Postoperative period after laparoscopic and conservative myomectomy. Myomectomy: postoperative period Hormone therapy after conservative myomectomy

Conservative myomectomy in the largest and most modern gynecology clinic in Moscow at a very affordable price. Call!

You can get advice through the feedback form.

Please note that all analyzes provided to the Clinic must be originals or certified copies.

Indications for myomectomy

1. Age

Partial removal of fibroids is indicated, as a rule, for young women. Optimally - up to 40-45 years, but in some cases it is permissible to perform the operation at an older age. According to statistics, about 20% of myomectomies are performed in women under 40 years old, and the average age of detection of a muscle tumor in women is 32 years.

2. No children

If a woman does not have a single child, then in deciding on the method of surgical treatment of fibroids, the first option will always be myomectomy.

3. Features of the location and size of nodes

The most optimal for surgical removal are small nodes on the leg, located on the outer wall or inside the uterus. However, with almost any type of nodes, enucleation (husking) of a muscle tumor can be performed, especially if the operation is performed by an experienced surgeon.

4. The desire of a woman

In some cases of fibroid treatment, a woman wants to save not only the organ, but also the menstrual function, even if there is no need for childbearing. If there is a technical possibility and there are no contraindications, then the doctor can meet this wish.

Complications after conservative myomectomy

The main disadvantage of partial tumor removal is the high risk of recurrence of fibroids after treatment. Even if the operating doctor is confident in the complete removal of the node, there is no guarantee that after a certain period of time in the same place or nearby, the nodular formation will not grow again. In addition, the following complicating points are possible:

inflammatory process in the pelvic area, the risk of which after myomectomy is more pronounced;
the formation of adhesions between the uterus and appendages, which can cause adhesive disease and tubal-peritoneal variant of infertility;
the occurrence of a scar, which to one degree or another can affect the course of a future pregnancy.

Of great importance in conservative treatment is the availability of modern endoscopic equipment in the hospital and sufficient experience of the doctor in performing myomectomy.

Preparing for a Myomectomy

In addition to the standard examination before the treatment of fibroids, which is typical for any gynecological operation (smears for the degree of purity, general clinical blood and urine tests, biochemical analysis of venous blood and coagulogram, determination of the blood group and pathogens of syphilis, hepatitis viruses and HIV), the following diagnostic studies will be required:

Ultrasound of the pelvic organs with an accurate description of the location and size of myomatous nodes;
hysteroscopy and aspiration from the uterine cavity to exclude precancerous changes or the presence of oncological pathology;
colposcopy (examination of the cervix under a microscope) with a mandatory smear for oncocytology.

It is mandatory to perform an ECG followed by a consultation with a therapist, which is necessary for the selection of effective pain relief.

Operation types

There are many ways to remove fibroids. The following operation options are possible:

1. Myomectomy by abdominal surgery (abdominal myomectomy)

The most technically simple and frequently used method in the treatment of fibroids, when, after a suprapubic incision in the abdomen, the doctor can easily and quickly remove any myomatous formations emanating from the uterine wall.

Nodes located deep in the wall of the organ are removed by gradual husking. The best option for a woman is if the doctor managed to remove the node without opening the uterine cavity, because in this case the risk of complications is much lower.

2. Laparoscopic myomectomy

The use of optical instruments makes it possible to detect and remove a node growing from the wall of the uterus through three small openings in the abdomen.

The technique requires the availability of equipment, experience and qualifications of a doctor, therefore it is not used everywhere.

3. Myomectomy through the vagina (hysteroscopic myomectomy)

This version of the operation is used in the case when the myomatous node grows from the uterine cavity. With the help of a special optical instrument (hysteroresectoscope), the doctor will detect and remove the nodular formation. In this case, the risk of complications is minimal.

In some cases, to remove a node growing from the posterior or lateral wall of the uterus, the doctor will use the vaginal myomectomy technique, when laparoscopic access to the small pelvis is through the posterior wall of the vagina.

Contraindications

Node-only deletion with preservation of the organ cannot be performed in the following cases:

the serious condition of the woman, due to large blood loss and a pronounced degree of anemia, in which the abandonment of the organ can cause deadly uterine bleeding;
recurrence of the occurrence of a myomatous node after a previous conservative operation;
violation of blood flow in the nodular formation with the development of partial necrosis of fibroid tissue;
the presence of an acute or chronic inflammatory process in the pelvis, which can lead to serious complications in the postoperative period;
suspicion of a malignant tumor in the pelvic organs.

