Procedure Laparoscopic Myomectomy
A myomectomy removes fibroids while leaving the uterus intact in order to maintain fertility. At The Center for Innovative GYN Care® we take the worry out of this procedure with our advanced LAAM-BUAO® technique, a safer laparoscopic myomectomy surgery using only two (2) small incisions. All of our procedures are performed in an outpatient setting and patients return home the same day. LAAM® is a major advancement used exclusively at CIGC®. Most women are only offered open myomectomies by non-specialists, requiring large incisions. The CIGC LAAM fibroid removal technique for fertility makes it possible for even very large fibroids to be removed through small, cosmetically pleasing incisions.
ARE YOU A CANDIDATE FOR LAAM-BUAO MYOMECTOMY?
A LAAM fibroid removal is for fertility. Myomectomy, or fibroid removal surgery, is generally a more invasive procedure than a hysterectomy, and is not recommended for women who no longer are able to have children.* (This includes women who are no longer interested in child bearing, 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.
In most patients, fibroids grow in the muscle of the uterus. Rarely are fibroids “pedunculated” or on stalks – these types of fibroids are more easily removed. Fibroids that are in the muscle (also known as “intramural”), on the outside (“serosal”), or in the cavity (“submucosal”) require an incision in the uterus for removal. The incision can be deep in the muscle, and will require repair and a longer healing time. In addition, the fibroids need to be removed through the abdominal wall in a myomectomy, which increases the size of the incisions and leads to increased pain.
This is important to understand, as many women believe a myomectomy is a less painful procedure than a hysterectomy. If preserving fertility is possible, a myomectomy is appropriate. If fertility is no longer an option, and fibroids are recurring, a hysterectomy may be a better solution. Discuss your plans for fertility with your doctor, and make sure you are both on the same page before proceeding with surgery.
*A WOMAN’S AGE IS THE SINGLE MOST IMPORTANT FACTOR AFFECTING HER FERTILITY.
Rates of fertility decrease as a woman reaches her mid-30s, and women who conceive later are at a greater risk of pregnancy complications. Women in their late 30s are approximately 40 percent less fertile than women in their early 20s.
However, once a woman is in her 40s, rates of fertility decrease exponentially. Ovarian reserve is diminished, and the lower quality of the eggs affects the quality of the potential embryo, leading to high rates of complications, including miscarriage.
AT AGE 40, FERTILITY HAS FALLEN BY HALF. (AT AGE 30, THE CHANCE OF CONCEIVING EACH MONTH IS ABOUT 20%; AT AGE 40 THE CHANCE OF CONCEIVING IS ABOUT 5%.)
AT AGE 43-44, WOMEN HAVE A 1% CHANCE OF GETTING PREGNANT WITH IVF. THE INTEGRITY OF THE EGGS, AND THE EMBRYOS THAT FORM ARE 80% LIKELY TO HAVE CHROMOSOMAL ABNORMALITIES.
WITHOUT IVF, WOMEN AGED 43-44 HAVE LESS THAN 1% CHANCE OF GETTING PREGNANT.
WHY THIS MATTERS FOR FIBROID REMOVAL
When fertility is no longer a viable option (1% or less), and fibroids are controlling your life, a myomectomy is not recommended.
Performing fibroid removal alone (a myomectomy), versus removing the uterus (hysterectomy), when fertility is no longer possible increases the risks to the patient. Women 43 or over, unless they have arranged to have a donor egg prior to having fibroid removal, should consider the benefits of a hysterectomy to ensure fibroids do not grow back.
A DualPortGYN hysterectomy at CIGC has a faster recovery than all other hysterectomy procedures, as well as any myomectomy procedure, and the recovery is less painful. Leaving the ovaries intact if they are healthy, a hysterectomy does not have to mean early menopause. The hormones that make estrogen are not affected by the removal of the uterus.
Fibroids and Infertility
The main reason myomectomy is performed is to preserve the uterus for pregnancy, or to remove fibroids that are preventing the uterus from becoming pregnant.
- Submucosal fibroids in the cavity should be removed since they may make conception of the pregnancy difficult, and may also increase the risk of miscarriage.
- Intramural fibroids should be removed in those patients with difficulty conceiving.
- In general, subserosal fibroids have little effect on the ability to become pregnant.
