Open Laparoscopic Myomectomy

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What is a Myomectomy?

A Myomectomy is an operation performed under general anaesthesia to remove fibroids without removing the uterus (womb).

Laparotomy (open) Myomectomy: the above operation is performed but through an incision in your tummy.

Laparoscopy (keyhole) Myomectomy: the above but through three to four small incisions in your tummy. This may not be suitable if you have large or multiple fibroids.

What is a fibroid?

A fibroid is a solid, benign (non-cancerous) growth or tumour that usually arises in the womb. They are made up of smooth muscle tissue, the same as the womb but in excess. They all vary in size, shape, number and position – ranging from the size of a pea to the size of a melon and there may be more than one present.

Why do I have fibroids?

Fibroids present themselves in one in four women making them very common. The average age range of women presenting with fibroids is between 30 to 50 years old. They can also occur in several female members of the same family.

It is not clear why fibroids are produced but their growth is stimulated by progesterone in the presence of oestrogen. If these hormone levels are heightened – for example in pregnancy and weighing over 70kg they can cause fibroids to swell. Likewise, fibroids tend to shrink after menopause.

Fibroids are three times more common in black African women than Caucasian women.

Why do I need a Myomectomy?

Women who have fibroids do not always need treatment as they do not always cause problems. One in three women can suffer various effects of them and a Myomectomy may be required to alleviate the symptoms you have been experiencing.

Some of these may include:

• Heavy and painful periods
• Breakthrough vaginal bleeding (in between periods)
• Anaemia
• Bloating/swollen abdomen
• Pelvic pain
• Back pain
• Urinary symptoms: including leakage, dribbling and passing urine frequently
• Fertility problems: infertility, premature labour and miscarriages
• Pain whilst having sexual intercourse

What can I expect before the operation?

At your pre-operative assessment and on your admission day the nurse will go through the hospital stay and explain your operation. Please do let us know about any concerns you have or any information you think we should know about, that will make your stay with us more comfortable.

You will need to make arrangements for your family, children or any other commitments that you have prior to coming in to hospital and to cover the length of your recovery. On arrival you will see an anaesthetist and the doctor performing the operation before you go to theatre. It is not unusual to feel anxious; the nursing staff will gladly discuss with you how you feel and talk through your emotions.

On the day of your admission please do not eat anything six hours before your admission time and this includes sweets and chewing gum. You can drink plain water up to two hours before your admission time.

Please note the following:

• If you are a smoker we strongly recommend that you do not smoke at all on the day before and the morning of your operation or for 48 hours after your operation
• Please bring in with you any medication that you usually take
• Do not bring in valuables or money except for some change for the Patientline TV and phone
• Do not wear make-up, nail varnish or jewellery
• Please remove your contact lenses

What does the operation involve?

Open Myomectomy

This involves removing the fibroids through a big cut in the abdomen. The incision is either across your bikini line or vertical (up and down) your tummy (midline). This incision may be approximately 10cm in length. This will be discussed with your doctor before the operation. The fibroids are removed by making cut/cuts into your womb and the womb sutured back with dissolvable stitches.

Keyhole Myomectomy

This operation is performed through three to four small incisions made in the abdomen.

Surgical instruments are inserted through the incisions, and the operation is carried out with the aid of an internal telescope and camera system. The fibroids are removed by making cut/cuts into your womb and the womb is sutured back through the keyhole incisions with dissolvable stitches. The fibroids are removed through one of the incisions with the help of an instrument known as a morcellator.

You will have between three to four scars on different parts of your tummy including your belly button. Each of these scars will be between 0.5cm and 1cm long.

Both operations can take a few hours to complete depending on how many fibroids you have and their sizes.

What are the risks?

