Myomectomy. Myomectomy: varieties and indications Conservative myomectomy course of operation

Myomectomy refers to an operation to remove fibroids that preserves the cervix and body of the uterus. It can be carried out using several methods, each of which strives to remove the existing fibroids in the most gentle way. Thanks to this, a woman remains capable of further conception and the successful bearing of a pregnancy ending in the birth of a child.

As a rule, the uterus is removed in women after forty years, when she has children and pregnancy is no longer in her plans. But even in this case, the doctor carefully monitors the nature of the tumor, assesses its condition and its activity, and also draws conclusions about the need to remove it. The main indications for surgery are the large size of myoma nodes (more than 12 weeks) and their intensive growth for more than four weeks during the year. There is no doubt the removal of the organ in the event of the possibility of degeneration of a benign tumor into a malignant state.

In some cases, a spontaneous decrease in the size of fibroids can occur in the body, when during menopause, due to a lack of female hormones, it becomes smaller and even completely disappears. This can delay the operation for some time and even completely cancel it.

With a small size of the tumor and in the absence of its growth for several years, especially in the case of a planned future pregnancy, drug therapy can be used. Hormonal drugs used in such patients often slow down the growth of fibroids, and can also completely stop its development. To achieve a positive result, several courses of hormonal treatment are usually carried out.

If an operation is necessary, then doctors try to perform a conservative myomectomy, however, in this case, the use of this method does not exclude the further development of the tumor process and repeated surgical intervention.

Indications

The operation is performed in accordance with the indications for this intervention, thanks to which it is possible to avoid serious complications and more severe stages of tumor development. Most often, the following changes in the patient's condition can lead to this:

1. The appearance of acyclic bleeding, as well as long-lasting menstruation with profuse blood loss, often ending in anemia.
2. Infertility, the cause of which is miscarriage due to exposure to large myoma nodes, the size of which exceeds 4 centimeters.
3. The need for stimulating therapy with the use of hormonal drugs for infertility, since these drugs increase the activity of myomatous nodes and contribute to their growth.
4. Large fibroids that exceed twelve weeks of pregnancy. Since such a tumor, with its growth, compresses the nearby internal organs of the small pelvis, in order to avoid disruption of their functions, the patient is offered an operation even if there are no complaints from her side.
5. The existing symptoms of compression of the pelvic organs, which appear regardless of the size of the fibroids. This may be an increased urge to urinate or defecate, the appearance of pain in the lower back, lower abdomen or sacrum, the cause of which is pressure on the nerve endings.
6. Atypical localization of fibroids, in which nodes can form in the cervix or in its isthmus, as well as intraligamentally (on the uterine ligaments).
7. Submucosal or submucous nodes, most often accompanied by heavy bleeding.
8. The subserous nature of the nodes on the leg, which are formed under the outer shell of the uterus with dimensions of more than 4-5 cm. In this condition, there is a high possibility of formation of torsion of the node, which is fraught with serious complications.
9. The development of necrosis with necrosis of tumor tissue.
10. The birth of a submucosal fibroid node.
11. Rapid tumor growth exceeding the increase for more than four weeks per year. As a rule, this is explained not so much by the growth of the tumor formation itself, but by its edema as a result of the inflammation occurring in it and the associated circulatory disorders.

Preference for myomectomy is the following conditions in the body of a woman:

1. Woman's age. Most often, such an operational method is resorted to in relation to young women up to forty, in extreme cases - up to forty-five years, and only with special indications such an operation is performed on older women. According to statistics, about twenty percent of women under the age of 40 undergo myomectomy, and the average age of patients with fibroids is only 32 years.
2. Planning for the birth of a child. In the absence of children, when choosing a surgical treatment option, preference is given to myomectomy.
3. Characteristic features of the myomatous node and its size. It is more convenient to remove the nodes on the leg, which are small in size and located in the uterine cavity or on one of its outer walls. Despite this, an experienced surgeon is able to remove fibroids by exfoliating at any location.
4. The patient's own wishes. Often, women strive to maintain their menstrual function, regardless of childbearing. Therefore, the doctor, in the absence of contraindications and the availability of opportunities, tries to fulfill this request.

The reasons leading to the need for myomectomy are other disorders in the body of a woman, which often manifest themselves in the form of concomitant gynecological diseases (for example, endometriosis), if there is a suspicion of a malignant nature of the neoplasm that arose after a histological examination. Some changes in the state of fibroids, obtained a second time as a result of infection, also require surgical intervention.

Training

The preparatory period before the upcoming operation is to conduct standard examinations. First of all, laboratory blood tests are carried out, among which the determination of hormonal levels is mandatory. In addition to all standard examinations that are typical for any gynecological operations, some additional diagnostic procedures should be carried out, which are as follows:

• organs located in the small pelvis with an accurate determination of the location of the tumor and its size;
• carrying out hysteroscopy and aspiration of materials from the uterine cavity to exclude existing precancerous changes in it or the presence of pathological disorders of an oncological nature;
• colposcopy, which involves examining the cervical part of the uterus under a microscope, taking smears for oncocytology;
• chest x-ray;

After receiving the results, the doctor draws conclusions and prepares a conclusion about the need for surgical intervention and the possibility of preserving the uterus.

Mandatory tests

Before the operation, it is necessary to pass tests that allow one to judge the state of the body at the moment and the absence of pathological conditions that are a contraindication for surgical intervention.