Heavy bleeding, pain, compression of fibroids against the bladder and back, and others.
UTERINE PRESERVATION FACTS & COMMON MISCONCEPTIONS
Myomectomy is more invasive, results in larger incisions and more pain, and may lead to additional surgery to either remove fibroids or the uterus in the future due to fibroid recurrence.
For many patients, there is a fear that removal of the uterus will result in:
- Menopause and menopausal symptoms such as hot flashes, night sweats, anxiety, depression, osteoporosis, etc.;
- Prolapse or “drop down” of the bladder, rectum, vagina, and other pelvic organs;
- Decreased lubrication or sexual function during intercourse; and
- Hair growth, weight gain, and hormonal problems.
A NOTE ABOUT HYSTERECTOMIES: OVARIES, not the uterus, control the release of hormones that control menstruation and menopause.
In many cases, the ovaries are NOT removed during the surgical procedure. Retaining the ovaries is also known as a “partial” hysterectomy, and will NOT lead to any of the hormonal symptoms noted above.
- Preservation of healthy ovaries maintains hormone production and function until the natural decline in production due to age.
- Removal of the uterus ONLY will alleviate many of the symptoms associated with fibroids, and prevent the fibroids from coming back, thereby avoiding additional surgery for recurrent fibroids.
- Laparoscopic hysterectomy with DualPortGYN also does not increase the risk of prolapse, or result in decreased lubrication with intercourse.
IMPORTANT INFORMATION ON HORMONE REPLACEMENT THERAPY RISKS & BENEFITS
COMBINATION THERAPY: HIGHER RISK OF BREAST CANCER, COMPLICATIONS
For relief of menopause symptoms, women who have their uterus MUST take combination hormone therapy to minimize the risk of uterine cancer. Estrogen-therapy alone can have a negative affect on the uterus. The complication is that combined therapy has been shown to increase breast cancer risk by nearly 300%.
Women’s Health Initiative Study: Estrogen Plus Progesterin Study
British Journal of Cancer: Menopausal hormone therapy and breast cancer: what is the true size of the increase risk?
This is very important for women who need surgery to remove fibroids to understand. If a patient has fibroids, and fertility is no longer desired or she has reached menopause, retaining the uterus has no benefit, and will require the higher risk hormone therapy for alleviation of menopause symptoms.
ESTROGEN ONLY-THERAPY: LESS OVERALL RISK OF COMPLICATIONS
Women who have had a hysterectomy should take estrogen-only therapy. Once the uterus is removed, low-dose estrogen is the safest form of hormone therapy, and has been proven in multiple studies to alleviate symptoms of menopause, while having low risk of blood clots or stroke, and no effect on heart disease, or breast or colorectal cancers.
For the vast majority of women, hormone replacement therapy, when given correctly, is extremely effective and safe. There are certainly women who should not take hormone replacement therapy at all due to medical reasons. Women should be educated on this matter and decide for themselves if the benefits outweigh the risks.
Women’s Health Initiative Study: Estrogen Alone Study
Myomectomy Pre-Operative Evaluation
All patients undergoing myomectomy should have at least a pelvic ultrasound to determine the size, number, and location of the fibroids. This is important, since fibroids in the cavity can only be treated by a less invasive approach, hysteroscopic myomectomy versus the need for laparoscopic or abdominal myomectomy.
A complete blood count, or CBC, is necessary. Blood loss is increased with myomectomy versus hysterectomy or other types of surgical procedures. A pregnancy test and electrolytes should also be obtained.
TYPES OF SURGICAL PROCEDURES FOR MYOMECTOMY
The following sections describe different types of myomectomy procedures from least invasive to most invasive, based on the overall size of the incisions and the location of the incisions.
LAAM-BUAO: Minimally Invasive Myomectomy
LAAM-BUAO (Laparoscopically Assisted Abdominal Myomectomy with Bilateral Uterine Artery Occlusion)
LAAM is a minimally invasive myomectomy technique with a 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 as intramural fibroids, as well as for serosal and pedunculated fibroids. Fibroid removal 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 at one quarter of an inch. Blood loss is controlled through either permanent blockage of the uterine arteries for removal of very large fibroids laparoscopically, or through the laparoscopic placement of a tourniquet or removable clips for temporary blockage of the arteries. The tourniquet is placed around the “neck” of the uterus, where the blood supplies converge.
