Minimally Invasive Myomectomy for Fertility
A myomectomy refers to a procedure which removes fibroids while leaving the uterus intact. The uterus is preserved so patients can maintain fertility. A myomectomy is best for women who want to continue to have children. However, it is not recommended for women who no longer wish to be pregnant.
For women planning a family, the presence of fibroids can lead to trouble conceiving, miscarriages, and serious complications during pregnancy. Undergoing a myomectomy is necessary for preventing these complications.
LAAM-BUAO®1 stands for Laparoscopically Assisted Abdominal Myomectomy with Bilateral Uterine Artery Occlusion. LAAM-BUAO®1 is a myomectomy technique developed by the surgeons at The Center for Innovative GYN Care® (CIGC®) that is minimally invasive and offers fast recovery. It is a hybrid technique that is used for removal of very large fibroids in the cavity, and for fibroids of any size located in the muscle (intramural) or the outside of the uterus (serosal), as well as fibroids on stalks (pedunculated).
LAAM BUAO procedures use retroperitoneal dissection, an advanced laparoscopic procedure, that allows for full visualization of the anatomy of the pelvis. Using this approach, the blood supply to the uterus is either temporarily occluded (O) or ligated (L). BUAO, therefore, stands for temporary occlusion of the artery, whereas BUAL stands for permanent ligation of the uterine artery. Most patients can undergo this procedure without the need for permanent blockage, or ligation of one or both uterine arteries. However, in patients with a very large uterus, it may be necessary to block one or both arteries permanently in order to avoid uncontrolled bleeding during the procedure requiring a hysterectomy. Studies have shown that ligation of the uterine arteries may have little effect on infertility. In patients with a very large uterus, fibroids must be removed in order to increase the chance of pregnancy. Patients with a very large uterus undergoing any form of myomectomy have risks associated with removal of the fibroids that can affect fertility, such as scarring to the uterine cavity where implantation of the embryo (egg and sperm joined) occurs, scarring to the fallopian tubes preventing transport of the embryo to the cavity, and abnormal healing of the uterine muscle affecting pregnancy and delivery.
Retroperitoneal dissection also allows for evaluation and mapping of the pelvis to avoid injury to the ureters, bladder, and bowel. This is extremely helpful in patients with a very large fibroid uterus considering fibroid removal, since it allows for the identification of these structures to avoid injury. Many patients will have endometriosis identified at the time of myomectomy. Should this be found, retroperitoneal approaches are helpful in the safe and effective excision of endometriosis at the time of the surgery.
- Incorporation of retroperitoneal techniques during the procedure to control bleeding and avoid complications.
- Excellent control of blood loss during and after the procedure.
- Application of a laparoscopic tourniquet through retroperitoneal dissection to control uterine artery blood supply to the uterus temporarily. The tourniquet is applied before the myomectomy is started and removed once the surgery is completed.
- Ligation of one or both uterine arteries may be required to control bleeding during the procedure to increase the safety of the operation and prevent hysterectomy. This may be necessary for those patients with larger uteri.
- Removal of fibroids of any size, number, and location for fertility patients, especially submucosal fibroids.
- The ability to “feel” the uterus for fibroids, allowing for removal in most cases of all the fibroids present.
- Robotic and laparoscopic approaches to myomectomy do not have the ability to feel for smaller fibroids, also called tactile sense, and can easily miss removal of moderate to smaller fibroids.
- Tactile sense also allows for assessment of the uterine cavity for fibroids near the lining, called submucosal fibroids, an allow for easy removal. These fibroids are a major cause of infertility and are more difficult to remove with other laparoscopic approaches.
- Reconstruction of the uterus using standard surgical techniques, ensuring the best and strongest uterine muscle closure. The standard closure with LAAM procedures provides a closure of the uterine muscle with the same strength as open surgery, but with a much smaller incision. This closure is faster, safer, and more secure that laparoscopic or robotic closure techniques.
- Applicable to patients with prior surgery, obese patients, and patients with multiple fibroids in the uterus.
- Does not use abdominal myomectomy, as abdominal myomectomy results in increased pain and recovery time, or robotic myomectomy, which results in increased pain and recovery time as well as incomplete removal of all fibroids.