Typically, this list includes the following studies:

• results of a clinical blood test;
• general urine analysis;
• conducting a biochemical blood test to determine total protein, bilirubin, AST and ALT, an analysis of blood glucose, the presence of creatinine and electrolytes.
• mandatory is the passage of fluorography;
• a blood test for belonging to a group and for the existing Rh factor;
• determination of blood clotting or coagulogram;
• smears taken from the vagina to determine the degree of purity;
• testing for hepatitis;
• carrying out the Wasserman reaction for the presence of syphilis and, according to f.50, for HIV.

Since the reason for the formation of fibroids is often a hormonal imbalance in a woman's body, she should be tested for hormones.
Types of surgery

When choosing the type of surgical intervention, the focus is on the size of the fibroids and what method of removal would be more appropriate in this case.

The main types of surgery that are used to remove myomatous nodes are the following:

1. Myomectomy, during which only the tumor itself is removed, and the body of the uterus and its cervical part remain intact.
2. Radical hysterectomy.

The most sparing of them is myomectomy, which is limited to resection of the tumor. This operation can be carried out in several ways.

Kinds

Conservative myomectomy

It is a gentle surgical operation used to remove the nodes of uterine fibroids. After it is carried out, women retain not only the uterus, but also the menstrual cycle with a full reproductive function. Conservative myomectomy consists of an operation using laparotomy and hysteroscopy.

Laparoscopic myomectomy

This type of surgery involves carrying out the necessary surgical manipulations through small holes in the abdominal wall. After it, there is almost no trace left on the body in the form of scars or scars. The advantages of this type are a shorter recovery period, the postoperative period is painless and, if performed correctly, is almost not accompanied by complications.

The disadvantages of the method are the impossibility of its application with a fibroid size exceeding nine weeks. The operation is not carried out in this way and when the fibroid node is located in an inconvenient and hard-to-reach place, since if bleeding is possible in these cases, certain difficulties arise with stopping it.

Abdominal myomectomy

The abdominal type of myomectomy is the excision of myomatous nodes by laparotomy with preservation of the uterus. It is a traditional surgical intervention with an incision in the lower abdomen. It can help with deep-seated nodes and with several nodular formations.

Most often, this method is used as an alternative to laparoscopy in the absence of the necessary equipment for it. This method preserves reproductive ability in the presence of large fibroids, as well as in case of its rapid growth or with intermuscular nodule formation. Abdominal myomectomy allows you to securely fix the site of removal of large fibroids using a special two-row vicryl suture, which is important for maintaining a subsequent pregnancy.

Abdominal myomectomy

The most common type of surgical removal of fibroids is abdominal surgery. It involves two methods of carrying out: removal with the help of myomectomy and hysterectomy. It is widely used in gynecology, as it does not require special equipment and narrow specialization of surgical personnel.

Endoscopic myomectomy

Endoscopic myomectomy is considered one of the gentle ways to remove fibroids, in which healthy tissues are not injured even with multiple nodes. This method is also preferable for the reason that it does not leave scars on the body of the uterus. The use of the latest endoscopic technologies and unique equipment make it possible to safely remove fibroid tumors even with its complicated forms. The procedure is carried out under anesthesia, providing for the features of removal in each individual case.

Hysteroscopic myomectomy

This method involves the removal of myomatous nodes through the vagina. This type of operation is used for small nodes, the growth of which is directed into the uterine cavity. This removal can be carried out on an outpatient basis using a flexible optical device - a hysteroscope, inserted into the uterine cavity through the vagina. The tumor itself is removed with specially designed manipulators.

It is especially favorable to carry out removal by this method with myoma less than five centimeters, and with most of it, which has a submucosal location, the operation is performed simultaneously. In cases where most of the tumor is located in the muscle layer, it is removed in two stages.

On what day of the cycle do they do it?

Of particular importance from the influence of the menstrual cycle on the day of the myomectomy was not noticed. As a rule, fibroids are removed from days 6 to 18 of the cycle. During the operation, the gestational age, if any, is more important, in this case the optimal period is from 14 to 19 weeks. At this time, the placenta is quite mature, and an increase in the level of progesterone is observed in the woman's blood. Due to this condition, the possibility of developing uterine contractions from surgery is reduced and the likelihood of abortion is minimal.

Execution features

The most important point in carrying out myomectomy is the choice of the site for making an incision on the body of the uterus, opening the capsule in which the node itself is enclosed and carrying out its correct exfoliation. The prevention of the formation of adhesions and the formation of a full-fledged scar on the uterus, which allows the further development of the planned pregnancy, depends on the thoroughness of stopping bleeding at the site of removal.

When opening the body of the uterus, the sutures are applied in three rows using Vicryl sutures, which subsequently dissolve on their own. If the uterus was not opened, then the bed at the place of removal is fixed with a two-row suture.

The incision of the capsule covering the node is carried out in the upper part of the tumor, thanks to this step it is possible not to affect large blood vessels and to avoid heavy bleeding. When enucleating the nodes, they try to get the most flat surface of the myoma bed, and in the case of a large tumor, especially located between the uterine ligaments, on the cervix or on its isthmus, to reduce tissue trauma and to stop bleeding from several small vessels, a round uterine ligament is dissected.

The final stage of the operation is the prevention of adhesive formations, for which one of the anti-adhesion solutions is introduced into the pelvic cavity, after its thorough drying.

Postoperative period

The recovery period after the operation lasts for several weeks. After using the laparoscopic method for removing fibroids, the patient can get up and move independently on the second day. The laparotomy method requires a longer postoperative recovery, so for three months after the operation it is necessary to avoid physical overexertion, to avoid difficulties with defecation in the form of constipation, since these actions can provoke a suture divergence. It is important to prevent disturbances in the functioning of the intestines, since such conditions can cause inflammation of the uterus and its appendages.