In each case, the doctor individually can decide to preserve the uterus, even if there are contraindications for the treatment of fibroids. Or the doctor decides to refuse a conservative myomectomy and perform a hysterectomy if a situation arises that threatens the health and life of a woman.

What does the patient feel during the operation?

The basic rule for all types of operations with penetration into the abdominal cavity is the need for good anesthesia. As a rule, different methods of general anesthesia are used. Therefore, with the conventional and laparoscopic methods of treating fibroids, the patient will be under anesthesia and will not feel anything.

When removing a node in the uterine cavity using a doctor may use local or regional anesthesia. In this case, a woman may have discomfort in the lower abdomen, but there will be no pain during treatment.

Rice. Removal of a nodule

After myomectomy

After any surgical intervention, a recovery period is required, but, as a rule, after a myomectomy, this time period is minimal. The need for subsequent treatment of fibroids depends on the initial condition (presence of anemia, condition after prolonged bleeding, inflammatory complications). If there are no problems, then after the usual operation, when a suprapubic incision is made in the abdomen, you need to stay in the hospital for about 5 days. After laparoscopic myomectomy, the doctor will let you go home after 3-4 days, and after hysteroscopic surgery - after 1 day.

Benefits of Myomectomy

Unlike a hysterectomy, any type of myomectomy has the following advantages:

preservation of the organ and menstrual function;
a woman has the opportunity to bear and give birth to a child.

Given the rather high risk of new nodes formation, the doctor in most cases advises to try to become pregnant in the near future after myomectomy in order to perform the childbearing function. This is especially important for women with

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 the 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:

The appearance of acyclic bleeding, as well as long-lasting menstruation with profuse blood loss, often ending in anemia.
Infertility, the cause of which is miscarriage due to exposure to large myoma nodes, the size of which exceeds 4 centimeters.
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.
Large fibroids that exceed twelve weeks of gestation. 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.
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.
Atypical localization of fibroids, in which nodes can form in the cervix or in its isthmus, as well as intraligamentally (on the uterine ligaments).
Submucosal or submucous nodes, most often accompanied by heavy bleeding.
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.
The development of necrosis with necrosis of tumor tissue.
The birth of a submucosal fibroid node.
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:

Woman's age. Most often, such an operative 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.
Planning for the birth of a child. In the absence of children, when choosing a surgical treatment option, preference is given to myomectomy.
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.
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 on the need for surgical intervention and on the possibility of preserving the uterus.

Mandatory tests

Before the operation, it is necessary to pass tests that allow you 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:

Myomectomy, during which only the tumor itself is removed, and the body of the uterus and its cervical part remain intact.
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 husking 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 divergence of the seam. 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 aggravated 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.

Uterine fibroids are the most common gynecological disease. According to medical statistics, it is diagnosed in at least 25-30% of women aged 35-50 years.

Moreover, in the last decade, there has been a trend towards the “rejuvenation” of this disease all over the world. Increasingly, fibroids are detected in 25-30-year-old patients, which negatively affects their reproductive health and ability to bear children. And the often occurring neglect of regular gynecological examinations leads to a rather late diagnosis of myomatosis, already at the stage of complications.

Treatment can be conservative and surgical. In this case, the operation to remove uterine fibroids is performed only if there are certain indications. The choice of surgical technique and determination of the scope of intervention depend on many factors.

What is a fibroid and what is it like?

Myoma is a benign hormone-dependent nodular neoplasm that originates from the myometrium - the muscular layer of the uterus. In this case, the serous membrane of the organ (peritoneum) and the internal mucous membrane (endometrium) are not involved in the pathological process, but cover the surface of the tumor.

Such a neoplasm does not germinate, but pushes the surrounding healthy tissues apart. This feature makes it technically possible to exfoliate relatively small myoma nodes while maintaining the integrity and functional usefulness of the uterine wall.

Tumor tissue may consist only of hypertrophied muscle fibers or include additional layers of connective tissue. In the latter case, the term "fibromyoma" is legal. Soft rather homogeneous muscle tissue formations are called leiomyomas.

