Multiple fibroids with preservation of the uterus
With multiple fibroids, the uterus can reach the size of 16–20 weeks of pregnancy; the surgeon, after clamping the uterine arteries, sequentially removes all nodes, trying to use a minimum of incisions and palpation finding small intramural nodes to reduce the risk of relapse, then layer-by-layer restores the uterine wall and its shape. Blood loss is controlled with a tourniquet, vasopressin and machine reinfusion if necessary; Sometimes preoperative hormonal preparation is prescribed to reduce nodes. An alternative if there are no plans for pregnancy is hysterectomy; the decision is made with the patient. After the operation, control of scars and planning of delivery by cesarean section.
Indications
- multiple fibroids (more than 4 nodes) and large nodes (more than 8-10 cm) if you want to preserve the uterus;
- intramural nodes, deeply located, deforming the cavity, in case of infertility and miscarriage;
- fibroids with rapid growth, anemia, compression of neighboring organs in women of reproductive age;
- impossibility of laparoscopic myomectomy (size, number, location of nodes, adhesions).
Benefits of Open Myomectomy
For multiple and large fibroids, laparotomy provides what is difficult to achieve laparoscopically: palpation search for all nodes, including small intramural ones, reliable multi-layer hand suture of the bed (important for a durable scar during subsequent pregnancy), control of bleeding and shorter duration of the operation. The uterus is preserved, menstrual and reproductive functions are restored. To reduce blood loss, a tourniquet on the uterine arteries, vasopressin are used, and in case of anemia - preoperative preparation. Recurrence of new nodes within 5 years is 15–25%.
When to choose laparotomy
Open access through a transverse Pfannenstiel incision (along the bikini line) remains the method of choice for very large sizes of the uterus and formations, multiple fibroids with deep nodes, severe adhesions after many operations, suspected malignancy with the need for revision, severe heart and lung diseases in which pneumoperitoneum is undesirable, as well as when laparoscopy is unavailable. Laparotomy gives the surgeon direct control of the tissue and a reliable multi-layer suture on the uterus; the scar after cosmetic suturing is barely noticeable. Recovery is longer than after laparoscopy: hospital stay 3–6 days, exercise limitation 1.5–2 months.