During the operation, as a result of which the preservation of the uterus was ensured, the complete restoration of its inner layer will occur over a period of six months to a year. After that, a woman can count on a full pregnancy and the absence of complications during its development.

Complications

Pathological disorders in the state of the reproductive organs, as well as mastopathy, like uterine fibroids, are the result of hormonal changes, so they are often considered complications of fibroids. But this is not true, since each pathological situation occurs by itself and the removal of fibroids does not cause it.

The weakening of sexual sensations is not a consequence of the operation, since these functions remain unchanged.

As complications, cases of a decrease in the level of sex hormones can be considered, so the following changes can occur in some patients:

• increasing the possibility of developing pathologies of the cardiovascular system in women under 50;
• the appearance of hot flashes, causeless irritability, sleep disturbances, increased fatigue;
• the occurrence of disorders in the processes of urination;
• soreness in the joints;
• symptoms of osteoporosis with the possibility of spontaneous fractures;
• the possibility of prolapse of the vaginal walls;
• due to endocrine disorders and a slowdown in metabolism, the likelihood of obesity increases.

In addition, women with an unstable psyche and increased emotionality may develop a depressive state, often to such an extent that the help of a specialist psychotherapist is required.

Pregnancy after myomectomy

The possibility of pregnancy after undergoing a myomectomy depends on three factors:

• on the volume of the intervention;
• from the postoperative state of the reproductive system;
• on the reliability of postoperative scars on the uterus.

Gynecologists believe that the possibility of a subsequent successful pregnancy largely depends on the exact implementation of postoperative recommendations. An important condition is a period of at least a year, which must elapse from the date of the operation. To relieve the load from the scar formed after the operation, doctors advise using a special bandage throughout the pregnancy.

Cesarean or independent childbirth?

When performing labor activity by pregnant women after myomectomy, special attention is paid to the condition of their scar on the uterus. Childbirth, carried out in a natural way, is possible in the absence of indications for a caesarean section. But if the patient has a burdened history, the pregnancy is considered overdue, there is a breech presentation, placental insufficiency, or the age of the woman with the first birth is more than thirty years, then in these cases, the indications for caesarean section after myomectomy are expanded. Immediately after childbirth, a control ultrasound is performed to assess the condition of the scar, and if it is impossible to use this diagnostic method, the uterus is examined manually.

Recommendations on the behavior of the patient in the postoperative period should be given by the attending physician before it is carried out. Since, after discharge from the hospital, the patient must change the dressing daily and treat the puncture or incision sites, she must learn to do this on her own. Until the damage is completely healed, she is not recommended to take a bath, visit a bath or sauna, and when using the shower, cover the wounds with a waterproof napkin.

The first week after the operation, it is better for a woman to alternate half-bed rest with slow walks.

Do I need to wear a bandage after surgery?

The need to wear a bandage is determined by the attending physician. It is not recommended to make a decision on its necessity on your own, as this can be harmful and lead to negative consequences for the body. If the doctor has prescribed wearing a bandage after myomectomy, then these recommendations should not be ignored. With the help of a bandage, it is possible to prevent the possibility of complications in the postoperative period and prevent the divergence of the superimposed suture.

What is the price

In the case of available indications, the operation of myomectomy can be performed free of charge, which is done in public medical institutions under the MHI policy. The same service in a private clinic may have a different cost, depending on the amount of surgical assistance, the method of the operation, the category of the clinic itself and the qualifications of the medical staff. Thus, the removal of fibroids using the laparoscopy method will cost from 30 to 75 thousand rubles, hysteroscopic myomectomy will cost much less, only from 7 to 20 thousand.

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A conservative myomectomy is a surgical operation in which the fibroids are removed. At the same time, the integrity of the reproductive organ is preserved, and, consequently, the reproductive function of the woman. Surgery can be performed hysteroscopically, laparoscopically or abdominally. In addition, for the treatment of uterine fibroids today, such a minimally invasive method as UAE is used. Due to its high efficiency and absolute safety, the popularity of UAE among doctors and patients is constantly growing.

Please note that this text was prepared without the support of our.

Make an appointment with the best specialists in Moscow: endovascular surgeon, candidate of medical sciences Bobrov B.Yu., gynecologist, candidate of medical sciences Lubnin D.M. can

Hysteroscopic uterine myomectomy

Hysteroscopic myomectomy is a method of surgical treatment of uterine fibroids with submucosal localization and growth directed into the lumen of the organ. The operation does not require an incision. Hysteroscopic myomectomy is performed with a special device - a resectoscope, which is inserted into the uterine cavity through. This intervention requires the use of anesthesia.

Hysteroscopic myomectomy: indications

Hysteroscopic myomectomy is indicated for the following conditions:

• submucosal localization of the myomatous node;
• uterine myoma growing on a leg;
• metrorrhagia and menorrhagia, provoking the development of anemia;
• infertility and miscarriage.

Hysteroscopic myomectomy: contraindications

Hysteroscopic myomectomy is contraindicated in the following cases:

• with a depth of the uterus more than 12 cm;
• with hyperplasia or adenocarcinoma of the endometrium;
• with infectious diseases of the reproductive system;
• with severe pathologies of the liver, kidneys and heart;
• with leiomyosarcoma.

Removal of sutures after myomectomy is performed after 10-14 days. Recovery usually occurs in 1.5-2 months.