- Discharge home the same day of surgery, with the ability to return to work in 10 to 14 days.
- Surgical time with LAAM® is usually less than 90 minutes, as compared to several hours for open surgery and up to four hours plus with robotics.
- Total incision length: 3.5 cm.
Research study published in the Journal of Minimally Invasive Gynecology compared the LAAM procedure to other myomectomy procedures and showed clear advantages. This data was based on 1380 patients who underwent fibroid removal surgery via open, robotic, laparoscopic or the LAAM approach. Here are the results:
1 Paul MacKoul, MD, FACOG, Rupen Baxi, MD, FACOG, Natalya Danilyants, MD, FACOG, Louise Q. van der Does, PhD, Leah R. Haworth, BSN, RN, Nilofar Kazi, BS. Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation. JMIG. 2019 Jul-Aug;26(5):856-64
2 Bedient CE, Magrina JF, Noble BN, et al. Comparison of robotic and laparoscopic myomectomy. AJOG, 2009;201:566.e1-5.
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6 Seinera et al. Laparoscopic myomectomy: indications, surgical technique and complications. Human Reproduction vol.12 no.9 pp.1927–1930, 1997.
7 Alessandri, Franco et al. Randomized study of laparoscopic versus minilaparotomic myomectomy for uterine myomas. JMIG. 2006; 13(2):92-97.
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12 Mayo Clinic
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14 Jones, H. W., III, & Rock, J. A. (2015). Te Linde’s operative gynecology (Eleventh edition). Philadelphia: Wolters Kluwer.
LAAM Compared to Other Minimally Invasive Myomectomy Techniques
All Fibroid Types
Moderate to Large Fibroids
Laparoscopic Minimally Invasive Myomectomy (Non-LAAM)
Laparoscopic minimally invasive myomectomy is less invasive than abdominal myomectomy and uses four incisions located in the pelvis and abdomen to remove fibroids, mainly superficial ones. This technique is not as effective at removing deep fibroids.
In general, the fibroids are removed from the uterus and electronically morcellated, using a device that “cores out” the fibroids through a 1.5 cm incision in the abdominal wall.
Bleeding is controlled through the use of Pitressin, a medicine that constricts blood vessels to the fibroids, as well as with electricity. Difficulties can be encountered with controlling bleeding, securing closure of the uterine muscle, and the timing of the procedure.
Location of the fibroids can pose problems with removal. Fibroids in the back of the uterus can be difficult or impossible to remove. Also, the procedure should not be used for patients with very large fibroids or large numbers of fibroids.
These types of surgeries require too much time with increased blood loss, often with fibroids still remaining after the surgery.
- Avoids the use of abdominal myomectomy in select cases
- Total incision length: 3 to 4 cm
- Minimally invasive, usually allowing discharge home the following day
- Good for removal of pedunculated or serosal fibroids
- Ability to return to work in seven to 10 days
- Difficulty with removal of larger fibroids located deeper in the muscle or in the cavity, large numbers of fibroids, or with fibroids in the back of the uterus
- Lack of tactile sense: The ability to feel for smaller fibroids deep in the muscle or cavity which increases the ability to remove all fibroids
- Not indicated for patients with multiple fibroids due to the need for increased surgical time and blood loss
- Closure more difficult, can be less effective than LAAM or abdominal approaches
- The need for morcellation during the procedure increases the time and cost of the operation
Robotic myomectomy is a minimally invasive myomectomy technique in which the surgeon uses a robot to perform the surgery. The robot is a tool and does not perform the surgery. The surgeon sits at a console, and directs the robot to remove the fibroids. In general, robotic myomectomies are not very effective in removal of very large or deeper fibroids, or for large numbers of fibroids, and often miss the removal of smaller fibroids that can grow over time. Robotics cannot use the tactile sense, or the ability to feel the fibroids, as can LAAM procedures. This severely limits the effectiveness of this approach to myomectomy. Multiple incisions are used throughout the abdomen and pelvis including those above the belly button. The time of surgery is extensive, with some procedures in excess of four hours’ duration. Cosmetics are poor, and the pain and recovery time from robotic myomectomies can be significant, with up to four to six weeks required.
