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Myomectomy Procedure
Myomectomy Procedure

Myomectomy Procedure - What to expect

A myomectomy is a surgical procedure to remove uterine fibroids while leaving the uterus intact. This type of procedure is a major surgery but, if it’s performed minimally invasively, can lead to virtually invisible scarring and a quick recovery. 

Types of myomectomy procedures include standard laparoscopic myomectomy, robotic myomectomy, open myomectomy, hysteroscopic myomectomy and the CIGC-exclusive Laparoscopically Assisted Abdominal Myomectomy (LAAM®). The LAAM procedure avoids some of the most common disadvantages of other procedures, such as increased difficulty in removing larger uterine fibroids and a higher risk of bleeding complications and the formation of adhesions after surgery. 

Patients who undergo the LAAM procedure experience superior outcomes, including low complication rates, no hospital stay and a thorough fibroid removal surgery performed by an expert GYN surgical specialist.

Preparing for Surgery

To best prepare for a successful surgery, it’s important to follow all pre-surgery instructions provided by your surgeon. These instructions will be explained in your pre-surgery appointment, but if you have any preoperative or postoperative questions later, please contact your surgeon.

Preoperative Testing

All patients need to complete preoperative testing within 14 days of the surgery date. Once any required testing is complete, fax all preoperative testing results to your surgeon 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.

During preoperative visits, your surgeon may ask for additional information such as what medications or supplements you’re currently taking and if there are any other factors that may affect your overall health and healing ability.

Before the Surgery

From about a week to the 24 hours leading up to your surgery, our doctors advise the following:

  • Do not take any aspirin products or blood thinners one week prior to your surgery.
  • Do not eat anything after midnight the night before the procedure.
  • Bathe or shower with an antimicrobial soap the day of or night before the surgery.
  • Wear loose-fitting clothing and avoid jewelry, makeup and creams/lotions on the day of your surgery.

What to Bring to the Clinic

On the day of your surgery, please bring your insurance card and picture ID and any form of copay you may need. All patients must have an adult to take them home after the procedure. No patients may go home in a taxi or rideshare unaccompanied by another adult.

Before the Procedure

After checking in, a nurse will escort you to a room where you can change into a surgical gown and prepare for your procedure. The nurse will then take some vital measurements, such as your temperature and blood pressure, in addition to a few other brief tests to assess surgical readiness. You will then be given anesthesia. 

During the Procedure

CIGC’s LAAM procedure takes approximately 30 minutes to an hour. The surgeon will make two small incisions: one 0.5-inch incision at the belly button and one 1.5-inch incision at the bikini line. The belly button incision is used to evaluate the uterine fibroids in the uterus and then they are removed through the bikini line incision. Using these two incisions, the surgeon is able to thoroughly remove any number and all sizes of uterine fibroids while expertly controlling blood loss, making the LAAM procedure one of the safest and most effective myomectomies performed today.

LAAM

LAAM stands for Laparoscopically Assisted Abdominal Myomectomy. LAAM is a minimally invasive myomectomy technique developed by the surgeons at The Center for Innovative GYN Care. It is a hybrid technique that is used for removal of uterine fibroids of all sizes and quantities, including large fibroids that are often not removed in other laparoscopic procedures.

Advantages

  • Surgeons have excellent control of blood loss during and after the procedure.
  • Surgeons are able to remove uterine fibroids of any size, number and location.
  • Surgeons have the ability to feel the uterus for fibroids, allowing for removal (in most cases) of all fibroids present.
    • Robotic and standard laparoscopic approaches to myomectomy do not give surgeons the ability to feel for smaller uterine fibroids, also called tactile sense, so they 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. These fibroids are a major cause of infertility and are more difficult to remove with other laparoscopic approaches.
  • Surgeons are able to reconstruct the uterus using standard surgical techniques, ensuring a strong uterine muscle closure. The standard closure with LAAM procedures provides a closure of the uterine muscle with the same strength as the closure used in open surgery, but through a much smaller incision.
  • LAAM is applicable to patients with a prior surgery, patients with an above average BMI and patients with multiple fibroids in the uterus.
  • Patients are discharged and can go home the same day of surgery, with the ability to return to work, school or other daily responsibilities in 10 to 14 days.
  • Surgical time and time under anesthesia with LAAM is usually 30 minutes to an hour, as compared to several hours for open surgery and four hours or more with robotics.
  • Total incision length is 0.5 inches (belly button incision) and 1.5 inches (bikini line incision).

Disadvantages

  • Disadvantages for the LAAM procedure are minimal. Research, 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 1,380 patients who underwent fibroid removal surgery via open, robotic, laparoscopic or the LAAM approach. Here are the results:
CIGC LAAM Procedure Standard Laparoscopic Robotic Open
Length of Procedure
1-1.5 hours
2.5 hours
3-4 hours
2-2.5 hours
Number of Incisions
2
3-4
4-7
1 large
Size of Each Incision
One 0.2 in
One 1.2 in
0.2 in
0.3-0.5 in
6-8 in
Number of Fibroids Removed
9.1
2.9
2.9
9.0
Hospital Stay
0 days
1 day
2-3 days
Recovery Time
10-14 days
Up to 3 weeks
Up to 3 weeks
Up to 8 weeks
Conversion to Open Surgery
0.7%
22.9%
8.2%
N/A
Complication Rates
During Surgery
2.8%
8.8%
10.7%
7.5%

Standard Laparoscopic Minimally Invasive Myomectomy (Non-LAAM)

A standard laparoscopic minimally invasive myomectomy is less invasive than an open myomectomy and uses four incisions located in the pelvis and abdomen to remove mainly superficial uterine fibroids. This technique is not as effective as LAAM at removing deep or large 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-centimeter 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. These types of surgeries require a longer amount of surgery time with increased blood loss, and some fibroids are often left behind after surgery.