Hysteroscopic myomectomy: consequences

This surgery may be accompanied by the following complications:

• damage to the organs of the peritoneum, blood vessels, impaired respiratory function;
• intraoperative complications that require resection of the uterus;
• the appearance of hematomas on the wall of the uterus, the invasion of infection;
• damage to the pelvic organs;
• hernias of the anterior abdominal wall;
• scarring on the organ;
• the development of relapses (observed in almost 30% of women).

Laparoscopic myomectomy

Laparoscopy (myomectomy) is used for subserous and intramural uterine myoma. The essence of the operation is the introduction into the abdominal cavity of a laparoscope equipped with a video camera and other surgical instruments, which is designed to remove the node through small incisions. The procedure requires anesthesia.

Conservative myomectomy, performed laparoscopically, ensures the preservation of the reproductive and menstrual function of a woman.

Before surgery, a woman needs to take a basic hormonal drug (gestrinone, goserelin), which helps to reduce the size of the node and reduce bleeding time during the operation. Hormonal treatment is necessary when the size of the myoma node exceeds 5 cm. With a myomatous node of subserous localization on the leg, preoperative preparation is not carried out.

Laparoscopic myomectomy: indications

Laparoscopic myomectomy is recommended for the following indications:

• subserous uterine fibroids growing on a stalk;
• infertility and miscarriage;
• metrorrhagia, menorrhagia, complicated by the development of anemia;
• rapid development or large sizes of uterine fibroids (more than 10 cm);
• pelvic pain associated with impaired blood flow in the myomatous node;
• violation of the activity of nearby organs when they are squeezed by a tumor;
• combination of uterine fibroids with other diseases, the treatment of which requires surgical removal.

Laparoscopic myomectomy: contraindications

Laparoscopic myomectomy is contraindicated in women with the following conditions:

• diseases of the cardiovascular, respiratory system, hemophilia, liver failure, diabetes mellitus, complicated hemorrhagic diathesis;
• malignant neoplasms of the internal genital organs;
• with a tumor size of more than 10 cm after taking hormonal drugs;
• multiple interstitial nodes (more than four).

Laparoscopic myomectomy is relatively contraindicated in patients with grade 2-3 obesity and adhesive processes.

Laparoscopic myomectomy: postoperative period

On the first day after myomectomy, the patient is recommended to comply with bed rest, which is explained by the use of anesthesia. In the evening, you are allowed to drink some non-carbonated water. You can get up and eat on the second day after the myomectomy was performed. Recovery after surgery lasts 2-5 days, after which the woman can be discharged from the hospital.

For the first 14 days, it is necessary to refuse to take baths, treat wounds with a 5% solution of potassium permanganate or iodine. You can return to your usual lifestyle in two to three weeks.

A woman should control the discharge after a myomectomy. Normally, after hysteroscopy, they can be bloody and not abundant. The appearance of such secretions is due to the fact that during the introduction of the resectoscope into the uterine cavity, the walls of the vagina can be injured. Medicinal ointments are used as wound healing agents. In addition, for some time the patient needs sexual rest. Other types of myomectomy may be accompanied by the appearance of a clear discharge that does not have an unpleasant odor and does not cause itching.

Full recovery of the body occurs at different times - depending on whether the patient has concomitant diseases (obesity, diabetes, arterial hypertension, etc.). Sex after surgery should be postponed for one to one and a half months.

After myomectomy, a woman needs regular visits to a gynecologist and an ultrasound scan to monitor the condition of the uterus.

Conservative laparoscopic myomectomy: reviews after surgery

According to experts, laparoscopic myomectomy is less traumatic than other methods of surgical treatment of uterine fibroids. In addition, after laparoscopy, the duration of the postoperative period is much shorter. On the first day after the operation, a woman needs narcotic analgesics. According to the indications, antibiotics are prescribed. The rehabilitation period in the hospital lasts, as a rule, no more than seven days.

Full recovery of working capacity is noted one month after myomectomy. In the case of removal of myomatous nodes from the posterior fornix of the vagina, for a period of about one to two months after the operation, the woman will have to give up sexual activity.

Pregnancy after conservative myomectomy

If there is a postoperative scar on the uterus, pregnancy should be planned no earlier than two years after myomectomy. During this period, experts do not recommend the use of intrauterine contraception.

To assess the degree of consistency of the scar, instrumental studies are carried out: ultrasound (ultrasound), hysteroscopy, hysterosalpingography. If conception occurs earlier than two years after myomectomy and if there are no objective signs of scar failure, pregnancy is not contraindicated, but the woman needs constant monitoring by a specialist.

Scars can cause complications in the process of bearing a fetus and lead to rather disastrous consequences: abortion, placental insufficiency (when the placenta is fixed in the damaged area of ​​the uterus).

In such situations, there is a violation of blood circulation between the expectant mother and the fetus, as a result of which the latter may develop hypoxia. In addition, there is a high risk of uterine rupture along the scar.

Hormone therapy after conservative myomectomy

After myomectomy, the patient needs dynamic observation, clinical examinations, and transvaginal echography. As a rule, after surgery, antibiotics are prescribed to prevent infection.

As is commonly believed, uterine and cervical fibroids is a hormone-dependent tumor, so it is advisable to use antiestrogenic drugs, androgenic hormones, estrogen-progestin drugs and GnRH analogues.

Despite the positive results of the treatment of uterine fibroids surgically and medically, the most effective method of dealing with this disease today is considered to be embolization of the uterine arteries.

UAE is a modern, absolutely painless, minimally invasive and organ-preserving endovascular method for the treatment of uterine fibroids. As early as three to six months after UAE, myomatous nodes are significantly reduced in size, and a year later the tumor completely disappears.