The growth of such a tumor of the uterus can occur in several directions:

with prolapse into the lumen of the organ, while the myoma is called submucosal or;
with stratification of the muscle layer, thickening and deformation of the uterine wall (interstitial variant);
with a protrusion of the node into the abdominal cavity ();
with stratification of sheets of the broad ligament of the uterus (intraligamentary myomatous node).

The nodes protruding beyond the contours of the organ may have a leg of various diameters or "sit" on a wide base, sometimes immersed in the middle muscle layer.

Myoma rarely undergoes malignancy, malignancy is diagnosed in less than 1% of patients. But in many cases, such a tumor of the uterus is accompanied by a variety of complications. They are usually the basis for deciding on surgical treatment.

When is uterine fibroid removal required?

Removal of uterine fibroids (myomectomy) refers to organ-preserving operations. Therefore, in women of reproductive age with an unrealized childbearing function, preference is given, if possible, to just this variant of surgical treatment.

In some cases, surgery even becomes a key stage in the treatment of infertility. This is possible if difficulties with conception or prolongation of the onset of pregnancy are due to deformation of the uterine cavity by submucosal or large interstitial nodes.

Indications

Removal of fibroids is necessary when conservative therapy does not reduce the size of the tumor and does not allow its growth to be contained. Also indications for surgical intervention are:

recurrent uterine bleeding;
persistent pain syndrome;
signs of displacement and dysfunction of adjacent organs;
with submucosal and subserous nodes, especially prone to ischemic necrosis and with a risk of pedicle torsion.

Contraindications

Myomectomy is not performed under the following conditions:

in the presence of large or multiple myoma nodes;
with the cervical location of the tumor;
profuse and uncorrected uterine bleeding (menometrorrhagia), which leads to severe anemia in the patient and even threatens her life;
with massive tumor necrosis, especially if it is accompanied by the addition of a secondary bacterial infection, septic, thrombosis, or threatens the development of peritonitis;
active growth of fibroids in a patient who is in;
a pronounced violation of the functioning of neighboring organs (bladder, ureters, intestines), due to their displacement and compression by a large myomatous node or the entire enlarged uterus.

All these conditions are indications for radical surgical treatment of fibroids. At the same time, it is produced.

Limitations for myomectomy are also the patient's severe somatic condition, her current infectious and septic diseases, and the identification of contraindications for general anesthesia. In such cases, surgery may be temporarily delayed or replaced with alternative therapies in combination with active conservative therapy.

Ways to remove uterine fibroids

Removal of fibroids surgically can be done in several ways. Their fundamental difference is the type of online access. In accordance with this, laparotomy, laparoscopic and hysteroscopic myomectomy are distinguished.

Laparotomy

This is a classic abdominal operation to remove uterine fibroids. It is accompanied by the imposition of incisions on the anterior abdominal wall of the patient with a scalpel or modern instruments, such as an electric knife. Such an access gives the operating physician the possibility of a fairly wide direct view of the abdominal cavity, but is the most traumatic for the patient.

Laparoscopy

A much more gentle method, which requires endoscopic equipment. Manipulations are made through punctures, applied in certain places of the anterior abdominal wall. Recovery after such an operation is much faster than when using a classical laparotomy.

Hysteroscopy

A minimally invasive technique that also requires special endoscopic equipment. In this case, the doctor does not need to make incisions and punctures; he uses the cervical canal to access the uterine cavity.

The choice of the method of operation depends on the specific clinical situation. At the same time, the size, number and localization of myomatous nodes, the presence and severity of complications, the age of the patient and the risk of tumor malignancy are taken into account. Of great importance is also the qualification and experience of the operating doctor, the equipment of the medical facility with endoscopic equipment.

How long the operation to remove uterine fibroids takes depends on the chosen technique, the amount of intervention and the presence of intraoperative difficulties and complications.

How is the laparotomy procedure performed?

The operation using laparotomy access is indicated for interstitial and deeply immersed subserous nodes. It is used for multiple myomatosis, complicated course of the disease, adhesive disease, in the presence of rough or insufficiently well-founded scars of the uterine body. Removal of large uterine fibroids and cervical tumors is also usually performed laparotomically.

Incisions in the laparotomy method of surgery to remove the uterus

To access the myomatous nodes on the anterior abdominal wall, a vertical or horizontal incision is made, followed by layer-by-layer dissection and expansion of the tissues. The affected organ is removed from the abdominal cavity. Only if there are well-visualized nodes on the anterior wall, the doctor can decide to perform manipulations on the submerged uterus.

