalk. Fibroids growing on the front facing of the womb are more suitable. Deep seated fibroids are not good candidates for such removal; although they can be excised, the incisions made may not be accessible for strong repair using laparoscopic techniques (as compared to an abdominal approach).

Pros & Cons of Laparoscopic Myomectomy

Making several small cuts on the abdomen in a laparoscopic procedure facilitate the women’s recovery as the amount of pain is significantly less than large abdominal incision. The advantage of short hospital stay is often times exaggerated. How soon a woman returns to work after a laparoscopic procedure also relies on the duration and extent of surgery (albeit laparoscopic approach) and the woman’s motivation. Unlike an abdominal myomectomy, when the surgeon can palpate for smaller deeper fibroids and remove them as well, it is not so readily done in a laparoscopic procedure because of the loss of tactile sensation with the instruments when compared with the fingers. As such, it is more likely to leave behind smaller obscured fibroids during laparoscopic myomectomy.

Robot Assisted Myomectomy

Robotic surgery is making an in-road in some surgical fields. It reduces surgeon’s fatigue when long surgeries are involved. Besides, the wrist-like movements of the instruments improve the effectiveness of laparoscopic procedures. There is real advancement in the ability to precisely operate through minimal access. The contribution of robotics is in: surgical precision, narrow space surgery and fatigue reduction. All these advantages come with a prohibitive price tag. We must therefore evaluate the appropriateness of using robotics, as not all procedure needs to be robot assisted. When we are dealing with huge fibroid uterus, it is far more safer to adequately access the lesion via an abdominal incision.

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