Modern clinics offering UAE are equipped with modern high-tech angiographs, with the help of which doctors have the opportunity to scan, visualize the smallest vessels and perform an endovascular procedure without incisions. A list of leading clinics where UMA can be done is presented.

Bibliography

• Savitsky G. A., Ivanova R. D., Svechnikova F. A. The role of local hyperhormonemia in the pathogenesis of the growth rate of the mass of tumor nodes in uterine myoma // Obstetrics and gynecology. - 1983. - T. 4. - S. 13-16.
• Sidorova I.S. Uterine fibroids (modern aspects of etiology, pathogenesis, classification and prevention). In: Uterine fibroids. Ed. I.S. Sidorova. M: MIA 2003; 5-66.
• Meriakri A.V. Epidemiology and pathogenesis of uterine fibroids. Sib honey journal 1998; 2:8-13.

Collapse

Such a common disease as uterine fibroids can be treated conservatively or surgically. The first method involves the use of hormonal drugs that stop tumor growth. The second method involves an operation to remove the node (or it along with the uterus). Myomectomy (removal of fibroids) can be performed in various ways. Laparoscopic myomectomy is popular as the least traumatic and safest method of treatment. Its features and the course of the procedure are described in this article.

Definition

Myomectomy is the removal of the myomatous node without (or almost without) trauma to the uterus itself. During one procedure, from one to 3-4 nodes are removed. Manipulation can be performed by abdominal, intravaginal and laparoscopic methods. The first two methods are more traumatic, and the recovery period after them is longer. Therefore, most often, doctors prescribe the third method.

Strictly speaking, laparoscopic removal of fibroids occurs through the abdominal wall. In it, as well as in the anterior wall of the uterus, small punctures (1 cm in diameter) are made. They are performed using a special device - a laparoscope. Since the device for such an intervention is equipped with a camera, what is happening is displayed on the doctor's monitor. On the monitor, the excision of the fibroids is done.

As it is clear from the description, the procedure is low-traumatic. The rehabilitation period is much shorter than with abdominal intervention. It is performed under general anesthesia and lasts about 30-50 minutes. During one procedure, it is possible to remove 3-4 nodules no larger than 1.5 cm in size. Larger formations cannot be removed in this way. A video showing the progress of this procedure is presented at the end of the material.

The intervention is safe and does not adversely affect the ability to become pregnant. Since damage to the uterus is minimal.

Indications

Laparoscopic removal of fibroids is performed in several cases. However, the exact decision is always made by the doctor. Only he can determine whether an operation is needed in a particular case. Is laparoscopy suitable? General indications for intervention are as follows:

1. The size of the formation is not more than one and a half centimeters;
2. Severe symptoms;
3. Pathological processes in the neoplasm (necrosis, torsion of the leg, etc.);
4. Squeezing by a tumor of neighboring organs;
5. Active node growth;
6. Resistance to hormonal conservative treatment;
7. Planning for pregnancy.

In fact, such small formations are surgically removed quite rarely. In general, doctors seek to treat them with hormones or arterial embolization. But in some cases, laparoscopy is the appropriate and most effective method.

Contraindications

Contraindications to this type of intervention are quite diverse. The main one is intolerance to anesthesia. And also - other contraindications to the operation. Specific cases where such intervention cannot be made are as follows:

1. The diameter of the tumor is more than one and a half centimeters;
2. Obesity, a large amount of excess weight;
3. Oncological processes;
4. A large number of spikes in the peritoneum and reproductive system;
5. The presence of any fluid in the uterine cavity.

This type of intervention is more gentle than abdominal or even intravaginal surgery. Therefore, it is often prescribed to patients with contraindications to traditional abdominal surgery. However, as can be seen from the above, it is not always possible to apply it.

In addition to these, there may be other contraindications associated with chronic diseases. Your doctor will inform you about them.

General training

Laparoscopic myomectomy, despite the fact that it is quite sparing, is still a full-fledged surgical intervention. Therefore, it requires some preparation. All training can be divided into two groups.

1. General preoperative preparation;
2. Specific drug preparation of the body.

• The diet should not contain products that cause gas formation, as well as constipation;
• It is better to eat lighter, reduce portions;
• Before the operation, a number of diagnostic studies are carried out, during which the volume and nature of the intervention is revealed.

In each case, there may be other ways to prepare for the operation. The doctor will notify the patient about them.

Medical preparation

Laparoscopic myomectomy requires a long preparation with medications. The patient is taking GnRH agonists. These are drugs such as Zoladex and Lucrin. Adequate dosage is prescribed by the doctor individually.

Although there are general reception schemes. Usually, you need to do one injection of the drug per month. The number of injections in the course varies from 2 to 6. This can cause degradation of nodes by almost a factor of two.

Why is it necessary to take these drugs? They act in a complex way. They reduce the blood supply to the organ and reduce the diameters of the nodes. It is believed that even one injection can help reduce the volume of fibroids by 30-40% compared to the original ones.

Stages

Regardless of the case in which the operation is performed, it is carried out in several stages. They, as well as their sequence, are mandatory for all patients.

Strictly speaking, the first stage is the introduction of the patient into anesthesia. Immediately after it works, the removal of uterine fibroids by the laparoscopic method begins.

Tumor excision

At the initial stage, the doctor punctures the peritoneum and uterine wall. Then the neoplasm is tightly clamped with a special device. With subserous myoma, coagulation of the uterine leg is done, i.e., stopping its blood supply. The leg is cut off. When the location is subserous-interstitial, a semicircular incision is made. And then the tumor is exfoliated.

Truncation of the stem

With interstitial tumors, the incision is made in the place where the uterus is most deformed. The cuts are longitudinal and transverse, as well as oblique. Their best direction is determined depending on the position of the neoplasm.

