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MYOMECTOMY

REASON FOR VISIT


•Infertility
•Intermenstrual bleeding

•Menorrhagia
•Pelvic pressure

•Pelvic pain

•Low back pain

•Leiomyosarcoma
•Myomas
•Degenerating myoma

•Fibroids
•Prolapsed myoma

•Pedunculated myoma

•Bladder pressure
•Urinary frequency

RISK ASSESSEMENT
•Endometrial cancer

•Uterine sarcoma

•Pregnancy

•Asymptomatic patients

•Heart diseases
•Diabetes
•Hypertension
•Bleeding disorders
•PID
PREPARATION OF THE PATIENT
•Blood tests
•Urinalysis
•Chest X-ray
•ECG
•Pregnancy test
•USG
•CT scan
•MRI
•Endometrial biopsy
•Hysterosalpingography (HSG)

•Hysteroscopy
•Stop using blood thinning medication

•Do not eat and drink 8 hrs before procedure


•Part was prepared and draped

ANESTHESIA
•General anesthesia

•Local anesthesia

•Spinal anesthesia

POSITION OF THE PATIENT


Supine position

THE PROCEDURE
ABDOMINAL MYOMECTOMY
•A Pfannenstiel incision was given
•Abdomen was opened in layers

•Vasopressin and saline was injected into the serosa prior to the

uterine incision
•An incision was made through the wall of the uterus into the

myoma.
•The plane between the myometrium and myoma was defined

•Myoma was dissected bluntly and sharply and the entire fibroid was

removed
•The defect was closed in layers with delayed absorbable suture.

•Abdomen was closed in layers with sutures/ staples

HYSTEROSCOPIC MYOMA RESECTION

•The patient was placed in the dorsal lithotomy position and

prepared and draped in a sterile manner.


•The patient's thighs were positioned at a 90° angle to the pelvis to

create enough space to manipulate the hysteroscope.


•The patient's perineum was just past the edge of the table, with the

coccyx and sacrum well supported on the flat surface of the table.
•The patient's legs were secured in the leg stirrups to avoid any

abrupt movements, which could cause nerve or muscle injury to the


patient.
•Seated with the operative field and hysteroscope at the level of the

patient’s abdomen
•The cervix was manually dilated with metal dilators to the same

diameter as the outer diameter of the outer sheath of the


hysteroscope setup.
•A single-tooth tenaculum was placed on the anterior lip of the

cervix while dilating to help straighten the cervix and uterus.


•Care was taken to avoid creating a false cervical passage that could

make it difficult to continue with the surgery.


•_________ (Lacrimal duct probes / Flexible uterine sounds) were

used to determine the correct angle.


•Ultrasonographic guidance was helped in dilation

•After the cervix was dilated, the hysteroscope was inserted into the

endocervical canal and advanced into the uterine cavity with the
distention medium flowing under direct visualization to limit the risk
of perforation.
•The tenaculum on the cervix was left in place to help in

manipulating the uterus


•The vaginal speculum was removed to increase maneuverability of

the hysteroscope.
•A purse-string suture was placed around the cervix using 0-Vicryl to

limit this leakage.


•The suture was removed at the end of the procedure

•A small ____mm hysteroscope was used with isotonic sodium

chloride distention medium.


•A __° scope was preferable to clearly visualize the tubal ostia.

•Myoma resection was performed with a loop electrode/ Nd: YAG

laser fiber/ electric myoma vaporizer by shaving the visible portion


of the myoma into small pieces sometimes, myomas deeply
embedded in the myometrium cannot be completely excised.

AFTER PROCEDURE
•Patient was shifted to intensive care unit
•Patient was observed for temp, pulse rate, blood pressure,
oxygenation
FINDINGS
_____ Cms of _____Myoma was removed

DURATION
______min/hrs

POSTOPERATIVE CARE
•Take pain medication as prescribed

•Take antibiotics as prescribed


•Do not use tampons, douche for 6 wks
•Avoid intercourse for 6 wks
•Raise the legs while sleeping

COMPLICATIONS
•Infection

•Hemorrhage
•Thromboembolism

•Uterine rupture in labor

•Uterine perforation

•Damage to the bladder


•Damage to the rectum
•Damage to the intestines
•Adhesions

•Cervical trauma
•Cervical lacerations
•Peritonitis
•Sepsis
•Gas embolism
•Circulatory collapse
•Fluid overload
•Hyponatremia
•Hypervolemia
•Hypotension
•Pulmonary edema
•Cerebral edema