Advantages

  • Opting for a standard laparoscopic approach avoids the use of open myomectomy in select cases.
  • Hospital stay is usually limited to one day.
  • Surgeons are generally able to remove pedunculated or serosal fibroids through this procedure.
  • Patients typically return to work, school or other daily responsibilities in seven to 10 days.

Disadvantages

  • Surgeons typically have difficulty with removal of larger uterine fibroids located deeper in the muscle or in the cavity, large numbers of fibroids or fibroids in the back of the uterus.
  • Surgeons have lack of tactile sense in this procedure. The ability to feel for smaller fibroids deep in the muscle or cavity increases the ability to remove all fibroids, but that isn’t always possible in a standard laparoscopic surgery.
  • This procedure is not indicated for patients with multiple fibroids due to the need for increased surgical time and resulting blood loss.
  • Closure can be more difficult and less effective than LAAM or abdominal approaches.
  • The need for morcellation during the procedure increases the time and cost of the operation.

Robotic Myomectomy

Robotic myomectomy is a minimally invasive myomectomy technique in which the surgeon uses a robot to perform the surgery. The surgeon sits at a console and directs the robot to remove the fibroids through four to seven small incisions throughout the abdomen. 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.

Advantages

  • Opting for a robotic approach avoids the need for an open surgery in select cases.
  • Hospital stay is usually limited to one day.

Disadvantages

  • Large fibroids both in size and quantity are typically not able to be removed in a robotic myomectomy.
  • Robotics cannot use the tactile sense, or the ability to feel the fibroids, as they can with LAAM procedures. This severely limits the effectiveness of this approach to myomectomy.
  • The time of surgery is extensive, with some procedures in excess of four hours.
  • Cosmetics are poor, and the pain and recovery time from robotic myomectomies can be significant.

Open Myomectomy

An open myomectomy uses much larger incisions to temporarily exteriorize or remove the uterus from the pelvis. The fibroids are then removed from the uterus, and the incisions are closed with sutures. An open myomectomy is an effective surgical method for removal of fibroids but relies on a very large incision that increases complications and extends recovery time. Patients stay in the hospital for an average of three days, with the ability to return to work, school or other daily responsibilities about eight weeks later. 

LAAM procedures provide the same level of fibroid removal and muscle repair as the open approach. However, the incisions with the LAAM approach are one-fourth to one fifth-third of the size, and patients can go home the same day as surgery and recover in about one fourth-third of the time.

Advantages

  • Removal of all fibroids, in any location or size, is possible with the abdominal approach.
  • An open myomectomy allows for strong closure of the muscle.

Disadvantages

  • Most patients have to stay in the hospital for an average of three days with increased pain, longer recovery and a higher complication rate.
  • Due to the large incision and longer surgery time, patients may experience increased bleeding as well as adhesion formation after the incision has healed.
  • Total incision length is 6 to 8 inches.

Hysteroscopic Myomectomy

The hysteroscopic myomectomy is limited to removing fibroids in the uterine cavity only through a hysteroscope. 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. 

A 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 because there are no abdominal incisions, and patients are generally able to return to work, school or other daily responsibilities in two days. In cases involving large fibroids, a second procedure is often needed to remove any fibroids that cannot be removed during a hysteroscopic myomectomy.

Complications

  • 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 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

After the Procedure

All CIGC procedures are performed on an outpatient basis, so patients may go home directly after their surgery. Pain after surgery will likely be minimal and can usually be relieved with over-the-counter medications like Tylenol or ibuprofen. Any pain should resolve within a few days, though it’s important to contact your surgeon if it doesn’t. Your surgeon or postoperative care nurse will give you information on what you need to do in case you experience complications (which are rare), but don’t hesitate to call if you have any concerns after you leave the surgery center.

Many patients undergo a myomectomy to help with infertility problems. Talk with your surgeon to understand how long you should wait before having intercourse or proceeding with fertility treatments. After fibroids are removed, the uterus will need some time to heal before you move forward with your fertility goals. 

The CIGC Difference

Compared to other myomectomy procedure types, CIGC’s LAAM procedure has lower complication rates, a much quicker recovery and can remove fibroids of greater size and number. LAAM was developed and perfected by our GYN surgical specialists to improve patient outcomes and give those desiring pregnancy their best chance at fertility. 

If you are considering a minimally invasive myomectomy for relief from fibroids, our specialists are ready to evaluate your symptoms and condition and recommend the solution that works for you.

References:

  1. MacKoul P, Baxi R, Danilyants N, van der Does LQ, Haworth LR, Kazi N. Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation. J Minim Invasive Gynecol. 2019;26(5):856-864. doi:10.1016/j.jmig.2018.08.016