With interligamentous nodes, several successive small incisions are made. This reduces the chance of injury to the uterus.

Muscle closure

After excision of the formation, the myometrium remains slightly damaged. Doctors restore it immediately. If the depth of the wound is less than 10 mm, then it is sutured with a single-row suture. For deeper wounds, a two-row suture is applied. The distance between the seams is about 10 mm.

Suturing

The shape of the sutures may vary depending on the nature of the damage. In fact, damage is often minor. But they are associated with the localization and size of the removed tumor.

Extracting nodes

This is a significant stage at which doctors need to extract and remove tumors from the organ. They can do this in different ways:

Deleting a node

1. Through the anterior uterine and abdominal walls;
2. Evacuation with a mocellator (also through the same wall);
3. Through an incision in the distal fornix of the vagina.

The most suitable method is chosen individually. The positions of formations, their diameter and some other characteristics are of importance.

Sanation

This is the final step. Its essence is to clean the uterine cavity from blood clots and foreign matter as much as possible. Prepare the body for speedy healing. The stage is very important and not only the postoperative period, but also the effectiveness of the operation depends on its correct implementation.

Cleansed uterine cavity

During it, accumulated blood clots are removed from the cavity. Then the bleeding areas are determined. They undergo meticulous hemostasis. The probability of developing an adhesive process depends on how well the final procedures are performed. If sanitation and hemostasis are of high quality, then most likely adhesions will not appear.

Postoperative period

Removal of uterine fibroids by laparoscopic method is the safest and most gentle way to get rid of the neoplasm. The postoperative recovery period is much shorter than with abdominal surgery. It's also much lighter.

The stationary mode for the patient remains for another 2-3 days. After 2-3 days she is discharged from the hospital. In the future, already at home, a woman should limit physical activity for a month. It is better to resume sexual activity not earlier than in a month and a half.

Diet needs to be important. During the first three days, it should be extremely light, with a gradual increase in energy value to a normal level over three days. Within two months, nutrition should be natural. Do not eat fatty, fried, smoked and other heavy foods.

Carefully you need to monitor the chair. It is important to prevent constipation, as well as flatulence, bloating. All these phenomena can slow down healing. Moreover, they can provoke a divergence of the seams.

Pregnancy

This type of intervention does not adversely affect the patient's ability to become pregnant. Whereas the presence of fibroids in the uterus, on the contrary, makes this probability much lower. Therefore, at the stage of pregnancy planning, doctors recommend first removing the neoplasms.

Pregnancy can be planned as early as 6-9 months after the intervention. These indicators are individual. In some patients, this postoperative period may last longer, in others less. Only the attending physician can accurately determine it.

Complications

Complications after such an intervention are unlikely. However, they occur in some patients. The following most typical complications can be distinguished:

1. Complications from anesthesia;
2. Respiratory disorders during anesthesia;
3. Injuries to organs in the abdominal cavity;
4. Ruptures of large vessels;
5. Uterine bleeding;
6. Bleeding at the incision sites;
7. Hematomas of uterine tissues with improper suturing of wounds of the myometrium;
8. Associated infections;
9. It is extremely rare, with a specific localization of tumors - injuries of the bladder.

The presence of complications does not always depend on the professionalism of doctors. Sometimes it's about the individual characteristics of the body.

Prices

How much does laparoscopic uterine fibroids surgery cost? It depends on where it is performed.

Intervention cost

A significant part of this price is the cost of anesthesia and hospitalization.

Myomectomy is a surgical operation, the essence of which is the removal of a benign tumor (fibroids) from the body of the uterus. A characteristic feature of this method of radical therapy for fibroids is the preservation of female menstrual and reproductive functions: only the neoplasm is removed, the uterus is minimally damaged. The degree of damage and the duration of the recovery period depend on the method of surgical intervention and the type of tumor.

Myomectomy is most effective when the tumor is located directly under the mucosa or under the serosa of the uterus. In this case, there is no significant defect in the muscle membrane. This type of surgery is also called a conservative myomectomy. Conservative myomectomy is practically the only method in the treatment of infertility caused by fibroids. In the recent past, myomectomy has been used primarily in patients in their reproductive years who plan to have children in the future.

In modern medicine, organ-preserving operations for uterine myoma are a priority for radical therapy in women of any age.

Several varieties of the described operation are practiced. The choice of the method of surgical intervention depends on the clinical picture, the size of the tumor and its location in the uterus. Cavity extensive operations for the removal of fibroids are less and less used at the present time: preference is given to endoscopic methods.

The types of myomectomy are as follows:

• Laparoscopy;
• Abdominal surgery.

Let's consider each method in more detail.

Hysteroscopic myomectomy

This operation is performed if the tumor is located directly under the mucous layer of the uterine wall and protrudes into the lumen of the organ (submucosal localization).
An external incision is not made - the surgeon inserts an instrument (resectoscope) through the vagina into the uterine cavity and removes the knot. The progress of the operation is monitored by a video camera equipped with a resectoscope or hysteroscope: the image is transmitted to the monitor screen.

This procedure is usually performed on the 1st week of the menstrual cycle. Apply local anesthesia or general intravenous anesthesia.

Advantages of this method:

• No external incisions;
• Reducing the risk of bleeding and infection;
• Short recovery period;
• Visual control of the procedure.

It is prescribed in the presence of subserous (or intramural) tumor nodes. Instruments are inserted inside through small incisions (more precisely, punctures of small diameter) in the navel. Together with surgical instruments, a mini-video camera is also inserted into the uterine cavity. Usually 2 (maximum - 3) incisions in the abdominal cavity are sufficient.