The serous membrane (visceral sheet of the peritoneum) is dissected and bluntly exfoliated, the myomatous node is isolated with the least possible trauma to the surrounding healthy myometrium. The tumor is exfoliated and removed. Sutures are placed on its bed, while the serosa is separately sutured. Bleeding vessels are carefully ligated, it is also possible to use an electrocoagulator. The abdominal cavity is drained, and the quality of hemostasis is monitored. After that, all layers of the abdominal wall are sutured in layers.

Possible complications during laparotomy removal of fibroids are associated with technical difficulties or errors during the operation. Perhaps massive intraoperative bleeding, accidental damage to neighboring organs.

Removal of uterine fibroids by laparoscopic method

Laparoscopic surgery is a gentle and at the same time highly effective way to remove subserous fibroids on a stalk or on a wide base. It is performed under general anesthesia in a specially equipped operating room.

Access to the uterus during laparoscopy is carried out through small punctures of the anterior abdominal wall in both iliac regions. The camera is inserted through the umbilical ring. The same puncture is used to inject carbon dioxide into the abdominal cavity, which is necessary to expand the spaces between the walls of the internal organs, to obtain sufficient visibility and space for the safe introduction of manipulators and instruments.

Laparoscopic surgery is a more gentle way to remove fibroids

The thin stalk of subserous fibroids is coagulated and cut off close to the wall of the uterus. In this case, suturing of the serous membrane is usually not required; the use of an electrocoagulator is sufficient.

If a node is removed on an interstitial basis, the doctor decapsulates and enucleates it. Such manipulations are necessarily supplemented by a step-by-step thorough hemostasis by electrocoagulation of all crossed vessels, regardless of their diameter.

The process of removal of the node on the basis is completed by the imposition of double-row endoscopic sutures on its bed. This is not only an additional method of hemostasis, but also contributes to the formation of a full-fledged scar in the future, which will retain its integrity even in the process of increasing the pregnant uterus. Suturing the defect of the serous membrane also helps to reduce the risk of postoperative.

The cut-off myomatous node is removed with the help of morcellators through the existing punctures. Sometimes an additional colpotomy hole is required.

After a control revision of the operation area and the entire abdominal cavity, the doctor removes the instruments and the camera, if necessary, evacuates excess carbon dioxide. The operation is completed by suturing the laparotomic openings. The patient usually does not need to stay in the intensive care unit and, after recovering from anesthesia, can be transferred to the recovery room under the supervision of a doctor and medical staff.

Currently, only subserous nodes are removed laparoscopically. But if the wide base of the fibroid (its interstitial component) is more than 50% of the total tumor volume, such an operation is not performed. In this case, a laparotomy is required.

Hysteroscopic myomectomy

Removal of uterine fibroids by hysteroscopy is a modern minimally invasive method of surgical treatment of submucous nodes. Such an intervention does not violate the integrity of the uterine wall and surrounding tissues and does not provoke the process of scarring.

In most cases, hysteroscopic myomectomy is not accompanied by clinically significant blood loss with the development of postoperative anemia. A woman who has undergone such an operation does not lose the ability to deliver naturally. She is also not usually considered to be at risk for miscarriage.

Hysteroscopic option for removal of uterine fibroids

All manipulations in the hysteroscopic version of the operation are performed transcervically using a hysteroscope. This is a special device with a camera, a source of local illumination and instruments, which is inserted into the uterine cavity through an artificially enlarged cervical canal. At the same time, the doctor has the ability to accurately control the manipulations he performs on the monitor, accurately examine suspicious areas of the mucous membrane and, if necessary, take a biopsy, and quickly stop the incipient bleeding.

Hysteroscopy is performed under general anesthesia, although the possibility of using spinal anesthesia is not ruled out. To cut off the myomatous node, tools for mechanical tissue cutting (analogue of a scalpel), an electrocoagulator, or a medical laser can be used. It depends on the technical equipment of the operating room, the skills and preferences of the operating doctor.

Laser removal of uterine fibroids is the most modern and gentle version of hysteroscopic myomectomy. After all, there is no compression, twisting and deep necrosis of surrounding tissues, no special measures are required to stop bleeding. Healing is fast and without the formation of rough scars.

Transcervical hysteroscopic myomectomy is not used for nodes larger than 5 cm in diameter, which are difficult to evacuate through the cervical canal. Dense postoperative scars on the wall of the uterus, internal adhesions (synechia) also significantly limit the use of this method.