An open myomectomy uses much larger incisions to exteriorize or remove the uterus from the pelvis. The fibroids are then removed from the uterus, and the incisions are closed with suture. An open myomectomy is an effective surgical method for removal of fibroids but relies on a very large incision that increases complications and recovery. Patients stay in the hospital for an average of three days, with the ability to return to work on average at eight weeks. LAAM procedures provide the same level of fibroid removal and muscle repair as the open approach. However, the incision with the LAAM approach is one fourth to one third the size, with discharge home the same day as surgery and recovery about one third of the time.
- Removal of all fibroids, in any location or size with the abdominal approach
- Strong closure of the muscle
- Hospitalization required with increased pain, longer recovery, and higher level of complication rates
- Increased bleeding, adhesion formation
- Total incision length of 9 to 12 cm or more
The hysteroscopic myomectomy is limited to removing fibroids in the uterine cavity only through a hysteroscope (hysteron = uterus) (scope = camera and light). The hysteroscope has a wire loop that cuts the fibroid away from the uterus using electricity. The “chips,” or pieces of the fibroid, are then removed from the cavity. The hysteroscopic myomectomy technique has many limitations. Because of these limitations, very large fibroids in the cavity or large fibroids involving a large portion of the muscle should be removed by other methods. The recovery is fast since there are no abdominal incisions, with patients generally being able to return to work in two days. In cases of large fibroids, often a second procedure is needed to remove the remaining fibroid.
- Perforation of the uterus
- Fluid overload due to absorption of the fluid used in the cavity to perform the procedure
- Most often, the surgery has to be stopped during the removal of larger fibroids, so that fluid overload does not occur. A second procedure can then be scheduled to remove the remaining fibroid several months later.
- Bleeding after the procedure
- Adhesion formation after the procedure
What to Expect After a Myomectomy
After a myomectomy, you may experience the following side effects:
- Some patients will develop bruises after the myomectomy operation, at the incision sites. The incision sites are made by “trocars,” plastic sleeves used for access during the surgery for the camera and for instruments. Sometimes these trocars cut tiny vessels just beneath the skin that cause limited bleeding. Even under the best of circumstances, it is sometimes impossible to see these small vessels. A bruise will develop that will resolve. Those patients with very large masses or fibroids may also develop bleeding at the incisions that can be more extensive due to longer manipulation of the trocar sites. Rarely, this bleeding can be very extensive, leading to a large bruise that tracts to the groin area. Please note that this type of bleeding almost always resolves. Pain or warmth may develop from the blood under the skin. Pain can be relieved with the ingestion of Motrin 600 mg every six hours or 800 mg every eight hours.
- Bleeding similar to a period is normal for the first week and should then gradually get lighter. Call the office if you have very heavy bleeding, increasing bleeding, or if you have urinary or rectal bleeding. The myomectomy procedure will cause your period to come within a few days after surgery.
- Swelling in the arms and legs: Swelling of the legs and sometimes arms can be common after surgery. This is due to increased fluid intake during the procedure. This will resolve over several days. If you notice persistent or increasing swelling, soreness, or tenderness in the calf, please call the office immediately.
- Abdominal swelling: Some degree of abdominal distension (swelling) is to be expected after surgery. This is due to distension of the intestines and resolves over time. It is usually mild to moderate only.
- Constipation can cause pain that can get worse with increased amounts of medication. If you experience constipation, drink lots of fluid and eat a high fiber diet. You may also use a mild laxative, such as Milk of Magnesia, or a stool softener, such as Colace. No prescription is required for either.
- Diarrhea sometimes is caused by antibiotics and will resolve once the antibiotics are stopped. A probiotic such as lactobacillus can help with this process. Rarely, severe diarrhea can develop. Call your doctor if you have severe diarrhea, bloody diarrhea, or if your diarrhea is accompanied by fever or worsening pain.
- Urinary retention
- Urinary retention is the inability to pass urine through the bladder. A very small number of patients will develop this problem due to the anesthetic used for the surgery. Most patients will have their bladder catheter removed immediately after the surgery. If you are sent home and are not able to pass urine, please go to a local ER. A catheter will be placed to allow the bladder to rest after the surgery and will be removed no less than five days after the surgery. It is important to have this catheter placed to avoid injury to the bladder.