Laparoscopy is a minimally invasive and less traumatic operation, which is preferred in many modern medical institutions. Using this method, most gynecological procedures are currently performed to eliminate pathologies in the fallopian tubes, directly in the uterus and ovaries.

Abdominal myomectomy (laparotomy)

Elimination of fibroids using traditional abdominal surgery. During the operation, performed under general anesthesia, 2 incisions are made - on the abdomen and on the body of the uterus. Visual control is direct: the surgeon monitors the procedure with his own eyes.

This operation takes longer because it involves suturing and requires a long postoperative period (about 6 months). A stay in the hospital is necessary for at least a few days until the doctors are convinced that there are no complications and infection. After the operation, a noticeable scar remains on the body.

Indications and contraindications

The main indications for myomectomy are: the size of the fibroids corresponding to 12-15 weeks of pregnancy and the tendency of the tumor to grow rapidly.

Other medical prescriptions for surgery:

• Frequent vaginal bleeding (leading to anemia);
• Violations of the functions of nearby organs;
• Submucosal type of tumor and other undesirable locations;
• Necrosis of tumor tissue;
• Infertility caused by the presence of a neoplasm (the tumor does not allow the fertilized egg to fully attach to the walls of the uterus).

The operation is not performed if the patients have infectious lesions of the reproductive organs, there are chronic diseases of the liver, kidneys, heart, as well as blood pathologies associated with clotting disorders. Myoma is not removed in the presence of multiple nodes (more than 4).

Postoperative period

After laparoscopy and hysteroscopy, the recovery period lasts only a few weeks. At the same time, a long stay in the ward is not necessary (maximum - 3-4 days). To relieve pain symptoms (if any), analgesics are prescribed.

For the recovery period (1-1.5 months), patients should refrain from playing sports, lifting weights, visiting solariums and saunas, and sexual activity. In the next few (up to six) months, sexual intercourse should be mandatory contraception.

Approximate cost in Moscow

Myomectomy is performed in many specialized clinics of the capital. In particular, in:

• "SM Clinic" on the street. Clara Zetkin, 33/28, tel. 777-48-49; Price - from 30,000 rubles;
• in the "Best Clinic" on Spartakovsky lane, 2, building 11, tel. 241-8-912; The cost of the procedure is 38,000 rubles;
• in the "Health Clinic" on Green Avenue, 17, building 1, tel. 672-87-87; The cost is from 17,000 rubles.

The video shows a fragment of the program "Health with Elena Malysheva", which shows bloodless laparoscopic myomectomy for a giant uterine myoma in a 25-year-old patient.

Operations for benign tumors of the uterus occupy a significant place in the practice of a gynecologist. Many interventions on the uterus can be performed laparoscopically with undeniable advantages over open surgery.

uterine fibroids- one of the most common benign diseases of the uterus, recorded in 20-25% of women of reproductive age.

The terminology for benign uterine tumors varies. The tumor may be dominated by smooth muscle fibers (myoma), connective tissue (fibroma), possibly the content of both components (fibroma). Before histological examination, the term “myoma” is more often used, which we will use in the future.

Uterine fibroids can be accompanied by heavy menstruation (menorrhagia), acyclic blood discharge (metrorrhagia), severe pain associated with a violation of the blood supply to the node, and with a significant increase in the diameter of the tumor - a violation of the function of neighboring organs.
Myomatous nodes that deform the uterine cavity may be due to infertility or miscarriage. However, an asymptomatic course or poor symptoms are possible even with large fibroids.

The growth of uterine fibroids appears to be related to the effect of estrogens on tissues. Uterine fibroids have been shown to decrease with the use of antiestrogen drugs or gonadotropin-releasing hormone (GnRH) agonists, so they are often prescribed before surgery.

The issue of indications for surgery, its volume (amputation, hysterectomy or myomectomy) and surgical access is decided individually. It depends on the woman's age, her desire to preserve fertility and menstrual function, the size and location of myomatous nodes, clinical manifestations and complications (menometrorrhagia, infertility, etc.). The use of GnRH analogues to reduce the size of nodes and the possibility of their removal by endoscopic methods (laparoscopically and hysteroscopically) have significantly changed approaches to solving this issue in recent years.

Classification

In relation to the muscular layer of the uterus, the following types of fibroids are distinguished:
1. Myoma on the leg.
2. Subserous-interstitial myoma.
3. Interstitial fibroids.
4. Submucous myoma.
5. Intraligamentally located fibroids.

Along with the above, there are mixed options for the localization of myomatous nodes.

Conservative myomectomy

Choice of surgical approach. Currently, conservative myomectomy can be performed by two operational approaches: laparoscopic and laparotomy. The results of myomectomy depend on the correct selection of patients and preoperative treatment with GnRH agonists.

A surgeon who prefers laparoscopic access should clearly understand the problems that may arise during the operation:
1. Bleeding.
2. Injury to neighboring organs.
3. Difficulties in extracting macropreparations of significant size.
4. The need for layer-by-layer restoration of uterine defects after husking of myomatous nodes, etc.

Laparoscopic myomectomy for multiple myomas, significant size of the nodes, their interstitial or intraligamentary localization is classified as a highly complex operation, often accompanied by complications.

Indications

Absolute contraindications

In the literature, the issue of the size of the myomatous node is discussed, which allows conservative myomectomy by laparoscopic access. According to many domestic and foreign authors, the size of the myomatous node should not exceed 8-10 cm, since with a larger size of the myomatous nodes after husking, it becomes difficult to remove them from the abdominal cavity. With the introduction of electromechanical morcellators into practice, it became possible to remove myoma nodes up to 15–17 cm in size.