Assistive operating technologies

To increase the effectiveness of surgical intervention and reduce the risk of intraoperative complications, the doctor may use some additional techniques. For example, laparoscopic and laparotomic removal of fibroids is sometimes combined with preliminary ligation, clamping or embolization of the uterine arteries. Such preparation for the operation is carried out several weeks before the main surgical treatment.

Forced restriction of blood supply to myomatous nodes is aimed not only at reducing their size. The conditions of artificially created ischemia lead to a reduction in healthy myometrium, which is accompanied by contouring of tumors and their partial isolation from the thickness of the uterine wall. In addition, surgical manipulations in the blood-poor area significantly reduce intraoperative blood loss.

Preliminary temporary clamping and ligation (ligation) of the uterine arteries are made from transvaginal access. After completion of the main operation, the superimposed terminals and ligatures are usually removed, although sometimes with multiple fibroids, a decision is made to permanently ligate the supply vessels.

Postoperative and recovery period

The postoperative period usually proceeds with pain syndrome of varying intensity, which may require the use of non-narcotic and even narcotic analgesics. The severity of pain depends on the type of operation performed, the volume of intervention and the individual characteristics of the patient.

With significant intraoperative blood loss in the first hours after the transfer of a woman to the ward of intensive blood loss, it may be necessary to transfuse blood and blood substitutes, introduce colloid and crystalloid solutions, and use agents to maintain an adequate level of blood pressure. But the need for such measures is rare, usually myomectomy takes place without clinically significant acute blood loss.

In the first 2 days, the doctor must control the functioning of the intestine, because any operation on the abdominal organs can be complicated by paralytic ileus. It is also important to prevent the development of constipation, since excessive straining during bowel movements is fraught with suture failure. That is why much attention is paid to the patient's nutrition, early rising and the rapid expansion of motor activity.

What can you eat after the operation?

It depends on the type of surgical treatment, the presence of anemia and concomitant diseases of the digestive tract.

The diet after removal of fibroids by laparotomy does not differ from the diet of people who have undergone other abdominal operations. On the first day, the patient is offered liquid and semi-liquid easily digestible food, in the subsequent menu they are quickly expanded. And by 5-7 days, a woman is usually already on the general table, if she does not need to follow the so-called "gastric" diet.

But laparoscopic and hysteroscopic myomectomy do not impose such strict restrictions even in the early postoperative period. In good condition, the patient can eat from the common table by the evening of the first day.

If fibroids have caused the development of chronic iron deficiency anemia or if the operation was accompanied by large blood loss, iron-rich foods must be introduced into the woman's diet. Additionally, antianemic iron-containing drugs may be prescribed.

Myomectomy allows you to remove existing nodes, but is not a prevention of the appearance of new uterine tumors. The fact is that fibroids have a hormone-dependent mechanism of development, and the operation does not affect the endocrine profile of the patient. Therefore, in the absence of proper preventive therapy, a relapse of the disease is possible. So what treatment is prescribed after removal of uterine fibroids? The therapeutic regimen is selected individually, it often includes the use of hormonal drugs.

Removal of fibroids imposes some restrictions. For the first few months, it is advisable for a woman not to visit baths, saunas and solariums, to avoid increased physical exertion.

In general, rehabilitation after removal of uterine fibroids takes about 6 months, after which the woman returns to her usual way of life. But at the same time, she also needs to undergo a gynecological examination every six months, as prescribed by the doctor, to conduct an ultrasound of the pelvic organs.

Consequences of the operation

Is it possible to become pregnant after removal of uterine fibroids - this is the main issue that worries patients of reproductive age. Myomectomy does not entail the disappearance of menstruation and the onset.

In the first few days, spotting is possible, which cannot be considered monthly. When determining the duration of the cycle, it is necessary to take into account only the date of the beginning of the previous menstruation. After this operation, menstruation usually resumes within 35-40 days. In this case, lengthening or shortening of 1-2 subsequent cycles is permissible.

Preservation of the patient's ovaries and uterus allows you to maintain her reproductive function. Therefore, pregnancy after removal of uterine fibroids is possible soon after the restoration of the functional usefulness of the endometrium.