There are risks with any operation but these are small. The main risks associated with undergoing a Myomectomy procedure are:

Common Risks:

• Postoperative pain (particularly shoulder tip pain if laparoscopy)
• Urinary infection, inability to pass urine and/or frequency
• Wound infection, bruising and delayed wound healing

Uncommon Risks:

• Damage to the bowel
• Damage to the bladder
• Pelvic abscess or infection
• Venous thrombosis and pulmonary embolism (blood clot in leg/lung)
• Hernia at the site of incision
• Haemorrhage requiring blood transfusion
• Return to theatre because of delayed bleeding
• Adverse reaction to the anaesthetic

Very Uncommon Risks:

• Need for hysterectomy (removal of the womb)

In order for you to make an informed choice about your operation please ask one of the doctors or nurses if you have any questions about the operation before signing the consent form.

What can I expect after the operation?

As you come round from the anaesthetic you may experience episodes of pain and/or nausea. Please let the nursing staff know and they will assess you and take appropriate action.

The nurses will assess you regularly to ensure that the PCA is effective. We will use a pain score to assess your pain 0-10; 0 = No Pain, 10 = Very Strong Pain.

Your nurse will be checking your blood pressure, heart rate, breathing and temperature and monitor the laparoscopic incisions and any vaginal bleeding. S/he will also ask you to move from side to side and to do leg and breathing exercises once you are able, this will help prevent any pressure damage, a DVT (deep vein thrombosis) or chest infection.

Open Myomectomy

You will have a drip attached (intravenous infusion); once you are fully awake you will be able to start drinking and eating. Your drip will then be discontinued. You may also have a catheter which will drain your urine. This is usually removed after 24-48 hours. We will monitor your urine output to make sure you are emptying your bladder properly and ask to measure two samples after it has been removed. We may scan your bladder after you have passed urine to make sure it is emptying well.

You may also have a drain which is inserted through your lower abdominal wall to drain off any fluid which may accumulate immediately after your operation. This is normally removed after 24-48 hours.

You can expect pain and discomfort in your abdomen for the first few days after the operation.

The nursing staff will assist with washing and encourage early movement. We would normally expect you to sit out of bed the day after your operation.

You will have a dressing on the wound that will be removed after 48 hours. You will be able to shower and mobilise around the ward. You may experience trapped wind which can cause discomfort, peppermint water and getting up and walking around will help this.

You may also find it difficult to open your bowels at first, we will give you mild laxatives to soften your stools and prevent you from getting constipated and having to strain.

Keyhole Myomectomy

You will have a drip attached (intravenous infusion); once you are fully awake you will be able to start drinking and eating. Your drip will then be discontinued. You may also have a catheter which will drain your urine.

You can expect pain and discomfort in your abdomen for the first few days after the operation. You may also experience shoulder tip pain from the gas and water that is used through the telescope which can get
trapped under your rib cage, this is common with laparoscopic surgery. You will be given pain killers to help this.

The nursing staff will assist with washing as necessary and encourage early mobilisation. We would normally expect you to sit out of bed and begin to walk around the day after your operation. If you have a catheter this is normally removed on day 1. We will monitor your urine output to make sure you are emptying your bladder properly and ask to measure two samples after the catheter has been removed. We may scan your bladder after you have passed urine to make sure you are emptying it well.

You will have two to four dressings on the cuts in your abdomen that will be removed after 48 hours. You may experience trapped wind which can cause discomfort, peppermint water and getting up and walking
around will help this.

You may also find it difficult to open your bowels at first, we will give you mild laxatives to soften your stools and prevent you from getting constipated and having to strain.

What about going home?

You will be seen and assessed by the gynaecology team each day to check on your recovery and decisions will be made about your care, this information will be shared with you. Please feel free to ask questions about your operation and recovery at any time.

Open Myomectomy

The average length of stay following a laparotomy Myomectomy is one to two days.

Keyhole Myomectomy

In most instances you can go home the following day. You may not see a doctor on the day of discharge as Nurse Led discharge is used.