4. Multiple interstitial nodes, the removal of which will not allow to preserve the childbearing function.
According to some surgeons, laparoscopic myomectomy can be performed in patients with no more than 4 nodes. In cases of more nodes, laparotomy is necessary.
5. In case of multiple uterine myoma, it is necessary to generally evaluate the possibility of conservative surgery due to the high recurrence rate (50% or more), while single fibroid nodes recur only in 10-20% of cases.
6. It should also be taken into account that the relativity of contraindications often depends on the qualifications of the surgeon.

Relative contraindications, according to some surgeons, include obesity of the II-III degree and a pronounced adhesive process after previous abdominal surgeries.

Preoperative hormonal preparation with GnRH agonists

Based on our own experience with the use of preoperative hormonal preparation, we noted a decrease in the size of myomatous nodes after the second injection of the drug by 35-40% compared with the initial ones (according to the results of ultrasound). These data allow us to recommend the use of 2 injections of GnRH agonists for hormonal preparation before conservative myomectomy.

Clinical Effects of GnRH Analogs

However, the disadvantages of GnRH agonists are also well known: hot flashes, sweating, irritability, changes in the localization of the nodes and the high cost of treatment.

Carrying out hormonal preoperative preparation is indicated when the size of the fibroid node is more than 4-5 cm. With subserous localization of the myomatous node on the leg, preoperative preparation is not carried out.
The technique of laparoscopic myomectomy largely depends on the size, location, presence of single or multiple nodes.

Conservative myomectomy is performed in four stages:
1. Clipping and husking of myomatous nodes.
2. Restoration of defects in the myometrium.
3. Extraction of myoma nodes.
4. Hemostasis and sanitation of the abdominal cavity.

Clipping and husking of the myomatous node

Myomectomy:
1 - subserous myoma node; 2 — capture of a node by a gear clip and cutting off by a Redik's hook; 3 - coagulation of the node bed with a spherical electrode; 4 - removal of the drug

Exfoliation of the subserous-interstitial myomatous node. For fixation, use a toothed clamp or a corkscrew.

With an intraligamentary location of the myomatous node, the incision of the serous cover of the uterus is carried out in the place of its greatest protrusion. With such localization of fibroids, special attention should be paid to identifying the ureters and atypically located uterine vascular bundles before making an incision. The direction of incisions in intraligamentary fibroids is usually transverse or oblique.

Both when removing deep intramural nodes, and when removing intraligamentary myomas, the principle of "onion skin" is used. The essence of the method lies in the fact that the pseudocapsule of fibroids is represented by myometrium rather than fibrous tissue. For husking, successive 1–2 mm incisions are made on the node near the site of splitting of the serous-muscular layers and the pseudocapsule, imagining the layers of the pseudocapsule in the form of onion layers.

This technique eliminates the possibility of opening the uterine cavity with intramural nodes. With the intraligamentary location of the node, this technique avoids damage to the vessels of the uterus and other adjacent structures. The technique is extremely useful for cervical myoma, when there is a lateral displacement of the uterine vessels and ureter.

Uterine incisions can be made with a monopolar coagulator or scissors after prior bipolar coagulation. The incision is made to the surface of the capsule of the myomatous node, easily recognizable by its white-pearl color. The nodes are exfoliated by successive tractions in different directions with the help of two clamps with simultaneous coagulation of all bleeding areas.

With conservative myomectomy by laparoscopic access, it is necessary to use rigid toothed clamps that allow you to securely fix the node during its exfoliation. The bed of the myomatous node is washed with saline and hemostasis is performed on all significantly bleeding areas of the myometrium. For these purposes, bipolar coagulation is preferred.

Repair of myometrial defects

Stages of suturing uterine defect after removal of fibroids

Extraction of macropreparation from the abdominal cavity

in. Extraction through an incision in the posterior fornix of the vagina. In the absence of a morcellator, posterior colpotomy can be used to extract myomatous nodes from the abdominal cavity. Posterior colpotomy can be performed using special vaginal extractors. In this case, the ball of the vaginal extractor is placed in the posterior fornix of the vagina, protruding it into the abdominal cavity.

Laparoscopic access using a monopolar electrode produces a transverse incision of the posterior fornix between the sacro-uterine ligaments. Then, a toothed 10-mm clamp is inserted into the abdominal cavity through the trocar, the myomatous node is captured by it, and it is removed from the abdominal cavity.
The vaginal extractor, due to the spherical expansion at the end, allows you to save the PP in the abdominal cavity after opening the posterior fornix of the vagina. If the node is larger than 6-7 cm, before removing it, it is first cut into two halves.

Removal of myomatous nodes from the abdominal cavity using posterior colpotomy does not lead to an increase in the duration of the operation, provides less trauma, prevention of postoperative hernias and a better cosmetic effect.

Hemostasis and sanitation of the abdominal cavity

Postoperative period

Contraception after surgery

Complications

Common complications of laparoscopy include damage to the main vessels and abdominal organs during the introduction of trocars, complications of anesthesia, respiratory disorders, TE, etc.

Also, with laparoscopic myomectomy, intra- and postoperative bleeding from the uterus or the bed of the myomatous node, hematomas in the uterine wall with inadequate layer-by-layer suturing of defects, and infectious complications are possible. Injuries to the ureters, bladder, and intestines are more likely to occur with a low or interstitial location of myomatous nodes. Perhaps the occurrence of hernias of the anterior abdominal wall after the extraction of macropreparations through it.