But it is advisable for a woman who has undergone such an operation to think about conception no earlier than 3 months after surgical treatment. And sexual intercourse is permissible only after 4-6 weeks. Compliance with these terms is especially important if a laparotomic myomectomy was performed with suturing on the uterine wall.

The possible consequences of the operation include the risk of premature termination of pregnancy in the future, the pathological course of childbirth, the development of adhesive disease.

Alternatives to surgery

The possibilities of modern medicine allow the use of alternative methods for the elimination of uterine fibroids. They can be minimally invasive or even non-invasive, meaning they go away without surgery.

These include:

. Malnutrition of tumor tissues leads to its aseptic lysis with the replacement of muscle cells with connective tissue. Embolization is performed using a catheter inserted under X-ray control through the femoral artery.
(focused ultrasound ablation) of fibroids, causing local thermal necrosis of the tumor tissue. But this technique can only be used to get rid of fibromyomatous and fibrous nodes. But leiomyoma is insensitive to FUS-ablation.

In some cases, such techniques are combined with laparoscopic myomectomy, which is necessary for multiple myomatosis and pedunculated subserous nodes.

Do not refuse to remove uterine fibroids. This organ-preserving operation does not lead to irreversible consequences for the woman's body and allows you to get rid of all the complications associated with the presence of myomatous nodes.

All materials on the site are prepared by specialists in the field of surgery, anatomy and related disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

Uterine fibroids are benign neoplasms that arise from the muscular layer of the uterus. Various reasons can provoke the appearance of fibroids. This is a hereditary predisposition, and numerous abortions, and problems with the menstrual cycle. However, the main reason is hormonal disorders in the body of a woman.

Is surgery always necessary?

If the tumor is small, for several years there has been no tendency to increase, and the woman is not planning a pregnancy, you can resort to drug treatment. Hormonal drugs in many cases can slow down, and sometimes completely stop the growth of fibroids.

Usually several courses of hormonal treatment are prescribed.

Surgical treatment of fibroids is carried out if the tumor has reached a sufficiently large size and complicates the patient's life. Of course, in almost all cases, they try to carry out a conservative myomectomy, that is, the removal of myoma nodes with the preservation of the uterus, especially in young women who plan to have children in the future. However, it should be borne in mind that such a myomectomy does not exclude the recurrence of the tumor, which will require a second operation.

Indications for surgery

The rapid growth of the tumor (per year by an amount coinciding with the size of the uterus during pregnancy at 4-5 weeks).
The size of the fibroids for surgery should correspond to the size of the uterus during pregnancy at 12 weeks.
Uterine bleeding and a decrease in hemoglobin levels due to volumetric blood loss.
Pronounced pain syndrome.
Concomitant gynecological diseases (endometriosis).
Suspicion of malignancy (cell atypia in histological examination).
Secondary changes in the tumor (infection, necrosis).
Fibroids of any size, having long legs and prone to twisting.
A knot that has arisen in the cervix or between the sheets of the broad ligament.
Habitual miscarriages, infertility.
Significant dysfunction of nearby organs (frequent urination, constipation).

Preparation before the operation

Before the operation, all standard studies are carried out: general blood and urine tests, biochemical parameters, clotting tests, blood grouping, chest X-ray, ECG. In addition, an ultrasound scan of the pelvic organs is performed with an accurate determination of the location of the tumors and their size, an examination of the rectum, a smear is taken for the flora from the vagina. Since hormonal disorders are the main cause of fibroids, a woman must also take a blood test for hormones.

After a thorough examination, conclusions can be drawn about the need for an operation. Surgical interventions with the removal of the uterus are more acceptable for women in menopause, while operations with preservation of the organ are tried to be used in women under 40 years old.

Types of surgery

The choice of the type of operation will depend on the size of the tumor, and whether it is possible to remove it by one method or another. The main types of surgical intervention are:

Myomectomy.
Embolization.
Radical hysterectomy.

Myomectomy

This is an operation to resect the tumor itself while preserving the body of the uterus. It can be done in several ways:

Laparotomy myomectomy is an abdominal operation in which access to the uterus is provided by means of an incision in the abdominal wall.

Now, in the age of modern technology, this type of surgical access is used infrequently. As a rule, this is justified in cases where the uterus is severely deformed due to a large number of myoma nodes or their large size.

After laparotomy, it is necessary to avoid physical exertion for a long time and carefully monitor the cleanliness of the suture. In addition, after this operation, a scar remains on the abdomen. The positive aspect of laparotomy is the ability to control the progress of the operation by the doctor.