- Removal of fibroids of any size and location for fertility patients;
- Applicable to patients with prior surgery, obese patients, and patients with multiple fibroids in the uterus;
- Excellent control of blood loss during and after the procedure;
- Reconstruction of the uterus using standard surgical techniques, ensuring the best possible and strongest uterine muscle closure;
- The ability to “feel” the uterus for fibroids, allowing for removal in most cases of all the fibroids present;
- Discharge home the same day of surgery, with the ability to return to work in 10 to 14 days;
- Avoids the use of abdominal myomectomy, which results in increased pain and recovery time; and
- Total incision length: 3.5 to 4.5 cm.
Other Non-CIGC Procedures for Comparison
Risk factors with laparoscopic 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. The following outlines other techniques, that, while they can be used to perform myomectomies , are less advantagous. It is important for patients to understand what options exist to make the best decision.
Minimally Invasive Myomectomy (Non-LAAM)
Laparoscopic fibroid removal is less invasive than abdominal myomectomy, and uses four incisions located in the pelvis and abdomen for removal of superficial and some 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 abdominal wall incision.
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.
- Minimally invasive, allowing discharge home the same day;
- Excellent for removal of pedunculated or serosal fibroids;
- Discharge home the same day, with the ability to return to work in seven to 10 days;
- Avoids the use of abdominal myomectomy in select cases; and
- Total incision length: 3 to 4 cm.
- Difficulty with removal of larger fibroids located deeper in the muscle or in the cavity, or with fibroids in the back of the uterus;
- Not indicated for patients with multiple fibroids due to the need for increased surgical time and blood loss; and
- Closure more difficult, can be less effective than LAAM or abdominal approaches.
Abdominal procedures for removal of fibroids use 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 a suture. Abdominal 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 at six to eight weeks on average.
LAAM procedures provide the same level of fibroid removal and muscle repair as the abdominal approach. However, the incision with the LAAM approach is one third to one fourth the size, with discharge home the same day of surgery and recovery about one third of the time.
- Removal of all fibroids, all locations and size with the abdominal approach;
- Strong closure of the muscle
- Hospitalization required with increased pain, longer recovery, and higher level of complications; and
- Increased bleeding, adhesion formation.
- Total incision length of 9 to 12 cm or more.
This procedure is limited to removal of fibroids in the uterine cavity ONLY through a hysteroscope (hystero=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. There are limitations to the procedure. 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.
WHY CIGC FOR MY MYOMECTOMY?
Deciding to have a myomectomy for fibroid removal is a big decision, as it is known to be more invasive than the alternative, a hysterectomy. Most patients who choose this route do so in order to maintain fertility. When viewed from this perspective, the procedure is worth it to preserve the uterus, but you still want to make sure you are in the best possible care for the procedure. Choosing a laparoscopic myomectomy doctor with a focus on advanced techniques is the best option.
WHY CHOOSE CIGC INSTEAD OF MY OB/GYN?
Minimally invasive fibroid removal at CIGC has been redefined. Our LAAM myomectomy technique makes it possible for women who are still able to maintain fertility to be candidates for a minimally invasive procedure regardless of the size, location or number of fibroids.
At CIGC, we are experienced laparoscopic myomectomy specialists, knowledgeable about the latest techniques and procedures used in GYN surgical care and recovery. We offer a safer, and more thorough minimally invasive fibroid removal surgery. Using exclusive techniques developed by our specialists, laparoscopic gynecologic surgery is our focus. We partner with OBGYNS to ensure our patients have the best of both worlds: exceptional surgical treatment from us, and stellar obstetrics from them.
Before performing a minimally invasive myomectomy, our doctors present you with all of your options to ensure that you are making the best choice for your lifestyle and current health.
Fast recovery after a myomectomy at CIGC is the norm. LAAM is one of the least invasive fibroid surgeries available, so pain is as minimal as possible and you are back on your feet more quickly.
As a patient, we urge you to find peace of mind in the form of the expertise and care of our surgical experts. Our physicians will help you to fully understand your condition as well as your options. We promise to employ only the most effective and least invasive surgical techniques to facilitate a swift recovery.
We have offices in Rockville and Annapolis, Maryland, as well as in Reston, Virginia for your convenience. Give us a call at (888) 787-4379.
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