Myomectomy

Introductions
• Uterine fibroids (also known as leiomyomas or myomas) are the most
common form of benign uterine tumors.
• They are monoclonal tumors of uterine smooth muscle, thus originating
from the myometrium. They are composed of large amounts of extracellular
matrix (ECM) containing collagen, fibronectin, and proteoglycans.
• Leiomyomas occur in 50–60% of women, rising to 70% by the age of 50 and,
in 30% of cases, cause morbidity due to abnormal uterine bleeding (heavy
menstrual bleeding inducing anemia) and pelvic pressure (urinary
symptoms, constipation and tenesmus).
• Clinical presentations of uterine leiomyomas include pelvic masses, pelvic
pain, infertility and obstetric complications.
Donnez & Dolmans, 2016
Risk factors

Donnez & Dolmans, 2016

Classification
Diagnosis
Pelvic examination
• Enlarged uterus or mass; anemia.

Ultrasonography
Gold standard!

Hysteroscopy
• Differentiate intracavitary myomas and large endometrial polyps. If irregular bleeding or if patient has risk
factors for endometrial hyperplasia (obesity, chronic anovulation)  endometrial biopsy.

MRI
• Can provide information on the number of fibroids, their size, vascularization, relationship with the
endometrial cavity & serosal surface, & boundaries with normal myometrium.
Managements
A. The normal uterine blood supply is represented
diagrammatically.
B. The uterine vascular patterns are altered by multiple myomas.
Indications in infertility:
1. Distorting the uterine cavity
Submucous:
interfere with fertility and should be removed in
infertile patients, regardless of the size or presence
of symptoms (Gambadauro,2012).
Intramural:
distorting: reduce the chances of conception not
distorting: controversial results.
Subserosal:
No evidence supports removal in
asymptomatic, infertile
3. >5-7cm
4. Multiple >3 (3-5 cm)
Contraindications:
1. No longer desire fertility or uterine preservation.
2. Endometrial cancer or uterine sarcoma.
3. Pregnant.
4. Asymptomatic: No evidence supports prophylactic
myomectomy for decreasing the risk of any adverse
outcome later in life.

Relative contraindications:
1. Strong possibility that a functional uterus could not be
reconstructed (numerous small F, very large F,
adenomyosis)
2. Fibroid located in the region of the uterine
vessels or broad ligament
 Myomectomy

Myomectomy of uterine body fibroids

Preoperative
Operative
Postoperative
Myomectom
y of cervical
fibroids
Myomectomy of broad ligament
fibroids
 Pre-operative
1. Route:
Submucous: hysteroscopically
intramural and serosal: laparotomy
2.Counseling
Multiple large
Broad ligament
Cornual
Cervical
: conversion to
hysterectomy
3. Determine
Small and buried F within the
 Consent
Risk:
1.Bleeding and transfusion.
25%
2.Conversion to hysterectomy 1-
2%
All patients should be warned of
this possibility.
3. Adhesion
post wall incisions: 90%
ant wall incisions: 50%
4. Recurrence
50% in 5 y
 Patient Preparation
1. Hematologic Status
Anemia:
Oral iron therapy
GnRHa
2. Antibiotic prophylaxis
1 g 1st or 2nd generation cephalosporin
3. Bowel Preparation
Not required unless extensive adhesions are
anticipated.
4. Vaginal preparation
If risk of conversion to hysterectomy is present
5. Timing
Immediate postmenstrual
When do we
convert to
hysterectomy?
1. Hospitalization: 1 to 4 days
{return of normal bowel function and febrile
morbidity usually dictate this course}

2. Postoperative activity
can be individualized
vigorous exercise: delayed until 4 to 6 weeks after
surgery.
3. Subsequent Pregnancy
No clear guidelines
Darwish et al (2005)
•wound healing usually is completed within 3
months.
•Local methods of contraception
(diaphragm, condoms, and spermicidal jelly or
foam) for at least 3 months
Adenomyosis resection
Introduction
• Adenomyosis is a benign gynecologic tumor and is classified into diffuse or
focal adenomyosis, depending on the extent and location of the disease as
well as the histological classification.
• Surgical treatment of adenomyosis remains a subject of discussion. Since
1990, in place of the classical V-shaped resection method, various
forms of surgical management have been attempted, including a uterine
muscle flap method that emphasizes fertility preservation, an asymmetric
dissection method, and various modified reduction methods.
• Focal adenomyosis resection is performed using either laparotomy or
laparoscopic surgery, whereas diffuse adenomyosis is limited to using
laparotomy.
Osada, 2018
Pre-operative examinations
• MRI examination  grasp accurately the location and extent of the
uterine adenomyosis and the position of the uterine cavity in order to
determine the site, direction, and depth of the incision to be made
into the uterus.
• Hysterosalpingography  examine the shape and size of the
uterinecavity

Osada, 2018
Surgical treatment
Wedge resection

Modified
reduction
Partial reduction
Transverse H-
incision

Wedge shaped
Laparotomy uterine wall
removal
Sugical

Laparoscopy Triple flap

Complete
excision
Asymmetric
dissection
Outcomes
• Post-adenomyomectomy improvements in dysmenorrhea and
hypermenorrhea vary but are recognized.
• The postoperative pregnancy rate also varies between 17.5% and 72.7%.
• In total, 2,365 uterine adenomyomectomies have been reported from
18 facilities worldwide (Table 1). Of these, 2,123 procedures have been
performed at 13 facilities in Japan, constituting 89.8% of the global
total. Among these, 449 pregnancies have been confirmed and 363
(80.8%) resulted in deliveries including 2 cases of stillbirths. There were
13 (3.6%) cases of uterine ruptures (Table 1). An additional 11 cases of
uterine rupture have been reported (Table 2).
Outcome
Contraception period prior to post-operative
pregnancy
• Contraception period varies by facility.
• Some facilities gave permission for pregnancies to be attempted
within 3 months after surgery.
• Most facilities recommended contraception periods of 6–12 months.
Laparotomy vs laparoscopy
• No evidence which is the best.
• Laparoscopic adenomyomectomy results in incompletely repaired
muscle defects, compared with laparotomy surgery. Thus, the risk of
uterine rupture is believed to increase during subsequent pregnancies
following laparoscopic procedures
Thank you