Laparoscopic myomectomy - a type of surgical intervention that allows you to carry out the necessary manipulations through small holes in the abdominal wall, as a result of which there are no scars on the body.

The advantage of such a myomectomy is that the recovery period after it is much faster.

However, this operation has limitations: the size of the fibroids should not exceed the size of the pregnant uterus at week 9. In addition, if the node is in a hard-to-reach place, laparoscopic surgery is not performed, since there is always a risk of bleeding, which in such conditions will be difficult to stop.

Hysteroscopic myomectomy

Hysteroscopic myomectomy - a method of removing myomatous nodes from the uterine cavity through the vagina. Naturally, this type of intervention is used with a small size of myomatous nodes growing into the uterine cavity (submucosal location).

Hysteroscopic myomectomy can be performed on an outpatient basis.

Contraindications for conservative myomectomy

Removal of only the tumor without removal of the uterus itself cannot be performed in the following cases:

Severe condition of the patient due to large blood loss and severe anemia. Leaving the uterus is fraught with life-threatening bleeding.
Tumor recurrence after previous organ-preserving surgery.
Chronic inflammatory process in the pelvic organs.

Hysterectomy

Complete removal of the uterus is one of the extreme surgical methods of treatment. Such an operation is prescribed for large fibroids, multiple, occurring with severe complications.

Removal of the organ can be performed both by laparotomy and laparoscopy and hysteroscopy.

Allocate a complete extirpation of the uterus - that is, its removal along with the neck and supravaginal amputation (the cervix is \u200b\u200bpreserved).

It must be said that hysterectomy is often performed unreasonably, according to some authors, in 8 out of 10 cases it could have been avoided by prescribing adequate hormonal therapy to the woman as preparation for surgery and then performing a conservative myomectomy.

Therefore, if the doctor insists on the complete removal of the uterus, and the woman does not agree, it is advisable to consult another doctor.

However, some women who do not plan to have more children agree to the removal of the uterus, since it cannot be said that this operation does not have its advantages:

A woman gets rid of pain and bleeding, including menopause.
There is no risk of tumor recurrence.
There is no risk of developing endometrial cancer.
There is no need for contraceptives.

Uterine artery embolization (UAE)

is a minimally invasive surgical intervention, the essence of which is to stop the blood supply to the fibroids. During the procedure, a thin tube (catheter) is passed through a puncture of an artery in the thigh to the vessels that supply the tumor with blood. Special substances are injected through this tube that clog the arteries and stop blood flow in them. As a result of impaired blood supply to myomatous nodes, the cells that make them up gradually die. After a few weeks, these cells are replaced by connective tissue. This tissue is resorbed, and the tumors are either significantly reduced in size or completely disappear.

Recovery after surgery

The postoperative period lasts several weeks. When performing the operation by the laparoscopic method, a woman can already get out of bed and walk on the second day. With laparotomy operations, recovery is longer. For three months after the operation, heavy physical exertion should be avoided, a postoperative bandage should be worn and constipation should be avoided, which can cause sutures to diverge. In addition, disturbances in the functioning of the intestines can lead to inflammatory diseases in the uterus and its appendages. Therefore, the products that a woman consumes should help cleanse the intestines.

If the uterus was preserved during the operation, then after the restoration of its inner layer in six months or a year, the woman will be able to plan a pregnancy. As a rule, it is not complicated by anything.

Consequences of myomectomy surgery

The main problem with conservative myomectomy is the high risk that the tumor may form again, even if the surgeon is sure that the node has been completely removed. The following complications are also possible:

The development of the process of inflammation in the pelvic organs.
The development of adhesive disease due to the appearance of adhesions between the uterus and fallopian tubes, ovaries, the end result of which can be infertility.
The course of further pregnancy and childbirth may be complicated due to a postoperative scar on the uterus.
Recurrence of fibroids elsewhere in the uterine wall.

Complications of hysterectomy

There are many "horror stories" about the consequences of hysterectomy, which are far from always true. These include an alleged increase in the risk of developing cancer of the breast and other organs, the inability to enjoy sexual life, the onset of early menopause, and others.

All this is very frightening for women, especially impressionable ones, they refuse the operation, even if they need it for health reasons.