- Pain around the incision sites is not uncommon and will resolve over several days. Most patients describe pain as minimal or moderate and will improve daily. If pain persists or becomes worse, a visit to the ER is recommended.
- Pelvic and rectal pain: Some patients describe pressure and pain with urination or with bowel movements. These symptoms are due to irritation to the rectum and bladder from the surgical procedure and will resolve with time.
- Chest and shoulder pain: The carbon dioxide gas used to insufflate the abdomen during the procedure (so the surgeon can see) will sometimes irritate the nerve between the neck and diaphragm and lead to mild to severe pain. This nerve tracks pain impulses from the lining of the chest cavity. The pain can occur during deep breaths. This resolves within two to three days and is not worrisome. If the chest pain is extreme or does not resolve, a visit to the local ER is important to rule out other causes, such as heart or lung issues.
- Anesthesia is the main cause for nausea immediately after surgery. After the first 24 hours, nausea is more likely caused by either your narcotic pain medication or antibiotics. If you are experiencing severe nausea, please call your doctor.
Myomectomy Recovery Time
The following is information about recovery time after a myomectomy:
- Getting back to work
- Patients are back to work as fast as seven to 10 days after smaller fibroid removal, and up to two to three weeks after removal of larger or greater numbers of fibroids
- Intercourse should be avoided for at least two weeks, then you may resume intercourse once you are feeling comfortable
- Driving after surgery
- Driving can begin only after you have stopped taking narcotics, and if you feel strong enough to be able to stop the vehicle in an emergency. If you are not confident, have someone drive you.
Myomectomy Recovery Tips
The following provides tips for recovering from a myomectomy:
- You will be given a prescription for Motrin prior to surgery (start Motrin after surgery) and a narcotic (Percocet, Tylenol 3, or Vicodin) at the hospital prior to your discharge
- To be effective, Motrin should be used in doses of 600 mg every six hours, or 800 mg every eight hours. Narcotics should be used sparingly since they will cause constipation. The first several days following surgery, most patients use mainly Motrin or extra strength Tylenol during the day, along with a narcotic sometimes at night to help with sleep. Using a heating pad on the lower abdomen is safe. Coughing can be uncomfortable initially because of abdominal discomfort. Placing a pillow on the abdomen to support your abdomen while coughing can be helpful.
- Use common sense when starting an exercise routine after surgery — start out slowly and over time, gradually increase time, distance, and speed
Changes to Your Body After a Myomectomy
- Fertility will be maintained; however, it is essential for the uterus to be completely healed before trying to conceive
- If the uterus is not completely healed, or not completely repaired during the surgery, placental abruption can occur, creating a dangerous situation for fetus and mother
Myomectomy Risks and Complications
Additional risks and complications after undergoing a myomectomy include:
- Excessive blood loss — due to excessive menstrual cycles and myomectomy
- Fertility risks
- These risks are inherent to any myomectomy procedure performed through any technique, and are dependent on the size, location, and number of fibroids removed
- Tubal scarring can occur with fibroids directly involving the fallopian tubes, and abnormal healing can occur due to removal of large numbers or size of fibroids
- Abnormal healing can result in uterine wall defects if many fibroids are removed
- Pregnancy or childbirth complication such as uterine rupture, abnormal placental development, intrauterine growth problems
- Also, most patients who become pregnant will need to undergo cesarean section surgery due to weakening of the uterine muscle upon removal of fibroids
- Hysterectomy if bleeding is uncontrollable or other abnormalities are found in addition to fibroids (rare)
- The spreading of cancerous tumors (rare)
- Cancers can be mistaken for fibroids and the removal of the tumor, especially when broken into smaller pieces, can spread cancer
The CIGC Difference
The CIGC difference is a commitment to providing an alternative to the invasive open myomectomy that often comes with painful and extensive recovery. The LAAM technique is a major advancement used exclusively at CIGC. Risk factors and limitations with laparoscopic, robotic, and open myomectomies led the surgeons at CIGC to create the LAAM-BUAO hybrid approach, taking the best parts of each surgery to create a better outcome for the patient. Risks and complications are greatly reduced, and patients after LAAM are back to work in two weeks.