As you physically recover from your Myomectomy the nursing team will discuss your convalescence. To prevent your operation from failing you should take note of the following:

Rest

During the first two weeks at home it is common to feel tired and exhausted, you should relax during the day gradually increasing the number of things you do each day. Avoid crossing your legs when you are lying down.

Vaginal bleeding

You can expect to have some vaginal discharge / bleeding for one to two weeks after the operation. This is like a light period and is red or brown in colour. Some women have no bleeding initially and have a sudden gush after about ten days; this is quite normally and should settle quickly. Sanitary towels should be used not tampons to reduce the risk of infection.

Stitches

Your incisions will be closed by stitches which are usually dissolvable over four to six weeks. If there is any problem with your stitches, please make an appointment with your practice nurse. We advise that you shower daily and keep the wounds clean and dry. There is no need to cover the wounds with any dressings.

Housework

Weeks 1-2: We recommend that you do light activities around the house and avoid any heavy lifting (no more than 1.5kgs in each hand)
Weeks 3-4: We recommend that you gradually introduce lighter household chores, dusting, washing up, making beds and ironing. You may begin to prepare food and cook remembering not to lift any heavy items.
Week 4-6: By this time you should resume normal daily activities.

Exercise

Exercise is important and it is advisable to go for short walks each day, increasing the distance gradually. You may return to normal exercise such as cycling and swimming after four to six weeks (keyhole) and six to eight weeks (open). You will be able to manage the stairs on your arrival home.

Diet

A well balanced nutritious diet with a high fibre content is essential to avoid constipation. Your bowels may take some time to return to normal after your operation and you may need to take laxatives.
You should include at least five portions of fruit and vegetables per day. You should aim to drink at least two litres of water per day.

Sex

You can resume sex when you feel recovered from the operation and feel ready for it. General advice to try for pregnancy is usually to wait three to four months, however this is not evidence based.

Returning to work

Depending on the operation, generally you will need two to six weeks off work. Most women are able to return to work after two to four weeks (keyhole) and four to six weeks (open), please discuss this with the doctor or nurse. The hospital doctor will provide a sick certificate for this period.

Driving

It is usually safe to drive after three to six weeks but this will depend on your level of concentration and ability to perform an emergency stop and your insurance cover.

Preventing DVT

There is a small risk of blood clots forming in your legs (DVT) after any operation. These clots can travel to your lungs (pulmonary embolism) which can be serious. Reduce these risks by:

• Being mobile
• Leg exercises
• Blood thinning injections
• Compression stockings

This will be discussed with you prior to leaving the hospital.

Are there any alternatives to having a Myomectomy?

A Myomectomy is often the preferred procedure for symptomatic women who wish to maintain their fertility. You may decide not to have this operation and want to try alternative methods of improving your symptoms such as;

• Pharmacological therapies
• Hysteroscopic Myomectomy / Transcervical resection of fibroids – a surgical procedure performed through the vagina for removal of fibroids which are seen within the cavity of the womb
• Endometrial ablation – a surgical procedure to remove the lining of your womb
• Uterine artery embolization – a less invasive surgical procedure performed under local anaesthetic. A catheter (small thin tube) is inserted into an artery where small embellished (clotted) particles are injected through the catheter to the arteries supplying the fibroids to cause a block of blood supply
• Hysterectomy – a surgical procedure to remove the womb

These can be discussed with your doctor in more detail.

Can fibroids reoccur?

After having a Myomectomy operation there is a very small chance that new fibroids can grow with your symptoms reoccurring.

Who can I contact with any concerns or questions?

If you have any problems or are worried, please do not hesitate to contact us on the gynaecology ward:

References/Useful links

1. Patient UK. (2012). Information Leaflets. Women’s Health Category. (www.patient.co.uk)
2. NICE. (2003). Laparoscopic Laser Myomectomy. London: NICE.
3. British Fibroid Trust www.britishfibroidtrust.org.uk/myomectomy.php