In fact, mastopathy, breast tumors and uterine fibroids are links in the same pathogenesis, hormonal disorders in the body. Therefore, in patients with fibroids, indeed, breast diseases are more common, and removal of the uterus does not affect them in any way.

According to the reviews of patients who have undergone amputation of the uterus, sexual sensations after this operation do not weaken, all nerve endings for sexual satisfaction are located in the vagina and cervix, which are preserved. Moreover, a woman ceases to experience pain during intercourse, and also liberates herself, since there is no need to think about protection.

As for the onset of early menopause, there is indeed a slight decrease in the synthesis of sex hormones, even if the appendages are preserved. The fact is that during the operation the ligament connecting the ovaries with the uterus is crossed. As a result, the blood supply to the ovaries deteriorates somewhat. Therefore, not all women, but it is possible:

An increase in the risk of occurrence and further development of heart and vascular diseases in women under the age of 50;
Increased irritability, insomnia, fatigue, depression, hot flashes;
There may be problems with urination (frequent urge to urinate, urinary incontinence);
The appearance of pain in the joints;
The development of osteoporosis, and, as a result, an increase in the risk of spontaneous fractures;
High probability of prolapse of the walls of the vagina;
Perhaps an increase in body weight as a result of the development of endocrine diseases, metabolic syndrome.

In addition to all this, emotional women can develop depression, they begin to consider themselves inferior. Sometimes in these cases, the help of a psychotherapist is required.

Operation cost

If there are indications, it is possible to conduct a free operation under the MHI policy in public clinics.

In private clinics, the cost of operations varies greatly depending on the volume of surgery, the qualifications of the doctor and other factors. An approximate range of prices is shown in the table below.

Conservative myomectomy by vaginal access- organ-preserving operation, which consists in the enucleation of the myomatous node with the preservation of the uterus by performing a posterior or anterior colpotomy. Conservative vaginal myomectomy is most effective for a solitary myomatous node in women planning a pregnancy. This technique allows avoiding excessive traumatization of the anterior abdominal wall, blood loss and adhesion formation, reduces the duration of the operation and the recovery period.

The conditions for performing a conservative vaginal myomectomy in operative gynecology include the presence of a single myomatous node, not exceeding 16 weeks of pregnancy in size, its localization in the region of the posterior or anterior wall of the uterus, good uterine mobility, the absence of adhesions in the small pelvis, chronic diseases of the appendages, cervical stenosis and vagina, the need to preserve the uterus for subsequent pregnancies. Conservative myomectomy through the vaginal approach can be performed with additional laparoscopic assistance.

Preoperative examination of patients before conservative myomectomy includes a consultation with a gynecologist, bacterioscopy and smear culture, colposcopy, oncocytological examination of smears, ultrasound scanning of the uterine cavity, histomorphological diagnosis of scrapings from the cervical canal and uterine cavity.

Conservative myomectomy with colpotomy access is performed under general anesthesia in the gynecological position of the patient. Before the start of the operation, catheterization and emptying of the bladder is performed. With the help of a bimanual study, the localization and size of the nodes, the displacement of the uterus and the adequacy of the colpotomy access are specified.

To reduce bleeding, the cervix and mucosa of the posterior vaginal fornix are infiltrated with a 0.1% solution of adrenaline, after which an anterior or posterior colpotomy is performed with a transverse incision 4–5 cm long. The sacro-uterine ligaments (with a posterior colpotomy) or the cervicovesical ligaments (with an anterior colpotomy) are crossed. The cervix is fixed in bullet forceps and brought down into the wound. An additional infiltration of the tissues of the uterus around the myomatous node is carried out with a solution of adrenaline. Then, the serous membrane of the uterus is dissected above the node, while the incision should be adequate to the size and localization of the fibroids and located as distally as possible to the large vessels of the uterus. The myomatous node is captured, released and removed into the colpotomy wound. If the node is larger than the colpotomy incision, fibroid fragmentation is performed. The knot is removed, after which stitches are applied to the uterus. Hemostasis is controlled, the uterus is probed to check the integrity, and then returned to the physiological position in the abdominal cavity. Drainage is installed in the abdominal cavity, the colpotomy incision is tightly sutured.

Specific complications that develop after conservative myomectomy performed through the vaginal approach include postoperative hematomas and Douglas pouch abscesses. A potential complication of any myomectomy is that uterine rupture is practically excluded due to the high quality of the scar after vaginal myomectomy.