LAAM fibroid removal at CIGC is accomplished through a small incision in the bikini line, usually no more than 1.5 inches in length, and an additional incision at the umbilicus (belly button) at one quarter of an inch. Bleeding is controlled through a laparoscopic tourniquet, which is placed around the “neck” of the uterus, where the blood supplies converge. This allows the LAAM procedure to be performed safely and effectively. The placement of a tourniquet is a significant advancement in controlling bleeding during laparoscopic myomectomy, and it is why LAAM has been proven to be safe and effective in removal of very large size and numbers of fibroids, in almost any location. Tourniquet placement often requires retroperitoneal dissection, a technique that helps CIGC laparoscopic GYN specialists visualize and map the pelvic cavity. The retroperitoneal space is covered by a membrane called the peritoneum.
By going behind (retro) the lining (peritoneal), the surgeon completely visualizes all of the anatomy of the pelvis including:
- Ureter (the tube that drains urine from the kidney to the bladder)
- Large vessels of the pelvis
- Lower portion of the bladder
As blood loss is one of the most concerning aspects of any myomectomy procedure, uterine artery occlusion (UAO) through placement of the tourniquet is a technique used by the CIGC surgeons to control the loss of blood during the procedure, avoid open surgery, and to prevent complications both during and after the surgery. In cases of very large fibroids, or large numbers of fibroids, permanent uterine artery ligation (UAL) may sometimes be necessary to further control bleeding and prevent hysterectomy.
Control of blood supply with laparoscopic tourniquet placement is essential to performing CIGC LAAM procedures. Many women undergoing myomectomy procedures with OBGYNs often have uncontrolled bleeding, requiring conversion to open surgery or possibly hysterectomy.
Most women are only offered open myomectomies by non-specialists, requiring large incisions. Robotic myomectomy is limited in its removal of very deep muscle fibroids, large numbers of smaller fibroids, or fibroids involving the uterine cavity, which can affect fertility. The CIGC LAAM fibroid removal technique for fertility makes it possible for even very large fibroids, large numbers of fibroids, and fibroids in any location to be removed through small, cosmetically pleasing incisions.
Prior to your surgery:
- All patients need to complete preoperative testing within 14 days of the surgical date
- Fax all preoperative testing results to your surgeon’s office at least five days prior to surgery, unless instructed otherwise.
- A nurse will contact you one to two days before your scheduled day of surgery, to review your medical history and preoperative instructions
- You cannot have anything to eat after midnight the night before the procedure
- Do not take any aspirin products or blood thinners one week prior to your surgery
- Bathe or shower with Hibiclens soap (found at the drugstore) the day of or the night before the surgery
- Wear loose fitting clothing, and no jewelry or make-up or creams/lotions on your skin
- Please bring your insurance card and picture ID and any form of copay
- The surgery scheduling team will send to your local pharmacy the appropriate prescriptions for after surgery
- All patients must have an adult escort to take them home due to anesthesia; you may not go home in a taxi unaccompanied
- If you have any preoperative or postoperative questions, please contact your surgeon’s office
A LAAM myomectomy is for fertility. Myomectomy, or fibroid removal surgery, is generally a more invasive procedure than a hysterectomy, and is not recommended for women who are no longer able to have children. This includes women who are no longer interested in childbearing, as well as women who are unable to have children, or who are menopausal. A hysterectomy eliminates incisions that require healing in the muscle, and the pain is generally much less. In most cases of laparoscopic or vaginal hysterectomy, the uterus is removed through the vaginal defect, with much smaller incisions used in the abdomen. Our expert surgeons will evaluate your medical history and recommend a procedure that is right for you.
The CIGC myomectomy surgeons only perform minimally invasive procedures. Our advanced-trained GYN specialists have made a commitment to surgery with the most modern techniques available. Even the most complex GYN surgeries at CIGC are performed with exceptional outcomes. Two of the techniques that make our LAAM procedure so effective are retroperitoneal (RP) dissection and uterine artery occlusion (UAO).
Ready for a Consultation
If you’re considering a myomectomy or hysterectomy for fibroids, our specialists are ready to provide an evaluation of your symptoms and condition(s) and recommend an appropriate solution.